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Pini S, Raia A, Amatori G, Nardi B, Carpita B, Tundo A, Dell'Osso L. A reevaluation of mixed depressive states from the DSM-5- TR perspective: a series of prototypical cases. Arch Clin Cases 2024; 11:22-28. [PMID: 38689821 PMCID: PMC11060145 DOI: 10.22551/2024.42.1101.10282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Mixed depressive states are defined by the co-presence of depressive and manic symptoms. They represent extremely variable conditions from the point of view of clinical expressiveness and are difficult to recognize, ranging from clear schizophrenic-like psychoses and pseudodemented pictures to subsyndromal psychopathology. At the basis of the extreme variability of depressive pictures with mixed features are the different combinations that depressive and manic symptoms can assume. Furthermore, the intensity of depressive symptoms and manic symptoms, combined, can be variable, a factor that contributes to making the picture even more variable. Each form of mixed depressive state therefore presents its own specific symptomatic characteristics and specific difficulties in differential diagnosis and each form requires a different therapeutic strategy. In this work we have distinguished four possible specific subtypes of mixed depressive states, describing their specific clinical presentation and the therapeutic options most supported by the literature with the aim of contributing to a better recognition of mixed depressive states, to avoid incorrect diagnoses at patient and treatments that are useless if not worsening.
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Affiliation(s)
- Stefano Pini
- Department of Psychiatry, Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Accursio Raia
- Department of Psychiatry, Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giulia Amatori
- Department of Psychiatry, Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Benedetta Nardi
- Department of Psychiatry, Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Barbara Carpita
- Department of Psychiatry, Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Liliana Dell'Osso
- Department of Psychiatry, Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
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Abstract
Mixed states have been discussed for more than 2 millennia. The theoretic conception of the coexistence of presumably opposite symptoms of mood or of different psychic domains is well established, although obscured by the presumed separation between bipolar and depressive disorders. Moreover, the lack of response to treatments and severe psychopathology raise important issues requiring urgent solution. The aim of this article was to review the development of the concept of mixed states from the classic literature to modern nosologic systems and to claim for the need of a new paradigm to address the still-open issues about mixed states.
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Affiliation(s)
- Gabriele Sani
- Institute of Psychiatry, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Psychiatry, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Roma, Italy.
| | - Alan C Swann
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Michael E. Debakey Veterans Affairs Medical Center, 1977 Butler Boulevard, 4th Floor, Houston, TX 77030, USA.
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Shahin I, Bonnin CDM, Saleh E, Helmy K, Youssef UM, Vieta E. Validity of the Shahin Mixed Depression Scale: A Self-Rated Instrument Designed to Measure the Non-DSM Mixed Features in Depression. Neuropsychiatr Dis Treat 2020; 16:2209-2219. [PMID: 33061391 PMCID: PMC7532079 DOI: 10.2147/ndt.s259996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 09/02/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The DSM5-defined mixed features in depression do not include psychomotor agitation, irritability or distractibility because they are considered overlapping symptoms. A growing number of modern psychiatrists have expressed dissatisfaction with this and proposed alternative sets of mixed symptoms that are much more common and clinically relevant. Among such alternative criteria were those proposed by Koukopoulos. He utilized the research diagnostic criteria of agitated depression (RDC-A) as a mixed depression subtype, and validated another form of mixed depression, the Koukopoulos criteria for mixed depression (K-DMX). PURPOSE This study provides psychometric validation for the first self-rated scale designed to measure the most common mixed symptoms in depression as proposed by Koukopoulos. PATIENTS AND METHODS We conducted a multicenter cross-sectional study of 170 patients with unipolar depression. They completed the Shahin Mixed Depression Scale (SMDS) and underwent expert interviews as a gold standard reference. SMDS' psychometric properties were assessed, including Cronbach's alpha, factor analysis, sensitivity, specificity, predictive value and accuracy. RESULTS We found significant association and agreement between mixity according to SMDS and the gold standard (K-DMX and RDC-A according to expert interview) with good internal consistency (Cronbach's alpha=0.87), high sensitivity (=91.4%), specificity (=98.0%), positive predictive value (=96.9%), negative predictive value (= 94.2%) and accuracy (=95.2%). Factor analysis identified one factor for psychomotor agitation and another for mixity without psychomotor agitation. CONCLUSION SMDS was a reliable and valid instrument for assessing the frequently encountered and clinically relevant mixed features in depression.
