Profiles of "manic" symptoms in bipolar I, bipolar II and major depressive disorders

Clinical predictors of unrecognized bipolar I and II disorders

OBJECTIVES

Bipolar disorder (BD) is correctly diagnosed in only 40-50% of patients. No previous study has investigated the characteristics of bipolar patients in psychiatric care with or without clinical diagnoses of BD. We investigated the demographic and clinical predictors of the absence of a clinical diagnosis of BD I and II among psychiatric patients.

METHODS

In the Jorvi Bipolar Study, 1,630 psychiatric in- and outpatients were screened with the Mood Disorder Questionnaire. Suspected cases were diagnosed with the Structured Clinical Interview for DSM-IV Axis I Disorders-Patient version (SCID-I/P) for BD. Patients with no preceding clinical diagnosis of BD, despite previous manic, hypomanic or mixed phases and treatment in psychiatric care, were classified as undiagnosed. The clinical characteristics of unrecognized BD I patients (23 of 90 BD I patients) and BD II patients (47 of 93 BD II patients) were compared to those of patients who had been correctly diagnosed.

RESULTS

No previous hospitalizations [odds ratio (OR) = 10.6, p = 0.001] or psychotic symptoms (OR = 4.4, p = 0.045), and the presence of rapid cycling (OR = 11.6, p = 0.001) predicted lack of BD I diagnosis. No psychotic symptoms (OR = 3.3, p = 0.01), female gender (OR = 3.0, p = 0.03), and shorter time in treatment (OR = 1.1, p = 0.03) predicted the lack of a BD II diagnosis.

CONCLUSIONS

Correct diagnosis of BD I is related to the severe phases of illness leading to hospitalizations. In BD II, the illness factors may not be as important as time elapsed in treatment, a factor that often leads to a delay in diagnosis or none at all. Excessive reliance on typical and cross-sectional presentations of illness likely explain the non-recognition of BD. The challenge for correctly diagnosing bipolar patients is in outpatient settings.

Testing predictors of bipolar-II disorder with a 2-day minimum duration of hypomania

The study's aim was to find if features often reported to distinguish bipolar and depressive disorders could predict bipolar-II disorder (BP-II). Consecutive major depressive episode (MDE) outpatients, including 284 with BP-II and 196 with major depressive disorder (MDD), were interviewed with the Structured Clinical Interview for DSM-IV, Hypomania Interview Guide, and Family History Screen, in a private practice. The minimum duration of past hypomania was 2 days. Mixed depression was defined as an MDE plus three or more intradepressive, non-euphoric hypomanic symptoms. BP-II predictors were early onset (<20 years), many recurrences (>4 MDEs), bipolar family history, mixed depression, and atypical depressions. Bipolar family history had the highest positive predictive value (PPV) (80.8%) but low sample frequency (32.7%); early onset had high PPV (75.2%) and a sample frequency of 37.0%; many recurrences had the highest frequency (70.4%) but the lowest PPV (66.5%). Combinations of three or more predictors had high PPV (79.0%) and a sample frequency of 46.6%. Predictors and combinations of predictors may correctly identify 75% to 80% of BP-II, reducing the misdiagnosis of BP-II as MDD (by prompting careful probing for hypomania history), and improving treatment of depression (as antidepressants alone may worsen BP-II course). As PPV is related to disease prevalence, findings need to be replicated in different settings.

