Mixed states in bipolar and major depressive disorders: systematic review and quality appraisal of guidelines

Verdolini, Norma; Hidalgo‐Mazzei, Diego; Murru, Andréa; Pacchiarotti, Isabella; Samalin, Ludovic; Young, Allan H.; Vieta, Eduard; Carvalho, André F.

doi:10.1111/acps.12896

Cited by 51 publications

(54 citation statements)

References 199 publications

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“…Our data suggest that individuals with bipolar disorder who experience AD are also more likely to have mixed manic episodes in their lifetime, which is in line with previous research that has identified a subtype of bipolar patients characterized by a clinical course of mixed episodes. 24,28,32 Our finding that agitated activity in bipolar depression is associated with concurrent depressive symptoms that have been shown to be common in mixed manic episodes 23,36 (poor concentration, poor appetite, insomnia, and suicide behavior) in other samples is of relevance here, and should be examined within the same sample. We do not have detailed symptom data for individual mixed manic episodes to be able to examine this in our sample.…”

Section: Discussionmentioning

confidence: 90%

“…23,28,36 Previous literature is not consistent regarding the association that we found between concurrent agitated and slowed activity. 24,28,32 Our finding that agitated activity in bipolar depression is associated with concurrent depressive symptoms that have been shown to be common in mixed manic episodes 23 Moreover, individuals who experience both AD and dysphoric mania during their lifetime could belong to a subtype of bipolar disorder characterized by mixed episodes with a high risk of suicide attempt for which antidepressant medication is not recommended. Similar to our results they found that AD was most strongly associated with somatic symptoms and anxiety, while dysphoric mania was associated with manic thought and hostility.…”

Section: Discussionmentioning

confidence: 92%

“…2,28 In particular, it has been shown that antidepressant therapy in AD increases both psychomotor agitation 16,29 and other concurrent excitatory symptoms, 30 and as a most serious consequence, antidepressants increase the risk of suicide in AD. 9,10,23,29,31,32 A further in-depth investigation of the prevalence and clinical correlates of AD in a large and representative sample of individuals with bipolar disorder would have clinical utility for the recognition of this serious form of depression in bipolar disorder. Therefore, the present study has three main aims: first, to evaluate the prevalence of agitation in the most severe depressive episode in a large, well characterized sample of participants with bipolar disorder; second, to investigate if the presence of AD is associated with other symptoms during the same depressive episode; and, thirdly, to explore whether the presence of AD is associated with lifetime clinical features.…”

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confidence: 99%

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Agitated depression in bipolar disorder

et al. 2019

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Objectives It has been suggested that agitated depression (AD) is a common, severe feature in bipolar disorder. We aimed to estimate the prevalence of AD and investigate whether presence of AD was associated with episodic and lifetime clinical features in a large well‐characterized bipolar disorder sample. Method The prevalence of agitation, based on semi‐structured interview and medical case‐notes, in the most severe depressive episode was estimated in 2925 individuals with DSM‐IV bipolar disorder recruited into the UK Bipolar Disorder Research Network. Predictors of agitation were ascertained using symptoms within the same episode and lifetime clinical features using multivariate models. Results 32.3% (n = 946) experienced agitation during the worst depressive episode. Within the same episode, significant predictors of presence of agitation were: insomnia (OR 2.119, P < 0.001), poor concentration (OR 1.966, P = 0.027), decreased libido (OR 1.960, P < 0.001), suicidal ideation (OR 1.861, P < 0.001), slowed activity (OR 1.504, P = 0.001), and poor appetite (OR 1.297, P = 0.029). Over the lifetime illness course, co‐morbid panic disorder (OR 2.000, P < 0.001), suicide attempt (OR 1.399, P = 0.007), and dysphoric mania (OR 1.354, P = 0.017) were significantly associated with AD. Conclusions Agitation accompanied bipolar depression in at least one‐third of cases in our sample and was associated with concurrent somatic depressive symptoms, which are also common features of mixed manic states. Furthermore, AD in our sample was associated with lifetime experience of mixed mania, in addition to severe lifetime illness course including comorbid panic disorder and suicidal behavior. Our results have implications for the diagnosis and treatment of agitated features in bipolar depression.

