Bipolar II versus unipolar chronic depression: a 312-case study

Differences between bipolar II depression and unipolar depression have been reported, such as a lower age at onset and more atypical features in bipolar II depression. The aim of the present study was to compare chronic/nonchronic bipolar II depression with chronic/nonchronic unipolar depression to determine whether the reported differences are present when chronicity is taken into account. Three hundred twelve outpatients in a bipolar II/unipolar major depressive episode were assessed with the Structured Clinical Interview for DSM-IV-Clinician Version (SCID-CV), the Montgomery and Asberg Depression Rating Scale (MADRS), and the Global Assessment of Functioning (GAF) Scale. No significant difference was found between chronic bipolar II and chronic unipolar depression (age at intake and onset, gender, duration of illness, recurrences, psychosis, atypical features, axis I comorbidity, and severity). A significantly lower age at onset and more atypical features were observed when comparing chronic/nonchronic bipolar II with nonchronic unipolar depression. These findings suggest that differences reported between bipolar II and unipolar depression are mainly due to nonchronic unipolar depression. Chronic unipolar depression may be a subtype intermediate between bipolar II depression and nonchronic unipolar depression.     

Chronic atypical major depressive episode in private practice: unipolar and bipolar II

OBJECTIVE: The aims of the study were to determine whether chronicity was more common in atypical vs. non-atypical unipolar/bipolar II major depressive episode (MDE), whether atypical unipolar and bipolar II MDE had same chronicity, and to compare chronic with non-chronic atypical MDE. METHOD: A total of 326 unipolar/bipolar II MDE private practice outpatients were interviewed with the DSM-IV Structured Clinical Interview. RESULTS: Chronicity was not significantly different in atypical compared to non-atypical MDE. Unipolar atypical MDE showed more chronicity than bipolar II atypical MDE and unipolar non-atypical MDE. Chronicity was not significantly different in atypical compared to nonatypical bipolar II MDE. Compared to non-atypical MDE, atypical MDE had significantly lower age at onset, more recurrences and more bipolar II patients. Chronic compared to non-chronic atypical MDE had significantly longer duration, more recurrences and more unipolar patients. CONCLUSION: Unipolar atypical MDE is more chronic than unipolar nonatypical MDE. Bipolar II atypical MDE is not more chronic than bipolar II non-atypical MDE.     

The clinical picture of bipolar II outpatient depression in private practice

Uncertainties exist about whether depressive episodes differ phenomenologically in unipolar and bipolar II patients. The aim of the present study was to better define the clinical picture and course of bipolar II depression. Three hundred and ninety-nine consecutive outpatients, presenting for treatment of unipolar and bipolar II depression, were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery-Asberg Depression Rating Scale and the Global Assessment of Functioning Scale. Bipolar II depression had significantly lower age at onset, more recurrences and more patients with DSM-IV atypical features. Gender, duration of illness, psychosis, chronicity, severity, axis I comorbidity, melancholic features, individual atypical symptoms and other symptoms of depression were not significantly different. The presence of DSM-IV atypical features predicted bipolar II diagnosis with 63% probability.     

Early-onset versus late-onset bipolar II chronic depression

Age at onset is an important dimension in the classification of mood disorders. Recent findings on early-onset (EO) versus late-onset (LO) unipolar chronic depressions support this subtyping. The aim of the present study was to determine clinical differences between EO and LO bipolar II chronic depression and to support this subtyping also in bipolar II. Eighty-seven consecutive bipolar II chronic depression outpatients were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale, and the Global Assessment of Functioning scale. EO cut-offs were 21 and 23 years of age. Variables, studied with linear and logistic regression, were age, gender, age at onset, illness duration, recurrences, atypical, melancholic, and psychotic features, axis I comorbidity, and severity. Lower age at onset was significantly associated with lower age, longer illness duration, less psychosis, less severity, more atypical features, and more axis I comorbidity. Results support the subtyping of bipolar II chronic depression in EO and LO on the basis of different clinical features.     