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Affiliation(s)
| | - Caterina Del Mar Bonnin
- Barcelona Bipolar Disorders and Depressive Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Elsayed Saleh
- Department of Psychiatry, Mansoura University, Mansoura, Egypt
| | - Khaled Helmy
- Training and Research Unit, New Nozha Hospital, Alexandria, Egypt.,Ciconia Recovery London (CRL), London, UK
| | - Usama M Youssef
- Department of Psychiatry, Zagazig University, Zagazig, Egypt
| | - Eduard Vieta
- Barcelona Bipolar Disorders and Depressive Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
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Koukopoulos A, Sani G. DSM-5 criteria for depression with mixed features: a farewell to mixed depression. Acta Psychiatr Scand 2014; 129:4-16. [PMID: 23600771 DOI: 10.1111/acps.12140] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2013] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To review the DSM-5 proposed criteria for mixed depression in light of robust and consistent historical and scientific evidence. METHOD An extensive historical search, a systematic review of the papers used by DSM-5 as reference papers, and a PubMed search were performed. RESULTS As Hippocrates, depressive mixed states have been described as conditions of intense psychic suffering, consisting of depressed mood, inner tension, restlessness, and aimless psychomotor agitation. In DSM-5, new criteria are proposed for a mixed features specifier, as part of depression either in major depressive disorder (MDD) or bipolar disorder. Those criteria require, as diagnostically specific, manic/hypomanic symptoms that are the least common kinds of symptoms that actually arise in depressive mixed states. The DSM-5 proposal is based, almost entirely, on a speculative wish to avoid 'overlapping' manic and depressive symptoms. Mixed states are, in fact, nothing but overlapping manic and depressive symptoms. CONCLUSION In this article, we review the psychopathology and research on mixed depressive states, and try to demonstrate that the DSM-5 proposal has weak scientific basis and does not identify a large number of mixed depressive states. This may be harmful because of the different treatment required by these conditions.
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Zivanovic O, Nedic A. Kraepelin's concept of manic-depressive insanity: one hundred years later. J Affect Disord 2012; 137:15-24. [PMID: 21497402 DOI: 10.1016/j.jad.2011.03.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 12/26/2010] [Accepted: 03/17/2011] [Indexed: 10/18/2022]
Abstract
Kraepelin's work is frequently cited and repeatedly interpreted as groundwork for the categorical classification of mental disorders. The scope of this paper is to present a fragment of Kraepelin's contribution to the nosology of manic-depressive illness from another point of view. Studying conscientiously the original text written by Emil Kraepelin more than one hundred years ago, the reader could conclude that the author's attitudes were more in line with numerous contemporaries who promote the dimensional approach to the classification in psychiatry and spectrum concept of mood disorders. This text is an attempt to inspire the reader to examine the original textbook.
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Affiliation(s)
- Olga Zivanovic
- Department of Psychiatry and Medical Psychology, Medical School Novi Sad, University of Novi Sad, Serbia.
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Koukopoulos A, Sani G, Koukopoulos AE, Manfredi G, Pacchiarotti I, Girardi P. Melancholia agitata and mixed depression. Acta Psychiatr Scand Suppl 2007:50-7. [PMID: 17280571 DOI: 10.1111/j.1600-0447.2007.00963.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The diagnostic entity of major depressive episode includes both simple and agitated or mixed depression. Mixed depression is characterized by a full depressive episode with several symptoms of excitatory nature. Mixed depressions worsen if treated with antidepressants. METHOD We have reviewed the clinical charts of the 2141 patients treated at the Centro Lucio Bini of Rome from January 1999 to June 2006. These patients were diagnosed according to DSM-IV criteria. Research diagnostic criteria were applied for agitated depression with motor agitation and Author's diagnostic criteria for agitated depression without motor agitation. RESULTS One thousand and twenty-six patients had a depressive episode as index episode. Three hundred and forty six (33%) were mixed depressive states. One hundred and thirty eight (44%) of them were spontaneous; in 173 cases, the onset of the mixed depression was associated with antidepressants. CONCLUSION Psychic and motor agitation are considered equally important for the definition of agitated depression. Treating agitated depression with antidepressants worsens the clinical picture. The use of Electroconvulsive Therapy (ECT), neuroleptics and anticonvulsants are recommended. The term Melancholia Agitata is proposed for agitated (mixed) depression.
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Affiliation(s)
- A Koukopoulos
- Centro Lucio Bini, Center for the Treatment and Research of Affective Disorders and Department of Psychiatry, University of Rome La Sapienza, c/o Sant'Andrea Hospital, Rome, Italy.
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Benazzi F. Delineation of the clinical picture of Dysphoric/Mixed Hypomania. Prog Neuropsychopharmacol Biol Psychiatry 2007; 31:944-51. [PMID: 17391823 DOI: 10.1016/j.pnpbp.2007.02.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2006] [Revised: 02/26/2007] [Accepted: 02/27/2007] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Franco Benazzi
- Hecker Psychiatry Research Center, University of California at San Diego, USA.
