Depressive mixed state: dimensional versus categorical definitions

Reviewing the diagnostic validity and utility of mixed depression (depressive mixed states)

Objective

To review the diagnostic validity and utility of mixed depression, i.e. co-occurrence of depression and manic/hypomanic symptoms.

Methods

PubMed search of all English-language papers published between January 1966 and December 2006 using and cross-listing key words: bipolar disorder, mixed states, criteria, utility, validation, gender, temperament, depression-mixed states, mixed depression, depressive mixed state/s, dysphoric hypomania, mixed hypomania, mixed/dysphoric mania, agitated depression, anxiety disorders, neuroimaging, pathophysiology, and genetics. A manual review of paper reference lists was also conducted.

Results

By classic diagnostic validators, the diagnostic validity of categorically-defined mixed depression (i.e. at least 2–3 manic/hypomanic symptoms) is mainly supported by family history (the current strongest diagnostic validator). Its diagnostic utility is supported by treatment response (negative effects of antidepressants). A dimensionally-defined mixed depression is instead supported by a non-bi-modal distribution of its intradepression manic/hypomanic symptoms.

Discussion

Categorically-defined mixed depression may have some diagnostic validity (family history is the current strongest validator). Its diagnostic utility seems supported by treatment response.

Bipolar spectrum disorder: What evidence for pharmacological treatment? A systematic review

BACKGROUND AND OBJECTIVES

Bipolar spectrum disorder (BSD) is an extended concept of bipolar disorder (BD) that includes conditions that do not fulfill the criteria. There is no recommendation today about its treatment. We reviewed relevant literature focusing on pharmacological treatments, looking for high-strength evidence leading to guidelines.

METHODOLOGY

A literature search was conducted using MedLine / PubMed database and Google Scholar up to September 2018. Search words were related to BSD and pharmacological treatment.

RESULTS

The literature search yielded 621 articles. Out of these, 35 articles met our selection criteria. There was limited high quality data. Only one randomized control trial (RCT) and one randomized open label trial were found. Most studies used different definition of BSD.

CONCLUSIONS

There is a considerable lack of data and no evidence supporting efficacy of pharmacological treatment for BSD. There is a need for a consensus on the definition of BSD and more evidence studies to evaluate drug's effectiveness in this condition.

The androgen model of suicide completion

Suicide is a devastating public health issue that imposes severe psychological, social, and economic burdens not only for the individuals but also for their relatives, friends, clinicians, and the general public. Among the different suicidal behaviors, suicide completion is the worst and the most relevant outcome. The knowledge of biological etiopathological mechanisms involved in suicide completion is limited. Hitherto, no objective markers, either alone or in combination, can reliably predict who will complete a suicide. However, such parameters are strongly needed to establish and optimize prediction and prevention. We introduce here a novel ideation-to-completion framework in suicide research and discuss the problems of studies aiming at identifying and validating clinically useful markers. The male gender is a specific risk factor for suicide, which suggests that androgen effects are implicated in the transition from suicidal ideation to suicide completion. We present multiple lines of direct and indirect evidence showing that both an increased prenatal androgen load (with subsequent permanent neuroadaptations) and increased adult androgen activity are involved in suicide completion. We also review data arguing that modifiable maternal behavioral traits during pregnancy contribute to the offspring's prenatal androgen load and increase the risk for suicide completion later in life. We conclude that in utero androgen exposure and adult androgen levels facilitate suicide completion in an synergistic manner. The androgen model of suicide completion provides the basis for the development of novel predictive and preventive strategies in the future.

Guidelines for the recognition and management of mixed depression

A significant minority of people presenting with a major depressive episode (MDE) experience co-occurring subsyndromal hypo/manic symptoms. As this presentation may have important prognostic and treatment implications, the DSM-5 codified a new nosological entity, the "mixed features specifier," referring to individuals meeting threshold criteria for an MDE and subthreshold symptoms of (hypo)mania or to individuals with syndromal mania and subthreshold depressive symptoms. The mixed features specifier adds to a growing list of monikers that have been put forward to describe phenotypes characterized by the admixture of depressive and hypomanic symptoms (e.g., mixed depression, depression with mixed features, or depressive mixed states [DMX]). Current treatment guidelines, regulatory approvals, as well the current evidentiary base provide insufficient decision support to practitioners who provide care to individuals presenting with an MDE with mixed features. In addition, all existing psychotropic agents evaluated in mixed patients have largely been confined to patient populations meeting the DSM-IV definition of "mixed states" wherein the co-occurrence of threshold-level mania and threshold-level MDE was required. Toward the aim of assisting clinicians providing care to adults with MDE and mixed features, we have assembled a panel of experts on mood disorders to develop these guidelines on the recognition and treatment of mixed depression, based on the few studies that have focused specifically on DMX as well as decades of cumulated clinical experience.

Factors related to suicidal behavior in patients with bipolar disorder: the effect of mixed features on suicidality

OBJECTIVES

The aim of the present study was to investigate various risk factors of suicidal behaviors, including the mixed features specifier, in patients with bipolar disorder.

METHODS

We retrospectively reviewed medical charts from 2005 to 2014. A total of 334 patients diagnosed with bipolar disorder using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision were enrolled. Subjects were categorized into two groups according to their history of suicidal behavior and the demographic and clinical characteristics of the groups were compared, including the mixed features specifier. We reevaluated the index episode using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria and classified subjects into an index episode with mixed features group and an index episode without mixed features group. Logistic regression was performed to evaluate significant risk factors associated with suicidal behavior.

RESULTS

Suicidal behavior had an independent relationship to mixed features at the index episode using DSM-5 criteria [odds ratio (OR)=3.39; 95% confidence interval (CI): 1.57-7.34] and number of previous depressive episodes (OR=1.62; 95% CI: 1.34-1.95) in bipolar patients. The mixed feature specifier was the strongest risk factor for suicidal behavior in the present study.

CONCLUSIONS

This study may help clinicians understand potential risk factors and manage bipolar disorders with suicidal behaviors. Clinicians should carefully monitor patients with bipolar disorder who exhibit numerous depressive episodes or mixed features for suicidal behavior.

DEPRESSION MEDIATES THE RELATION OF INSOMNIA SEVERITY WITH SUICIDE RISK IN THREE CLINICAL SAMPLES OF U.S. MILITARY PERSONNEL

BACKGROUND

A growing body of empirical research suggests insomnia severity is directly related to suicide ideation, attempts, and death in nonmilitary samples, even when controlling for depression and other suicide risk factors. Few studies have explored this relationship in U.S. military personnel.

