The frequent recurrence of treatment-refractory depression is emerging as the greatest unmet need in the clinical management of patients with rapid-cycling bipolar disorder, and particularly those comorbid presentations with alcohol and drug abuse. The age-corrected risk of major affective disorder was 23.5% in 179 relatives of rapid cyclers and 31% in 189 relatives of matched non-rapid cyclers, suggesting that rapid cycling is not genetic and does not aggregate within families. Findings from neuroimaging studies continue to enrich our understanding of the pathophysiology of mood disorders generally and rapid-cycling bipolar disorder particularly. Researchers found that the clinical presentation of bipolar disorder I (BP-I) was similar in children and adolescents. Despite being the oldest among the pharmacological armamentarium in the treatment of bipolar disorder, lithium continues to draw attention to its utility as an effective agent in the treatment of different aspects and phases of this disorder.

Depression in certain types of individuals carry an increased risk of suicide. In the context of untreated high risk factors and increasing despair, it is no mystery that treatment-resistant depression (trd)/treatment-refractory depression (TRD) accentuates the risk of suicide inherent in a high risk individual. It seems important to consider both chronic and acute risk factors in the assessment of suicide risk, especially when deciding on intervention strategies and tactics. Studies of nearly 100 inpatient suicide records and approximately 30 outpatient suicide cases suggest four typical clinical patterns. Illustrative case vignettes are presented to emphasize these observed patterns. These patterns are not by any means exhaustive, but may be a useful beginning for the clinician treating various forms of treatment-resistant or refractory depression to be able to recognize. Expertise in the treatment of resistant depression is a skill that every practicing clinician should develop.