Depressive mixed state: Testing different definitions

The aim of this study was to test different definitions of depressive mixed state (DMX) (major depressive episode (MDE) with some concurrent hypomanic symptoms), to find which one could better define DMX. Unipolar and bipolar II MDE outpatients (n = 168) were interviewed with the DSM-IV Structured Clinical Interview. Depressive mixed state was defined as a MDE with two or more (DMX2), and as a MDE with three or more (DMX3) concurrent hypomanic symptoms. DMX2 was present in 71.8% bipolar II patients, and in 41.5% unipolar (P < 0.01). DMX3 was present in 46.6% of bipolar II, and in 7.6% unipolar patients (P < 0.01). DMX2 and DMX3 had almost the same significant and non-significant associations with study variables (diagnosis, gender, age, age at onset, illness duration, MDE recurrences, axis I comorbidity, MDE severity, depression chronicity, hypomanic, MDE, psychotic, melancholic, and atypical symptoms and features). DMX3 was more strongly associated with bipolar II than DMX2 (odds ratio 10.4 vs 3.5). Findings suggest that DMX3 may be a better definition of DMX due to its stronger association with bipolar II disorder. Findings have important clinical and treatment implications because antidepressants may worsen DMX, and the presence of DMX may induce clinicians to assess systematically and carefully the history of past hypomania.     

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.     

Agitated Depression: Unipolar? Bipolar? or Both?

The classification of agitated depression (major depressive episode (MDE) plus psychomotor agitation) in mood disorders is unclear. DSM-IV is neutral on this point. As antidepressants may increase agitation, a better understanding of agitated depression is important for clinical practice. Study aim was to find if agitated depression was closer to bipolar or to unipolar disorders, by studying its association with variables typically related to bipolar disorders (early onset, many recurrences, more atypical features, more bipolar family history), and by studying its association with bipolar II disorder. Consecutive 151 unipolar and 226 bipolar II psychoactive drug-free MDE outpatients were interviewed with the Structured Clinical Interview for DSM-IV, when presenting for MDE treatment. Agitated MDE patients were compared with nonagitated MDE patients. Statistics were t test for means, two-sample test of proportion, and logistic regression (STATA 7). Agitated MDE was present in 85 patients (22.5%). It had significantly more bipolar II disorder patients (80.0% vs. 54.1%, p = 0.0000), more females, lower age at onset, longer duration of illness, more MDE recurrences, more atypical features, more MDE symptoms, and more family history of bipolar disorders, than nonagitated MDE. To control for the possible confounding effect of bipolar II disorder, logistic regression was used. All the significant differences became nonsignificant. Results might suggest that agitated MDE might be closer to the bipolar spectrum than to unipolar disorder, because it was associated with variables typically distinguishing bipolar from unipolar disorders, and with bipolar II disorder. Further studies on this topic are needed.     

Prevalence of bipolar II disorder in atypical depression

The diagnostic validity of atypical depression is based on its superior response to monoamine oxidase inhibitors compared to tricyclic antidepressants, and on latent class analysis. The studies on atypical depression have often not included bipolar patients. The aim of the present study was to find the prevalence of bipolar II disorder among DSM-IV atypical depression outpatients. Bipolar II and unipolar atypical depressions were also compared to find if they were variants of the same disorder or if instead they were different disorders. One hundred and forty consecutive unipolar and bipolar II outpatients, presenting for treatment of an atypical major depressive episode, were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale (MADRS), and the Global Assessment of Functioning Scale. The prevalence of bipolar II disorder was 64.2%. The age at baseline and onset were significantly lower in bipolar II versus unipolar patients. All the other variables (MADRS items, duration of illness, severity, gender, psychosis, comorbidity, chronicity, recurrences) were not significantly different. The prevalence of bipolar II disorder among atypical depressed outpatients was higher than previously reported. Received: 27 July 1998 / Accepted: 19 January 1999     

Is 4 days the minimum duration of hypomania in bipolar II disorder?

