Characteristics of depressive and bipolar disorder patients with mixed features

Abstract

ObjectiveTo assess differences between subjects with vs. without mixed features in major affective disorders.MethodsIn 3099 out‐patient subjects with DSM‐5 major depressive disorder (MDD, n = 1921) or bipolar disorders (BD, n = 1178), we compared those with (Mx) vs. without (Non‐Mx) mixed features (agitated‐irritable depression or dysphoric [hypo]mania) in an index episode.ResultsPrevalence of Mx averaged 21.9% [CI: 20.5–23.4] overall, ranking: BD‐II > BD‐I > MDD, and in BD depression ≥ [hypo]mania > MDD. Mx subjects were significantly more likely than Non‐Mx cases to (i) have other mixed episodes, (ii) have higher irritable and agitated ratings, (iii) have more substance abuse, (iv) switch into mixed episodes, (v) have more suicide attempts and higher suicidal ratings, (vi) change diagnosis from depression to BD, (vii) have higher hypomania scores when depressed or depression scores when [hypo]manic, (viii) be unmarried or separated with fewer children and siblings, (ix) be diagnosed more with BD than MDD, (x) be unemployed, (xi) have BD, suicide and divorce among first‐degree relatives, (xii) be female, (xiii) be younger at illness‐onset. Both BD and MDD Mx subjects also received antidepressants less, but antipsychotics and mood‐stabilizers more, alone and in combination with antidepressants.ConclusionsMood disorder subjects with agitated‐irritable depression or dysphoric [hypo]mania differed from those without such mixed features, including having a less favorable clinical course and repeated mixed episodes. They may represent a distinct and prevalent, syndromal clinical subtype with prognostic and therapeutic significance.

Agitated depression in bipolar disorder

“…48 A potential limitation of our study is the conceptualization of the term agitated depression. There is not a unanimous definition of AD in the literature to date 1,20 with concurrent manic symptoms in the absence of motor agitation. 34 We did not have data on other specific manic/hypomanic symptoms concurrent with the depressive episode, and thus could not extend our definition.…”

“…It has previously been shown that individuals with bipolar disorder who experience mixed states have a more severe illness course with high risk of suicide. 20,28 Rihmer et al 25 reported a high prevalence of depressive mixed states among suicide attempters, and in particular psychomotor agitation is known to be a significant risk factor for suicide. 26 Consistent with previous research, we found an association between AD and lifetime suicide attempt.…”

“…48 A potential limitation of our study is the conceptualization of the term agitated depression. There is not a unanimous definition of AD in the literature to date 1,20 and the existence of different definitions may affect the estimates of AD prevalence and correlated variables across different studies. We used the OPCRIT definition of AD, 17 which is consistent with both the original Kraepelin definition of AD in which mood and ideation are in the negative polarity and activity in a positive polarity 4 and with RDC criteria for AD.…”

“…Although we found a higher prevalence of AD in BD-II (36.8%) than BD-I (30.3%), lifetime diagnosis was not a significant predictor of the presence of AD after controlling for other clinical and socio-demographic features. Previous research is not consistent about the prevalence of AD in bipolar disorder20 probably due to the various definitions of AD employed across different studies, including the more extended definition of depression with mixed features,34 in addition to heterogeneity between samples. However, Judd et al,16 found a prevalence…”

“…Both forms are often characterized by suicidal impulses and sometimes psychotic features. Many authors define AD as a major depressive episode with psychomotor agitation and/or the presence of excitatory symptoms [9][10][11][12][13][14][15][16][17][18][19] although AD still does not have an unequivocal definition 20 and is defined inconsistently across different studies in both unipolar depression and bipolar disorder.…”