Hostname: page-component-6766d58669-kl59c Total loading time: 0 Render date: 2026-05-17T05:36:33.779Z Has data issue: false hasContentIssue false
  • English
  • Français

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

Published online by Cambridge University Press:  16 April 2020

Franco Benazzi
Franco Benazzi*
Affiliation:
Hecker Psychiatry Research Center, University of California at San Diego, San Diego, CA, USA Collaborating Center, Forli, Italy Department of Psychiatry University of Szeged, Szeged, Hungary Department of Psychiatry, National Health Service, Forli, Italy
*
*Corresponding address: Via Pozzetto 17, 48015 Castiglione di Cervia RA, Italy. Tel.: +39 335 6191 852; fax: +39 054 330 069. E-mail address: francobenazzi@fbenazzi.it
Get access

Abstract

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.

Keywords

Bipolar I disorderBipolar II disorderMajor depressive disorderMixed depressionDepressive mixed statesDepressionAnxietyAgitation

Information

Type
Review
Information
European Psychiatry , Volume 23 , Issue 1 , January 2008 , pp. 40 - 48
Copyright
Copyright © Elsevier Masson SAS 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Abrams, R., Taylor, M.A.A comparison of unipolar and bipolar depressive illness. Am J Psychiatry 1980;137:1084–1087Google ScholarPubMed
Akiskal, H.S., Djenderedjian, A.H., Rosenthal, R.H., Khani, M.K.Cyclothymic disorder: validating criteria for inclusion in the bipolar affective group. Am J Psychiatry 1977;134:1227–1233Google ScholarPubMed
Akiskal, H.S., Mallya, G.Criteria for the “soft” bipolar spectrum: treatment implications. Psychopharmacol Bull 1987;23:68–73Google ScholarPubMed
Akiskal, H.S., Maser, J.D., Zeller, P.J., Endicott, J., Coryell, W., Keller, M.et al.Switching from ‘unipolar’ to bipolar II. An 11-year prospective study of clinical and temperamental predictors in 559 patients. Arch Gen Psychiatry 1995;52:114–123CrossRefGoogle ScholarPubMed
Akiskal, H.S.The prevalent clinical spectrum of bipolar disorders: beyond DSM-IV. J Clin Psychopharmacol 1996;16(2 Suppl. 1):S4–S14CrossRefGoogle ScholarPubMed
Akiskal, H.S., Hantouche, E.G., Bourgeois, M.L., Azorin, J.M., Sechter, D., Allilaire, J.F.et al.Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN). J Affect Disord 1998;50:175–186CrossRefGoogle Scholar
Akiskal, H.S., Azorin, J.M., Hantouche, E.G.Proposed multidimensional structure of mania: beyond the euphoric-dysphoric dichotomy. J Affect Disord 2003;73:7–18CrossRefGoogle ScholarPubMed
Akiskal, H.S., Benazzi, F.Family history validation of the bipolar nature of depressive mixed states. J Affect Disord 2003;73:113–122CrossRefGoogle ScholarPubMed
Akiskal, H.S., Hantouche, E.G., Allilaire, J.F., Sechter, D., Bourgeois, M.L., Azorin, J.M.et al.Validating antidepressant-associated hypomania (bipolar III): a systematic comparison with spontaneous hypomania (bipolar II). J Affect Disord 2003;73:65–74CrossRefGoogle Scholar
Akiskal, H.S., Hantouche, E.G., Allilaire, J.F.Bipolar II with and without cyclothymic temperament: “dark” and “sunny” expressions of soft bipolarity. J Affect Disord 2003;73:49–57CrossRefGoogle ScholarPubMed
Akiskal, H.S.Demystifying borderline personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatr Scand 2004;110:401–407Google ScholarPubMed
Akiskal, H.S., Benazzi, F., Perugi, G., Rihmer, Z.Agitated “unipolar” depression re-conceptualized as a depressive mixed state: implications for the antidepressant-suicide controversy. J Affect Disord 2005;85:245–258CrossRefGoogle ScholarPubMed
Akiskal, H.S., Mendlowicz, M.V., Jean-Louis, G., Rapaport, M.H., Kelsoe, J.R., Gillin, J.C.et al.TEMPS-A. validation of a short version of a self-rated instrument designed to measure variations in temperament. J Affect Disord 2005;85:45–52CrossRefGoogle Scholar
Akiskal, H.S., Akiskal, K.K., Haykal, R.F., Manning, J.S., Connor, P.D.TEMPS-A. progress towards validation of a self-rated clinical version of the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire. J Affect Disord 2005;85:3–16CrossRefGoogle ScholarPubMed
