Bipolar mood disorders among Polish psychiatric outpatients treated for major depression

A piece of the puzzle: Does bipolarity partly explain the high prevalence of treatment resistance in depression?

In this cross-sectional study we examined whether the prevalence of treatment resistant depression (TRD) can be partly attributed to level of bipolarity. We included data of 201 patients with either episodic depression or TRD, who received treatment for their depression at either an outpatient or 2nd opinion/daytime setting, within a specialised mental healthcare department in the Netherlands. Whether level of TRD, assessed by the 'Dutch Measure for quantification of Treatment Resistance in Depression', can be partly explained by level of bipolarity, assessed by 'the Bipolarity Index', was examined using linear regression. We found no direct association between level of TRD and level of bipolarity, nor did comorbid anxiety disorders obscure an existing association. In this study we found no evidence for overlooked bipolarity contributing to the high prevalence of TRD. If replicated, we could state that additional screening on bipolarity with an instrument such as the 'Bipolarity Index' in the specialised mental health care is unnecessary.

Diagnostic Stability in Bipolar Disorder: A Narrative Review

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate diagnostic stability in bipolar disorder• Analyze the factors contributing to diagnostic stability OBJECTIVE: Diagnostic stability is the degree to which a diagnosis remains unchanged during follow-up. It is an important measure of predictive validity in bipolar disorder (BD). In this study, we review the literature concerning diagnostic stability in BD, analyze the factors contributing to diagnostic stability, and describe the implications of diagnostic boundaries and diagnostic delay.

METHODS

A comprehensive literature search of MEDLINE and EMBASE databases was conducted, including all studies published from 1980 to 2016, to evaluate the diagnostic stability of BD. Thirty-seven articles were included: 6 focusing mainly on BD, 18 on psychotic disorders, 10 on depression, and 3 on diagnostic stability in psychiatric disorders in general. Data analysis was performed in standardized fashion using a predefined form.

RESULTS

Despite a high variability of the methodological approaches taken, an acceptable degree of diagnostic stability was found. The most common criteria for evaluating diagnostic stability were prospective consistency and retrospective consistency. The mean prospective and retrospective consistencies were 77.4% and 67.6%, respectively. A large majority of studies were performed in Europe or in North America (67.5%), compared to 21.6% in Asia and only 10.8% in Africa, Oceania, and South America. Extreme ages, female gender, psychotic symptoms, changes to treatment, substance abuse, and family history of affective disorder have been related to diagnostic instability.

CONCLUSIONS

Several factors appear to have a negative impact on the diagnostic stability, but the evidence is insufficient to draw any robust conclusions. Nevertheless, despite variable prospective and retrospective consistencies, the overall diagnostic stability is good. Standardized methods need to be used to obtain more accurate assessments of stability.

Serum level of nerve growth factor is a potential biomarker of conversion to bipolar disorder in women with major depressive disorder

AIM

The aim of this study was to identify biomarkers associated with major depressive disorder (MDD) and conversion from MDD to bipolar disorder (BD) in an outpatient sample of women.

METHODS

This was a longitudinal study including women diagnosed with MDD and aged 18 to 60 years. The follow-up was 3 years. The diagnosis was performed using the Mini International Neuropsychiatric Interview Plus. Blood collection was just performed in the first phase. Serum interleukin-6, tumor necrosis factor-α, brain-derived neurotrophic factor, glial cell-derived neurotrophic factor, and nerve growth factor (NGF) levels were measured using a commercial immunoassay kit.

RESULTS

We included 156 women. The conversion rate from MDD to BD was 15.4% (n = 24). NGF serum levels were increased in patients who converted to BD compared to the remitted MDD group and current MDD group (P = 0.013). The Bonferroni post-hoc test for multiple comparisons revealed significant differences for higher NGF levels in patients who converted to BD compared to patients with current MDD (P = 0.037). Interleukin-6, tumor necrosis factor-α, brain-derived neurotrophic factor, and glial cell-derived neurotrophic factor serum levels did not differ among the groups.

CONCLUSION

Our results suggest that NGF might be a useful biomarker associated with early detection of conversion to BD, helping clinicians in the clinical diagnosis.

Hypersomnia and Bipolar Disorder: A systematic review and meta-analysis of proportion

BACKGROUND

Hypersomnia is a common problem amongst individuals with Bipolar Disorder (BD). The objective of this meta-analysis is to estimate the frequency of hypersomnia in individuals with BD, and identify associated factors METHODS: Our search focused on articles documenting the frequency of hypersomnia among individuals with BD indexed in PubMed database and in the Cochrane Library, following the recommendations from the Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) Group. A meta-analysis of proportion was conducted; funnel plot and Egger's test were used for the assessment of publication bias. Subgroups analyses were performed in order to evaluate possible confounders and associated factors.

RESULTS

We identified 10 studies, which included 1824 patients with BD. The overall estimate of the proportion of BD cases that reported hypersomnia was 29.9% [95% confidence interval (CI): 25.8 - 34.1%, I² = 59.2%; p < .05]. The funnel plot and the Egger's test suggest a low risk of publication bias (p = .527). The polarity of mood state, Bipolar Disorder type, use of medication, age, diagnostic criteria and hypersomnia criteria were not significantly related to hypersomnia.

LIMITATIONS

There is a possibility that smaller cross-sectional studies were not included. The high heterogeneity between studies is frequent in meta-analysis of both interventional and observational studies. Hypersomnia was not the primary outcome in some of the included studies.

CONCLUSIONS

To our knowledge, this is the first systematic review and meta-analysis of hypersomnia prevalence in patients with BD. Further studies focused on clinical correlates and implications for health outcomes in BD are warranted.

A web-based study of bipolarity and impulsivity in athletes engaging in extreme and high-risk sports

BACKGROUND

We hypothesised that men and women who engage in extreme or high-risk sports would score higher on standardised measures of bipolarity and impulsivity compared to age and gender matched controls.

METHODS

Four-hundred and eighty extreme or high-risk athletes (255 males and 225 females) and 235 age-matched control persons (107 males and 128 females) were enrolled into the web-based case-control study. The Mood Disorder Questionnaire (MDQ) and Barratt Impulsiveness Scale (BIS-11) were administered to screen for bipolarity and impulsive behaviours, respectively.

RESULTS

Results indicated that extreme or high-risk athletes had significantly higher scores of bipolarity and impulsivity, and lower scores on cognitive complexity of the BIS-11, compared to controls. Further, there were positive correlations between the MDQ and BIS-11 scores.

CONCLUSION

These results showed greater rates of bipolarity and impulsivity, in the extreme or high-risk athletes, suggesting these measures are sensitive to high-risk behaviours.

Atypical features in depression: Association with obesity and bipolar disorder

OBJECTIVES

Depression with atypical features amounts to a significant proportion of depressed patients. Studies have shown its association with bipolarity and, recently, with obesity. In this study, we investigated atypical features of depression in relation to overweight/obesity in three diagnostic categories: unipolar depression, bipolar depression and dysthymia.

METHODS

Out of 512 depressed patients screened, we recruited 182 research subjects, consisting of 91 pairs, matched by age, gender and diagnosis, in which one member of the pair was within the normal weight range (BMI≤25) and the other was either overweight or obese (BMI>25). There were 35 pairs with unipolar depression, 27 with bipolar depression and 29 with dysthymia. Symptoms of atypical depression, such as increased appetite, hypersomnia, leaden paralysis, longstanding pattern of interpersonal rejection sensitivity, and, a significant weight gain in the past 3 months, were assessed.

RESULTS

All the symptoms of atypical depression were significantly more pronounced in those depressed patients with a BMI>25, compared with depressed subjects with a normal weight. Except for hypersomnia, these symptoms scored significantly higher in women compared to men. Among the diagnostic categories, symptoms of atypical depression were significantly higher in patients with bipolar disorder compared with both major depressive disorder and dysthymia.