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Benazzi F. Is there a continuity between bipolar and depressive disorders? PSYCHOTHERAPY AND PSYCHOSOMATICS 2007; 76:70-6. [PMID: 17230047 DOI: 10.1159/000097965] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Recent studies questioned the current categorical split of mood disorders into bipolar disorders (BP) and depressive disorders (MDD). METHODS Medline database search of papers from the last 10 years on the categorical-dimensional classification of mood disorders. Various combinations of the following key words were used: mood disorders, bipolar, unipolar, major depressive disorder, spectrum, category/categorical, classification, continuity. Only English language clinical papers were included, review papers were excluded, similar papers selected by quality. The number of papers found was 1,141. The number of papers selected was 109. RESULTS The continuity/spectrum between BP (mainly BP-II) and MDD was supported by the following findings:(1) high frequency of mixed states (mixed mania, mixed hypomania, mixed depression, i.e. co-occurring depression and noneuphoric manic/hypomanic symptoms) because opposite polarity symptoms in the same episode do not support a hypomania/mania-depression splitting; (2) MDD was the most common mood disorder in BP probands' relatives; (3) no bimodal distribution of distinguishing symptoms between BP and MDD; (4) bipolar signs not uncommon in MDD; (5) many MDD shifting to BP; (6) many lifetime manic/hypomanic symptoms in MDD; (7) correlation between lifetime manic/hypomanic symptoms and MDD symptoms; (8) hypomania factors in MDD; (9) MDD often recurrent; (10) similar cognitive style. The categorical distinction between BP (mainly BP-I) and MDD was supported by the following findings: (1) BP more common in BP probands' relatives; (2) lower age at BP onset; (3) females as common as males in BP-I, more common than males in MDD; (4) BP-I depression more atypical and retarded, MDD depression more sleepless and agitated; (5) BP more recurrent. CONCLUSIONS Focusing on mood spectrum's extremes (BP-I vs. MDD), a categorical distinction seems supported. Focusing on midway disorders (BP-II and MDD plus bipolar signs), a continuity/spectrum seems supported. Results seem to support both a categorical and a dimensional view of mood disorders.
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Affiliation(s)
- Franco Benazzi
- Hecker Psychiatry Research Center, and Department of Psychiatry, National Health Service, Forli, Italy.
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Benazzi F. Mixed depression and the dimensional view of mood disorders. Psychopathology 2007; 40:431-9. [PMID: 17709973 DOI: 10.1159/000107427] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Accepted: 11/14/2006] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Franco Benazzi
- Hecker Psychiatry Research Center and Department of Psychiatry, National Health Service, Forli, Italy.
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Abstract
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.
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Abstract
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.
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Akiskal HS, Benazzi F. The DSM-IV and ICD-10 categories of recurrent [major] depressive and bipolar II disorders: evidence that they lie on a dimensional spectrum. J Affect Disord 2006; 92:45-54. [PMID: 16488021 DOI: 10.1016/j.jad.2005.12.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Hagop S Akiskal
- International Mood Center, University of California at San Diego, VA Psychiatry Service, 116A, 3350 La Jolla Village Drive, 92161, USA.
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Abstract
OBJECTIVE Unlike dysphoric mania, we are unaware of any formal studies of dysphoric hypomania (DH). For this reason, DH is not formally recognized by DSM-IV and ICD-10. Analogous to the DSM-IV approach in the diagnosis of manic mixed state, in this exploratory study we operationalized DH as coexisting full syndromal hypomanic and major depressive states. METHODS In an Italian outpatient private practice setting, 320 BP-II outpatients [meeting DSM-IV criteria except for shorter (> or =2 days) floor duration for history of hypomanic episodes] were further interviewed with the modified SCID-CV for the simultaneous presence of hypomanic and depressive signs and symptoms during the index presenting affective episode or its exacerbation. Hypomania always included irritable mood plus at least four hypomanic signs and symptoms. Such non-euphoric hypomania had to last at least 1 week. RESULTS Only 45 (14.0%) met our proposed criteria for DH. Less stringently defined depressive mixed states (DMX) were excluded from further analyses. When compared with 120 of the 320 (37.5%) 'pure' BP-II (i.e., not meeting mixed state criteria), DH emerged as an irritable affective state, demonstrated a significantly higher rate of females, mood lability, racing/crowded thoughts, distractibility, increased talkativeness, psychomotor agitation, and increased goal-directed drives. Psychomotor agitation/activation had a specificity of 87% and sensitivity of 94%, correctly classifying 92% of cases of DH. CONCLUSIONS The DSM-IV concept of dysphoric manic mixed state can be extended to DH. In the latter, eutrophic exuberance is replaced by irritable-labile mood, and the hypomanic expansiveness finds expression in mental, psychomotor and behavioral activation that could involve increased drives (e.g., travel, substances, and sex) and social disinhibition. It is useful to contrast the foregoing picture of DH as hypomanic exuberance muted by leaden paralysis, with that of our previous work on DMX as a major depressive mixed state with more subtle excitatory hypomanic intrusions. We discuss methodologic, theoretical and practical implications of categorical (DH) and dimensional (DMX) conceptualizations of mixed states beyond mania.
