Depression with DSM-IV atypical features: a marker for bipolar II disorder

The aim of the study was to find the prevalence of atypical features in bipolar II depression versus unipolar depression. Five hundred and fifty seven unipolar and bipolar II depressed outpatients were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale, and the Global Assessment of Functioning Scale. DSM-IV atypical features were significantly more common in bipolar II patients than in unipolar patients (45.4% vs 25.4%, odds ratio 2.4). As the diagnosis of bipolar II disorder is often based on diagnosis of past hypomania, which may not be very reliable, depression with atypical features may point to bipolar II disorder diagnosis. Received: 18 February 1999 / Accepted: 29 October 1999     

The Montgomery Asberg Depression Rating Scale in bipolar II and unipolar out-patients: A 405-patient case study

The aim of the present study was to find if the Montgomery Asberg Depression Rating Scale (MADRS) can identify symptom differences between bipolar II and unipolar depression. Four hundred and five consecutive bipolar II and unipolar depressed out-patients were interviewed with the Comprehensive Assessment of Symptoms and History structured interview, following DSM-IV criteria, the MADRS, and the Global Assessment of Functioning Scale. The Montgomery Asberg Depression Rating Scale items were not significantly different between bipolar II and unipolar patients. Comparisons among atypical and non-atypical bipolar II and unipolar patients showed that only MADRS items of 'reduced sleep' and 'reduced appetite' were significantly different between atypical and non-atypical patients.     

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.     

Gender Differences in Bipolar II and Unipolar Depressed Outpatients: A 557-Case Study

The aim of the present report was to study gender differences in bipolar II and in unipolar depressed outpatients. Consecutive 557 bipolar II and unipolar outpatients presenting for treatment of depression were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale, and the Global Assessment of Functioning Scale. Atypical features were significantly more common in bipolar II and in unipolar females than in males, in bipolar II females than in unipolar females, and in bipolar II males than in unipolar males. Female gender was significantly associated with atypical features, but not with diagnosis. Age at intake/onset, duration of illness, severity, recurrences, psychosis, and chronicity were not significantly different in bipolar II and in unipolar females and males (apart from comorbidity). Age at onset was significantly lower in bipolar II females than in unipolar females. This difference was not related to the higher prevalence of atypical features in bipolar II females.     

Chronic depression subtypes: a 257 case study

The aim of the study was to compare Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) three subtypes of chronic depression (chronic major depressive episode [MDE] occurring in major depressive and bipolar II disorders, dysthymic disorder with MDE, and MDE without full interepisode recovery occurring in major depressive and bipolar II disorders) with each other, and with nonchronic depression, and to find if this subdivision was supported by clinical data. Two hundred and fifty seven consecutive MDE outpatients were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale (MADRS), and the Global Assessment of Functioning (GAF) scale. Clinical variables (age, age at onset, duration of illness, severity, gender, recurrences, atypical and psychotic features, axis I comorbidity, bipolar II, and unipolar diagnoses) were compared among the chronic depression subtypes, and versus nonchronic depression. Chronic MDE had significantly less comorbidity than the other two chronic depression subtypes. All the other variables were not significantly different. Chronic depression subtypes had significantly longer duration of illness, less comorbidity, and more recurrences than nonchronic depression. These findings do not support the DSM-IV subtyping of chronic depression.     

Non-reactive mood in outpatient depression: A 557-case study

INTRODUCTION: The aim of the study was to find the prevalence of non-reactive mood in major depressive episode (MDE) outpatients, and to compare mood non-reactive and mood reactive patients. Five hundred and fifty-seven consecutive unipolar and bipolar METHOD: Five hundred and fifty-seven consecutive unipolar and bipolar II outpatients, presenting for MDE treatment, were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale (MADRS), and the Global Assessment of Functioning (GAF) scale. RESULTS: Non-reactive mood was assessed by MADRS. Non-reactive mood was present in 12.0% of patients. There was no significant age, gender, bipolar II, or unipolar difference between non-reactive and reactive mood patients, while MDE severity was significantly greater in non-reactive mood patients. CONCLUSION: Non-reactive mood is uncommon among bipolar II and unipolar depressed outpatients. It is associated with severe depression, and the proportions of bipolar II and unipolar patients are not different between non-reactive and reactive mood patients. (Int J Psych Clin Pract 2000; 4:119-121)     