Akiskal, H.S., Benazzi, F.Toward a clinical delineation of dysphoric hypomania – operational and conceptual dilemmas. Bipolar Disord 2005;7:456–464CrossRefGoogle Scholar
Akiskal, H.S., Benazzi, F.The DSM-IV and ICD-10 categories of recurrent [major] depressive and bipolar II disorders: evidence that they lie on a dimensional spectrum. J Affect Disord 2006;92:45–54CrossRefGoogle Scholar
American Psychiatric Association, Diagnostic and statistical manual of mental disorders. 4th ed. 2000 Washington, DC: American Psychiatric Association Text Revision (DSM-IV-TR)Google Scholar
Andreasen, N.C., Grove, W.M.The classification of depression: traditional versus mathematical approaches. Am J Psychiatry 1982;139:45–52Google ScholarPubMed
Angst, J., Gamma, A., Benazzi, F., Ajdacic, V., Eich, D., Rossler, W.Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 2003;73:133–146CrossRefGoogle Scholar
Angst, J., Adolfsson, R., Benazzi, F., Gamma, A., Hantouche, E., Meyer, T.D.et al.The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord 2005;88:217–233CrossRefGoogle ScholarPubMed
Angst, J., Sellaro, R., Stassen, H.H., Gamma, A.Diagnostic conversion from depression to bipolar disorders: results of a long-term prospective study of hospital admissions. J Affect Disord 2005;84:149–157CrossRefGoogle ScholarPubMed
Axelson, D., Birmaher, B., Strober, M., Gill, M.K., Valeri, S., Chiappetta, L.et al.Phenomenology of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry 2006;63:1139–1148CrossRefGoogle ScholarPubMed
Baethge, C., Baldessarini, R.J., Khalsa, H.M., Hennen, J., Salvatore, P., Tohen, M.Substance abuse in first-episode bipolar I disorder: indications for early intervention. Am J Psychiatry 2005;162:1008–1010CrossRefGoogle ScholarPubMed
Balazs, J., Benazzi, F., Rihmer, Z., Rihmer, A., Akiskal, K.K., Akiskal, H.S.The close link between suicide attempts and mixed (bipolar) depression: implications for suicide prevention. J Affect Disord 2006;91:133–138CrossRefGoogle ScholarPubMed
Bauer, M.S., Whybrow, P.C., Winokur, A.Rapid cycling bipolar affective disorder. I. Association with grade I hypothyroidism. Arch Gen Psychiatry 1990;47:427–432CrossRefGoogle ScholarPubMed
Bauer, M.S., Crits-Christoph, P., Ball, W.A., Dewees, E., McAllister, T., Alahi, P.et al.Independent assessment of manic and depressive symptoms by self-rating. Scale characteristics and implications for the study of mania. Arch Gen Psychiatry 1991;48:807–812CrossRefGoogle Scholar
Bauer, M.S., Whybrow, P.C., Gyulai, L., Gonnel, J., Yeh, H.S.Testing definitions of dysphoric mania and hypomania: prevalence, clinical characteristics and inter-episode stability. J Affect Disord 1994;32:201–211CrossRefGoogle ScholarPubMed
Bauer, M.S., Simon, G.E., Ludman, E., Unutzer, J.“Bipolarity” in bipolar disorder: distribution of manic and depressive symptoms in a treated population. Br J Psychiatry 2005;187:87–88CrossRefGoogle Scholar
Beasley, C.M., Sayler, M.E., Weiss, A.M., Potvin, J.H.Fluoxetine: activating and sedating effects at multiple fixed doses. J Clin Psychopharmacol 1992;12:328–333CrossRefGoogle ScholarPubMed
Benazzi, F.Age at onset of bipolar II depressive mixed state. Psychiatry Res 2001;103:229–235CrossRefGoogle ScholarPubMed
Benazzi, F.Which could be a clinically useful definition of depressive mixed state?. Prog Neuropsychopharmacol Biol Psychiatry 2002;26:1105–1111CrossRefGoogle ScholarPubMed
Benazzi, F.Bipolar II depressive mixed state: finding a useful definition. Compr Psychiatry 2003;44:21–22CrossRefGoogle ScholarPubMed
Benazzi, F.The role of gender in depressive mixed state. Psychopathology 2003;36:213–217CrossRefGoogle ScholarPubMed
Benazzi, F.Depressive mixed state: dimensional versus categorical definitions. Prog Neuropsychopharmacol Biol Psychiatry 2003;27:129–134CrossRefGoogle ScholarPubMed
Benazzi, F.Bipolar II disorder and major depressive disorder: continuity or discontinuity?. World J Biol Psychiatry 2003;4:166–171CrossRefGoogle ScholarPubMed