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Affiliation(s)
- Hagop S Akiskal
- International Mood Center, University of California at San Diego, La Jolla, 92161, USA.
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Sato T, Bottlender R, Kleindienst N, Möller HJ. Irritable psychomotor elation in depressed inpatients: a factor validation of mixed depression. J Affect Disord 2005; 84:187-96. [PMID: 15708416 DOI: 10.1016/s0165-0327(02)00172-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2002] [Accepted: 05/06/2002] [Indexed: 10/25/2022]
Abstract
BACKGROUND Early authors described hypomanic symptoms as mixed features in depressive episode, but this syndrome has not been sufficiently explored in previous studies. METHODS 958 consecutive depressed patients were assessed by using a standardized method in terms of 43 psychiatric symptoms at hospitalization. RESULTS A principal component analysis, followed by varimax rotation, extracted six interpretable factors: typical vegetative symptoms, depressive retardation/loss of feeling, hypomanic syndrome, anxiety, psychosis, and depressive mood/hopelessness. The extracted factor structure was relatively stable among several patient groups. There was no evidence that the hypomanic factor was exaggerated by antidepressant pretreatments before hospitalization. Bipolar diagnoses were associated with higher scores on depressive retardation and hypomanic symptoms, and a lower score on anxiety. LIMITATIONS Psychiatric syndromes and their interrelationships, found in the present study, may be strongly influenced by the rating instrument used. The sample of this study was depressed inpatients. The results should not be generalized for depressed outpatients or epidemiological depressed populations. CONCLUSIONS Hypomanic symptoms, as characterized by the flight of ideas, racing thought, increased drive, excessive social contact, irritability, and aggression are a salient syndrome in acutely ill depressed patients, lending support to the factor validity of mixed depression. The symptoms may not be related to pretreatments with antidepressants, or comorbidity of substance abuse, suggesting that they reflect various natural phenomenological manifestations of depressive episodes. Anxiety is unlikely to play a major role in the core phenomenological features of mixed depression. Hypomanic symptoms during a depressive episode were more represented in bipolar disorders, which may serve for further clarifications of latent bipolarity in unipolar depression, and prediction of switch into maniform states under biological depression treatments.
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Affiliation(s)
- T Sato
- Psychiatrische Klinik, Ludwig-Maximilians-Universität München, Nussbaumstrasse 7 80336 Munich, Germany.
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Koukopoulos A, Albert MJ, Sani G, Koukopoulos AE, Girardi P. Mixed depressive states: nosologic and therapeutic issues. Int Rev Psychiatry 2005; 17:21-37. [PMID: 16194768 DOI: 10.1080/09540260500064744] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This paper focuses on the clinical importance of affective mixed states with special attention given to agitated depression, which has lost its status as a mixed state in the DSM and ICD systems. Following a historical review of the topic, the psychopathological elements are examined. Psychic and motor agitation are considered equally important for the definition of agitated depression and the concept of latent agitated depression is introduced for those major depressive episodes that become agitated following antidepressant treatment. The thesis is advanced that the erroneous nosologic position of agitated depression and its treatment as simple, unipolar depression is at least partly responsible for the problematic issues of the unfavourable treatment outcome and high suicide rates among depressive patients.
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Affiliation(s)
- Athanasios Koukopoulos
- Centro Lucio Bini, Centre for the Treatment and Research of Affective Disorders, Rome, Italy.
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Akiskal HS, Benazzi F. Validating Kraepelin's two types of depressive mixed states: "depression with flight of ideas" and "excited depression". World J Biol Psychiatry 2004; 5:107-13. [PMID: 15179670 DOI: 10.1080/15622970410029919] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Despite a venerable classic tradition going back to at least Kraepelin, depressive mixed states (DMX) are not represented in official diagnostic manuals in psychiatry. We have operationalised this condition as a major depressive episode (MDE) with three or more intra-episode hypomanic signs and symptoms (DMX3). Of 320 consecutive bipolar II outpatients, presenting for MDE treatment and interviewed using the Structured Clinical Interview for DSM-IV, modified to permit the systematic evaluation of hypomanic features during the index MDE, 200 met our criteria for DMX3 (62.5%). When compared with the remaining non-DMX bipolar II, they had significantly earlier age at onset, higher percentage of females, atypical features and bipolar family history. Multivariate logistic regression ofintra-MDE hypomanic signs and symptoms found evidence supporting an "excited depression" subtype (defined by the core feature of psychomotor agitation, and further characterised by talkativeness, irritable mood and distractability) and a "depression with flight of ideas" subtype (defined by the core feature of racing/crowded thoughts, and further characterised by risky pleasurable impulses including, among others, those with intense sexual arousal). We thereby documented the existence of two distinct DMX subtypes which testify to the clinical acumen of Kraepelin (and his pupil Weygandt) who in 1899 described these two subforms of depressive mixed states in more severely ill hospitalised patients.