Bipolar II disorder : epidemiology, diagnosis and management

Bipolar II disorder (BP-II) is defined, by DSM-IV, as recurrent episodes of depression and hypomania. Hypomania, according to DSM-IV, requires elevated (euphoric) and/or irritable mood, plus at least three of the following symptoms (four if mood is only irritable): grandiosity, decreased need for sleep, increased talking, racing thoughts, distractibility, overactivity (an increase in goal-directed activity), psychomotor agitation and excessive involvement in risky activities. This observable change in functioning should not be severe enough to cause marked impairment of social or occupational functioning, or to require hospitalisation. The distinction between BP-II and bipolar I disorder (BP-I) is not clearcut. The symptoms of mania (defining BP-I) and hypomania (defining BP-II) are the same, apart from the presence of psychosis in mania, and the distinction is based on the presence of marked impairment associated with mania, i.e. mania is more severe and may require hospitalisation. This is an unclear boundary that can lead to misclassification; however, the fact that hypomania often increases functioning makes the distinction between mania and hypomania clearer. BP-II depression can be syndromal and subsyndromal, and it is the prominent feature of BP-II. It is often a mixed depression, i.e. it has concurrent, usually subsyndromal, hypomanic symptoms. It is the depression that usually leads the patient to seek treatment.DSM-IV bipolar disorders (BP-I, BP-II, cyclothymic disorder and bipolar disorder not otherwise classified, which includes very rapid cycling and recurrent hypomania) are now considered to be part of the 'bipolar spectrum'. This is not included in DSM-IV, but is thought to also include antidepressant/substance-associated hypomania, cyclothymic temperament (a trait of highly unstable mood, thinking and behaviour), unipolar mixed depression and highly recurrent unipolar depression.BP-II is underdiagnosed in clinical practice, and its pharmacological treatment is understudied. Underdiagnosis is demonstrated by recent epidemiological studies. While, in DSM-IV, BP-II is reported to have a lifetime community prevalence of 0.5%, epidemiological studies have instead found that it has a lifetime community prevalence (including the bipolar spectrum) of around 5%. In depressed outpatients, one in two may have BP-II. The recent increased diagnosing of BP-II in research settings is related to several factors, including the introduction of the use of semi-structured interviews by trained research clinicians, a relaxation of diagnostic criteria such that the minimum duration of hypomania is now less than the 4 days stipulated by DSM-IV, and a probing for a history of hypomania focused more on overactivity (increased goal-directed activity) than on mood change (although this is still required for a diagnosis of hypomania). Guidelines on the treatment of BP-II are mainly consensus based and tend to follow those for the treatment of BP-I, because there have been few controlled studies of the treatment of BP-II. The current, limited evidence supports the following lines of treatment for BP-II. Hypomania is likely to respond to the same agents useful for mania, i.e. mood-stabilising agents such as lithium and valproate, and the second-generation antipsychotics (i.e. olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole). Hypomania should be treated even if associated with overfunctioning, because a depression often soon follows hypomania (the hypomania-depression cycle). For the treatment of acute BP-II depression, two controlled studies of quetiapine have not found clearcut positive effects. Naturalistic studies, although open to several biases, have found antidepressants in acute BP-II depression to be as effective as in unipolar depression; however, one recent large controlled study (mainly in patients with BP-I) has found antidepressants to be no more effective than placebo. Results from naturalistic studies and clinical observations on mixed depression, while in need of replication in controlled studies, indicate that antidepressants may worsen the concurrent intradepression hypomanic symptoms. The only preventive treatment for both depression and hypomania that is supported by several, albeit older, controlled studies is lithium. Lamotrigine has shown some efficacy in delaying depression recurrences, but there have also been several negative unpublished studies of the drug in this indication.

The Bipolar Depression Rating Scale (BDRS): its development, validation and utility

OBJECTIVES

Unipolar and bipolar depression differ neurobiologically and in clinical presentation. Existing depression rating instruments, used in bipolar depression, fail to capture the necessary phenomenological nuances, as they are based on and skewed towards the characteristics of unipolar depression. Both clinically and in research there is a growing need for a new observer-rated scale that is specifically designed to assess bipolar depression.

METHODS

An instrument reflecting the characteristics of bipolar depression was drafted by the authors, and administered to 122 participants aged 18-65 (44 males and 78 females) with a diagnosis of DSM-IV bipolar disorder, who were currently experiencing symptoms of depression. The Bipolar Depression Rating Scale (BDRS) was administered together with the Hamilton Depression Rating Scale (HAM-D), Montgomery Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS).

RESULTS

The BDRS has strong internal consistency (Cronbach's alpha = 0.917), and robust correlation coefficients with the MADRS (r = 0.906) and HAM-D (r = 0.744), and the mixed subscale correlated with the YMRS (r = 0.757). Exploratory factor analysis showed a three-factor solution gave the best account of the data. These factors corresponded to depression (somatic), depression (psychological) and mixed symptom clusters.

CONCLUSIONS

This study provides evidence for the validity of the BDRS for the measurement of depression in bipolar disorder. These results suggest good internal validity, provisional evidence of inter-rater reliability and strong correlations with other depression rating scales.

Is there a continuity between bipolar and depressive disorders?

BACKGROUND

Recent studies questioned the current categorical split of mood disorders into bipolar disorders (BP) and depressive disorders (MDD).