LIMITATIONS

The preponderance of women, the assessment of atypical depression by adaptation of the DSM criteria, entirely Polish population, specificity of selection criteria.

CONCLUSIONS

The results demonstrated a higher intensity of atypical depression's symptoms in overweight/obese depressed patients. They also confirm the association between obesity and bipolarity.

Gender differences in demographic and clinical features and prescribing patterns of psychotropic medications in patients with major depressive disorder in China

PURPOSE

Little is known about gender differences associated with major depressive disorder (MDD) in China. This study examined gender differences associated with other demographic and clinical characteristics and psychotropic drug treatment in Chinese patients with MDD.

METHODS

A total of 1178 patients with MDD from 13 psychiatric hospitals or psychiatric units of general hospitals in China nationwide were enrolled. Cross-sectional data including patients' demographic and clinical characteristics and prescriptions of psychotropic medications were recorded using a standardized protocol and data collection procedure.

RESULTS

The sample consisted of 793 female and 385 male patients. Univariate analyses revealed that male patients were younger than female patients, had a younger age of onset of depression, had less lifetime depressive episodes and had more bipolar features (i.e. patients who screened positive for hypomanic symptoms on the 32-item Hypomania Checklist, but did not meet the diagnostic criteria for DSM-IV bipolar disorders as measured by the Mini International Neuropsychiatric Interview). Also, men were more likely to be employed than women and less likely to have depressive episodes following stressful life events. In multivariate analyses, being employed, having bipolar features and not having depressive episodes following stressful life events were independently associated with being a male patient with major depressive disorder. There was no difference in use of psychotropic medications by gender.

CONCLUSIONS

Most gender differences in MDD patients in this study are not consistent with findings of Western studies suggesting that gender differences in MDD may be determined by both biological and sociocultural differences among ethnically different patient populations.

Age-dependent symptomatology of depression in hospitalized patients and its implications for DSM-5

BACKGROUND

We investigated effects of current age and age at onset on symptomatology of depression with reference to proposed revisions in DSM-5.

METHODS

The study entailed medical records of 326 inpatients diagnosed with major depressive disorder, including 520 depressive episodes, with 113 first episodes lifetime. Subjects were divided into three groups: young-adults, middle-aged adults and older adults.

RESULTS

In young-adults, active suicidal ideation, lifetime suicidal attempts, irritability, anhedonia and persistent depressive symptoms between the episodes were more frequent than in the other groups. Among older adults, depression was associated with insomnia, hypochondriasis, somatization, decreased appetite, weight loss, memory impairment and decreased activity. The older age was not associated with higher number of previous episodes of depression, bigger severity or duration of a single episode or a different degree of remission. Early-onset depression was associated with more suicidal attempts.

LIMITATIONS

The study was retrospective and the sample may be treated only as representative for hospitalized depressed patients.

CONCLUSIONS

Age and age at onset are important factors influencing the course and symptomatology of a depressive episode. Depressive episodes with anxiety and with suicide risk severity are important specifiers that vary with the age at onset and/or age of the patient and should be considered for inclusion in the DSM-5 revision.

Sociodemographic and clinical features of bipolar disorder patients misdiagnosed with major depressive disorder in China

OBJECTIVES

Bipolar disorder (BD) is frequently misdiagnosed as major depressive disorder (MDD), which may lead to inappropriate treatment and poor outcomes. This study aimed to compare demographic and clinical features between patients with MDD and those with BD, but being misdiagnosed as MDD, in China.

METHODS

A total of 1487 patients diagnosed with MDD were consecutively evaluated in 13 psychiatric hospitals or psychiatric units of general hospitals nationwide in China. The patients' sociodemographic and clinical characteristics were recorded using a standardized protocol and data collection procedure. The Mini-International Neuropsychiatric Interview (MINI) was used to establish DSM-IV diagnoses, and identify patients with MDD and those with BD, but being misdiagnosed with MDD.

RESULTS

The proportions of BD (all types), bipolar I disorder (BD-I), and bipolar II disorder (BD-II) misdiagnosed as MDD in clinical practice were 20.8%, 7.9%, and 12.8%, respectively. Multiple logistic regression analyses revealed that compared to MDD patients, BD-I was characterized by more atypical depressive features (increased appetite, increased sleep, and weight gain) [odds ratio (OR) = 2.0, 95% confidence interval (CI): 1.2-3.2], more psychotic symptoms (OR = 2.1, 95% CI: 1.3-3.5), more lifetime depressive episodes (OR = 1.1, 95% CI: 1.1-1.2), and earlier age of onset (OR = 0.97, 95% CI: 0.9-0.99); BD-II was characterized by more psychotic symptoms (OR = 2.1, 95% CI: 1.4-3.1) and earlier age of onset (OR = 0.96, 95% CI: 0.9-0.97). In addition, compared to BD-II patients, BD-I patients were characterized by more frequent depressive episodes per year (OR = 3.1, 95% CI: 1.5-6.6).

CONCLUSIONS

Depressive episodes in the context of BD-I and BD-II, among those who were misclassified as MDD, present some different clinical features compared to MDD. This finding should be taken into account in guiding diagnostic practices in China.

Diagnostic conversions from major depressive disorder into bipolar disorder in an outpatient setting: results of a retrospective chart review

BACKGROUND

The aim of the study was to check the stability of a diagnosis of major depressive disorder (MDD) in an outpatient setting, as well as to assess the scope of diagnostic conversions into bipolar disorder (BD).

METHODS

Retrospective chart review of 122 patients with a primary diagnosis of MDD.

RESULTS

Diagnostic conversion from MDD into BD was noticed in 40 subjects (32.8%), 25 patients (20.5%) were treatment-resistant. Mean time to the conversion was 9.27±8.64 years. A negative correlation between the age of illness onset and time to diagnostic conversion was observed (-0.41; p<0.05). Earlier onset of MDD was associated with higher risk of diagnostic conversion (<30vs≥30 years of age at onset: 69% vs 28%, p=0.0001; <35vs≥35 years of age: 50% vs 25%, p=0.0065). Treatment-resistance was more prevalent in the BD conversion group (40% vs 11%; p=0.0002). Diagnostic conversion into BD was also related longer duration of treatment received, higher number of illness episodes, and higher number of hospitalizations.

LIMITATIONS

Retrospective design of the study.

CONCLUSIONS

The problem of diagnosis evolution from MDD to BD was observed in about 1/3 of patients, and was associated with treatment-resistance of depression, earlier onset of depression, longer time of treatment, higher number of depressive episodes and hospitalizations. The variables above may be a useful predictor of bipolar diathesis.

Prescribing patterns of antidepressants, antipsychotics and mood stabilizers in bipolar patients misdiagnosed with major depressive disorder in China

OBJECTIVE

Bipolar disorder (BD) is frequently misdiagnosed as major depressive disorder (MDD), which may lead to inappropriate treatment and poor outcomes. This study aimed to examine prescribing patterns of antidepressants, antipsychotics and mood stabilizers in BD patients misdiagnosed with MDD in China.

METHODS

A total of 1487 patients originally diagnosed with MDD were consecutively screened for diagnostic revision in 13 psychiatric hospitals or psychiatric units of general hospitals in China nationwide. The patients' sociodemographic and clinical characteristics were recorded using a standardized protocol and data collection procedure. The Mini International Neuropsychiatric Interview (MINI) was used to establish DSM-IV diagnoses. Data on psychotropic prescriptions were collected by a review of medical records.

