A case for mixed depression with Bourdain

Mixed depression according to some researchers is rather common but for some reason 0AMZgedO_400x400people don’t think of it when someone like Bourdain commits suicide. Perhaps the depression goes unrecognized since the person’s behavior isn’t consistent with depression and the hypomanic symptoms are not meeting some arbitrary threshold. According to Targum:

“Mixed” depression is a clinical presentation in which a patient meets the full criteria for MDD and, at the same time, has a mixture of other features that are consistent with hypomania or mania. However, when only two or three of these manic symptoms are present, the duration fails to meet current criteria for hypomania (4 days) or mania (7 days), and therefore the diagnosis does reach the full criteria for a hypomanic or manic episode.2  

One hypomanic symptom would be Bourdain’s restlessness and consistent traveling in search of the perfect meal in Parts Unknown. This is at odds with depression but his affect while doing so often seemed depressed to me. His commentary for the most part rather acerbic/cynical but punctuated with periods of levity.

A second sign of hypomanic symptoms was his suicide. It is fairly well known that suicide increases with mixed states. A mixed state is often a high energy state combined with a depressed mood. What constitutes high energy though is somewhat debatable. Most see it as an increase in physical activity which is productive but I contend from personal experience that one can have an extremely restless mind and be quite fatigued at the same time. In addition to the high energy there is often insomnia which might be attributed to stress or depression and not a symptom of hypomania.

A third sign of bipolar disorder was that Bourdain also seemed irritable which is another symptom of hypomania but most would probably see it as consistent with agitated depression. Depressed people can be irritable but it is usually not combined with excess goal orientated energy.

A fourth indication of bipolar was he was an ex addict. Addiction is more common among people with bipolar and could be due to a need to medicate or control an agitated and unhappy mind. What is unknown is had he relapsed or was he taking any antidepressants which might have precipitated the suicide. Antidepressants are known to aggravate bipolar depression and it is not a stretch to think they might have been involved.

A fifth sign was that he was married twice and in a relationship with a third woman. Multiple marriages are more consistent with bipolar tendencies. Irritability, grandiosity and restlessness is obviously going to cause more conflict.

And finally, his success as author, journalist and chef supports someone with a tendency towards hypomania. On average individuals with bipolar tend to be more productive and creative people which he certainly was. He wrote numerous books and was a famous TV personality.

Symptoms can fluctuate to quite a degree in bipolar disorder/unipolar depression and if that happens within a day this is often just attributed to what is know as diurnal variation. Personally, I experienced a very pronounced variation when younger. Somewhat of a mixed state early in morning, around 3am- 6am and then an improvement as the day went on. At night I often felt much better and was considerably more productive. This was considered as still consistent with Dysthymia according to my doctor.

What really seems to confound a diagnosis of “mixed depression” or bipolar disorder is how one evaluates what is “high energy”. Is it always productive or can it be nonproductive as in anxiety? Dr. Phelps is one doctor who challenges how excessive energy is evaluated. How can one measure a racing mind which can occur in mania or depression with mixed features. It sounds like it often depends on self report and a rather subjective evaluation of a patient’s symptoms.

 

 

 

 

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Interesting that so many commenters want to be…

Interesting that so many commenters want to be spared the details of Kate Spade’s suicide. I think to a degree necessary because it shocks people out of complacency. Depression and suicide are still thought to be moral failings and always due to some external factor. This individual apparently was well off and respected. This story supports depression as more of a disease with unknown and perhaps uncontrollable factors. This scares people, as it probably should. https://www.npr.org/sections/thetwo-way/2018/06/05/617145848/fashion-designer-kate-spade-found-dead-in-apparent-suicide

Robbin Williams’ suicide

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one picture where he seems genuinely happy

I’m incredibly sad and shocked to hear that Robbin Williams appeared to have committed suicide. I don’t usually get all that upset about the passing of celebrities. I think the difference this time was that I felt like I had more in common with him them other ones. Robbin Williams had suffered with depression along with substance abuse problems for most of his life. His manic-like behavior often seemed to over shadow his depressed side. Additionally he seemed like a genuinely caring person which is rare now these days.

One wonders why he couldn’t reach out to someone about his pain. Perhaps like many he found it difficult to convey his pain to others due perhaps to pride or hopelessness. In my experience people tend to dismiss people with major depression since many people have only experienced a milder version and think the severely depressed individual must be experiencing the same degree of depression.

One celebrity tweeted that he was selfish to commit suicide. This makes me quite angry because it denies that the person was in unbearable pain. If someone was in pain from cancer I don’t think people would dismiss their suffering as readily.

Now looking back at many of his pictures, his eyes appear quite sad and his smile forced. I think the lesson from this is not to automatically dismiss others who appear depressed. Depression is too often seen as a normal condition and not an abnormal one.

edit: I just learned that he was suffering from Parkinson’s disease. That could explain the depression since it can be a symptom of Parkinson’s.

Presence of ‘activation syndrome’ suggests bipolarity

KraepelinWavesWhen younger(in my twenties) I noticed that SSRIs initially gave me panic attacks and akathisia. I always had a suspicion that my depression had a degree of bipolarity about it and this study confirms it a little. Activation syndrome is more common among bipolar patients and it consists of the following symptoms:

The components of activation syndrome, as stated by the US Food and Drug Administration, are anxiety, agitation, panic attack, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, and mania/hypomania. The syndrome is believed to flag suicidality risk in patients taking antidepressants.

If an individual has these symptoms it increases the chance of being bipolar by 3.27 fold.

On multivariate analysis, a bipolar diagnosis was one of only two variables independently associated with activation syndrome, increasing the likelihood 3.27-fold.

The other variable was experiencing a mixed depressed state which like a bipolar diagnosis, increases suicidality. In the past another mood researcher Benazzi, a proponent of ‘mixed depression’, believed that individuals with a few hypomanic traits such as irritability, insomnia and agitation while depressed were more likely to have bipolar disorder.

The other significant variable was being in a depressive mixed state, which raised the likelihood for activation syndrome 4.13-fold. The researchers note that a depressive mixed state is reportedly almost as common in patients with MDD who attempt suicide while on antidepressive treatment as it is in patients with bipolar disorder.

Given the small size of the study and the naturalistic/retrospective nature, further studies are needed to confirm the connection between activation syndrome and bipolarity.