METHODS

Medline database search of papers from the last 10 years on the categorical-dimensional classification of mood disorders. Various combinations of the following key words were used: mood disorders, bipolar, unipolar, major depressive disorder, spectrum, category/categorical, classification, continuity. Only English language clinical papers were included, review papers were excluded, similar papers selected by quality. The number of papers found was 1,141. The number of papers selected was 109.

RESULTS

The continuity/spectrum between BP (mainly BP-II) and MDD was supported by the following findings:(1) high frequency of mixed states (mixed mania, mixed hypomania, mixed depression, i.e. co-occurring depression and noneuphoric manic/hypomanic symptoms) because opposite polarity symptoms in the same episode do not support a hypomania/mania-depression splitting; (2) MDD was the most common mood disorder in BP probands' relatives; (3) no bimodal distribution of distinguishing symptoms between BP and MDD; (4) bipolar signs not uncommon in MDD; (5) many MDD shifting to BP; (6) many lifetime manic/hypomanic symptoms in MDD; (7) correlation between lifetime manic/hypomanic symptoms and MDD symptoms; (8) hypomania factors in MDD; (9) MDD often recurrent; (10) similar cognitive style. The categorical distinction between BP (mainly BP-I) and MDD was supported by the following findings: (1) BP more common in BP probands' relatives; (2) lower age at BP onset; (3) females as common as males in BP-I, more common than males in MDD; (4) BP-I depression more atypical and retarded, MDD depression more sleepless and agitated; (5) BP more recurrent.

CONCLUSIONS

Focusing on mood spectrum's extremes (BP-I vs. MDD), a categorical distinction seems supported. Focusing on midway disorders (BP-II and MDD plus bipolar signs), a continuity/spectrum seems supported. Results seem to support both a categorical and a dimensional view of mood disorders.

Bipolar disorder--focus on bipolar II disorder and mixed depression

Bipolar II disorder (recurrent depressive and hypomanic episodes) and related disorders (united in the bipolar spectrum) are understudied, despite a prevalence of about 5% in the community and about 50% in depressed outpatients. The apparent increase in prevalence of the bipolar spectrum is related to several changes in diagnostic criteria, including improved probing for history of hypomania (focused more on overactivity than on mood change), lower minimum duration of hypomania, and inclusion of unipolar depressions with bipolar signs (eg, family history of bipolar disorder, mixed depression). Prevalence of mixed depression, a combination of depression and manic or hypomanic symptoms, is high in patients with bipolar disorders. Controlled studies are needed to investigate treatment of mixed depression; antidepressants can worsen manic and hypomanic symptoms, and mood stabilising agents might be necessary.

Retrospective analysis of psychomotor agitation, hypomanic symptoms, and suicidal ideation in unipolar depression

In bipolar depression, psychomotor agitation is relatively common and often is associated with other noneuphoric hypomanic symptoms and suicidal ideation. Our goal in this retrospective study was to ascertain the co-occurrence of agitation, bipolar features, and suicidal ideation in unipolar disorder. We retrospectively evaluated 314 inpatients with DSM-IV major depressive disorder (MDD) and no other Axis I diagnosis with the National Institutes of Mental Health (NIMH) Life Chart Method and the Operational Criteria for Psychotic Illness (OPCRIT) checklist to ascertain their symptom profiles across all episodes. Univariate and multivariate comparisons were performed between the subgroups with and without psychomotor agitation (OPCRIT item 23> or =1). Agitated depression (AD, a major depressive episode with psychomotor agitation) was present in 19% of the sample. Compared to nonagitated counterparts, patients with AD were older and had lower educational levels and more dysphoria, insomnia, positive thought disorder, and psychotic manifestations. Hypomanic symptoms other than agitation were relatively uncommon (<10%) and more represented in subjects with AD. No significant differences emerged between AD and control groups with respect to most bipolar validators (gender, familiarity, recurrence). Patients with AD had higher levels of suicidal ideation than non-AD controls; however, such a difference was no longer significant after controlling for psychotic features. Excessive self-reproach, early awakening, diurnal changes, poor appetite, and hypomanic symptoms were independently associated with suicidal thoughts in nonpsychotic MDD. Incomplete information on drug treatment, exclusion of patients with Axis I comorbidity, and tertiary care setting were the most important limitations of the study. Although we failed to support the bipolar nature of MDD-AD by common validators, probably because we used a more heterogeneous definition of agitation compared to similar studies, our data confirm the association of agitation with hypomanic symptoms and suicidal thoughts in major depression, and emphasize the complex phenomenology of AD in an inpatient setting.

