After the initial split into bipolar disorder and unipolar depression, the last 30 years have seen the progressive subdivision of mood disorders into further subgroups: bipolar I, bipolar II, rapid cycling bipolar disorder, minor depression, dysthymia, SAD, and so on. In the process the characteristics of the course of a disorder have been incorporated into the classification, which means that course and prognosis are no longer independent of the diagnostic definition.
The distinction between bipolar disorder and unipolar depression is fundamental. These disorders differ markedly in their course and outcome, with bipolar disorder having an earlier onset, higher episode frequency, slightly shorter episode length, and poorer outcome (fewer full recoveries, slightly more chronicity), but, unexpectedly, probably fewer suicides. All bipolar disorders and most unipolar depressive disorders are recurrent, with a minority having a really good prognosis without residual symptoms and further recurrences. Bipolar II disorders probably have a slightly better prognosis than bipolar I disorders.
Therapeutic decisions on the length of acute treatment will depend on the length of the individual's previous episodes and on the average episode length observed in follow-up studies. The length of affective episodes has probably not changed in 100 years. Antidepressants cannot shorten the episodes but can minimize the symptoms. Treatment should be maintained for the duration of episodes, which are frequently masked; otherwise relapses must be expected.
The choice of a long-term prophylactic medication also has to take into consideration the previous individual course of the disorder plus the general scientific knowledge about course and prognosis, and to keep in mind the increased mortality, especially the high suicide mortality associated with mood disorders. (44) Recurrence is also a feature in mild cases, but in contrast with severe cases the suicide mortality is probably low. Decisions about long-term medication also have to take into account whether there are residual symptoms during the intervals; such symptoms are a strong risk factor for further recurrence. Over the lifetime, each new recurrence is associated with a new risk of suicide. Any cessation of treatment has to take these risks into account. So far there are no positive recommendations for the cessation of prophylactic treatment.
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