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Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 92%

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confidence: 99%

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Agitated depression in bipolar disorder

et al. 2019

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“…Evidence regarding pharmacotherapy for mixed depression is even more scarce. Nonetheless, six international guidelines have mentioned pharmacological strategies for mixed depression [26]. The mainstay (2) · LUR + Li/VPA (1) · OFC (2) -· ASN (4) CINP-BD 2017 -· OLZ + MS (2) · SGA: ARP, ASN, OLZ (3) , ZPD (4) · MS: CBZ (3) , VPA (4) · OFC (4) -RANZCP Mood Disorders CPG · SGA: OLZ, QTP · MS: VPA · SGA (OLZ, QTP) or VPA + AD · OLZ + VPA --…”

Section: Pharmacotherapy For Mixed Depressionmentioning

confidence: 99%

“…· SGA: LUR, ASN, QTP, QTP-XR, ARP, ZPD (1) , OLZ, CAR (2) · MS: LMT, VPA, Li (2) · SGA + MS (Li/LMT/VPA) · Li + VPA · Li/VPA + LMT · OFC · MS: CBZ (3) · CBZ + Li (3) · Li + pramipexole (3) · Li + ECT (3) · MS or SGA + SSRI/ bupropion/ MAOI (3) WFSBP mixed states -· Z PD + TAU · SGA: LUR, OLZ (3) · MS: CBZ (3) · ECT This table is adapted from a 2018 report by Verdolini et al [26] (Acta Psychiatr Scand). (1) -(4), grades of evidence; AD, antidepressants; ARP, aripiprazole; ASP, asenapine; CAR, cariprazine; ECT, electroconvulsive therapy; Li, lithium; LMT, lamotrigine; LUR, lurasidone; MAOI, monoamine oxidase inhibitor; MS, mood stabilizers; OFC, olanzapine + fluoxetine; OLZ, olanzapine; QTP, quetiapine; SGA, second-generation antipsychotics; SSRI, selective serotonin reuptake inhibitor; TAU, treatment as usual; VPA, valproic acid; ZPD, ziprasidone.…”

Section: Mixed Depression Guidelinesmentioning

confidence: 99%

Early recognition and appropriate pharmacotherapy for mixed depression: the key to resolving complex or treatment-refractory clinical cases

Takeshima

2019

CNPT

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Mixed depression refers to the co-existence of a major depressive episode (MDE) and sub-threshold manic/ hypomanic symptoms. Mixed depression is a common clinical entity, occurring in approximately 50% and 30% of MDEs due to bipolar disorder (BD) and major depressive disorder (MDD), respectively. However, it remains underdiagnosed and very often misdiagnosed as simply major depression, adjustment disorder, anxiety disorder, or borderline personality disorder. Mixed depression suggests a diagnosis of BD in patients experiencing an MDE, and is associated with future progression to BD, antidepressant-induced mania/hypomania, and a family history of BD in patients with MDD. Patients with mixed depression exhibit poor prognosis, experiencing more severe episodes of longer duration, less inter-episodic remission, higher recurrence rates, more rapid cycling, a higher rate of co-morbid substance use and anxiety disorders, and a higher risk of suicidality. Antidepressant use can exacerbate symptoms of agitation and irritability and induce newlydeveloped suicidality without improving depressive symptoms. Because treatment strategies differ for mixed and non-mixed states, it is important to screen all patients with depression for co-existing manic/hypomanic symptoms. In this report, the author briefly reviews the clinical presentation, diagnosis, and impact of mixed depression on the course of mood disorders and pharmacological treatment.

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Mood Stabilizers: Course and Duration of Therapy, Withdrawal Syndromes, and Resistance to Therapy

Schoretsanitis

Paulzen

2022

NeuroPsychopharmacotherapy

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Mixed states in bipolar and major depressive disorders: systematic review and quality appraisal of guidelines

Abstract: The unmet needs for the mixed symptoms treatment were associated with diagnostic issues and limitations of previous research, particularly for maintenance treatment.

Cited by 51 publications

References 199 publications

Agitated depression in bipolar disorder

Agitated depression in bipolar disorder

Early recognition and appropriate pharmacotherapy for mixed depression: the key to resolving complex or treatment-refractory clinical cases

Mood Stabilizers: Course and Duration of Therapy, Withdrawal Syndromes, and Resistance to Therapy

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