METHODS

The present study entailed secondary data analyses examining the associations of insomnia severity with suicide ideation and attempts in three clinical samples: Air Force psychiatric outpatients (n = 158), recently discharged Army psychiatric inpatients (n = 168), and Army psychiatric outpatients (n = 54). Participants completed the Beck Scale for Suicide Ideation, the Beck Depression Inventory-II or Patient Health Questionnaire-9, the Insomnia Severity Index, and the Posttraumatic Stress Disorder Checklist at baseline; two samples also completed these measures during follow-up.

RESULTS

Sleep disturbance was associated with concurrent (β's > 0.21; P's < 0.059) and prospective (β's > 0.39; P's < 0.001) suicide ideation in all three samples. When adjusting for age, gender, depression, and posttraumatic stress, insomnia severity was no longer directly associated with suicide ideation either concurrently (β's < 0.19; P's > 0.200) or prospectively (β's < 0.26; P's > 0.063), but depression was (β's > 0.22; P's < 0.012). Results of a latent difference score mediation model indicated that depression mediated the relation of insomnia severity with suicide ideation.

CONCLUSIONS

Across three clinical samples of military personnel, depression explained the relationship between insomnia severity and suicide risk.

Gender differences in the association of agitation and suicide attempts among psychiatric inpatients

OBJECTIVE

To determine if the relationship of agitation with suicide ideation and suicide attempts differed between men and women.

METHOD

Self-reported severity of agitation and other suicide risk factors was obtained from 7698 consecutive patients during admission for inpatient psychiatric treatment during a 5-year period.

RESULTS

Agitation was highest among men with a history of suicide attempts. Agitation was significantly associated with frequency of suicide ideation and history of suicide attempt, but the gender-by-suicide interaction was only significant as a predictor of suicide attempt history. For men, agitation was associated with significantly increased risk for suicide attempt, but for women, agitation was not associated with risk for suicide attempt history. Results were unchanged when analyses were repeated among the subgroup of patients with suicide ideation.

CONCLUSIONS

Agitation is associated with history of suicide attempt among male but not female psychiatric inpatients. Agitation differentiates between those men who have only thought about suicide and those who have made suicide attempts.

Koukopoulos׳ diagnostic criteria for mixed depression: a validation study

BACKGROUND

Mixed depression (MxD) is one subtype of depressive experiences within the depressive spectrum. MxD definition is debated among experts. Koukopoulos׳ proposed diagnostic criteria focused primarily on psychic agitation, marked irritability, and intense mood lability as markers of a mixed depressive episode. The present study validates Koukopoulos׳ criteria as diagnostic for MxD.

METHODS

A sample of 435 patients from the International Mood Network (IMN), multi-center, international network of sites, and the Centro LucioBini of Rome was analyzed. Koukopoulos׳ criteria were assessed in all patients.

RESULTS

The most prevalent MxD criteria were "absence of psychomotor retardation" (84%), "mood lability or marked reactivity" (78%), and "psychic agitation or inner tension" (75%). Multivariable predictors of a MxD (+) diagnosis were: higher current CGI (OR=1.23, 95% CI 1.23, 2.84), lower rates of previous bipolar type I diagnosis (OR=0.54, 95% CI -3.28, -0.13), mixed symptoms on the index episode (OR=10.02, 95% CI 2.32, 24.12), rapid cycling course (OR=2.6 95% CI 1.45, 3.56), past substance abuse (OR=3.02, 95% CI 2.01, 5.67) and lower education status (OR=0.44, 95% CI -3.23, -0.98). This model showed a sensitivity of 76.4%, specificity of 86.3%, negative predictive value of 75%, and positive predictive value of 86%.

LIMITATIONS

An external validation of these criteria in an independent sample is warranted.

CONCLUSION

A broad definition of mixed depression was internally validated with multiple diagnostic validators and was sensitively and specifically predicted. Contrary to DSM-5, Koukopoulos׳ broad criteria include agitation, irritability and mood lability as core features.

Suicidal behavior in bipolar disorder: epidemiology, characteristics and major risk factors

BACKGROUND

Suicide is one of the leading causes of death and a major public health problem worldwide, and the majority of suicide attempters and completers suffer from some major affective disorder at the time of their death, which, in the majority of cases is unrecognized, under- or misdiagnosed and untreated.

METHODS

Based on a systematic literature search, the authors give a detailed and critical overview of established risk factors of suicide in bipolar disorder.

RESULTS

Among affective disorders, bipolar disorder carries the highest risk of suicide, yet not all bipolar patients commit or even attempt suicide during their illness. While the general suicide risk factors also apply for bipolar disorders, there are several disease-specific risk factors as well which should be taken into account when evaluating suicide risk in case of patients.

CONCLUSION

It is crucial to identify suicide risk factors in bipolar disorder to be able to differentiate those patients within this already increased-risk illness group who are at especially high risk and therefore to allow for better prediction and prevention of suicidal acts.

The argument of antidepressant drugs in the treatment of bipolar depression: mixed evidence or mixed states?

INTRODUCTION

The role of antidepressant drugs in acute and maintenance treatment of bipolar depression is a matter of debate that cannot be decided from the evidence available in the current literature.

AREAS COVERED

This review includes two sections: in the first, important contributions from the current literature, emphasizing randomized controlled trials (RCTs) and meta-analysis, highlight current controversies and methodological issues; in the second, the impact of mixed depressive features in bipolar depression is evaluated from a psychopathological perspective.

EXPERT OPINION

Methodological issues may complicate evaluation of the evidence from RCTs regarding antidepressants and mixed states. Moreover, nosological constructs may also contribute to the inconclusive findings, by introducing heterogeneity in patient selection and diagnosis. Acknowledging the impact of mixed features in the course of bipolar depression, essentially by the careful reading of classical Kraepelinian contributions, could enhance clinical management. This would in turn allow a more judicious use of antidepressants, ideally helping to shed some light on the much controversial 'antidepressant-related suicidality', and help to further clarify the reasons for the current literature discordance on this topic.

Bipolar disorder: "pure" versus mixed depression over a 1-year follow-up

OBJECTIVES

To compare two samples of Bipolar (BD) patients presenting "pure" (D) and mixed (Mx) depression to assess any difference in terms of clinical outcome, social functioning and quality of life during a 1-year follow-up.