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Affiliation(s)
- Hagop S Akiskal
- International Mood Center, University of Californai at San Diego, and VA Psychiatry Service CA 92161, USA.
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Schwartzmann A, Lafer B. [Diagnosis and treatment of mixed states]. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2004; 26 Suppl 3:7-11. [PMID: 15597132 DOI: 10.1590/s1516-44462004000700003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Mixed States are described in the literature using based on different definitions resulting in different descriptions of the clinical and demographic characteristics, of these episodes, but although they are always asdeemed a severe form of Bipolar disorder with worse prognosis and more prevalent than previously described. The aim of this article is to present a review of these different definitions and their impact on the study of mixed states. Pharmacological treatment is also discussed.
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Bottlender R, Sato T, Kleindienst N, Strauss A, Möller HJ. Mixed depressive features predict maniform switch during treatment of depression in bipolar I disorder. J Affect Disord 2004; 78:149-52. [PMID: 14706725 DOI: 10.1016/s0165-0327(02)00265-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Case observations imply that depressed patients with mixed features are of high risk for maniform switch during acute treatment. METHODS The medical records of 158 bipolar I depressives were examined with respect to mixed depressive features at admission, naturalistic medications, and maniform switch during inpatient treatment. RESULTS Besides pharmacological variables, the number of mixed depressive symptoms (flight of ideas, racing thoughts, logorrhea, aggression, excessive social contact, increased drive, irritability, and distractibility) at admission was associated with a higher risk for, and the acceleration of, maniform switch during inpatient treatment. LIMITATIONS This was a retrospective study in patients receiving naturalistic treatment. The cohort was hospital based and thus not representative of the full range of bipolar affective disorder. CONCLUSIONS In line with recent studies, our results underline the factors inherent in subjects at a higher risk of switch. Investigation of the relationships between several inherent factors and their interactions with pharmacological treatments may be important in resolving the controversy surrounding antidepressant-induced mania. Further validation studies on mixed depression are warranted.
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Affiliation(s)
- Ronald Bottlender
- Department of Psychiatry, Ludwig-Maximilians University, Munich, Germany
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Sato T, Bottlender R, Schröter A, Möller HJ. Frequency of manic symptoms during a depressive episode and unipolar 'depressive mixed state' as bipolar spectrum. Acta Psychiatr Scand 2003; 107:268-74. [PMID: 12662249 DOI: 10.1034/j.1600-0447.2003.00051.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To report the frequency of intra-episode manic symptoms in depressive episodes, and to evaluate unipolar depressive mixed state (DMS) as bipolar spectrum. METHOD A total of 958 (863 unipolar, 25 bipolar II, and 70 bipolar I) depressive in-patients were assessed in terms of manic symptoms at admission, and several clinical variables using standardized methods. RESULTS The frequency of manic symptoms (flight of idea, logorrhea, aggression, excessive social contact, increased drive, irritability, racing thoughts, and distractibility) was significantly higher in bipolar depressives than in unipolar depressives. Unipolar depressives with DMS - defined as having two or more manic symptoms - had more similarities to bipolar depressives than to other unipolar depressives in clinical variables such as onset age, family history of bipolar disorder, and possibly suicidality. CONCLUSION Depressive mixed state is frequent, particular in bipolar depressives. Unipolar depressives with DMS may be better classified into bipolar spectrum.
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Affiliation(s)
- T Sato
- Psychiatrische Klinik, Ludwig-Maximilian University, Munich, Germany.