Challenging the unipolar-bipolar division: does mixed depression bridge the gap?

BACKGROUND

Mixed states, i.e., opposite polarity symptoms in the same mood episode, question the categorical splitting of mood disorders in bipolar disorders and unipolar depressive disorders, and may support a continuum between these disorders. Study aim was to find if there were a continuum between hypomania (defining BP-II) and depression (defining MDD), by testing mixed depression as a 'bridge' linking these two disorders. A correlation between intradepressive hypomanic symptoms and depressive symptoms could support such a continuum, but other explanations of a correlation are possible.

METHODS

Consecutive 389 BP-II and 261 MDD major depressive episode (MDE) outpatients were interviewed, cross-sectionally, with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide (to assess intradepressive hypomanic symptoms) and the Family History Screen, by a mood disorders specialist psychiatrist in a private practice. Patients presented voluntarily for treatment of depression when interviewed drug-free and had many subsequent follow-ups after treatment start. Mixed depression (depressive mixed state) was defined as the combination of MDE (depression) and three or more DSM-IV intradepressive hypomanic symptoms (elevated mood and increased self-esteem were always absent by definition), a definition validated by Akiskal and Benazzi.

RESULTS

BP-II, versus MDD, had significantly lower age at onset, more recurrences, atypical and mixed depressions, bipolar family history, MDE symptoms and intradepressive hypomanic symptoms. Mixed depression was present in 64.5% of BP-II and in 32.1% of MDD (p=0.000). There was a significant correlation between number of MDE symptoms and number of intradepressive hypomanic symptoms. A dose-response relationship between frequency of mixed depression and number of MDE symptoms was also found.

CONCLUSIONS

Differences on classic diagnostic validators could support a division between BP-II and MDD. Presence of intradepressive hypomanic symptoms by itself, and correlation between intradepressive hypomanic symptoms and depressive symptoms could instead support a continuum. Other explanations of such a correlation are possible. Depending on the method used, a BP-II-MDD continuum could be supported or not.

Mixed depression and the dimensional view of mood disorders

BACKGROUND

Mixed depression (MxD), i.e. depression plus cooccurring noneuphoric manic/hypomanic symptoms, questions the current categorical dividing of mood disorders into bipolar disorders and depressive disorders, and supports a dimensional approach. The study aim was to test a dimensional approach to mood disorders by looking for a progressive grading of age at onset and bipolar family history loading between bipolar II disorder (BP-II) and major depressive disorder (MDD).

METHODS

Consecutive 389 BP-II and 261 MDD major depressive episode outpatients were interviewed (off psychoactive drugs) with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide (to assess intradepressive noneuphoric hypomanic symptoms), and the Family History Screen, by a mood disorder specialist psychiatrist in a private practice. BP-II and MDD MxD and non-MxD were compared on age at onset and bipolar family history loading (the diagnostic validators). A dose-response was tested between the number of intradepressive hypomanic symptoms and bipolar family history loading, and a correlation was tested between the number of intradepressive hypomanic symptoms and age at onset.

RESULTS

MxD was present in 64.5% of BP-II and in 32.1% of MDD. There were significant differences in classic diagnostic validators (onset age, bipolar family history). The comparisons between BP-II and MDD MxD and non-MxD on age at onset and bipolar family history found a clear and significant grading in age at onset from BP-II MxD to MDD non-MxD (a progressive increase), and a clear and significant grading in bipolar family history loading from BP-II MxD to MDD non-MxD (a progressive decrease). A dose-response relationship was found between the number of intradepressive hypomanic symptoms and bipolar family history loading. The area under the ROC curve was small. A significant correlation was found between the number of intradepressive hypomanic symptoms and age at onset.

CONCLUSIONS

The presence of MxD in a significant proportion of MDD, the progressive grading of age at onset and bipolar family history from BP-II MxD to MDD non-MxD, the dose-response relationship between intradepressive hypomanic symptoms and bipolar family history loading, and the correlation between intradepressive hypomanic symptoms and age at onset could support a dimensional approach to mood disorders (BP-II and MDD). On the other hand, the significant differences on classic diagnostic validators could support a categorical distinction. A mixed approach (dimensional and categorical) to mood disorders could be supported.