RESULTS

Three hundred and nine of the 1487 patients (20.8%) fulfilled DSM-IV criteria for BD; 118 (7.9%) for BD-I and 191 (12.8%) for BD-II on the MINI. Of the BD patients (n = 309), 227 (73.5%) received any use of antidepressants, 73 (23.6%) antipsychotics and 33 (10.7%) mood stabilizers. In multiple logistic regression analyses, compared with those with MDD, patients with BD-I were more likely to receive antidepressants (OR 1.7, 95% CI 1.1-2.8, p = 0.02), antipsychotics (OR 1.6, 95% CI 1.04-2.5, p = 0.04) and mood stabilizers (OR 3.9, 95% CI 2.1-7.2, p < 0.001), whereas patients with BD-II were more likely to receive mood stabilizers (OR 2.4, 95% CI 1.3-4.4, p = 0.003). There was no difference in the use of antidepressants (OR 1.1, 95% CI 0.8-1.5, p = 0.7) and antipsychotics (OR 1.3, 95% CI 0.9-1.9, p = 0.2) between BD-II and MDD. In addition, there was no difference between BD-I and BD-II in any use of antidepressants, antipsychotics and mood stabilizers.

CONCLUSIONS

The prescription of antidepressants for BD patients misdiagnosed with MDD is very common, and only a very small proportion of patients received guideline-concordant treatment. Considering the potentially hazardous effects of inappropriate pharmacotherapy in this population, continuing education and training addressing the correct diagnosis of BD and rational use of psychotropic medications are needed in China.

Undiagnosed bipolar disorder in patients treated for major depression in China

BACKGROUND

Bipolar disorder (BD) is a recurrent, complex illness and often misdiagnosed and treated as a major depressive disorder (MDD). This study set out (1) to investigate the proportion of BD in patients treated for MDD using DSM-IV diagnostic criteria; (2) to test the usefulness of the screening tool - the 32-item Hypomania Checklist (HCL-32) in Chinese patients; and (3) to assess whether MDD patients with subthreshold manic features (patients who screened positive for BD on the HCL-32, but did not meet the diagnostic criteria for DSM-IV BD as measured by Mini International Neuropsychiatric Interview (MINI)) differ from those with BD, and from those suffering from MDD without manic features in terms of basic demographic and clinical variables.

METHODS

A total of 1487 patients treated for MDD were consecutively examined in 13 mental health centers in China. The patients' socio-demographic and clinical characteristics were recorded using a standardized protocol and data collection procedure. The HCL-32 was self-completed by patients to identify hypomanic symptoms, and the MINI was used by clinicians to establish DSM-IV diagnoses.

RESULTS

The proportions of undiagnosed BD (all types), BD-I and BD-II were 20.8%, 7.9% and 12.8%, respectively. The HCL-32 had low positive predictive value (0.43). Compared to MDD patients without subthreshold manic features, MDD patients with subthreshold manic features were younger at onset, less likely to be married and had more depressive episodes on a seasonal basis, and more frequent depressive episodes overall. Compared to BD patients, MDD patients with subthreshold manic features had an older age at onset and less frequent depressive episodes and less family history of psychiatric disorders, appetite, weight gain and time spent sleeping, suicide ideation and attempts and psychotic symptoms.

CONCLUSIONS

At least one fifth of Chinese patients treated for MDD may have an undiagnosed BD. The HCL-32 is useful to identify broader subthreshold bipolar features. The findings need to be confirmed by longitudinal studies using more comprehensive, standardized instruments.

Bipolarity and inadequate response to antidepressant drugs: clinical and psychopharmacological perspective

OBJECTIVES

The reason why depression may respond poorly to treatment with antidepressant drugs may be connected with the features of bipolarity. Evidence to this effect has accumulated in recent studies of various kinds of depression in mood disorders. Additional evidence for such a connection may be the efficacy of mood-stabilizing drugs in the augmentation of antidepressants in treatment-resistant depression.

METHODS

This review is based on clinical and psychopharmacological research performed over the past five years. The clinical investigation was based on the response to antidepressants of bipolar depression or to symptoms of hypomania, assessed mainly by the Mood Disorder Questionnaire (MDQ) and the Hypomania Checklist-32 (HCL-32). The psychopharmacological research tested the efficacy of augmentation of antidepressants in treatment-resistant depression by mood-stabilizing drugs of the 1st and 2nd generations.

RESULTS

A number of studies have pointed to an association between bipolar depression, or symptoms of hypomania and an inadequate response to antidepressants. Such a connection was also found in the Polish TRES-DEP study which included 1051 depressed patients. Pharmacological studies have demonstrated the efficacy of first generation mood-stabilizing drugs (lithium, carbamazepine) and second generation drugs (quetiapine, olanzapine, risperidone, ziprasidone, lamotrigine) for augmentation of antidepressants in treatment-resistant depression. Some evidence has been presented that mixed depressive episodes may also belong to this category.

CONCLUSIONS

The results of these clinical and psychopharmacological studies appear to confirm an association between bipolarity and a poor response of depression to treatment with antidepressant drugs.

Cyclothymic and hyperthymic temperaments may predict bipolarity in major depressive disorder: a supportive evidence for bipolar II1/2 and IV

BACKGROUND

The concept of soft bipolar spectrum has not been fully confirmed. The aim of the present study is to investigate the validity of bipolar II1/2 and IV concept.

METHODS

The subjects were 46 consecutive outpatients. The individual temperament of each patient was recorded using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A). The operational definition of bipolar II1/2 was those who had depression with cyclothymic temperament and that of bipolar IV was those who had depression with hyperthymic temperament. Finally, drug responses were investigated.

RESULTS

DSM-IV-TR diagnoses were bipolar I (N=1), bipolar II (N=9), major depressive disorder (N=34) and depressive disorder not otherwise specified (N=2). Excluding one bipolar I patient, who had both cyclothymic and hyperthymic temperaments, patients with bipolar II1/2 (N=32) and IV (N=13) as well as bipolar II (N=9) were classified into the soft bipolar spectrum, although there was considerable overlap. The categorization of soft bipolar spectrum and unipolar depression significantly predicted depressive, cyclothymic, irritable, and anxious temperaments. Moreover, soft bipolar spectrum patients with lithium treatment were significantly more in remission than those without lithium treatment. In addition, more of those with selective serotonin reuptake inhibitors (SSRIs) had a significant tendency to lower remission than those without SSRIs.

LIMITATIONS

This is a cross-sectional study with a relatively small number of subjects.

CONCLUSIONS

The present findings suggest that cyclothymic and hyperthymic temperaments may predict bipolarity, and the validity of bipolar II1/2 and IV concept is supported.

Use of the Hypomania Checklist-32 and the Mood Disorder Questionnaire for detecting bipolarity in 1,051 patients with major depressive disorder

Purpose

To use the Hypomania Checklist (HCL-32) and the Mood Disorder Questionnaire (MDQ), for detecting bipolarity in depressed patients.

Patients

One thousand and fifty-one patients fulfilling ICD-10 criteria for unipolar major depressive episode, single or recurrent, were studied. Patients were assessed using a structured demographic and clinical data interview, and by the Polish versions of the HCL-32 and MDQ questionnaires.

Results

Hypomanic symptoms exceeding cut-off criteria for bipolarity by HCL-32 were found in 37.5% of patients and, by MDQ, in 20% of patients. Patients with HCL-32 (+) or MDQ (+) differed significantly from patients with HCl-32 (−) and MDQ (−) respectively, by being less frequently married, having more family history of depression, bipolar disorder, alcoholism and suicide, earlier onset of illness, and more depressive episodes and psychiatric hospitalizations. The percentage of patients resistant to treatment with antidepressant drugs was significantly higher in HCL-32 (+) vs HCL-32 (−) and in MDQ (+) vs MDQ (−): 43.9% vs 30.0%, and 26.4% vs 12.4%, respectively.

Conclusions

The results confirm a substantial percentage of bipolarity in major depressive disorder. Such patients have a number of clinical characteristics pointing on a more severe form of the illness and their depression is more resistant to treatment with antidepressants.