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20
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Hantouche EG, Allilaire JP, Bourgeois ML, Azorin JM, Sechter D, Chatenêt-Duchêne L, Lancrenon S, Akiskal HS. The feasibility of self-assessment of dysphoric mania in the French national EPIMAN study. J Affect Disord 2001; 67:97-103. [PMID: 11869756 DOI: 10.1016/s0165-0327(01)00442-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND There is presently considerable uncertainty on how to best assess mixed mania. The present contribution explores the feasibility of discriminating manic and dysphoric manic states on the basis of self-rating in the acute phase of the illness. METHODS In the French four-site national EPIMAN study of 104 patients devoted to the clinical evaluation and subclassification of mania, we used the Multiple Visual Analog Scales of Bipolarity (MVAS-BP, 26 items) of Ahearn-Carroll in a self-assessment format. The study was conducted on consecutive patients hospitalized for an acute DSM-IV mania. The severity of mania was measured by the Beigel-Murphy scale (MSRS) assessed by psychiatrists. When mania abated, temperaments according to Akiskal and Mallya were administered in their French version. RESULTS Principal component analysis revealed a general factor explaining 33% of the variance and, after rotation, seven factors defining different dimensions of the phenomenology of mania. The factorial scores, as well as the dimensional scores of the Carrol-Klein model significantly distinguished pure versus dysphoric mania made on clinical grounds. Gender seemed to influence two factors: high 'anxious-depressive' score in females (which is in line with female overrepresentation in mixed mania), vs. high score in males on the 'gregariousness' factor (which represents social disinhibition of the hyperthymic temperament known to be more prevalent in men). LIMITATION Cross-sectional correlational study in need of longitudinal validation. CONCLUSIONS EPIMAN data deriving from a national clinical population showed the feasiblity and face validity of self-assessment in acute mania, in particular its dysphoric subtype. Temperament in women seemed to contribute to the genesis of mixed (dysphoric) mania in accordance with Akiskal's hypothesis of opposition of temperament and polarity of bipolar episodes in mixed states. Self-assessment was capable of capturing accurately the subthreshold depressive symptomatology of mixed mania, which can be missed in hetero-evaluation by hasty clinical interview.
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Affiliation(s)
- E G Hantouche
- Hôpital, Pitié-Salpêtrière, Université de Paris VI, Paris, France
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Abstract
This paper reviews the historical origins of the contemporaneous resurgence of interest in mixed states. This is a classical concept whose origins can be traced back to ancient times. In more modern times, already in the pre-Kraepelinian era we can find descriptions and classifications of "mixed states". For example, in his classification of mental disorders described "mixtures of exaltations and depression", and he distinguished among "mixed mood disorders", "mixed mental disorders", and "mixed volition disorders". Subsequently, (the father of empirical and biological psychiatric research in Germany) described the "mid-forms". Half a century later we encounter the crucial role of Emil Kraepelin and the development and systemization of his views between 1899 and 1913--leading to the characterization of such conditions as "depressive-anxious mania", "excited depression", and "stuporous mania". The remainder of this article focuses on the essential points of the first book on mixed states in the psychiatric literature: On The Mixed States of Manic-Depressive Insanity by. For much of the present 20th century nothing new emerges, followed by a contemporary renaissance of mixed states, particularly in the United States. The paper concludes with proposal of mixed states as temperament intruding into an episode of opposite polarity.
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Affiliation(s)
- A Marneros
- Department of Psychiatry and Psychotherapy, Martin-Luther University Halle-Wittenberg, 06097 Halle, Germany.
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Benazzi F, Akiskal HS. Delineating bipolar II mixed states in the Ravenna-San Diego collaborative study: the relative prevalence and diagnostic significance of hypomanic features during major depressive episodes. J Affect Disord 2001; 67:115-22. [PMID: 11869758 DOI: 10.1016/s0165-0327(01)00444-x] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Depressive mixed state (DMX), defined by hypomanic features during a major depressive episode (MDE) is under-researched. Accordingly, study aims were to find DMX prevalence in unipolar major depressive disorder (MDD) and bipolar II depressive phase, to delineate the most common hypomanic signs and symptoms during DMX, and to assess their sensitivity and specificity for the diagnosis of DMX and bipolar II. METHODS 161 unipolar and bipolar II MDE psychotropic drug- and substance-free consecutive outpatients were interviewed during an MDE with the Structured Clinical Interview for DSM-IV. DMX was defined at two threshold levels as an MDE with two or more (DMX2), and with three or more (DMX3) simultaneous intra-episode hypomanic signs and symptoms. RESULTS DMX2 was present in 73.1% of bipolar II, and in 42.1% of unipolar MDD (P<0.000); DMX3 was present in 46.3% of bipolar II, and in 7.8% of unipolar MDD (P<0.000). The most common hypomanic manifestations during MDE were irritability, distractibility, and racing thoughts. Irritability had the best combination of sensitivity and specificity for the diagnosis of DMX2 and DMX3. Various combinations of irritability, distractibility, and racing thoughts correctly classified the highest number of DMX2 and DMX3, and had the strongest predictive power. DMX2 had high sensitivity and low specificity for bipolar II, whereas DMX3 had low sensitivity (46.3%) and high specificity (92.1%). LIMITATIONS Single interviewer, cross-sectional assessment, and interviewing clinician not blind to patients' unipolar vs. bipolar status. CONCLUSIONS When conservatively defined (>or = 3 intra-episode hypomanic signs and symptoms during MDE), DMX is prevalent in the natural history of bipolar II but uncommon in unipolar MDD. These findings have treatment implications, because of growing concerns that antidepressants may worsen DMX, which in turn may respond better to mood stabilizers. These data also have methodological implications for diagnostic practice: rather than solely depending on the vagaries of the patient's memory for past hypomanic episodes, the search for hypomanic features--ostensibly elation would not be one of those--during an index depressive episode could enhance the detection of bipolar II in otherwise pseudo-unipolar patients. Strict adherence to current clinical diagnostic interview instruments (e.g. the SCID) would make such detection difficult, if not impossible.
