BIPOLAR AFFECTIVE DISORDER UNSPECIFIED TYPE, A CASE PRESENTATION

OBJECTIVE: Bipolar Affective Disorder(BAD) is a condition with

periods of mania, hypomania and depression. Mood fluctuations are

common during the process of disorder. The first episode of BAD is

generally depressive, and these episodes persist significantly longer

than manic or hypomanic episodes throughout the course of illness.

Patients diagnosed with unipolar depression should be asked whether

they have had a period when they were overactive, more talkative,

increased in goal-directed activity, and decreased need for sleep. We

aimed to present a case that was treated for 4 years with the diagnosis

of unipolar depressive disorder and then diagnosed as bipolar affective

disorder (BAD) unspecified type. Informed consent was obtained from

the patient for the case presentation.

CASE: The patient was a 46 year old male and married with his third

wife and had no additional disease. According to his medical records;

it was learned that he had been receiving antidepressant treatment for

four years with the diagnosis of major depressive disorder (MDD)

until he was admitted to our clinic. Despite the fact that the patient,

who uses his medications regularly and goes to the outpatient clinic

controls regularly, was hospitalized twice for four years, there was no

adequate improvement in his symptoms and psychococial functioning.

The patient was referred to our clinic with the preliminary diagnosis

of treatment-resistant MDD. When the patient is evaluated in detail;

it was learned that he had signs and symptoms such as psychomotor

agitation, decreased need for sleep, increased in appetite and irritability

every year during seasonal changes. On the other hand, his signs and

sympyoms never fulfilled the diagnostic criteria of manic or hypomanic

episode. Additionally, the patient's uncle and brother were found to

be suffering from BAD Type 1. Hence, his diagnosis was established

as bipolar affective disorder "unspecified type". The patient was

treated with sertaline 100 mg/per day, mirtazapine 15 mg/per day, and

aripiprazole 10 mg/per day before hospitalization. Considering the

diagnosis of BAD unspecified type, bupropion 300 mg/per day, lithium

900 mg/per day, valproic acid 1000 mg/perday was administered to the

patient. After the follow-up, it was observed that the patient's signs and

symptoms decreased. Hamilton depression rating scale(HDRS) scores

decreased from 29 to 7. Young Mani Rating Scale (YMRS) decreased

from 4 to 2.

DISCUSSION: The concept of bipolar spectrum is used to define

conditions between classic unipolar depression and BAD Type 1.

Recurrent depressions, family history of bipolar or antidepressantinduced mania, with no response to antidepressant treatment, mixed

and melancholic features, early onset of depression and more depressive

episodes, inadequate response to antidepressants, hyperthymic and

cyclothymic temperaments are features suggestive of bipolar spectrum.

We think that our case highlight importantance of diagnosis and

treatment for BAD spectrum. The diagnosis and treatment approach as

BAD spectrum were redefined due to the characteristics of our patient

such as seasonal sleep rhythm and mood changes, unresponsiveness to

antidepressant treatment, and the presence of a family history of bipolar

mood disorder. Thus, positive results were obtained in the follow-up

process of our case.

Keywords: bipolar affective disorder, depression, mood stabilizer