Various forms of depression

The current subtyping of depression is based on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR) categorical division of bipolar and depressive disorders. Current evidence, however, supports a dimensional approach to depression, as a continuum/spectrum of overlapping disorders, ranging from bipolar I depression to major depressive disorder. Types of depression which have recently been the focus of most research will be reviewed: bipolar II depression, mixed depression, agitated depression, atypical depression, melancholic depression, recurrent brief depression, minor depressive disorder, seasonal depression, and dysthymic disorder. Most research has focused on bipolar II depression, mixed depression (defined by depression and superimposed manic/hypomanic symptoms), and atypical depression. Mixed depression, by its combination of opposite polarity symptoms, has been found to be common by systematic probing for co-occurring manic/hypomanic symptoms. Mixed depression is a treatment challenge for clinicians, because antidepressants alone (ie, not protected by mood-stabilizing agents) may worsen its manic/hypomanic symptoms, such as irritability and psychomotor agitation, which the Food and Drug Administration (FDA) has listed as possible precursors to suicidality.

A continuity between bipolar II depression and major depressive disorder?

BACKGROUND

A recent series of studies has questioned the current categorical split of mood disorders into bipolar and depressive disorders. Mixed states, especially mixed depression (i.e., depression plus co-occurring, noneuphoric, hypomanic symptoms) might support a continuity between bipolar II (BP-II) depression and major depressive disorder (MDD). The aim of the study was to assess the distribution of intradepressive hypomanic symptoms rating between BP-II and MDD depressions. A bi-modal distribution would support a categorical distinction, and no bi-modality would support continuity.

METHODS

Consecutive 389 BP-II and 261 MDD major depressive episode (MDE) outpatients were interviewed (off psychoactive drugs) with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide (HIG, to assess intradepressive hypomanic symptoms), and the Family History Screen, by a mood specialist psychiatrist in a private practice. Mixed depression was defined as MDE plus 3 or more intradepressive, noneuphoric hypomanic symptoms, a definition validated by Akiskal and Benazzi. The distribution of intradepressive hypomanic symptoms rating was studied by Kernel density estimate and by histogram.

RESULTS

BP-II depression, versus MDD depression, had significantly lower age at onset, was significantly more likely to be atypical and mixed, had more depression recurrences, and a higher bipolar family history loading. BP-II depression, versus MDD depression, had significantly more irritability, racing/crowded thoughts, distractibility, psychomotor agitation, talkativeness, increased goal-directed activity, and excessive risky activities. HIG scores were significantly higher in BP-II. The distribution of intradepressive hypomanic symptoms rating showed no bi-modality in the entire depression sample.

CONCLUSIONS

Interpretation of study findings relies on the method used to define a categorical disorder. By using classic diagnostic validators (such as family history and age at onset), BP-II and MDD depressions would seem to be distinct disorders. Instead, by using the 'bi-modality' approach, a continuity would seem to be supported. Which of these methods for classification is the best has yet to be shown.

The DSM-IV and ICD-10 categories of recurrent [major] depressive and bipolar II disorders: evidence that they lie on a dimensional spectrum

BACKGROUND

Presently it is a hotly debated issue whether unipolar and bipolar disorders are categorically distinct or lie on a spectrum. We used the ongoing Ravenna-San Diego Collaboration database to examine this question with respect to major depressive disorder (MDD) and bipolar II (BP-II).

METHODS

The study population in FB's Italian private practice setting comprised consecutive 650 outpatients presenting with major depressive episode (MDE) and ascertained by a modified version of the Structured Clinical Interview for DSM-IV. Differential assignment of patients into MDD versus BP-II was made on the basis of discrete hypomanic episodes outside the timeframe of an MDE. In addition, hypomanic signs and symptoms during MDE (intra-MDE hypomania) were systematically assessed and graded by the Hypomania Interview Guide (HIG). The frequency distributions of the HIG total scores in each of the MDD, BP-II and the combined entire sample were plotted using the kernel density estimate. Finally, bipolar family history (BFH) was investigated by structured interview (the Family History Screen).