METHODS

A total of 114 depressed outpatients (HDRS > 13) were included. "Pure" depressed (D, n = 76) were divided from "mixed" depressed (Mx, n = 38) by the number of concomitant manic symptoms. All patients were evaluated by the Hamilton Depression Rating Scale (HDRS), the Hamilton Anxiety Rating Scale (HARS), the Young Mania Rating Scale (YMRS), the Global Assessment of Functioning (GAF), the Social Adjustment Self-reported Scale (SASS) and the Quality of Life Scale (QoL), at baseline and after 1, 3, 6 and 12 months of treatment.

RESULTS

Mx patients were significantly younger at the onset of BD. Manic features persisted significantly higher in Mx than in D patients all over the follow-up period. Axis I comorbidities had a negative impact on the course of social functioning over the medium term period, while Mx patients showed a faster improvement in social adjustment than "pure" depressed patients.

CONCLUSIONS

Mixed features may persist relatively stable throughout a depressive episode, having a negative impact over clinical and functional outcome, but not on social adjustment.

Depression across mood disorders: review and analysis in a clinical sample

OBJECTIVES

In this article we aimed to: (1) review literature concerning the clinical and psychopathologic characteristics of Bipolar (BP) depression; (2) analyze an independent sample of depressed patients to identify any demographic and/or clinical feature that may help in differentiating mood disorder subtypes, with special attention to potential markers of bipolarity.

METHODS

A sample of 291 depressed subjects, including BP -I (n = 104), BP -II (n = 64), and unipolar (UP) subjects with (n = 53) and without (n = 70) BP family history (BPFH), was examined to evidence potential differences in clinical presentation and to validate literature-derived markers of bipolarity. Demographic and clinical variables and, also, single items from the Hamilton Depression Rating Scale (HDRS), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Young Mania Rating Scale (YMRS) were compared among groups.

RESULTS

UP subjects had an older age at onset of mood symptoms. A higher number of major depressive episodes and a higher incidence of lifetime psychotic features were found in BP subjects. Items expressing depressed mood, depressive anhedonia, pessimistic thoughts, and neurovegetative symptoms of depression scored higher in UP, whereas depersonalization and paranoid symptoms' scores were higher in BP. When compared with UP, BP I had a significantly higher incidence of intradepressive hypomanic symptoms. Bipolar family history was found to be the strongest predictor of bipolarity in depression.

CONCLUSIONS

Overall, our findings confirm most of the classical signs of bipolarity in depression and support the view that some features, such as BPFH, together with some specific symptoms may help in detecting depressed subjects at higher risk for BP disorder.

Phenomenology of psychotic mood disorders: lifetime and major depressive episode features

BACKGROUND

The nosological and clinical implications of psychotic features in the course of mood disorders have been widely debated. Currently, no specification exists for defining a subgroup of lifetime Psychotic Mood Disorder (PMD) patients.

METHODS

A total of 2178 patients were examined, including subjects with Bipolar Disorder (BP) type I (n=519) and II (n=207) and Major Depressive Disorder (n=1452). Patients were divided between PMD (n=645) and non-psychotic Mood Disorders (MD) (n=1533) by the lifetime presence of at least one mood episode with psychotic features. Subjects having a depressive episode at the time of assessment were also examined: HAM-D and YMRS scores were compared between MD and PMD subjects, both with and without current psychotic features.

RESULTS

A diagnosis of BP-I, a higher familial load for BP, a higher number of mood episodes lifetime, and a higher prevalence of OCD and somatic comorbidities were all associated to PMD. A diagnosis of BP (OR=4.48) was the only significant predictor for psychosis. PMD with non-psychotic depression were apparently less severe than MD patients and had a lower rate of "non-responders" to AD treatment. Sub-threshold manic symptoms and suicidal risk were also more pronounced among PMD.

LIMITATIONS

The lack of information about number and polarity of previous psychotic mood episodes may be the major limitations of our study.

CONCLUSIONS

BP diagnosis is the most significant predictor for psychosis in mood disorders. Non-psychotic mood episodes in PMD patients may be characterized by a distinctive symptom profile and, possibly, a different response to treatment.

Late-life bipolar depression due to the soft form of bipolar disorder compared to unipolar depression: an inpatient chart review study

BACKGROUND

Several studies have been conducted regarding the clinical features of the manic state in elderly patients with bipolar disorder; however, little information is available about bipolar depression in these patients, especially depression related to bipolar II disorder (BP-II) and bipolar disorder not otherwise specified (BP-NOS).

METHODS

A chart review study of 87 patients (age > or = 60 years) hospitalized due to a major depressive episode (MDE) was conducted.

RESULTS

Thirty-two (36.8%) and 55 (63.2%) patients were diagnosed with bipolar disorder and major depressive disorder (MDD), respectively. BP-II/BP-NOS accounted for 81.3% of bipolar disorder and 29.9% of MDE. Of the 26 BP-II/BP-NOS patients, 73% had been initially diagnosed with MDD (61.0%) or others (12.0%). Compared to MDD patients, BP-II/BP-NOS patients showed a significantly younger age-at-onset of the first MDE (median, 52 vs. 66 years, p=0.000) and significantly more frequent MDEs (median, 3 vs. 1, p=0.000). The depressed mixed state (DMX) was observed in 61.5% of BP-II/BP-NOS patients in contrast to only 16.4% of MDD patients (p=0.000). The multiple logistic regression analysis revealed that younger age at onset of first MDE and DMX were independent markers of bipolarity.

LIMITATIONS

Certain features were retrospectively specified by a single reviewer.

CONCLUSION

Late-life depression due to BP-II/BP-NOS is generally misdiagnosed, but should never be neglected in elderly inpatients. Some features of the depression suggest bipolarity. In particular, DMX was found to be an independent marker of bipolarity, which supports the mixed nature of this disorder across generations.

