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The primacy of mania: A reconsideration of mood disorders

Published online by Cambridge University Press:  16 April 2020

Athanasios Koukopoulos*
Centro Lucio Bini, 42, Via Crescenzio, 00193Rome, Italy
S. Nassir Ghaemi
Mood Disorders Program, Department of Psychiatry, Tufts Medical Center, Boston, MA, USA
*Corresponding author. Tel.: +39 06 687 4727; fax: +39 06 6880 2345. E-mail address: ((A. Koukopoulos).
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In contemporary psychiatry, depression and mania are conceived as different entities. They may occur together, as in bipolar disorder, or they may occur separately, as in unipolar depression. This view is partly based on a narrow definition of mania and a rather broad definition of depression. Generally, depression is seen as more prominent, common, and problematic; while mania appears uncommon and treatment-responsive. We suggest a reversal: mania viewed broadly, not as simply episodic euphoria plus hyperactivity, but a wide range of excitatory behaviors; and depression seen more narrowly. Further, using pharmacological and clinical evidence, and in contrast to previous theories of mania interpreted as a flight from depression, we propose the primacy of mania hypothesis (PM): depression is a consequence of the excitatory processes of mania. If correct, current treatment of depressive illness needs revision. Rather than directly lifting mood with antidepressants, the aim would be to suppress manic-like excitation, with depression being secondarily prevented. Potential objections to, and empirical tests of, the PM hypothesis are discussed.

Original article
Copyright © Elsevier Masson SAS 2009

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