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Affiliation(s)
- F Benazzi
- Department of Psychiatry, National Health Service, Forli, Italy.
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Perugi G, Akiskal HS, Micheli C, Toni C, Madaro D. Clinical characterization of depressive mixed state in bipolar-I patients: Pisa-San Diego collaboration. J Affect Disord 2001; 67:105-14. [PMID: 11869757 DOI: 10.1016/s0165-0327(01)00443-8] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although mixed states were classically described as various concomitant admixtures of depression and mania, the official current definitions in both DSM-IV and ICD-10 tend to restrict the concept to manic patients with full syndromal depression. Recent research has actually shown that mania with few depressive symptoms constitutes the most prevalent clinical presentation of mixed or dysphoric mania. Major depressive patients with few concomitant manic symptoms are not officially recognized within the current nosology. In this paper we attempt to delineate the clinical profile of such depressive mixed states in the context of bipolar I disorder. METHODS In the Pisa day center, we studied 195 bipolar I patients who either met Pisa criteria for bipolar mixed state (n=159) or DSM-III-R criteria for major depressive episode (bipolar major depression or B-MD, n=36). Of the 159 patients identified by Pisa criteria as mixed state, 86 also met the criteria of the DSM-III-R for mixed episode (core mixed state or MS group), while 32 met the DSM III-R criteria for major depressive episode (provisionally defined as depressive mixed states, D-MS); the remaining patients (n=41, 25.7%) with predominatly manic picture were not included in the present comparisons. RESULTS The three groups (B-MD, MS and D-MS) had close similarities in clinical and sociodemographic characteristics such as age, sex distribution, marital status, schooling, residence, age at onset, age of first treatment, age of first hospitalization, degree of chronicity of the index episode, stressor within the 6 months before the index episode, lifetime suicide attempts and premorbid temperament. First degree family history for bipolar illness and that for other mental disorders was also similar, except for major depression that was more common among the relatives of D-MS. MS and D-MS were further distinguished from B-MD by the fact that the latter followed a more 'cyclic' course with shorter yet greater number of episodes, and which began with a pure depressive episode; by contrast, MS and D-MS had fewer episodes of longer duration, less interepisodic remission, and tended to begin with a mixed episode. Incongruous psychotic features were more common in the two mixed groups compared to B-MD, and the most common features of the D-MS group were agitation, psychotic depression with irritable mood, pressured speech and/or flight of ideas. LIMITATION It was not feasible to collect information blind to clinical status in patients with severe psychotic mood states. CONCLUSION These data confirm the existence of psychotic agitated depressive mixed states with flight of ideas, distinct from cyclic retarded pure bipolar depressive states. The recognition of these affective states is clinically important to protect patients from the potentially harmful indiscriminate use of antidepressants and to provide them with the benefits of an anticonvulsant, a short-term neuroleptic, or ECT.
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Affiliation(s)
- G Perugi
- Institute of Psychiatry, University of Pisa, Via Roma 67, 56100 Pisa, Italy.
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Abstract
The extensive use of antidepressant drugs in the treatment of all forms of depression makes the question of the real nature of agitated depression a crucial issue because many patients have adverse outcomes, including increased agitation, increased insomnia, increased risk of suicide, and sometimes the onset of psychotic symptoms. Agitated depression is no longer considered a mixed state in the DSM system. After a review of the literature on melancholia agitata as a mixed state and on the introduction of the concept of mixed states, this article has examined the psychopathology of agitated depression. The main symptoms are depressive mood with marked anxiety, restlessness, and often delusions. In other cases, psychic agitation and racing or crowded thoughts prevail alongside anxiety and depressed mood. The mixed nature of these symptoms has been discussed and new diagnostic criteria proposed, including those syndromes without marked restlessness but with evident psychic agitation and racing or crowded thoughts. It is suggested that all the varieties of agitated depression be called mixed depression, with the following diagnostic criteria: A. Major depressive episode B. At least two of the following symptoms: 1. Motor agitation 2. Psychic agitation or intense inner tension 3. Racing or crowded thoughts.