Continuum of depressive and manic mixed states in patients with bipolar disorder: quantitative measurement and clinical features

Bipolar mixed states combine depressive and manic features, presenting diagnostic and treatment challenges and reflecting a severe form of the illness. DSM-IV criteria for a mixed state require combined depressive and manic syndromes, but a range of mixed states has been described clinically. A unified definition of mixed states would be valuable in understanding their diagnosis, mechanism and treatment implications. We investigated the manner in which depressive and manic features combine to produce a continuum of mixed states. In 88 subjects with bipolar disorder (DSM-IV), we evaluated symptoms and clinical characteristics, and compared depression-based, mania-based, and other published definitions of mixed states. We developed an index of the extent to which symptoms were mixed (Mixed State Index, MSI) and characterized its relationship to clinical state. Predominately manic and depressive mixed states using criteria from recent literature, as well as Kraepelinian mixed states, had similar symptoms and MSI scores. Anxiety correlated significantly with depression scores in manic subjects and with mania scores in depressed subjects. Discriminant function analysis associated mixed states with symptoms of hyperactivity and negative cognitions, but not subjective depressive or elevated mood. High MSI scores were associated with severe course of illness. For depressive or manic episodes, characteristics of mixed states emerged with two symptoms of the opposite polarity. This was a cross-sectional study. Mixed states appear to be a continuum. An index of the degree to which depressive and manic symptoms combine appears useful in identifying and characterizing mixed states. We propose a depressive or manic episode with three or more symptoms of the opposite polarity as a parsimonious definition of a mixed state.

Impact of depressive mixed state in an emergency psychiatry setting: a marker of bipolar disorder and a possible risk factor for emergency hospitalization

BACKGROUND

Depressive mixed state (DMX) has been reported to be one of the most useful clinical markers for bipolar II disorder (BP-II) in the outpatient setting. However, the significance of DMX in emergency psychiatry has not been well studied.

METHODS

A chart review study of 139 patients who were hospitalized in an emergency psychiatric ward with an initial diagnosis of major depressive disorder (MDD).

RESULTS

In 42 (30.2%) patients, the diagnosis was changed to bipolar disorder after a median observation period of 189 days from hospitalization, and of these, 34 were diagnosed as having BP-II. DMX was observed in 56 (40.3%) patients at the time of hospitalization. Compared with patients who remained in MDD, significantly more patients who later developed bipolar disorder had experienced DMX (59.5% vs. 32.0%, p = 0.0044). In multivariate analysis, DMX was one of the independent predictors of conversion to bipolar disorder (OR 2.45, p = 0.037), and the independent predictors for DMX were chronic depression and atypical features (OR 2.85, p = 0.010; OR 3.67, p = 0.046, respectively). In addition, DMX was significantly more frequently observed at emergency hospitalization than at non-emergency hospitalization (48.6% vs. 29.1%, p = 0.0065).

LIMITATIONS

A single reviewer evaluated DMX by chart review.

CONCLUSION

DMX is a useful marker of bipolar disorder (mainly BP-II) in the emergency psychiatric setting and is closely related to emergency hospitalization for mood disorders. To confirm these findings, a prospective study that systematically evaluates DMX is needed.

Manic symptoms and impulsivity during bipolar depressive episodes

OBJECTIVES

In contrast to the extensive literature on the frequent occurrence of depressive symptoms in manic patients, there is little information about manic symptoms in bipolar depressions. Impulsivity is a prominent component of the manic syndrome, so manic features during depressive syndromes may be associated with impulsivity and its consequences, including increased risk of substance abuse and suicidal behavior. Therefore, we investigated the prevalence of manic symptoms and their relationships to impulsivity and clinical characteristics in patients with bipolar depressive episodes.

METHODS

In 56 bipolar I or II depressed subjects, we investigated the presence of manic symptoms, using Mania Rating Scale (MRS) scores from the Schedule for Affective Disorders and Schizophrenia (SADS), and examined its association with other psychiatric symptoms (depression, anxiety, and psychosis), age of onset, history of alcohol and/or other substance abuse and of suicidal behavior, and measures of impulsivity.

RESULTS

MRS ranged from 0 to 29 (25th-75th percentile, range 4-13), and correlated significantly with anxiety and psychosis, but not with depression, suggesting the superimposition of a separate psychopathological mechanism. Impulsivity and history of substance abuse, head trauma, or suicide attempt increased with increasing MRS. Receiver-operating curve analysis showed that MRS could divide patients into two groups based on history of alcohol abuse and suicide attempt, with an inflection point corresponding to an MRS score of 6.

DISCUSSION

Even modest manic symptoms during bipolar depressive episodes were associated with greater impulsivity, and with histories of alcohol abuse and suicide attempts. Manic symptoms during depressive episodes suggest the presence of a potentially dangerous combination of depression and impulsivity.

Midbrain binding of [123I]nor-beta-CIT in atypical depression

BACKGROUND

Altered serotonin (SERT) and dopamine transporter (DAT) densities have been recorded in major depression. Atypical depression (ATD) has been suggested to be connected to decreased serotonergic transmission, but no studies have been published on the association between brain serotonin transporter density and ATD.

METHODS

PATIENTS with depression (n=29) were divided into three groups according to DSM-IV criteria: atypically depressed, melancholic patients, and "undifferentiated" patients. Depressive symptoms were evaluated with the 29-item Hamilton Depression Rating Scale (HAM-D-29). Single photon emission computed tomography (SPECT) with [(123)I]nor-beta-CIT was used to evaluate serotonin transporter density (SERT) in the midbrain and dopamine transporter density (DAT) in the striatum of patients and healthy controls (n=18).

RESULTS

All subgroups except those with undifferentiated depression had lower SERT densities compared to controls. No significant differences were found in the densities between the subgroups. Atypical scores of HAM-D-29 were associated with SERT densities in the midbrain (beta=-0.40, t=-2.3, p=0.03), even after adjustment for age, gender and HAM-D-21 scores (beta=-0.39, t=-2.32, p=0.03).

CONCLUSIONS

The association between atypical scores of HAM-D-29 and midbrain SERT densities suggests a relationship between serotonergic dysfunction and ATD.

Major depressive disorder in adolescents: family psychiatric history predicts severe behavioral disinhibition

BACKGROUND

Major Depressive Disorder (MDD) becomes increasingly prevalent during adolescence and is associated with substantial psychiatric comorbidity and psychosocial impairment. The marked behavioral heterogeneity evident among adolescents with MDD suggests the possibility of distinct subtypes. This study was designed to determine whether family psychiatric histories differ between groups of MDD adolescents defined by the presence or absence of severe behavioral disinhibition.

METHODS

Adolescents with MDD (n = 71) completed the Buss-Durkee Hostility Inventory--Adapted, Adolescent Aggressive Incidents Interview (AAII), Measure of Aggression, Violence, and Rage in Children, Diagnostic Interview Schedule for Children, Suicidal Ideation Questionnaire-JR., Suicidal Behavior Inventory, and Reynolds Adolescent Depression Scale. Parents completed the Family Informant Schedule and Criteria, Children's Affective Liability Scale, AAII, and a partial DISC. Behavioral disinhibition (BD) measures were used to assign adolescents to MDD+BD (n = 41) and MDD-BD (n = 30) groups.