RESULTS

There were 261 MDD and 389 BP-II. As in the previous smaller samples, categorically defined BP-II compared with MDD had significantly earlier age at onset, higher rates of familial bipolarity (mostly BP-II), history of MDE recurrences (>or=5), and atypical features. However, examining hypomania scores dimensionally, whether we examined the MDD, BP-II, or the combined sample, kernel density estimate distribution of these scores had a normal-like shape (i.e., no bimodality). Also, in the combined sample of MDE, we found a dose-response relationship between BFH loading and intra-MDE hypomania measured by HIG scores.

LIMITATIONS

Although the interviewer (FB) could not be blind to the diagnostic status of his private patients, the systematic rigorous interview process in a very large clinical population minimized any unintended biases.

CONCLUSIONS

Unlike previous studies that have examined the number of DSM-IV hypomanic signs and symptoms both outside and during MDE, the present analyses relied on the more precise hypomania scores as measured by the HIG. The finding of a dose-response relationship between BFH and HIG scores in the sample at large strongly suggests a continuity between BP-II and MDD. Our data indicate that even in those clinically depressed patients without past hypomanic episodes (so-called "unipolar" MDD), such scores are normally rather than bimodally distributed during MDE. Moreover, the absence of a 'zone of rarity' in the distribution of hypomanic scores in the combined total, MDD and BP-II MDE samples, indicates that MDD and BP-II exist on a dimensional spectrum. From a nosologic perspective, our data are contrary to what one would expect from a categorical unipolar-bipolar distinction. In practical terms, intra-MDE hypomania and BFH, especially in recurrent MDD, represent strong indicators of bipolarity.

Psychometric delineation of the most discriminant symptoms of depressive mixed states

Recent studies have shown that depressive mixed state (DMX), i.e., a major depressive episode (MDE) plus 3 or more intra-MDE hypomanic symptoms, is prevalent in bipolar-II disorder (BP-II) and not uncommon in major depressive disorder (MDD) outpatients. The main aim of the present analyses was to find the most discriminant intra-MDE hypomanic signs and symptoms predicting depressive mixed state. Consecutive 602 MDE outpatients (348 BP-II, 254 MDD) were interviewed with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide, and the Family History Screen, by a senior psychiatrist in a private practice. Sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of individual intra-MDE hypomanic signs and symptoms for depressive mixed state showed that irritability had a balanced combination of SE, SP, PPV, NPV, and that psychomotor agitation and greater talkativeness had the highest SP and PPV, but lower SE. By virtue of reducing misdiagnoses, SP and PPV are the most important of these tests for clinicians. On the basis of SP and PPV, our results suggest that, though not the most prevalent, irritability (50.3%) and psychomotor agitation (27.7%) represent the most discriminant features of depressive mixed state. Presence of these features should serve as a "red flag" to help clinicians probe more skillfully for the diagnosis of depressive mixed state. Beyond its diagnostic significance, the foregoing signs and symptoms are among the clinical features the FDA lists as presaging "suicidality" on antidepressant monotherapy.

Influence of postpartum onset on the course of mood disorders

BACKGROUND

To ascertain the impact of postpartum onset (PPO) on the subsequent time course of mood disorders.

METHODS

This retrospective study compared per year rates of excited (manic or mixed) and depressive episodes between fifty-five women with bipolar (N = 22) or major depressive (N = 33) disorders with first episode occurring postpartum (within four weeks after childbirth according to DSM-IV definition) and 218 non-postpartum onset (NPPO) controls. Such patients had a traceable illness course consisting of one or more episodes alternating with complete symptom remission and no additional diagnoses of axis I disorders, mental retardation or brain organic diseases. A number of variables reported to influence the course of mood disorders were controlled for as possible confounding factors

RESULTS

Bipolar women with postpartum onset disorder had fewer excited episodes (p = 0.005) and fewer episodes of both polarities (p = 0.005) compared to non-postpartum onset subjects. No differences emerged in the rates of depressive episodes. All patients who met criteria for rapid cycling bipolar disorder (7 out of 123) were in the NPPO group. Among major depressives, PPO patients experienced fewer episodes (p = 0.016). With respect to clinical and treatment features, PPO-MDD subjects had less personality disorder comorbidity (p = 0.023) and were less likely to be on maintenance treatment compared to NPPO comparison subjects (p = 0.002)

CONCLUSION

Such preliminary findings suggest that PPO mood disorders may be characterized by a less recurrent time course. Future research in this field should elucidate the role of comorbid personality disorders and treatment. Moreover it should clarify whether PPO disorders are also associated with a more positive outcome in terms of social functioning and quality of life.