Bipolar II Depression with Melancholic Features

Bipolar II depression with melancholic features has been understudied. The aims of the present study were to find the prevalence of melancholic features in bipolar II depression and in unipolar depression, and to compare melancholic with nonmelancholic bipolar II/ unipolar depression in private practice. One hundred and sixty two consecutive unipolar and bipolar II depressed outpatients were interviewed with the DSM-IV Structured Clinical Interview, the Montgomery–Asberg Depression Rating Scale, and the Global Assessment of Functioning Scale. Melancholic features were present in 19.2% of bipolar II patients and in 22.6% of unipolar patients, a nonsignificant difference. Melancholic bipolar II patients versus nonmelancholic bipolar II patients had significantly more psychosis and higher severity. All the other variables (age, age at onset, gender, illness duration, recurrences, atypical features, chronicity, comorbidity) were not significantly different. Melancholic bipolar II patients versus melancholic unipolar patients were not significantly different. Nonmelancholic bipolar II patients versus nonmelancholic unipolar patients had significantly lower age, lower age at onset, more atypical features, and more comorbidity. The prevalence of melancholic features in bipolar II depression in private practice was higher than previously reported in academic centers.     

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.     

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.     

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.     

Depressive mixed states: unipolar and bipolar II

Depressive mixed states (DMS) (major depressive episodes with some hypomanic symptoms) are understudied, and not classified in DSM-IV. The study aim was to find prevalence of DMS among depressed outpatients, to study clinical differences between DMS and non-DMS, and relationships of DMS with unipolar and bipolar II. Ninety eight consecutive DSM-IV bipolar II and unipolar depressed outpatients were interviewed with the Structured Clinical Interview for DSM-IV. DMS was defined as an MDE with at least two concurrent hypomanic symptoms. DMS was present in 62.2% of patients [48.7% of unipolar, 71.9% of bipolar II, (p=0.022)]. DMS had significantly fewer unipolar, more bipolar II patients, lower age at onset, and more atypical features than non-DMS. Bipolar II DMS had significantly more recurrences, more atypical features, and lower age at onset (trend) than unipolar DMS. Bipolar II DMS had (trend) lower age at onset and more atypical features than bipolar II non-DMS. High DMS prevalence has important treatment implications, as antidepressants may worsen DMS, and some antidepressant-resistant depressions may be DMS responding to mood stabilizers. DMS may be distinct from non-DMS, but not from unipolar and bipolar II disorders, and this distinction may be due mainly to high bipolar II prevalence in DMS. Received: 16 February 2000 / Accepted: 31 May 2000     

Bipolar II disorder is common among depressed outpatients

The aim of this study was to find the prevalence of bipolar II disorder among major depressive episode private practice outpatients. Consecutive 578 unipolar and bipolar outpatients were interviewed with Comprehensive Assessment of Symptoms and History structured interview, Montgomery Asberg Depression Rating Scale, and the Global Assessment of Functioning Scale. The prevalence of bipolar II disorder was 43.4%. Bipolar II disorder is common among depressed outpatients.     

Atypical bipolar II depression compared with atypical unipolar depression and nonatypical bipolar II depression

Aim of the study was to find out whether atypical bipolar II depression was distinct from both atypical unipolar depression and nonatypical bipolar II depression. Seventy-nine consecutive atypical bipolar II depressed outpatients were compared with 42 consecutive atypical unipolar depressed outpatients and with 53 consecutive nonatypical bipolar II depressed outpatients. Among the variables studied (age at intake, age at onset, female gender, duration of illness, psychosis, comorbidity, chronicity, recurrences, severity), age at intake and onset were significantly lower in the atypical bipolar II group than in the other groups. The other variables, apart from psychosis, were not significantly different. Findings suggest that atypical bipolar II depression may have an age at onset different from that of atypical unipolar depression and nonatypical bipolar II depression. As different ages at onset may identify distinct subtypes of depression, this finding might suggest that atypical bipolar II depression may be distinct from both atypical unipolar depression and nonatypical bipolar II depression.     