The utility of Mood Disorder Questionnaire for the detection of bipolar diathesis in treatment-resistant depression

BACKGROUND

Treatment-resistant depression is a heterogeneous entity. There are many variables associated with poor response to antidepressants, one of which is missed bipolarity. Therefore, the present study investigated the bipolar diathesis between patients with treatment-resistant (TR) depression and non-treatment-resistant (NTR) depression as assessed with the Mood Disorder Questionnaire (MDQ).

METHOD

The population studied included 1051 patients diagnosed with single or recurrent major depressive disorder. They were classified into a non-treatment-resistant group (481 patients) and a treatment-resistant group (570 patients). The psychiatrist, using information from the patient's medical history, psychiatric examination and available documentation, assessed each eligible patient. The symptoms of bipolarity were additionally assessed by the Mood Disorder Questionnaire.

RESULTS

A positive screen on the MDQ defined as endorsement of at least 6 of the 13 yes or no questions was an independent risk factor for treatment resistance.The total MDQ score was significantly higher in TR vs NTR (4.33 vs 2.66 points p<0.001) and the percentage of patients screened positive was significantly higher in TR than in NTR (13.7% vs 5.6% p<0.001). Factor analysis resulted in 2 factors with eigenvalues >1 explaining 91.5% of total variance.

CONCLUSIONS

Using the MDQ scale we confirmed the association between bipolarity and worse response to antidepressant drugs in patients with major depressive disorder.

Polish version of the Hypomania Checklist (HCL-32) scale: the results in treatment-resistant depression

We performed the factor analysis of the Polish version of the Hypomania Check List (HCL-32) scale and assessed the utility of HCL-32 in discriminating patients with treatment-resistant and treatment non-resistant depression. The study included 1,051 patients with single or recurrent depressive episode among which 569 met the criteria for treatment-resistant depression. The Polish version of HCL-32 was employed to all patients. The Cronbach's alpha for entire scale was 0.93 which indicates high degree of consistency. The factor analysis of the scale yielded three factors with item loadings of 0.4 or more. Factor 1, comprising ten items connected with elevated mood and increased activity explained more than half of total variance, Factor 2 (two items) was connected with sexual activity, and factor 3 (three items) with irritability. The mean score of HCL-32 was significantly higher in treatment-resistant versus non-resistant depression (11.9 +/- 8.3 vs. 8.5 +/- 7.7, respectively, P < 0.001). Also, the percentage of patients having positive response to 14 or more items of the scale was significantly higher in treatment-resistant than in non-resistant depression (43.9 vs. 30.0%, respectively, P < 0.001). Therefore, using Polish version of HCL-32 we have confirmed the association between bipolarity and worse response to antidepressant drugs in patients with mood disorders.

The impact of age at onset of bipolar I disorder on functioning and clinical presentation

OBJECTIVES

Recent studies have proposed the existence of three distinct subgroups of bipolar 1 disorder based on age at onset (AAO). The present study aims to investigate potential clinical and functional differences between these subgroups in an Australian sample.

METHODS

Participants (n = 239) were enrolled in the Bipolar Comprehensive Outcomes Study (BCOS), a 2-year longitudinal, observational, cross-sectional study. Assessment measures included the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAMD21), Clinical Global Impressions Scale (CGI-BP), SF-36, SLICE/Life Scale, and the EuroQol (EQ-5D). Participants were also asked about their age at the first major affective episode.

RESULTS

Three AAO groups were compared: early (AAO < 20, mean = 15.5 ± 2.72; 44.4% of the participants); intermediate (AAO 20-39, mean = 26.1 ± 4.8; 48.14% of the participants) and late (AAO > 40, mean = 50.6 ± 9.04; 7.4% of the participants). Higher rates of depression, suicidal ideation and binge drinking were reported by the early AAO group. This group also reported poorer quality of life in a number of areas. The early AAO group had a predominant depressive initial polarity and the intermediate group had a manic predominance.

CONCLUSION

Early AAO is associated with an adverse outcome.

"Mixed hypomania" in children and adolescents: is it a pediatric bipolar phenotype with extreme diurnal variation between depression and hypomania?

BACKGROUND

Although DSM-IV and the literature on pediatric bipolarity recognize mania and mixed phases neither recognizes states of "mixed hypomania." There has been preliminary presentation of the latter phenomenon in the adult bipolar literature. The authors herein describe this phenomenon in a consecutive clinical series of bipolar children and adolescents.

METHODS

This exploratory study involved 47 consecutive bipolar patients between the ages of 7 and 17 years presenting to an outpatient clinic. They were evaluated using a structured instrument designed to ascertain the presence of major depressive episodes (MDE), hypomania, mania, psychotic disorders, behavioral disorders such as oppositional defiant disorder and conduct disorder and substance use disorders. We defined mixed hypomania as MDE and hypomania coexisting over at least 2 weeks.

RESULTS

Of 47 patients, 9 girls (42.9%) and 9 boys (34.6%) were bipolar II mixed. This paper focuses on them. The mean ages of the bipolar II girls and boys were 14.3 (1.9) years and 12.0 (3.4) years, respectively (p<0.05, t=2.45, df=17). This mixed subgroup tended to experience rising mood in the evening, often with spikes of euphoria; a history of late afternoon to evening increased talkativeness or pressured speech was common. Some patients exhibited flight of ideas. Psychomotor acceleration, heightened level of energy, and increased goal directed activity between 1900 and 0300 were frequently reported. Retrospectively obtained circadian information revealed, in most cases an age inappropriate phase delay of sleep onset: After falling asleep in the early hours of the morning the patients awoke feeling depressed, lethargic and as if they could sleep throughout much of the day.

LIMITATION

Cross-sectional, exploratory study based on a relatively small sample size and in need of replication in other clinical settings.

CONCLUSION

Mixed hypomania was a common phenomenon in pediatric bipolar II patients. It is apt to go unrecognized in cross-sectional assessments done in the morning or in the early or mid-afternoon. Those with this proposed phenotype would appear "depressed" at these times. Alternatively, what we have proposed can also be described as severe diurnal variation between depression and hypomania in the evening. Further study is required combining 24-hour clinical observation and state of the art technologically derived data.

Classifying mood disorders by age-at-onset instead of polarity

BACKGROUND

Polarity is the pillar of the current categorical unipolar-bipolar division of mood disorders. However, genetic studies on these polarity-based phenotypes have been largely inconclusive. Recent clinical and epidemiological studies seem to support more of a continuum than a splitting of mood disorders. A reshaping of the classification of mood disorders thus seems required. Age-at-onset and recurrence have been suggested to be more clinically and genetically useful in the phenotyping of mood disorders.

STUDY AIM

To test a classification of mood disorders based on age-at-onset, and to delineate its phenotypes.

METHODS

A total of 441 consecutive bipolar II disorder (BP-II) and 289 unipolar major depressive disorder (MDD) outpatients, presenting for treatment of a major depressive episode (MDE) in a clinical and research private practice, were assessed by a mood disorder specialist psychiatrist (FB) using a Structured Clinical Interview for the DSM-IV, modified for better probing past hypomania [Benazzi, F. Bipolar disorder-focus on bipolar II disorder and mixed depression. Lancet 2007a;369: 935-945]. The sample was divided according to age-at-onset. Age-at-onset was defined by the age at onset of the first MDE. Early-age-at-onset (EO) was defined as age at onset before 21 years, late-age-at-onset (LO) as onset at or after age 21 years. The study's current goal had not been planned when data were recorded between 1999 and 2006. Variables were compared in EO versus LO mood disorders, investigating phenotype differences. The main focus was on 'classic' diagnostic validators: MDE clinical picture, gender, course, and family history. Age, gender, BP-II, and mania/hypomania family history (possible confounding) were controlled for in the analyses. Logistic regression was used.