Mood patterns and classification in bipolar disorder

PURPOSE OF REVIEW

The aim of this review is to highlight recent studies that have questioned the current split of mood disorders into the categories of bipolar and depressive disorders.

RECENT FINDINGS

A continuity between bipolar disorders (mainly bipolar II disorder) and major depressive disorder was supported by several lines of evidence: depressive mixed states (mixed depression) and dysphoric (mixed) hypomania (opposite polarity symptoms in the same episode do not support the splitting between mania/hypomania and depression); family history, major depressive disorder is the most common mood disorder in relatives of bipolar probands; lack of points of rarity between the depressive syndromes of bipolar II disorder and major depressive disorder; bipolar features in major depressive disorder; major depressive disorder shifting to bipolar disorders; history of manic/hypomanic symptoms in major depressive disorder and correlation between lifetime manic/hypomanic symptoms and depressive symptoms in major depressive disorder; factors of hypomania inside major depressive disorder; recurrent course of major depressive disorder; depression more common than mania and hypomania in bipolar disorders; trait mood lability in major depressive disorder.

SUMMARY

This review of the recent findings on the relationship between bipolar disorders (especially bipolar II disorder) and depressive disorders seems to support a continuity among mood disorders, and runs against the current classification of mood disorders dividing them into independent categories. Further research is needed in the area, in part because of its possible treatment impact.

Impact of temperamental mood lability on depressive mixed state

BACKGROUND

Cyclothymic temperament (which includes mood lability) is common in bipolar II disorder (BP-II). Depressive mixed state (DMX), a major depressive episode (MDE) mixed with intra-episode hypomanic symptoms (3 or more, according to a recently validated definition), was found to be common in BP-II and not uncommon in major depressive disorder (MDD). The study aim was to find the impact of temperamental mood lability (TML) on DMX.

METHODS

Consecutive 148 BP-II and 117 MDD outpatients presenting for MDE treatment were interviewed by the Structured Clinical Interview for DSM-IV as modified by Benazzi and Akiskal to reduce the false negative BP-II. Intra-MDE hypomanic symptoms were systematically assessed. Kraepelin, Angst, and Akiskal's definitions of temperamental mood lability (i.e., frequent up and down fluctuations of mood between major mood episodes since young age) were followed.

RESULTS

DMX was present in 61.5%, TML in 52.8%. In the DMX sample, TML was present in 57.6%, and in the non-DMX sample TML was present in 45.0% (OR = 1.6, 95% CI = 1.0-2.7). In the DMX sample, independent predictors of DMX with TML were BP-II and young age at onset. Intra-MDE hypomanic symptoms, and MDE, melancholic and atypical symptoms were not significantly different between DMX patients with TML and DMX patients without TML, apart from more temperamental interpersonal sensitivity in DMX patients with TML (OR = 2.0, 95% CI = 1.0-3.8).

DISCUSSION

DMX patients with TML had a younger onset age, suggesting that TML may facilitate the onset of DMX or that it may be a precursor of DMX. The association of BP-II with DMX, TML, and interpersonal sensitivity can make the course of BP-II more unstable and its treatment more complex.

The relationship of major depressive disorder to bipolar disorder: continuous or discontinuous?

Recent studies have questioned current diagnostic systems that split mood disorders into the independent categories of bipolar disorders and depressive disorders. The current classification of mood disorders runs against Kraepelin's unitary view of manic-depressive insanity (illness). The main findings of recent studies supporting a continuity between bipolar disorders (mainly bipolar II disorder) and major depressive disorder are presented. The features supporting a continuity between bipolar II disorder and major depressive disorder currently are 1) depressive mixed states (mixed depression) and dysphoric (mixed) hypomania (opposite polarity symptoms in the same episode do not support a splitting of mood disorders); 2) family history (major depressive disorder is the most common mood disorder in relatives of bipolar probands); 3) lack of points of rarity between the depressive syndromes of bipolar II disorder and major depressive disorder; 4) major depressive disorder with bipolar features such as depressive mixed states, young onset age, atypical features, bipolar family history, irritability, racing thoughts, and psychomotor agitation; 5) a high proportion of major depressive disorders shifting to bipolar disorders during long-term follow-up; 6) a high proportion of major depressive disorders with history of manic and hypomanic symptoms; 7) factors of hypomania present in major depressive disorder episodes; 8) recurrent course of major depressive disorder; and 9) depressive symptoms much more common than manic and hypomanic symptoms in the course of bipolar disorders.