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Perugi G, Akiskal HS, Micheli C, Musetti L, Paiano A, Quilici C, Rossi L, Cassano GB. Clinical subtypes of bipolar mixed states: validating a broader European definition in 143 cases. J Affect Disord 1997; 43:169-80. [PMID: 9186787 DOI: 10.1016/s0165-0327(97)01446-8] [Citation(s) in RCA: 154] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To validate and clinically characterize mixed bipolar states derived from the concepts of Kraepelin and the Vienna School and defined as sustained instability of affective manifestations of opposite polarity--that usually fluctuate independently of one another--in the setting of marked emotional perplexity. METHOD Our criteria for mixed states represent a modified "user-friendly" operationalization of these classical concepts. We compared 143 mixed state patients, so defined, with 118 DSM III-R manic patients, systematically evaluated with the Semistructured Interview for Depression (SID) in our in-patient and day-hospital facilities. RESULTS The two groups were comparable from demographic and familial standpoints (including family history for bipolar disorder). Mixed states were predominant in the past history of index mixed patients who were more likely to have experienced stressors and to have attempted suicide; manic and hypomanic episodes were more common in the past history of the index manic patients who, in addition, had more episodes and hospitalizations. Although rates of chronicity and rapid cycling were not significantly different in the two groups, the modal episodes in the mixed states were 3-6 months, and in mania they were less than 3 months. Two thirds of both groups arose from a dysregulated baseline temperamental dysregulation, which in manics, was largely hyperthymic, and in mixed patients, was both hyperthymic and depressive. Of our 143 mixed states, only 54% met the DSM III-R criteria for mixed states (which conformed to "dysphoric mixed mania"); of the remaining, 17.5% could be described as "mixed agitated psychotic depressive states" with irritable mood and flight of ideas, and 26% as "unproductive-inhibited manic" with fatigue and indecisiveness. The family history and course of these "non-DSM III-R" mixed states were essentially similar to DSM III-R mixed states. LIMITATION Family history could not be obtained blind to clinical status in patients with severe psychotic mood states. CLINICAL RELEVANCE These data favor the classical European approach to mixed states over the grossly under-inclusive current official diagnostic systems. CONCLUSION The phenomenology of mixed states is more than the mere superposition of opposite affective symptoms and, in many instances, it represents an expansive-excited phase intruding into a depressive temperament, and a melancholic episode intruding into a hyperthymic temperament.
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Affiliation(s)
- G Perugi
- Institute of Psychiatry, University of Pisa, Italy
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Vieta E, Gastó C, Otero A, Nieto E, Vallejo J. Differential features between bipolar I and bipolar II disorder. Compr Psychiatry 1997; 38:98-101. [PMID: 9056128 DOI: 10.1016/s0010-440x(97)90088-2] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Although bipolar II disorder is generally viewed as a mild form of classic manic-depressive illness, recent investigations suggest that it could be a valid diagnostic category different from bipolar I in genetic, biological, clinical, and pharmacological aspects. Twenty-two patients fulfilling Research Diagnostic Criteria for the diagnosis of bipolar II disorder and 38 bipolar I patients were evaluated with the Schedule for Affective Disorders and Schizophrenia by two independent interviewers and compared. Bipolar II patients had significantly more previous episodes (P = .001), including both depressive (P = .003) and hypomanic (P = .006) switches, but had been hospitalized (P = .001) and presented psychotic symptoms (P < .001) less frequently. These results suggest that bipolar II disorder is less severe than bipolar I with regard to symptom intensity, but is more severe with respect to episode frequency.
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Affiliation(s)
- E Vieta
- Department of Psychiatry, Hospital Clínic, Barcelona, University of Barcelona, Spain
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Dell'Osso L, Placidi GF, Nassi R, Freer P, Cassano GB, Akiskal HS. The manic-depressive mixed state: familial, temperamental and psychopathologic characteristics in 108 female inpatients. Eur Arch Psychiatry Clin Neurosci 1991; 240:234-9. [PMID: 1828997 DOI: 10.1007/bf02189532] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Data on 108 hospitalized bipolar I women were analyzed to characterize those whose course was marked with at least one mixed episode (i.e. an episode with concomitant manic and depressed features) on the basis of various anamnestic and cross-sectional clinical features in comparison with those without mixed episodes. Our data revealed a later age of appearance of the first mixed episode in the course of bipolar illness with a tendency to recur true to type; greater prevalence of mood incongruent psychotic features; lower frequency of hyperthymic temperament; and familial depressive, rather than bipolar, disorders. These characteristics tend to identify the mixed state as a distinct longitudinal pattern of manic-depressive illness.
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Affiliation(s)
- L Dell'Osso
- Institute of Psychiatry, University of Pisa, Italy
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Neil JF, Himmelhoch JM, Mallinger AG, Mallinger J, Hanin I. Caffeinism complicating hypersomnic depressive episodes. Compr Psychiatry 1978; 19:377-85. [PMID: 679670 DOI: 10.1016/0010-440x(78)90021-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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