RESULTS

First, EO was regressed on each variable, one at a time, to find significant associations. Second, EO was regressed on all of the variables whose odds ratio (OR) was statistically significant in the previous analyses in order to find independent predictors. Independent predictors of EO mood disorder were history of hypomania, high recurrence, atypical depression, and family history of mania/hypomania. Controlling for BP-II (in addition to age and gender) did not impact the findings. The highest OR was that between EO and high recurrence (OR=4.00). Distinguishing MDE symptoms of EO mood disorder included hypersomnia and psychomotor agitation when controlling for age and gender, and, by controlling also for BP-II, hypersomnia only.

DISCUSSION

A close association among EO mood disorder, high recurrence, and bipolarity (history of hypomania, family history of mania/hypomania) was found. Compared to most previous studies testing EO versus LO in bipolar (mainly BP-I) or in unipolar MDD samples, the present study tested a mixed BP-II and MDD sample and controlled for polarity, reducing, as much as possible, the impact of polarity on the findings. EO (below age 21 years) was distinguished by hypersomnic depression, high recurrence, high history of hypomania, and high history of mania/hypomania. Replications are needed, especially in mixed samples also including BP-I. Results, if replicated, could have implications not only for clinical and genetic studies, but also for treatment (e.g., mood stabilizers could have better long-term effects than antidepressants in EO mood disorders, antidepressants could have negative long-term effects on EO).

Prevalence and correlates of bipolar II disorder in major depressive patients at a psychiatric outpatient clinic in Hong Kong

BACKGROUND

Western studies indicate a high prevalence of bipolar II disorder defined by a Research Diagnostic Criteria 2-day hypomania duration criterion (30 to 61%) amongst clinically depressive patients. The situation in Chinese patients with depression is unknown.

METHODS

64 (52.5% response rate) patients first presenting to a Hong Kong public psychiatric outpatient clinic in 2005 with a diagnosis of major depression were recruited. The SCID and Family History Screen were administered.

RESULTS

DSM-IV bipolar II was found in 20.5% of depressive outpatients; 35.9% had bipolar II disorder defined by RDC 2-day duration criterion for hypomania. Family bipolarity, age of onset, and depressive recurrence distinguished bipolar II subjects from unipolar depressives irrespective of duration criteria chosen for hypomania.

LIMITATIONS

Sample size was limited.

CONCLUSIONS

Bipolar II disorder is common amongst Chinese depressive outpatients. The evaluation method and 2-day duration criterion for hypomania were supported by bipolar validators. Replication using larger samples is needed to arrive at a more representative prevalence estimate and to enable more refined nosological evaluation.

Bipolarity in depressive patients without histories of diagnosis of bipolar disorder and the use of the Mood Disorder Questionnaire for detecting bipolarity

OBJECTIVES

The present study was performed to evaluate the frequency of bipolar disorders among patients (a) presenting with depressive episodes but (b) who have never been diagnosed with bipolar disorder (c) in routine clinical practice in Korean subjects and to identify which clinical features were helpful in discriminating bipolar patients from unipolar patients. In addition, authors assessed the practical use of the Mood Disorder Questionnaire (MDQ) to distinguish bipolar from unipolar disorder in these subjects and tested whether modifications of the MDQ scoring could improve its performance.

METHODS

We evaluated consecutive patients who satisfied the inclusion criteria of a current depressive episode, plus at least one previous depressive episode. Subjects were interviewed for diagnosis using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV after completing the MDQ. To improve assessment of hypomania history, the interviewer made strenuous efforts to explore a possible history of hypomania, and patient-derived data were supplemented by information from family members or close relatives.

RESULTS

Fifty-nine patients (53.2%) were classified as having bipolar disorder, leaving a group of 52 (46.8%) with unipolar depression. Among bipolar disorders, 1.8% (n = 2) had bipolar I disorder; 29.7% (n = 33), bipolar II disorder; 6.3% (n = 7), bipolar III disorder (history of antidepressant-induced hypomania without spontaneous hypomanic episode); and 15.3% (n = 17), bipolar disorder not otherwise specified (1-3 days brief hypomania). Postpartum depression (relative risk [RR] [95% confidence interval {CI}], 2.00 [1.23-3.24]), early age of onset (RR [95% CI], 1.85 [1.30-2.64]), mood lability (RR [95% CI], 1.85 [1.30-2.64]), brief depressive episode (RR [95% CI], 1.66 (1.16-2.37]), bipolar family history (RR [95% CI], 1.62 [1.08-2.43]), history of suicide attempt (RR [95% CI], 1.47 (1.05-2.04]), and alcohol problem (RR [95% CI], 1.45 (1.04-2.02]) were found to have higher risks for bipolar disorder among depressive subjects. We found that a modified scoring of the MDQ (ignoring question on functional impairment and co-occurrence of symptoms) yielded a sensitivity of 0.68 and a specificity of 0.63 for bipolar diagnosis, whereas the figures were 0.29 and 0.77, respectively, with the standard MDQ scoring.

CONCLUSIONS

The results of this study clearly indicate that a high frequency of bipolar disorders in depressive patients who have never been diagnosed with bipolar disorders and clinical features indicating bipolarity could help to differentiate bipolar subjects from unipolar subjects. Adapting the standard scoring, the MDQ showed limited use for detecting bipolar disorder; however, if the scoring modification is adapted, the MDQ can offer tolerable sensitivity.

Defining mixed depression

BACKGROUND

Mixed depression, i.e. a major depressive episode plus co-occurring manic/hypomanic symptoms, has recently become the focus of research. However, it is still unclear if its definition should be based on specific manic symptoms or on a number/score of manic symptoms. Different definitions may have different diagnostic utility, such as treatment impacts.

STUDY AIM

Study aim was to test which definition of mixed depression was more supported, by using, as diagnostic validator, early age at onset on the basis of previous studies supporting its bipolar nature.

METHODS

Consecutive 336 Bipolar II Disorder (BP-II), and 224 Major Depressive Disorder (MDD) outpatients were cross-sectionally assessed for major depressive episode (MDE) and concurrent DSM-IV hypomanic symptoms when presenting for treatment of depression, by a mood disorder specialist psychiatrist using the Structured Clinical Interview for DSM-IV as modified by Akiskal and Benazzi (J Clin Psychiatry, 2005) and the Hypomania Interview Guide (HIG), in a private practice. Mixed depression was defined as co-occurrence of MDE and hypomanic symptoms. Early age at onset (EO) below 21 years was used as diagnostic validator.

RESULTS

Multivariable logistic regression of EO versus all within-MDE hypomanic symptoms, controlled for BP-II, showed that no specific symptom was independently associated with EO. By ROC analysis versus EO, the best combination of sensitivity and specificity, and the highest figure of correctly classified, were shown by a cutoff number >=3 symptoms, and by a cutoff HIG score >=8. Both cutoffs had similar strength of association with EO. Mixed depression defined by >=3 within-MDE hypomanic symptoms (A), or by a HIG score >=8 (B), were more frequent in EO group versus LO group (A: 70.5% versus 49.8%; B: 60.7% versus 40.9%; p<0.001), and in BP-II versus MDD (A: 72.3% versus 39.7%; p<0.001; positive predictive value for BP-II=73.1%; B: 63.9% versus 29.0%; p<0.001; positive predictive value for BP-II=76.7%).

DISCUSSION

Findings could support the diagnostic validity of a definition of mixed depression based on a cutoff number/score of within-depression hypomanic symptoms versus one based on specific symptoms, complementing and supporting previous studies using bipolar family history as validator. Diagnosing mixed depression has treatment impacts, such as careful use of antidepressants added to mood stabilising agents or no use of antidepressants, as recently shown by large naturalistic and controlled studies.

How best to identify a bipolar-related subtype among major depressive patients without spontaneous hypomania: superiority of age at onset criterion over recurrence and polarity?

BACKGROUND

History of high depressive recurrence (without history of mania/hypomania) has been proposed as a mood subtype close to bipolar disorders. Herein we test whether this is the best approach to this question.