Unipolar depression with bipolar family history: links with the bipolar spectrum

The aim of the present paper was to find if unipolar major depressive disorder (MDD) with bipolar family history could be included in the bipolar spectrum, by comparing it to unipolar MDD without bipolar family history, and to bipolar II disorder, on typical bipolar variables. A sample of 280 consecutive bipolar II outpatients, and a sample of 135 consecutive unipolar MDD outpatients, presenting for major depressive episode (MDE) treatment, were interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (4th edn). Hypomanic symptoms during the MDE were systematically assessed. Clinical variables used to validate the inclusion of unipolar MDD with bipolar family history in the bipolar spectrum were young age of onset, many MDE recurrences, atypical features, and depressive mixed state (DMX; an MDE plus >2 concurrent hypomanic symptoms), following many previous studies reporting that these variables were typical features of bipolar disorders. Means were compared by t-test and frequencies by chi2 test (stata 7). Two-tailed P < 0.05 was chosen. Unipolar MDD with bipolar family history was present in 20% of MDD patients. Comparisons among unipolar MDD with bipolar family history (UP+BPFH), unipolar MDD without bipolar family history (UP-BPFH), and bipolar II (BPII), found that UP+BPFH versus UP-BPFH had a significantly lower age, lower age of onset, fewer recurrences, and more DMX; that UP+BPFH versus BPII had no significant differences (apart from recurrences); and that UP-BPFH versus BPII had significantly different age, age of onset, recurrences, atypical features, and DMX. Findings suggest that UP+BPFH shows many bipolar signs, and that it could therefore be included in the bipolar spectrum. Unipolar MDD with bipolar family history had a clinically significant 20.0% frequency in the unipolar MDD sample, supporting the clinical usefulness of this depression subtype. The subtyping of MDD based on bipolar family history could have treatment implications.     

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.     

Sensitivity and specificity of DSM-IV atypical features for bipolar II disorder diagnosis

The aim of the study was to find the sensitivity and the specificity of DSM-IV atypical features (mood reactivity, weight gain, appetite increase, hypersomnia, leaden paralysis, interpersonal rejection sensitivity) for the diagnosis of bipolar II disorder. Consecutive 557 unipolar (54.9%) and bipolar II (45.0%) major depressive episode (MDE) outpatients were interviewed with the Structured Clinical Interview for DSM-IV and the Global Assessment of Functioning Scale. Bipolar II was diagnosed broadly, with a minimum duration of hypomania of at least some days, instead of the 4 days required by DSM-IV. MDE with atypical features was significantly more common in bipolar II patients. For the diagnosis of bipolar II disorder, MDE with atypical features, sensitivity was 0.45, and specificity was 0. 74. Among individual atypical features, hypersomnia had the best combination of sensitivity (0.35) and specificity (0.81). Combinations of two and three features did not improve sensitivity and specificity. As the diagnosis of past hypomania may not be very reliable from a patient's interview, atypical features may be an important marker of bipolar II disorder.     

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.     

Female vs. male outpatient depression: a 448-case study in private practice

1. Aims of the study were to find the prevalence of female depression, and to study the differences between female and male depression, in private practice. Four hundred forty eight consecutive unipolar and bipolar II depressed outpatients were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale, and the Global Assessment of Functioning scale. 2. Prevalence of female depression was 67.8%. Female to male ratio was 2:1. Among the variables investigated (age at intake, age at onset, duration of illness, severity, chronicity, psychosis, recurrences, atypical features, comorbidity), atypical features and comorbidity were significantly associated with female depression. 3. Private practice outpatient female depression (chronic, psychotic, or recurrent) was not more severe than male depression.     

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     

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

OBJECTIVES: Unipolar and bipolar depression differ neurobiologically and in clinical presentation. Existing depression rating instruments, used in bipolar depression, fail to capture the necessary phenomenological nuances, as they are based on and skewed towards the characteristics of unipolar depression. Both clinically and in research there is a growing need for a new observer-rated scale that is specifically designed to assess bipolar depression. METHODS: An instrument reflecting the characteristics of bipolar depression was drafted by the authors, and administered to 122 participants aged 18-65 (44 males and 78 females) with a diagnosis of DSM-IV bipolar disorder, who were currently experiencing symptoms of depression. The Bipolar Depression Rating Scale (BDRS) was administered together with the Hamilton Depression Rating Scale (HAM-D), Montgomery Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS). RESULTS: The BDRS has strong internal consistency (Cronbach's alpha = 0.917), and robust correlation coefficients with the MADRS (r = 0.906) and HAM-D (r = 0.744), and the mixed subscale correlated with the YMRS (r = 0.757). Exploratory factor analysis showed a three-factor solution gave the best account of the data. These factors corresponded to depression (somatic), depression (psychological) and mixed symptom clusters. CONCLUSIONS: This study provides evidence for the validity of the BDRS for the measurement of depression in bipolar disorder. These results suggest good internal validity, provisional evidence of inter-rater reliability and strong correlations with other depression rating scales.