Benazzi, F.Agitated depression: a valid depression subtype?. Prog Neuropsychopharmacol Biol Psychiatry 2004;28:1279–1285CrossRefGoogle ScholarPubMed
Benazzi, F.Factor structure of recalled DSM-IV hypomanic symptoms of bipolar II disorder. Compr Psychiatry 2004;45:441–446CrossRefGoogle ScholarPubMed
Benazzi, F.The problem of the treatment of bipolar-II depression. Bipolar Disord 2004;6:440–441CrossRefGoogle ScholarPubMed
Benazzi, F.Mixed states in bipolar II disorder: should full hypomania always be required?. Psychiatry Res 2004;127:247–257CrossRefGoogle ScholarPubMed
Benazzi, F.Is depressive mixed state a transition between depression and hypomania?. Eur Arch Psychiatry Clin Neurosci 2004;254:69–75CrossRefGoogle Scholar
Benazzi, F.Family history validation of a definition of mixed depression. Compr Psychiatry 2005;46:159–166CrossRefGoogle ScholarPubMed
Benazzi, F.Unipolar depression with racing thoughts: a bipolar spectrum disorder?. Psychiatry Clin Neurosci 2005;59:570–575CrossRefGoogle ScholarPubMed
Benazzi, F.Suicidal ideation and depressive mixed states. Psychother Psychosom 2005;74:61–62CrossRefGoogle ScholarPubMed
Benazzi, F.Bipolar family history of the hypomanic symptoms and dimensions of mixed depression. Compr Psychiatry 2005;46:399–404CrossRefGoogle ScholarPubMed
Benazzi, F.Possible bipolar nature of irritability in major depressive disorder. J Clin Psychiatry 2005;66:1072CrossRefGoogle ScholarPubMed
Benazzi, F.Impact of temperamental mood lability on depressive mixed state. Psychopathology 2005;39:19–24CrossRefGoogle ScholarPubMed
Benazzi, F.Borderline personality-bipolar spectrum relationship. Prog Neuropsychopharmacol Biol Psychiatry 2006;30:68–74CrossRefGoogle ScholarPubMed
Benazzi, F.Challenging the unipolar-bipolar division: does mixed depression bridge the gap?. Prog Neuropsychopharmacol Biol Psychiatry 2007;31:97–103CrossRefGoogle ScholarPubMed
Benazzi, F.Is overactivity the core feature of hypomania in bipolar II disorder?. Psychopathology 2007;40:54–60CrossRefGoogle ScholarPubMed
Benazzi, F.Delineation of the clinical picture of dysphoric/mixed hypomania. Prog Neuropsychopharmacol Biol Psychiatry 2007;31:944–951CrossRefGoogle ScholarPubMed
Benazzi, F., Akiskal, H.S.The dual factor structure of self-rated MDQ hypomania: energized activity versus irritable-thought racing. J Affect Disord 2003;73:59–64CrossRefGoogle ScholarPubMed
Benazzi, F., Akiskal, H.S.Clinical and factor analytic-validation of depressive mixed states: a report from the Ravenna-San Diego collaboration. Curr Opin Psychiatry 2003;16(suppl 2):S71–S78CrossRefGoogle Scholar
Benazzi, F., Akiskal, H.S.A downscaled practical measure of mood lability as a screening tool for bipolar II. J Affect Disord 2005;84:225–232CrossRefGoogle ScholarPubMed
Benazzi, F., Akiskal, H.Irritable-hostile depression: further validation as a bipolar depressive mixed state. J Affect Disord 2005;84:197–207CrossRefGoogle ScholarPubMed
Benazzi, F., Akiskal, H.S.Biphasic course in bipolar II outpatients: prevalence and clinical correlates of a cyclic pattern described by Baillarger and Falret in hospitalised patients in 1854. J Affect Disord 2006;96:183–187CrossRefGoogle ScholarPubMed
Benazzi, F., Koukopoulos, A., Akiskal, H.S.Toward a validation of a new definition of agitated depression as a bipolar mixed state (mixed depression). Eur Psychiatry 2004;19:85–90CrossRefGoogle Scholar
Biondi, M., Picardi, A., Pasquini, M., Gaetano, P., Pancheri, P.Dimensional psychopathology of depression: detection of an ‘activation’ dimension in unipolar depressed outpatients. J Affect Disord 2005;84:133–139CrossRefGoogle ScholarPubMed
Birmaher, B., Axelson, D., Strober, M., Gill, M.K., Valeri, S., Chiappetta, L.et al.Clinical course of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry 2006;63:175–183CrossRefGoogle ScholarPubMed