RESULTS

The MDD+BD group had a higher prevalence of drug use disorders in biological fathers than the MDD-BD group. The MDD+BD group also had higher proportions of paternal second degree relatives with alcohol use disorders, drug use disorders, and psychiatric hospitalizations, and a higher proportion of maternal second degree relatives with antisocial personality disorder.

LIMITATIONS

Limitations include reliance on single informants for family psychiatric histories and the failure to distinguish between child- and adolescent-onset depression.

CONCLUSIONS

Family psychiatric histories differentiated MDD adolescents grouped by the presence or absence of behavioral disinhibition, suggesting possible etiologic mechanisms. Further research on subtypes or comorbid presentations may assist in the development of targeted treatment strategies.

Bipolar II and the bipolar spectrum

In studies made in the last decade, patients consulting doctors because of depression and anxiety have very often turned out to suffer from bipolar type II and similar conditions with alternating depression and hypomania/mania (the bipolar spectrum disorders - BP). Specifically, about every second patient seeking consultation because of depression has been shown to suffer from BP, mainly bipolar type II. BP is often concealed by other psychiatric conditions, e.g. recurrent depression, psychosis, anxiety, addiction, personality disorder, attention-deficit hyperactivity disorder and eating disorder. BP shows strong heredity. Relatives of patients with BP also have a high frequency of the psychiatric conditions just mentioned. Conversion ("switching") from recurrent unipolar depressions (recurrent UP) to BP is common in very long longitudinal studies (over decades). Mood-stabilizing medicines are recommended to a great extent in the treatment of BP, since anti-depressive medicines are often not effective and involve a substantial risk of inducing mood swings. Particularly in the long-term pharmacological treatment of depression in BP anti-depressive medicines may worsen the condition, e.g. inducing a symptom triad of dysphoria, irritability and insomnia: ACID (antidepressant-associated chronic irritable dysphoria).

Borderline personality-bipolar spectrum relationship

BACKGROUND

The relationship between borderline personality disorder (BPD) and bipolar disorders, especially bipolar-II disorder (BP-II), is unclear. Several reviews on the topic have come to opposite conclusions, i.e., that BPD is a bipolar spectrum disorder or instead that it is unrelated to bipolar disorders. Study aim was to find which items of BPD were related to BP-II, and which instead had no relationship with BP-II.

STUDY SETTING

An outpatient psychiatry private practice, more representative of mood disorders usually seen in clinical practice in Italy. INTERVIEWER: A senior clinical and mood disorder research psychiatrist.

PATIENT POPULATION

A consecutive sample of 138 BP-II and 71 major depressive disorder (MDD) remitted outpatients. ASSESSMENT INSTRUMENTS: The Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version (SCID-CV) was used for diagnosing, the SCID-II Personality Questionnaire was used by patients to self-assess borderline personality traits. Interview methods: Patients were interviewed with the SCID-CV to diagnose BP-II and MDD. The questions of the Personality Questionnaire relative to borderline personality were self-assessed by patients. As clinically significant distress or impairment of functioning was not assessed by the questionnaire, a diagnosis of borderline personality disorder could not be made, but borderline personality traits (BPT) could be assessed (i.e., all DSM-IV BPD items but not the impairment criterion).

RESULTS

BPT items were significantly more common in BP-II versus MDD. The best combination of sensitivity and specificity for predicting BP-II was found by using a cutoff number of BPT items > or =5: specificity was 71.4%, sensitivity was 45.9%. BPT (defined by > or =5 items) was present in 29.5% of MDD and in 46.3% of BP-II (p=0.019). Logistic regression of BP-II versus BPT items number found a significant association. Principal component factor analysis of BPT items found two orthogonal factors: "affective instability" including unstable mood, unstable interpersonal relationships, unstable self-image, chronic emptiness, and anger, and "impulsivity" including impulsivity, suicidal behavior, avoidance of abandonment, and paranoid ideation. "Affective instability" was associated with BP-II (p=0.010), but "impulsivity" was not associated with BP-II (p=0.193). Interitem correlation was low. There was no significant correlation between the two factors.

DISCUSSION

Study findings suggest that DSM-IV BPD may mix two sets of unrelated items: an affective instability dimension related to BP-II, and an impulsivity dimension not related to BP-II, which may explain the opposite conclusions of several reviews. A subtyping of BPD according to these dimensions is supported by the study findings.

Agitated depression in bipolar II disorder

STUDY AIM

To test diagnostic validity or utility of agitated depression (AD) in bipolar II disorder (BP-II).

METHODS

Three hundred and twenty BP-II major depressive episode (MDE) outpatients interviewed with the Structured Clinical Interview for DSM-IV, Hypomania Interview Guide (HIG), and Family History Screen. AD defined as MDE with psychomotor agitation. Mixed depression defined as MDE with > or =4 hypomanic symptoms. AD, non-AD, mixed-AD, non-mixed-AD, and mixed-non-AD were compared versus diagnostic validators.

RESULTS

AD was present in 35.0%, 75.8% of AD were mixed, while only 14.3% of non-AD were mixed (P=0.0000). AD (n=112), versus non-AD (n=208), had significantly higher age, more females, recurrences, bipolar I family history, and much more concurrent hypomanic symptoms. Mixed-AD (n=85), versus non-mixed-AD (n=27), was not significantly different, apart from more hypomanic symptoms (by definition), but there were clinically significant differences.

CONCLUSIONS

Findings may partly support subtyping of AD in BP-II, on the basis of its frequent clustering of hypomanic symptoms, and its different family history. This subtyping may impact on treatment of BP-II depression, as antidepressants alone may increase agitation while mood stabilising agents can treat agitation before using antidepressants.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mixed states: the most common outpatient presentation of bipolar depressed adolescents?

BACKGROUND

The purpose of this study was to determine the rate of bipolar disorder in adolescent outpatients presenting with DSM-IV major depressive episode (MDE) and, among the bipolar group, to find out what proportion were in a mixed state.

METHODS

247 MDE Hispanic adolescents presenting to a community mental health clinic received structured screens for hypomania/mania by history. One hundred met the criteria for bipolar I or II disorder, depressed. Patients meeting the full DSM-IV criteria for both MDE andhypomania/mania simultaneously for at least 1 continuous week during the index episode were classified as being in a mixed state.