DSM-IV requires that bipolar II disorder has hypomania with a minimum duration of 4 days, a cutoff not based on data. The study aim was to test if hypomania lasting 2 to 3 days could identify a group of bipolar II with typical clinical features of bipolar disorders. Consecutively, 65 unipolar and 103 bipolar II major depressive episode (MDE) outpatients were interviewed with the Structured Clinical Interview for DSM-IV. Almost all had had 2 to 3 days of hypomania, and all had had more than one hypomania. Typical clinical variables distinguishing bipolar from unipolar disorders (age at onset, atypical features, and recurrences) were compared. Bipolar II had significantly lower age at onset, more recurrences, and more atypical features. Findings suggest that hypomania lasting 2 to 3 days may identify a bipolar II group having typical features of bipolar disorders. Received: 27 September 2000 / Accepted: 6 November 2000     

Prevalence and clinical features of atypical depression in depressed outpatients: a 467-case study.

The prevalence of DSM-IV atypical depression and differences between atypical versus non-atypical depression were investigated in 467 unipolar and bipolar depressed outpatients in private practice. Consecutive outpatients presenting for treatment of a major depressive episode were assessed with the Comprehensive Assessment of Symptoms and History following DSM-IV criteria, the Montgomery-Asberg Depression Rating Scale, and the Global Assessment of Functioning Scale. The prevalence of atypical depression was 38.1%. Of the variables investigated (unipolar and bipolar diagnoses, age at onset, gender, psychosis, comorbidity, chronicity, duration of illness, recurrences, and severity), age at onset was significantly lower, and female gender, comorbidity, and bipolar II disorder were significantly more common in atypical than nonatypical depression. Comparisons between bipolar II atypical depression and unipolar atypical depression did not show significant differences, apart from age at onset. Findings suggest that there are important clinical differences between atypical and non-atypical depression in private practice outpatients.     

Bipolar II disorder family history using the family history screen: findings and clinical implications

Psychiatric family history of bipolar II disorder is understudied. The aims of the current study were to find the psychiatric family history of bipolar II patients using a new structured interview, the Family History Screen by Weissman et al (2000), and to find bipolar disorders family history predicting power for the diagnosis of bipolar II. One hundred sixty-four consecutive unipolar major depressive disorder (MDD) and 241 consecutive bipolar II major depressive episode (MDE) outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID). The Family History Screen was used. Sensitivity and specificity of predictors of the diagnosis of bipolar II (bipolar [type I and II] family history, bipolar II family history, atypical depression, depressive mixed state, many MDE recurrences, early onset) were studied. Bipolar II subjects had significantly more bipolar I, more bipolar II (50.7%), more MDE, and more social phobia in first-degree relatives than did unipolar subjects. Bipolar II subjects had many more first-degree relatives with bipolar II than with bipolar I. Among the predictors of the diagnosis of bipolar II, bipolar II family history had the highest specificity (82.8%), while early onset had the highest sensitivity. Discriminant analysis of predictor variables found that bipolar II family history and early onset were highly significant predictors. In conclusion, bipolar II family history was common in bipolar II patients, and it had high specificity for predicting bipolar II. If detected, it could reduce bipolar II misdiagnosis by inducing careful probing for a history of hypomania.     

Is there a link between atypical and early-onset "unipolar" depression and bipolar II disorder?

The aim of the present study was to determine whether there is a link between "unipolar" depression with atypical features and early onset, and bipolar II disorder, using atypical features and early onset as markers of bipolarity. A total of 158 consecutive unipolar and 234 bipolar II major depressive episode (MDE) outpatients were interviewed using the Structured Clinical Interview for DSM-IV (SCID). Patients were divided into those with and without atypical features, and into those with and without early onset. Comparisons were made on variables reported to distinguish bipolar from unipolar: age of onset, recurrences, atypical features, depressive mixed state (MDE plus three or more concurrent hypomanic symptoms [DMX3]), and bipolar II family history. Compared to bipolar II patients, patients with atypical unipolar were not significantly different regarding age of onset, DMX3, recurrences, and bipolar II family history. Compared to non-atypical unipolar patients, atypical unipolar patients had a significantly different age of onset. Nonatypical unipolar patients, versus bipolar II patients, were significantly different regarding age of onset, recurrences, DMX3, and bipolar II family history. Early onset unipolar, versus bipolar II, were not significantly different regarding atypical features, recurrences, DMX3, and bipolar II family history. Later onset unipolar patients, versus bipolar II patients, were significantly different regarding atypical features, recurrences, DMX3, and bipolar II family history. These results support a link of atypical and early-onset "unipolar" depression with bipolar II disorder, and support Pages and Dunner's suggestion to combine bipolar II and recurrent unipolar into a single group.     