METHODS

We systematically evaluated consecutive 224 Major Depressive (MDD) and 336 Bipolar II Disorders (BP-II) outpatients in a private practice, by the SCID for DSM-IV (modified for better probing hypomania by Akiskal and Benazzi [Akiskal, H.S., Benazzi, F., 2005. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J. Clin. Psychiatry 66, 914-921]). We conducted univariate and multivariate analyses on such putative bipolar validators as early age at onset of first major depressive episode (before 21 years), high recurrence, family history for bipolar disorders, and depressive mixed states (mixed depression, i.e. depression plus concurrent hypomanic symptoms), in order to identify an MDD subgroup close to BP-II.

RESULTS

All bipolar validators were independent predictors of BP-II. Early onset was the only variable which identified an MDD subgroup significantly associated with all bipolar validators. This MDD subgroup was similar to BP-II on age at onset and bipolar family history, and had a high frequency of mixed depression. A dose-response relationship was found between number of bipolar validators present in MDD, and bipolar family history loading among MDD relatives.

LIMITATIONS

Study limited to outpatients.

CONCLUSIONS

From among the bipolar validators, early age at onset of first major depression (<21 years) was superior to high recurrence (>4 depressive episodes) in identifying an MDD subgroup close to BP-II, which might be subsumed under the broad bipolar spectrum. Implications of unipolar-bipolar boundaries and genetic investigations are discussed.

Continuous distribution of atypical depressive symptoms between major depressive and bipolar II disorders: dose-response relationship with bipolar family history

BACKGROUND

Despite the categorical position of formal diagnostic approaches (i.e. ICD-10 and DSM-IV) to mood disorders, atypical depression (AD) occupies an ambiguous position between major depressive (MDD) and bipolar II (BP-II) disorders.

METHODS

Three hundred and eighty-nine and 261 consecutive BP-II and MDD patients, respectively, presenting for treatment of depression in an Italian private practice, were interviewed by a mood specialist psychiatrist using the Structured Clinical Interview for DSM-IV Axis I Disorders - Clinician Version as modified by the authors to improve the probing for hypomania. Familial bipolarity was measured by the Family History Screen. AD was defined, according to DSM-IV, as a major depressive episode with the 'atypical features' specifier.

RESULTS

BP-II, versus MDD, had the usual distinguishing features (i.e. earlier age at onset, higher rate of depressive recurrences, AD symptoms, and bipolar family history). Such categorical distinction notwithstanding, the distribution of the number of AD symptoms between BP-II and MDD depressions, studied by Kernel estimate, was continuous, showing no bimodality. Furthermore, there was a dose-response relationship between such symptoms and bipolar family history.

CONCLUSIONS

The continuous distribution of a distinct clinical feature (i.e. atypical symptoms) between BP-II and MDD supports a dimensional view of depressive disorders. Our data could also be interpreted as providing further support for the subclassification of AD within the bipolar spectrum.

A tetrachoric factor analysis validation of mixed depression

BACKGROUND

Mixed depression, i.e. a Major Depressive Episode plus co-occurring manic/hypomanic symptoms, has recently become the focus of research. However, its diagnostic validity and bipolar nature are still not firmly supported. A bipolar nature could have significant treatment impacts.

STUDY AIM

The aim was to psychometrically validate the concept of, and the bipolar nature, of mixed depression, by using (for the first time) tetrachoric factor analysis of its hypomanic symptoms.

METHODS

Consecutive 441 Bipolar II Disorder (BP-II), and 289 Major Depressive Disorder (MDD) outpatients were cross-sectionally assessed for Major Depressive Episode (MDE) and concurrent hypomanic symptoms (as binary variables) when presenting for treatment of depression, by a mood disorder specialist psychiatrist (FB), using the Structured Clinical Interview for DSM-IV (as modified by [Akiskal HS, Benazzi F. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J Clin Psychiatry 2005; 66: 914-921.]) in a private practice. Consecutive 275 remitted BP-II were also assessed for past hypomania. Mixed depression was defined as co-occurrence of MDE and 3 or more, usually subthreshold, hypomanic symptoms.

RESULTS

In multivariable logistic regression, BP-II independent predictor variables were young onset age, MDE recurrences, mixed depression, and bipolar family history. Factor analysis of past hypomania symptoms found three factors: an "irritable mental overactivity" factor, an "elevated mood" factor, and a "motor overactivity" factor. Factor analysis of intradepression hypomanic symptoms in BP-II, and in MDD, found two similar mental and motor overactivity factors. Multivariate regression of the intradepression hypomanic factors versus bipolar validators, such as bipolar family history and young onset age, found significant associations.

DISCUSSION

Findings could support the diagnostic validity, and the bipolar nature, of mixed depression, on the basis of the close similarities found between the factor structure of inter-depression hypomania and intra-depression hypomanic symptoms. Impacts on treatment of a bipolar nature of mixed depression may be significant (e.g. more use of mood stabilising agents, less/no use of antidepressants).

Psychotic features in bipolar and unipolar depression

BACKGROUND

While some prior studies have found higher rates of psychotic depression in those with bipolar disorder or a bipolar relative, others have failed to confirm these observations. We examined the relationship of psychotic depression to polarity in several large familial samples of mood disorder.

METHODS

A total of 4,724 subjects with major mood disorder in three family studies on the genetics of bipolar I disorder (BPI) or recurrent major depressive disorder (MDDR) were administered semi-structured interviews by clinicians. Determination of psychotic features was based on a report of hallucinations and/or delusions during the most severe depressive episode in the Schedule for Affective Disorders and Schizophrenia-Lifetime Version or the Diagnostic Interview for Genetic Studies interview. Rates of psychotic depression were calculated by diagnostic category and comparisons were made between diagnoses within and across studies using the generalized estimating equation.

RESULTS

A diagnosis of BPI disorder was strongly predictive of psychotic features during depression compared to MDDR [odds ratio (OR) = 4.61, p < 0.0005]. Having bipolar II compared to MDDR was not predictive of psychosis (OR = 1.05, p = 0.260), nor was having a family history of BPI in MDDR subjects (OR = 1.20, p = 0.840).

CONCLUSIONS

Psychotic features during a depressive episode increased the likelihood of a BPI diagnosis. Prospective studies are needed to confirm these findings. The potential genetic underpinnings of psychotic depression warrant further study.

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.

Delineation of the clinical picture of Dysphoric/Mixed Hypomania

BACKGROUND

While Mixed Depression (i.e. depression plus subthreshold concurrent manic/hypomanic symptoms) has recently seen a wave of studies, little is known about Dysphoric/Mixed Hypomania (i.e. combination of syndromal hypomania and depression) compared to Bipolar I Disorder Mixed State (i.e. combination of syndromal mania and depression).

STUDY AIM

To delineate the clinical picture of Dysphoric/Mixed Hypomania.

METHODS

Consecutive 441 Bipolar II Disorder (BP-II) Major Depressive Episode (MDE) outpatients were cross-sectionally assessed for depression and concurrent hypomanic symptoms when presenting for treatment of depression, by a mood disorder specialist psychiatrist (FB), using the Structured Clinical Interview for DSM-IV, in a private practice. Consecutive 275 remitted BP-II were also assessed for the clinical picture of past (recalled) Hypomania. Dysphoric Hypomania was defined as the co-occurrence of DSM-IV irritable mood Hypomania and MDE.

RESULTS

Frequency of Dysphoric Hypomania was 17.0%, and it was 66.4% for Mixed Depression. Irritable mood, always present by definition in Dysphoric Hypomania, was present in 65.9% of recalled Hypomania and elevated mood in 81.4%. Dysphoric Hypomania had significantly more racing/crowded thoughts, and much less increased goal-directed activity. Functioning was always impaired in Dysphoric Hypomania (by definition), while it was improved in most recalled Hypomanias. Factor structure was different: recalled Hypomania had three factors ('elevated mood', 'irritability and racing/crowded thoughts', 'goal-directed and risky overactivity'), Dysphoric Hypomania had five factors ('depressive vegetative symptoms', 'low mood and psychomotor agitation', 'risky activities', 'loss of interest', 'racing/crowded thoughts and suicidality').