RESULTS

One hundred of the 247 adolescents were bipolar (40.5%). Of these bipolars, 58 (58.0%) were boys. The mean age of the bipolar patients was 14.6 (+/-1.5) years. Eighty-two (82.0%) were in a mixed state. Of those in mixed states, 46 (56.1%) were boys, 45 (54.9%)had psychotic features, 40 (48.8%) had family histories of either major depressive disorder or of bipolar disorders, 26 (31.7%) had family histories of bipolar disorder, 55 (67.1%) had suicidal ideation and 42 (51.2%) had a history of a physically self-destructive act such as wrist cutting or overdoses.

DISCUSSION

The mixed state was the most common presentation for bipolar adolescents who were in the midst of an MDE at the time of presentation to a mental health clinic. Such presentation dictates different treatments. Although this clinic caters to Hispanic youth with relatively severe affective illness, we submit that our data can be generalized to other settings in light of the fact that the unavailability of psychiatric beds for such destitute patients is driving them to ambulatory clinics. To the best of our knowledge, this is the first report of such a high prevalence of mixed states in adolescent bipolar patients evaluated in the course of routine clinical practice in an outpatient setting.

Gender, suicidality and bipolar mixed states in adolescents

BACKGROUND

The purpose of this study was to determine the relationship between mixed states and suicidality among adolescent outpatients presenting with a DSM-IV defined major depressive episode (MDE).

METHODS

Two-hundred and forty-seven adolescents meeting the criteria for MDE were screened for the presence of concurrent, intra-MDE hypomania/mania (i.e., mixed states). All patients were asked whether they had current suicidal ideation or had recently attempted any self-destructive physical act associated with the thought of dying (i.e., a suicide attempt). The data were subjected to analysis using univariate logistic regression.

RESULTS

One hundred of the 247 (40.5%) adolescents were bipolar type I or type II. Of these, 82% were in mixed states. Of the patients with suicidal ideation, 62.8% were girls, and of those with histories of a suicide attempt, 69.4% were girls. Girls had more than twice the risk of having suicidal ideation (OR=2.2, p=0.004) and nearly 3 times the risk of having histories of a suicide attempt than boys (OR=2.87, p<0.0001). Being in a mixed state per se did not predict either suicidal ideation or a suicide attempt among all of the 247 patients. However, mixed states apparently independently contributed to the risk of (non-fatal) suicidal behavior among girls only. Of the mixed states, girls had nearly 4 times the risk of having made a suicide attempt compared with those without mixed states (OR=3.9, p=0.003). Age, presence of psychotic features and family history of mood disorder had little or no bearing on suicidality.

LIMITATIONS

Correlational chart review study, no data collection on Axis I and Axis II comorbidity and adverse life-events.

CONCLUSIONS

This report of greater suicidality in adolescent girls in a mixed state parallels the well-known adult literature of high frequency of mixed states in women. The findings are of relevance to the controversy of antidepressants and suicidality in juvenile depressives in that they identify a vulnerable group. In line with earlier suggestions by the senior author [Akiskal, H.S., 1995. Developmental pathways to bipolarity: are juvenile-onset depressions pre-bipolar? J. Am. Acad. Child Adolesc. Psych. 34, 754-763], our data highlight the public health importance of the wider recognition of bipolar mixed states in juvenile patients masquerading as unipolar depression. Finally, it appears to us that it is the failure of our formal nosology on mixed states--rather than the antidepressants per se--which is the root problem in this controversy.

Family history validation of a definition of mixed depression

PURPOSE

The study aim was to test different definitions of mixed depression, defined as a depression with concurrent hypomanic symptoms.

METHODS

Consecutive 245 non-tertiary care outpatients with bipolar II disorder (BP-II) and 189 non-tertiary care outpatients with major depressive disorder (MDD) were interviewed (off psychoactive drugs) using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders-Clinician Version, Hypomania Interview Guide (HIG), and Family History Screen when presenting for major depressive episode (MDE) treatment. Intra-MDE hypomanic symptoms were systematically assessed. Mixed depression was defined as an MDE with concurrent hypomanic symptoms. Receiver operating characteristic (ROC) analysis and multivariate analysis were used to test different definitions of mixed depression (dimensional and categorical ones). Factor analysis was also used. Bipolar family history was the validator.

FINDINGS

Bipolar II disorder, vs MDD, had significantly more intra-MDE hypomanic symptoms (racing/crowded thoughts, irritable mood, psychomotor agitation, more talkativeness, and increased goal-directed and risky activities). Major depressive episode plus 3 or more hypomanic symptoms was present in 68.7% of BP-II and 42.3% of MDD. A "motor activation" factor, including psychomotor agitation and talkativeness, and a "mental activation" factor including racing/crowded thoughts were found. Different definitions (dimensional and categorical ones) of mixed depression were tested vs bipolar family history as validator (ie, MDE plus more than 1, 2, 3, and 4 concurrent hypomanic symptoms, MDE plus psychomotor agitation, MDE plus racing thoughts). Major depressive episode plus more than 1 hypomanic symptom had the highest sensitivity but the lowest specificity. Instead, MDE plus more than 4 hypomanic symptoms had the lowest sensitivity and the highest specificity. The better-balanced combination of sensitivity and specificity was shown by MDE plus more than 2 hypomanic symptoms. The same definition also showed the highest ROC area value. Multivariate regression of bipolar family history vs different mixed depression definitions found that the only strong and significant predictor was MDE plus more than 2 hypomanic symptoms. A dose-response relationship was found between the number of hypomanic symptoms during MDE and the bipolar family history loading.

CONCLUSIONS

Mixed depression (MDE plus 3 or more hypomanic symptoms) was common in BP-II and MDD. A dimensional definition based on 3 or more hypomanic symptoms during depression was the most supported by using bipolar family history as validator. The study of mixed depression may be important for its possible impact on treatment (antidepressants could increase hypomanic symptoms, and mood stabilizers and antipsychotics could control hypomanic symptoms during antidepressant treatment).

Mixed depression: a clinical marker of bipolar-II disorder

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Irritable-hostile depression: further validation as a bipolar depressive mixed state

BACKGROUND

"Hostile depression" has unofficially long been described as a depressive subtype, but since DSM-III, the affect has been made a defining characteristic of borderline personality disorder. The related affect of irritability in DSM-IV-TR subsumes various hostile nuances and is included in the stem question for mood disorders--especially for hypomanic episodes; in children, it is nonetheless a sign of depression. Then, there is the unofficial more general concept of depression with anger attacks, until recently ostensibly a "unipolar" (UP) disorder. A veritable tower of Babel indeed. In the present analyses, our aim was to extend previous research on irritable-hostile depression to more specific parameters of bipolarity and depressive mixed state (DMX).