Mixed states in bipolar II disorder: should full hypomania always be required?

The aim of the study was to test whether the definition of depressive mixed states (DMX) in bipolar II disorder should require satisfaction of full criteria for hypomania or if only a few hypomanic symptoms should be required. Consecutive outpatients with bipolar II major depressive episode (MDE) (n=260) were assessed with the Structured Clinical Interview for DSM-IV. Presence of hypomanic symptoms during MDE was systematically assessed, and symptoms were graded by rating scale. The following three definitions of DMX were compared: (1) MDE plus full criteria for hypomania, (2) MDE plus three or more hypomanic symptoms (DMX3), and (3) MDE plus one or two hypomanic symptoms (DMX1-2). DMX definitions were compared on variables typically associated with bipolar disorders (young age of onset, many recurrences, atypical features of depression, and bipolar family history). The distributions of hypomanic symptom scores, age, and age of onset were studied by Kernel density estimation curves and by histograms. Bimodality would support distinct disorders, whereas lack of bimodality would support continuity among the different DMX definitions. The frequency of DMX+full hypomania was 12.3%, that of DMX3 was 46.9%, and that of of DMX1-2 was 38.8%. Comparisons among the groups on bipolar validators found that most differences were not significant. Kernel density estimation curves and histograms did not show bimodality, and had near normal distribution shapes. The findings do not support a categorical definition of bipolar II DMX like that of DSM-IV for bipolar I mixed state but are consistent with a dimensional definition of bipolar II DMX. The high frequency of DMX in bipolar II MDE supports the need for controlled studies to test the effects of antidepressants on depressive mixed state (as clinical observations suggest possible negative effects).     

Characteristics of bipolar II patients with interpersonal rejection sensitivity

The study aim was to find the characteristics of bipolar II patients with the DSM-IV atypical feature 'interpersonal rejection sensitivity' (IRS), a personality trait. A total of 145 bipolar II outpatients were interviewed using the Structured Clinical Interview for DSM-IV and depression rating scales. Among the variables studied (age, age at onset, duration of illness, severity, gender, recurrences, psychosis, chronicity and comorbidity), age and age at onset were significantly lower, females more common, and psychotic features less common in bipolar II patients with IRS, suggesting that bipolar II disorder with IRS was not more severe.     

Chronic depression: a case series of 203 outpatients treated at a private practice.

OBJECTIVE: To determine the prevalence of chronic depression among outpatients seen for depression. DESIGN: Case series. SETTING: Private practice. PATIENTS: Two hundred and three outpatients with mood disorders, excluding patients with comorbid substance abuse disorders and severe personality disorders. OUTCOME MEASURES: Prevalence rate and patient variables (diagnosis, age at baseline, age at onset, sex, number of previous episodes of depression, atypical features, psychiatric comorbidity, psychosis, duration of illness and baseline severity). RESULTS: The prevalence of chronic depression was 46.7%, which is higher than previously reported. The number of depressive episodes was higher, the presence of psychotic symptoms was more common and the duration of illness was longer in patients with chronic depression than in those with nonchronic depression. CONCLUSIONS: Chronic depression is more severe than nonchronic depression and is a prevalent illness in outpatients with depression seen in private practice.     

Early- versus late-onset bipolar II disorder

OBJECTIVE: To compare the clinical features and the outcome between patients with early- and late-onset bipolar II disorder. DESIGN: Case series. SETTING: Outpatient private practice. PATIENTS: One hundred and seventy-nine consecutive outpatients with bipolar II disorder presenting for treatment of a major depressive episode. OUTCOME MEASURES: Duration of illness, severity of depression, recurrences, psychosis, chronicity, atypical features and comorbidity. RESULTS: Patients with early-onset (before 20, 25 or 30 years of age) bipolar II disorder had a significantly longer duration of illness and more recurrences compared with patients with late-onset (after 20, 25 or 30 years of age) bipolar II disorder. All other variables were not significantly different between the 2 groups. CONCLUSIONS: Indicators of worse outcome (severity of depression, psychosis, chronicity, comorbidity) were not significantly different between patients with early- and late-onset bipolar II disorder.     