DISCUSSION

Dysphoric Hypomania was uncommon among depressed outpatients (while Mixed Depression was common). Its clinical picture was closer to depression than to hypomania. If it were seen as a simple depression, antidepressants could be used alone (i.e. not protected by mood stabilising agents), risking the worsening of intra-depression irritable hypomania (which was related to suicidality). Systematic assessment of intra-depression hypomanic symptoms is supported.

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.

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.

Is overactivity the core feature of hypomania in bipolar II disorder?

BACKGROUND

Recent studies found that overactivity (increased goal-directed activities) may be as important as mood change (elevated and/or irritable mood) for the diagnosis of mania/hypomania (on family history and psychometric grounds), questioning DSM-IV-TR criteria always requiring mood change and listing overactivity among the other symptoms. The aim of the study was to find out if overactivity was at least as important as mood change for the diagnosis of hypomania.

SAMPLING AND METHODS

A consecutive sample of 137 bipolar II disorder (BP-II) and 76 major depressive disorder remitted outpatients were interviewed with the Structured Clinical Interview for DSM-IV by a senior clinical and research psychiatrist in a private practice. Patients were asked if they had had hypomanic symptoms and episodes, and which were the most common hypomanic symptoms during the various episodes. The study aim had not been planned when variables were collected for different study goals.

RESULTS

Overactivity was the most common hypomanic symptom in BP-II, more common than elevated mood, and had the strongest association with BP-II among all the hypomanic symptoms (overactivity odds ratio = 15.4, elevated mood odds ratio = 12.6). Three factors were found: an 'elevated mood' factor including elevated mood and increased self-esteem; a 'mental activation' factor including racing/crowded thoughts, and a 'behavioral activation' factor including overactivity. There was no relationship between overactivity and mood change. Irritable mood was not associated with overactivity and elevated mood. BP-II was present in 21.6%of patients without a history of overactivity, and in 81.0% of patients with a history of overactivity. BP-II was present in 25.0% of patients without elevated mood, and in 63.3% of patients with elevated mood. As a predictor of BP-II, overactivity had a sensitivity of 90.5%, a specificity of 61.8%, and a positive predictive value of 81.0% (elevated mood: 72.2, 82.8, and 88.3%, respectively). Five or more hypomanic symptoms had the most balanced combination of sensitivity (82.4%) and specificity (85.5%) for BP-II, and a positive predictive value of 91.1%. Overactivity was present in 89.5% of patients with a history of > or = 5 hypomanic symptoms, while elevated mood was present in 76.6%.

CONCLUSIONS

Theresults seem to support the view that overactivity may be a core feature of hypomania, suggesting the upgrading of overactivity to a stem criterion for hypomania.

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.

Types of depression more frequent in bipolar than in unipolar affective illness: results of the Polish DEP-BI study

BACKGROUND

The aim of the study was to assess the relative frequency of various kinds of depression in patients with bipolar and unipolar affective illness. The study was performed in the framework of the DEP-BI project aimed at assessing the prevalence of bipolar disorders among depressive outpatients treated by psychiatrists in Poland.

METHODS

Eight-hundred and eighty patients (237 male, 643 female) participated in the study. The patients were classified into the following diagnostic categories: bipolar affective illness type I, type II, bipolar spectrum disorder and unipolar affective illness. The various kinds of depression in each group were assessed by means of a semistructured questionnaire added to the diagnostic interview.

RESULTS

In the group of bipolar patients, a significantly higher frequency of psychotic depression in male compared to female patients was observed. Male bipolar patients compared with unipolar depressed ones had significantly more episodes of psychotic depression (odds ratio, OR, 4.29) and atypical depression (hypersomnia and hyperphagia; OR 2.82), and those with bipolar spectrum had more episodes of treatment-resistant depression (OR 2.56). Female bipolar patients compared with unipolar depressed ones had significantly more frequently an early onset of depression (before 25 years; OR 2.95) and postpartum depression (OR 2.48). On the other hand, the percentage of agitation, irritability, distractibility, thought racing and panic attacks during depression was not different in patients with bipolar and unipolar affective illness either in males or females.

CONCLUSIONS

Some kinds of depression occur with a higher frequency in patients with bipolar compared to unipolar affective illness. The occurrence of a given type of depression may constitute an aid for the diagnosis of bipolar illness. The results of this study did not confirm the concept of bipolar mixed depression based on the presence of anxiety symptoms occurring during the depressive episode. The limitation of our study may be the lack of formal criteria or a structured interview to assess the symptoms occurring during depressive episodes.

Validating the bipolar spectrum in the French National EPIDEP Study: overview of the phenomenology and relative prevalence of its clinical prototypes

BACKGROUND

Few studies have been undertaken to ascertain the feasibility of using the bipolar (BP) spectrum in clinical practice. The only systematic national study is the French EPIDEP Study of consecutive inpatients and outpatients presenting with major depressive episodes (MDE). The protocol was developed in 1994 and implemented in 1995; publication of its first data began in 1998. This report provides the complete data set of the EPIDEP.

METHODS

Forty-eight psychiatrists, practicing in 15 sites in four regions of France (Paris, Besançon, Bordeaux and Marseille), were all trained on a common protocol based on DSM-IV criteria for MDE (n=537) subdivided into BP-I (history of mania), BP-II (history of hypomania), as well as extended definitions of the "softer spectrum" beyond BP-I and BP-II. Measures tapping into this spectrum included the Hypomania Checklist (HCA), the cyclothymic (CT), depressive (DT) and hyperthymic (HT) temperament scales. These measures and course permitted post-hoc assignment of MDE in the bipolar spectrum, based in part on the Akiskal, H.S., Pinto, O., 1999. [The evolving bipolar spectrum: Prototypes I, II, III, IV. Psychiatr. Clin. North Am. 22, 517-534] proposal: depression with history of spontaneous hypomanic episodes (DSM-IV, BP-II), cyclothymic depressions (BP-II(1/2)), antidepressant-associated hypomania (BP-III) and hyperthymic depressions (BP-IV). <<Strict UP>> was thereby limited to an exclusion diagnosis for the remainder of MDE.

LIMITATION

In the clinical setting, psychiatrists cannot be entirely blind to the observations in the various clinical evaluations and instruments. However, the systematic multisite collection of such data tended to minimize any such biases.

RESULTS

After excluding patients lost to follow-up, among 493 presenting with MDE with complete data files, the BP-II rate was estimated at index at 20%; 1 month later, systematic probing for hypomania doubled the rate of BP-II to 39%. The comparison between BP-II and UP showed differential phenomenology, such as hypersomnia, increased psychomotor activation, guilt feelings and suicidal thoughts in BP-II. Related data demonstrated the importance of CT in further qualifying of MDE to define a distinct, more severe ("darker") BP-II(1/2) variant of BP-II. Moreover, BP-III, arising from DT and associated with antidepressants, emerged as a valid soft bipolar variant on the basis of the phenomenology of hypomania and bipolar family history. Finally, we found preliminary evidence for the inclusion of BP-IV into the bipolar spectrum, its total hypomania score falling intermediate between BP-II and strict UP. Using this broader diagnostic framework, the bipolar spectrum (the combined "hard" BP-I phenotype, BP-II and the soft spectrum) accounted for 65% of MDE.