METHODS

Consecutive 348 bipolar-II (BP-II) and 254 unipolar (UP) major depressive disorder (MDD) outpatients (off psychoactive agents, including substances of abuse), were interviewed with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide, and the Family History Screen. Borderline personality, a confounding variable, rare in the FB setting, was excluded. Irritability was defined according to DSM-IV-TR, which includes various features of hostility and anger. Depressive mixed state (DMX) was defined as a major depressive episode (MDE) plus three or more concurrent intradepressive hypomanic symptoms, whether it occurred in BP-II or MDD.

RESULTS

MDE with irritability was present in 59.7% (208/348) of BP-II and in 37.4% (95/254) of MDD (p=0.0000). In BP-II, MDE with, versus MDE without, irritability had significantly younger index age, higher rates of axis I comorbidity, atypical depressive features, and DMX. Upon logistic regression, we found a significant independent association between BP-II MDE with irritability and DMX. In UP, MDE with, versus without, irritability had significantly younger age and age at onset, higher rates of atypical depression, DMX, and bipolar family history. Logistic regression revealed a significant independent association between MDE with irritability and DMX. Given that we had excluded patients with borderline personality, the high prevalence of irritable-hostile depressives in this outpatient population means that hostility cannot be considered the signature of that personality. Factor analysis revealed independent "psychomotor activation" and "irritability-mental activation" factors. Odds ratios of irritability for DMX were highest in the "UP" MDD group (=12.2); for predicting DMX, irritability had the best psychometric profile of sensitivity of 66.3% and a specificity of 86.1% for this group as well.

LIMITATION

We did not use specific instruments to measure irritable, hostile, and angry affects.

CONCLUSIONS

These analyses show that irritable-hostile depression is distinct from agitated depression. Whether arising from a BP-II or MDD baseline, irritable-hostile depression emerges as a valid entity with strong links to external bipolar validators, such as bipolar family history. Irritable-hostile phenomenology in depression appears to be a strong clinical marker for a DMX. Irritable-hostile depression as a variant of DMX deserves the benefit of what seems to work best in practice, i.e., anticonvulsant mood stabilizers and/or atypical antipsychotics. Formal treatment studies are very much needed.

Agitated depression: a valid depression subtype?

PURPOSE

The diagnostic validity of agitated depression (AD, a major depressive episode (MDE) with psychomotor agitation) is unclear. It is not classified in DSM-IV and ICD-10 classification of mental and behavioural disorder (ICD-10). Some data support its subtyping. This study aims to test the subtyping of AD.

METHODS

Consecutive 245 bipolar-II (BP-II) and 189 major depressive disorder (MDD) non-tertiary-care MDE outpatients were interviewed (off psychoactive drugs) with Structured Clinical Interview for DSM-IV Axis I Disorders--Clinician Version (SCID-CV), Hypomania Interview Guide (HIGH-C), and Family History Screen. Intra-MDE hypomanic symptoms were systematically assessed. AD was defined as an MDE with psychomotor agitation. Mixed AD was defined as an MDE with four or more hypomanic symptoms (including agitation).

FINDINGS

AD was present in 34.7% of patients. AD was mixed in 70.1% of AD patients. AD, vs. non-AD, had significantly (at alpha = 0.05) lower age at onset, more BP-II, females, atypical depressions, bipolar-I (BP-I) and BP-II family history, and was more mixed; racing/crowded thoughts, irritability, more talkativeness, and risky behaviour were significantly more common. Mixed AD, vs. non-AD, had significantly (at alpha = 0.01) lower age at onset, more intra-MDE hypomanic symptoms, BP-II, females, atypical depressions, BP-II family history, and specific hypomanic symptoms (distractibility, racing thoughts, irritable mood, more talkativeness, risky activities). Mixed AD, vs. non-mixed AD, had significantly more intra-MDE hypomanic symptoms (by definition), more recurrences, and more specific hypomanic symptoms (by definition). Non-mixed AD, vs. non-AD, had significantly more intra-MDE hypomanic symptoms and more talkativeness.

CONCLUSIONS

AD was common in non-tertiary-care depression outpatients, supporting its diagnostic utility. AD and many bipolar diagnostic validators were associated, supporting its link with the bipolar spectrum. Mixed AD, but not non-mixed AD, had differences vs. non-AD similar to those of AD, suggesting that psychomotor agitation by itself may not be enough to identify AD as a subtype. Findings seem to support the subtyping of mixed AD. This subtyping may have important treatment impact, as antidepressants alone might increase agitation.

Factor structure of recalled DSM-IV hypomanic symptoms of bipolar II disorder

The DSM-IV-TR definition of hypomania in bipolar II disorder (BP-II) has yet to show its validity. The aim of the current study was to find the factor structure of hypomania by using DSM-IV-TR symptoms, and to assess the DSM-IV-TR definition of hypomania. One hundred ninety-seven consecutive BP-II remitted outpatients were interviewed by the Structured Clinical Interview for DSM-IV (SCID-CV) as modified by Benazzi and Akiskal (2003) and by Benazzi (2003), in a private practice, assessing the symptoms that were more common during past hypomanic episodes. The factor structure of hypomania was studied by principal component factor analysis. Almost all patients reported overactivity (increased goal-directed activity) during hypomania, and less commonly elevated mood. Overactivity plus three or more symptoms identified 89.3% of DSM-IV-TR BP-II. Factor analysis found three factors: factor 1, including racing thoughts ("mental activation"); factor 2, including elevated mood ("high mood"); and factor 3, including overactivity ("behavioral activation"). Elevated mood was correlated only with two of the nine DSM-IV-TR hypomanic symptoms. The three-domains structure of hypomania by Kraepelin (i.e., increased mood, thought, and activity) was found in the DSM-IV-TR definition of hypomania, partly supporting its list of symptoms. However, DSM-IV-TR priority given to mood change for the diagnosis of hypomania was not supported. An upgrading of overactivity to at least a priority level similar to mood change was supported by (1) its high frequency, (2) its utility to diagnose BP-II, and (3) by factor analysis showing that elevated mood (the "prototypical" symptom of hypomania in DSM-IV-TR) correlated with few symptoms, and that three factors (of which only one included elevated mood) were present.

Depressive mixed state: a feature of the natural course of bipolar II (and major depressive) disorder?