Highly recurrent unipolar may be related to bipolar II

Unipolar and bipolar disorders may be subgroups of a single mood disorder, of which the key feature is not polarity, but the episodic, recurrent course. The aim of this study was to determine whether highly recurrent unipolar was related to bipolar II, by comparing clinical and family history features. Eighty-nine consecutive unipolar and 151 consecutive bipolar II outpatients, presenting for major depressive episode (MDE) treatment, were interviewed using the Structured Clinical Interview for DSM-IV (SCID) and the Family History Screen. Unipolar patients were divided into highly recurrent (>4 MDEs) (HRUP) and low recurrent (相似文献   

Challenging the unipolar–bipolar division: Does mixed depression bridge the gap?

BACKGROUND: Mixed states, i.e., opposite polarity symptoms in the same mood episode, question the categorical splitting of mood disorders in bipolar disorders and unipolar depressive disorders, and may support a continuum between these disorders. Study aim was to find if there were a continuum between hypomania (defining BP-II) and depression (defining MDD), by testing mixed depression as a 'bridge' linking these two disorders. A correlation between intradepressive hypomanic symptoms and depressive symptoms could support such a continuum, but other explanations of a correlation are possible. METHODS: Consecutive 389 BP-II and 261 MDD major depressive episode (MDE) outpatients were interviewed, cross-sectionally, with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide (to assess intradepressive hypomanic symptoms) and the Family History Screen, by a mood disorders specialist psychiatrist in a private practice. Patients presented voluntarily for treatment of depression when interviewed drug-free and had many subsequent follow-ups after treatment start. Mixed depression (depressive mixed state) was defined as the combination of MDE (depression) and three or more DSM-IV intradepressive hypomanic symptoms (elevated mood and increased self-esteem were always absent by definition), a definition validated by Akiskal and Benazzi. RESULTS: BP-II, versus MDD, had significantly lower age at onset, more recurrences, atypical and mixed depressions, bipolar family history, MDE symptoms and intradepressive hypomanic symptoms. Mixed depression was present in 64.5% of BP-II and in 32.1% of MDD (p=0.000). There was a significant correlation between number of MDE symptoms and number of intradepressive hypomanic symptoms. A dose-response relationship between frequency of mixed depression and number of MDE symptoms was also found. CONCLUSIONS: Differences on classic diagnostic validators could support a division between BP-II and MDD. Presence of intradepressive hypomanic symptoms by itself, and correlation between intradepressive hypomanic symptoms and depressive symptoms could instead support a continuum. Other explanations of such a correlation are possible. Depending on the method used, a BP-II-MDD continuum could be supported or not.     

Should mood reactivity be included in the DSM-IV atypical features specifier?

Background The definition of atypical depression is still an unsolved issue. DSM-IV atypical features specifier criteria always require mood reactivity, but why mood reactivity should be included is unclear. The study aim was to test whether mood reactivity should be included in DSM-IV atypical features specifier. Methods Consecutively, 164 unipolar and 241 «soft» bipolar II major depressive episode (MDE) outpatients were interviewed with the Structured Clinical Interview for DSM-IV. The DSM-IV criteria for atypical features specifier were strictly followed. Associations were tested by univariate logistic regression. Results MDE with atypical features was present in 41.4 % of patients. Bipolar II disorder was significantly more common in patients with atypical features. MDE with atypical features was significantly associated with bipolar II, female gender, lower age of onset, more axis I comorbidity, fewer psychotic features, and more depressive mixed states. In the whole sample, mood reactivity was significantly associated with all the atypical symptoms, apart from leaden paralysis, and all the other atypical symptoms were significantly associated with each other. In the bipolar II sub-sample, mood reactivity was associated with many, but not all, atypical symptoms, while in the unipolar sub-sample it was associated with no atypical symptom. Atypical symptoms were significantly more common in mood reactive than in non-mood reactive patients, apart from leaden paralysis. Bipolar II disorder and mood reactivity were strongly associated. Conclusions Results may support the inclusion of mood reactivity in the DSM-IV atypical features specifier for bipolar II disorder, but not for unipolar depression.