CONCLUSION

The EPIDEP study achieved its objectives by demonstrating the feasibility of identifying the bipolar spectrum at a national level, and refining its phenomenology through rigorous clinical characterization and validation of bipolar spectrum subtypes, including MDE with brief hypomanias, cyclothymia and hyperthymia. The spectrum accounted for two out of three MDE, making "strict UP" less prevalent than BP as redefined herein. Our findings were anticipated by Falret, who in 1854 had predicted that many melancholic patients in the community would 1 day be classified in his circular group. We also confirmed Baillarger's observation in the same year that episodes (in this study, hypomanic episodes) could last as short as 2 days. Our findings deriving from a systematic French national database a century and a half later invite major shifts in clinical and public health services, as well as in the future conduct of psychopharmacologic trials. In this respect, the systematic training of clinicians in four regions of France represents a national resource for affective disorders and can serve as a model to effect change in diagnostic practice in other countries.

Challenging DSM-IV criteria for hypomania: diagnosing based on number of no-priority symptoms

BACKGROUND

DSM-IV definition of hypomania of bipolar-II disorder (BP-II), which includes elevated/irritable mood change as core feature (i.e., it must always be present), is not based on sound evidence.

STUDY AIM

Following classic descriptions of hypomania, was to test if hypomania could be diagnosed on the basis of its number (9) of DSM-IV symptoms, setting no-priority symptom.

METHODS

Consecutive 422 depression-remitted outpatients were re-interviewed by a mood specialist psychiatrist using the Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version [a semi-structured interview modified by Benazzi and Akiskal (J Affect Disord, 2003; J Clin Psychiatry, 2005) to improve the probing for BP-II] in a private practice. History of episodes of subthreshold (i.e., 2 or more symptoms) and threshold (i.e., meeting DSM-IV criteria of elevated mood plus at least 3 symptoms, or irritable mood plus at least 4) hypomania, lasting at least 2 days, and which were the most common symptoms during the episodes, were systematically assessed.

RESULTS

Bipolar-II disorder (BP-II) patients (according to DSM-IV criteria, apart from hypomania duration) were 260, and major depressive disorder (MDD) patients were 162. Mood change was present in all BP-II by definition. The most common symptoms were overactivity, which was present in almost all BP-II, followed by elevated mood and racing thoughts. ROC analysis of the number of hypomanic symptoms predicting BP-II found that a cut point of 5 or more symptoms over 9 had the best combination of sensitivity (90%) and specificity (84%), and the highest figure of correctly classified (87%) BP-II. History of episodes of 5 or more hypomanic symptoms was met by almost all BP-II.

LIMITATIONS

Single interviewer.

CONCLUSIONS

Following classic descriptions of hypomania, not setting any priority among the three basic domains of hypomania (mood, thinking, behavior), results suggest that a cutoff number of 5 symptoms over 9 (of those listed by DSM-IV) could be used to diagnose hypomania of BP-II. Diagnosing hypomania by counting a checklist of symptoms should make it easier to diagnose BP-II, and should reduce the current high misdiagnosis of BP-II as MDD, significantly impacting the treatment of depression.

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.

Bipolar or unipolar? - the question for clinicians and researchers

BACKGROUND

Correct diagnosis and criteria of affective disorders is always a subject of interest to researchers and practitioners.

METHODS

The study aimed at assessing frequency of various traits and symptoms of bipolar affective disorders (BP-I, BP-II, BP-S spectrum) in patients (n=246) treated for recurrent affective disorders (unipolar-UP). The analysis was based on criteria of affective disorders of Ghaemi et al. and Hirschfeld's Mood Disorders Questionnaire.

RESULTS

UP was confirmed in 32.9% of individuals, whereas 19.5% were BP-I, 35% BP-II and 12.6% BP-S. UP patients were significantly more often professionally active than those with BP (37.2% vs. 22.7%). Duration of a disorder was significantly shorter and the number of depressive episodes lower in the UP group. In comparison with UP, BP-I were associated with the previous occurrence of unusual and/or risky behaviour (OR=24.5), excessive, irrational expenditure (OR=21.1), lack of a critical attitude with respect to social behaviour (OR=20.3), increased sex drive (OR=17.7), and excessive self-confidence (OR=12). BP-II were associated with a lack of criticism with regard to social behaviour (OR=12.7) and unusual and/or risky behaviour (OR=10). Spectrum BP were most strongly associated with short term hypomanic episodes, including drug induced episodes (OR=15.8) and lack of criticism (OR=11.8). Early onset of depression (before 25 years of age) increased the risk of all three types of BP (by a factor of 3 to 5).

LIMITATIONS

This was a naturalistic study, in which treatment was uncontrolled.

CONCLUSIONS

Results of the study are a voice in the discussion on too narrow criteria defining bipolar affective disorders.

Treatment resistance in unipolar depression: Is it an iatrogenic phenomenon caused by antidepressant treatment of patients with a bipolar diathesis?

Major depressive disorder is a common psychiatric illness that is considered generally treatable; however, there are some patients who fail to respond in spite of adequate trials of antidepressants. Clinical factors known to contribute to treatment resistance include psychiatric and physical comorbidity, undiagnosed bipolarity, and treatment non-adherence. There is also emerging evidence that the use of antidepressants in some 'unipolar' patients may lead to a pattern of progressive diminution of therapeutic response and ultimately treatment resistance. A large number of these patients may have a bipolar diathesis even though there are no symptoms of hypomanic, manic or mixed episodes. It is hypothesized that the widespread and injudicious use of antidepressants in patients with a bipolar diathesis might result in treatment-induced resistant depression. Furthermore, attempts to manage the antidepressant-led mood instability might cause increased utilisation of other psychotropic drugs including sedative/hypnotics, neuroleptics and mood stabilisers and contribute to polypharmacotherapy.

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.

Symptoms of depression as possible markers of bipolar II disorder

Underdiagnosis and misdiagnosis of bipolar-II disorder (BP-II) as a major depressive disorder (MDD) are frequently reported. The study aim was to find which symptoms of depression could be possible cross-sectional markers of BP-II, in order to reduce underdiagnosing BP-II.

METHODS

Consecutive 379 BP-II and 271 MDD major depressive episode (MDE) outpatients 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. Inside-MDE hypomanic symptoms (elevated mood and increased self-esteem always absent by definition) were systematically assessed. Mixed depression was defined as an MDE plus 3 or more inside-MDE hypomanic symptoms, a definition validated by Akiskal and Benazzi.

RESULTS

The MDE symptoms significantly more common in BP-II versus MDD were weight gain, increased eating, hypersomnia, psychomotor agitation, worthlessness, and diminished ability to concentrate. The inside-MDE hypomanic symptoms significantly more common in BP-II were distractibility, racing/crowded thoughts, irritability, psychomotor agitation, more talkativeness, increased risky and goal-directed activities. Multiple logistic regression showed that hypersomnia, racing/crowded thoughts, irritability, and psychomotor agitation were independent predictors of BP-II. Irritability had the most balanced combination of sensitivity and specificity predicting BP-II. Psychomotor agitation had the highest specificity but the lowest sensitivity. Racing/crowded thoughts had the highest sensitivity but the lowest specificity. These symptoms had a similar positive predictive value (PPV) for BP-II, which was around 70% (PPV is more clinically useful than sensitivity and specificity), which in turn was similar to the PPV of mixed depression and atypical depression (two diagnostic clinical markers of BP-II). All possible combinations of these symptoms had a PPV similar to that of the individual symptoms. The validity as BP-II markers of these symptoms was supported by a significant association with bipolar family history.

CONCLUSIONS

Hypersomnia, racing/crowded thoughts, irritability, and psychomotor agitation may be useful, cross-sectional markers of BP-II. Finding these symptoms in depression should lead the clinician to careful probing for history of hypomania, which should reduce the BP-II misdiagnosed as MDD. Results may also have treatment impacts, as antidepressants used alone (i.e., no concurrent mood stabilising agent) in BP-II depression misdiagnosed as MDD may increase cycling.

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.

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.

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.