BACKGROUND

Depressive mixed state (DMX), i.e., a combination of hypomanic and depressive symptoms during the same episode, has recently seen a rebirth of studies after Kraepelin's description. Kraepelin observed, in an inpatient sample, that DMX was related to the number of episodes and to duration of manic-depressive insanity (illness).

STUDY AIM

The aim was to test Kraepelin's observations in a very different sample.

METHODS

563 consecutive outpatients with major depressive episode (MDE)--320 with bipolar II disorder and 243 with major depressive disorder--were interviewed, in a private practice, by the Structured Clinical Interview for DSM-IV as modified by Benazzi and Akiskal (2003). Hypomanic symptoms during MDE were systematically assessed in patients while off psychoactive drugs. DMX was dimensionally defined, following Akiskal and Benazzi (2003), as an MDE plus 3 or more combined hypomanic symptoms. Kraepelin's examples of DMX, i.e., agitated depression (MDE plus psychomotor agitation) and depression with flight of ideas (MDE plus racing thoughts) were also tested. Univariate and multivariate logistic regression was used to study associations.

RESULTS

DMX was present in 49.5% of the patients. Multiple logistic regression of DMX versus MDE recurrences and duration of illness, controlled for age, found a strong and significant association only between DMX and duration of illness. The same association was found between agitated depression and duration of illness (but not in depression with racing thoughts).

LIMITATION

There was only a single interviewer.

DISCUSSION

The findings support Kraepelin's observation of a link between DMX and durations of illness, but not that between DMX and recurrences. Onset of DMX could be more related to the natural course of manic-depressive illness than to a kindling process.

Toward a validation of a new definition of agitated depression as a bipolar mixed state (mixed depression)

PURPOSE

As psychotic agitated depression is now a well-described form of mixed state during the course of bipolar I disorder, we sought to investigate the diagnostic validity of a new definition for agitated (mixed) depression in bipolar II (BP-II) and major depressive disorder (MDD).

MATERIALS AND METHODS

Three hundred and thirty six consecutive outpatients presenting with major depressive episodes (MDE) but without history of mania were evaluated with the Structured Clinical Interview for DSM-IV when presenting for the treatment of MDE. On the basis of history of hypomania they were assigned to BP-II (n = 206) vs. MDD (n = 130). All patients were also examined for hypomania during the current MDE. Mixed depression was operationally defined by the coexistence of a MDE and at least two of the following excitatory signs and symptoms as described by Koukopoulos and Koukopoulos (Koukopoulos A, Koukopoulos A. Agitated depression as a mixed state and the problem of melancholia. In: Akiskal HS, editor. Bipolarity: beyond classic mania. Psychiatr Clin North Am 1999;22:547-64): inner psychic tension (irritability), psychomotor agitation, and racing/crowded thoughts. The validity of mixed depression was investigated by documenting its association with BP-II disorder and with external variables distinguishing it from unipolar MDD (i.e., younger age at onset, greater recurrence, and family history of bipolar disorders). We analyzed the data with multivariate regression (STATA 7).

RESULTS

MDE plus psychic tension (irritability) and agitation accounted for 15.4%, and MDE plus agitation and crowded thoughts for 15.1%. The highest rate of mixed depression (38.6%) was achieved with a definition combining MDE with psychic tension (irritability) and crowded thoughts: 23.0% of these belonged to MDD and 76.9% to BP-II. Moreover, any of these permutations of signs and symptoms defining mixed depression was significantly and strongly associated with external validators for bipolarity. The mixed irritable-agitated syndrome depression with racing-crowded thoughts was further characterized by distractibility (74-82%) and increased talkativeness (25-42%); of expansive behaviors from the criteria B list for hypomania, only risk taking occurred with some frequency (15-17%).

CONCLUSIONS

These findings support the inclusion of outpatient-agitated depressions within the bipolar spectrum. Agitated depression is validated herein as a dysphorically excited form of melancholia, which should tip clinicians to think of such a patient belonging to or arising from a bipolar substrate. Our data support the Kraepelinian position on this matter, but regrettably this is contrary to current ICD-10 and DSM-IV conventions. Cross-sectional symptomatologic hints to bipolarity in this mixed/agitated depressive syndrome are virtually absent in that such patients do not appear to display the typical euphoric/expansive characteristics of hypomania-even though history of such behavior may be elicited by skillful interviewing for BP-II. We submit that the application of this diagnostic entity in outpatient practice would be of considerable clinical value, given the frequency with which these patients are encountered in such practice and the extent to which their misdiagnosis as unipolar MDD could lead to antidepressant monotherapy, thereby aggravating it in the absence of more appropriate treatment with mood stabilizers and/or atypical antipsychotics.

Melancholic outpatient depression in Bipolar-II vs. unipolar

BACKGROUND

DSM-IV melancholic major depressive episode (MDE) in bipolar II disorder (BP-II) is understudied. Study aim was to compare melancholic MDE in BP-II vs. unipolar major depressive disorder (MDD) on diagnostic validators and clinical features.

METHODS

Consecutive 39 BP-II and 34 unipolar MDD outpatients in a private practice were interviewed (off psychopharmacotherapy) with the Structured Clinical Interview for DSM-IV, as modified by Benazzi and Akiskal [J. Affect. Disord. 73 (2003) 1], when presenting for treatment of MDE. DSM-IV criteria of melancholic features specifier were followed. Variables studied were index age, gender, age at onset of the first MDE, number of MDE recurrences, severity (measured by GAF, index MDE psychotic features, index MDE symptoms lasting more than 2 years, Axis I comorbidity), index MDE and melancholic symptoms, bipolar family history. Diagnostic validators were onset, family history, course of illness, and clinical picture.

RESULTS

BP-II melancholic MDE, vs. MDD melancholic MDE, had significantly lower age at onset and more bipolar family history. Psychomotor agitation was significantly more common in BP-II melancholic MDE, but was present only in 43.5%. Psychomotor retardation was more common in MDD melancholic MDE at a trend level, but was present only in 20.5%.

CONCLUSIONS

Psychomotor agitation was more common in BP-II melancholic MDE vs. unipolar MDD, while previous studies on bipolar I (BP-I) had usually found more retardation. The difference could be related to BP-I and BP-II being at least partly distinct disorders. The relatively low frequency of psychomotor change does not seem to support the view that this is the core feature of melancholia. Differences on diagnostic validators (most importantly family history) further support the distinction of melancholic MDE between BP-II and MDD, and support DSM-IV classification.