Bipolar family history of the hypomanic symptoms and dimensions of mixed depression

BACKGROUND

There are no data on the bipolar family history (BPFH) of the hypomanic symptoms and dimensions of mixed depression (defined as a depression plus concurrent hypomanic symptoms). These data may be important for the genetics of mixed depression. The study aim was to investigate the BPFH of the hypomanic symptoms of mixed depression.

METHODS

Consecutive 243 bipolar II disorder (BP II) and 189 major depressive disorder (MDD) outpatients, presenting for treatment of a major depressive episode (MDE), were interviewed using the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide, and the Family History Screen. Mixed depression was defined as an MDE plus 3 or more intra-MDE hypomanic symptoms (following a definition validated by Akiskal and Benazzi [J Affect Disord 2003;73:113-22]).

RESULTS

Major depressive episode with BPFH vs MDE without BPFH had significantly more BP II, lower age of onset, more MDE recurrences, more atypical depressions, more mixed depressions, and more intra-MDE hypomanic symptoms (irritability, racing/crowded thoughts, psychomotor agitation, more talkativeness, distractibility). Factor analysis of intra-MDE hypomanic symptoms found 2 factors (dimensions): one factor including psychomotor agitation and more talkativeness, and one factor including racing/crowded thoughts, irritability, and distractibility. Logistic regression showed that mixed depression was more strongly associated with BPFH than hypomanic symptoms and dimensions. There was a dose-response relationship between number of intra-MDE hypomanic symptoms and BPFH loading (marked increase at n = 3) in the entire BP II and MDD sample.

CONCLUSIONS

Findings showed that hypomanic symptoms were more common in the MDE with BPFH of BP II and of MDD, suggesting that a bipolar vulnerability may be required for mixed depression. Mixed depression was more strongly associated with BPFH than hypomanic symptoms and dimensions, suggesting that it could be the focus of future FH studies.

Mixed depression: a clinical marker of bipolar-II disorder

BACKGROUND

Recent studies have found that mixed depression [i.e., a major depressive episode (MDE) plus intra-MDE hypomanic symptoms] is common in bipolar-II disorder (BP-II), and not uncommon in major depressive disorder (MDD) depressed outpatients. Study aim was to test the predictive power for the diagnosis of BP-II of several dimensional definitions of mixed depression, searching for a clinical marker which could reduce the current underdiagnosis of BP-II.

METHODS

Consecutive 348 BP-II and 254 MDD depressed outpatients were interviewed by the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide, and the Family History Screen, by a senior psychiatrist in a private practice. Intra-MDE hypomanic symptoms were systematically assessed. Mixed depression was defined as an MDE plus intra-MDE hypomanic symptoms.

RESULTS

Dimensional definitions of mixed depression (at least 2, 3, 4, 5 or more intra-MDE hypomanic symptoms) were tested for predicting BP-II. A definition requiring 2 or more hypomanic symptoms had the highest sensitivity, the lowest specificity, and the lowest positive predictive value. A definition requiring 5 or more hypomanic symptoms had the highest specificity, the lowest sensitivity, and the highest positive predictive value. The most balanced combination of sensitivity and specificity was found for a definition requiring 3 or more hypomanic symptoms. This definition had the highest positive predictive value, and the highest ROC area (i.e., the best global performance). This definition had also the most balanced combination of sensitivity and specificity for predicting bipolar family history. In order to validate this definition as a clinical marker of BP-II, as bipolar validators were used BP-II, young onset, many recurrences, atypical depression features, and bipolar family history (the most important one). Univariate logistic regression found that this definition was associated with most bipolar validators, especially bipolar family history. Multiple logistic regression found that bipolar family history was its strongest predictor.

CONCLUSIONS

Findings suggest that a definition of mixed depression requiring 3 or more intra-MDE hypomanic symptoms may be a useful clinical marker for predicting the diagnosis of BP-II. Presence of mixed depression should lead to skillful probing for history of hypomania, which would probably reduce the BP-II misdiagnosed as MDD. Findings may also impact treatment of BP-II, as intra-MDE hypomanic symptoms may become more severe by antidepressants alone, and mood stabilising agents may be required before (or concurrently with) antidepressants.