Bottlender, R., Sato, T., Kleindienst, N., Strausz, A., Moller, H.-J.Mixed depressive features predict maniform switch during treatment of depression in bipolar I disorder. J Affect Disord 2004;78:149–152CrossRefGoogle ScholarPubMed
Brown, E.B., McElroy, S.L., Keck, P.E. Jr., Deldar, A., Adams, D.H., Tohen, M.et al.A 7-week, randomized, double-blind trial of olanzapine/fluoxetine combination versus lamotrigine in the treatment of bipolar I depression. J Clin Psychiatry 2006;67:1025–1033CrossRefGoogle ScholarPubMed
Cassano, G.B., Frank, E., Miniati, M., Rucci, P., Fagiolini, A., Pini, S.et al.Conceptual underpinnings and empirical support for the mood spectrum. Psychiatr Clin North Am 2002;25:699–712CrossRefGoogle ScholarPubMed
Cassano, G.B., Rucci, P., Frank, E., Fagiolini, A., Dell'Osso, L., Shear, M.K.et al.The mood spectrum in unipolar and bipolar disorder: arguments for a unitary approach. Am J Psychiatry 2004;161:1264–1269CrossRefGoogle ScholarPubMed
Cassidy, F., Forest, K., Murry, E., Carroll, B.J.A factor analysis of the signs and symptoms of mania. Arch Gen Psychiatry 1998;55:27–32CrossRefGoogle ScholarPubMed
Cassidy, F., Murry, E., Forest, K., Carroll, B.J.Signs and symptoms of mania in pure and mixed episodes. J Affect Disord 1998;50:187–201CrossRefGoogle ScholarPubMed
Cassidy, F., Ritchie, J.C., Carroll, B.J.Plasma dexamethasone concentration and cortisol response during manic episodes. Biol Psychiatry 1998;43:747–754CrossRefGoogle ScholarPubMed
Cassidy, F., Ahearn, E.P., Carroll, B.J.Substance abuse in bipolar disorder. Bipolar Disord 2001;3:181–188CrossRefGoogle ScholarPubMed
Cassidy, F., Pieper, C.F., Carroll, B.J.Subtypes of mania determined by grade of membership analysis. Neuropsychopharmacology 2001;25:373–383CrossRefGoogle ScholarPubMed
Cassidy, F., Carroll, B.J.Frequencies of signs and symptoms in mixed and pure episodes of mania: implications for the study of manic episodes. Prog Neuropsychopharmacol Biol Psychiatry 2001;25:659–665CrossRefGoogle Scholar
Cassidy, F., Ahearn, E., Carroll, B.J.A prospective study of inter-episode consistency of manic and mixed subtypes of bipolar disorder. J Affect Disord 2001;67:181–185CrossRefGoogle ScholarPubMed
Cassidy, F., Ahearn, E.P., Carroll, B.J.Thyroid function in mixed and pure manic episodes. Bipolar Disord 2002;4:393–397CrossRefGoogle ScholarPubMed
Cassidy, F., Wilson, W.H., Carroll, B.J.Leukocytosis and hypoalbuminemia in mixed bipolar states: evidence for immune activation. Acta Psychiatr Scand 2002;105:60–64CrossRefGoogle ScholarPubMed
Chang, K.D., Keck, P.E. Jr., Stanton, S.P., McElroy, S.L., Strakowski, S.M., Geracioti, T.D. Jr.Differences in thyroid function between bipolar manic and mixed states. Biol Psychiatry 1998;43:730–733CrossRefGoogle ScholarPubMed
Cole, D.P., Soares, J.C., Mallinger, A.G., Kupfer, D.J., Frank, E.Mixed affective states and thyroid function: a controversy revisited. Bipolar Disord 1999;1(Suppl 1):28Google Scholar
Coryell, W., Endicott, J., Maser, J.D., Keller, M.B., Leon, A.C., Akiskal, H.S.Long-term stability of polarity distinctions in the affective disorders. Am J Psychiatry 1995;152:385–390Google ScholarPubMed
Dayer, A., Aubry, J.M., Roth, L., Ducrey, S., Bertschy, G.A theoretical reappraisal of mixed states: dysphoria as a third dimension. Bipolar Disord 2000;2:316–324CrossRefGoogle ScholarPubMed
DeBattista, C., Solomon, A., Arnow, B., Kendrick, E., Tilston, J., Schatzberg, A.F.The efficacy of divalproex sodium in the treatment of agitation associated with major depression. J Clin Psychopharmacol 2005;25:476–479CrossRefGoogle ScholarPubMed
Dell'Osso, L., Placidi, G.F., Nassi, R., Freer, P., Cassano, G.B., Akiskal, H.S.The manic-depressive mixed state: familial, temperamental and psychopathologic characteristics in 108 female inpatients. Eur Arch Psychiatry Clin Neurosci 1991;240:234–239CrossRefGoogle ScholarPubMed
Dikeos, D.G., Wickham, H., McDonald, C., Walshe, M., Sigmundsson, T., Bramon, E.et al.Distribution of symptom dimensions across Kraepelinian divisions. Br J Psychiatry 2006;189:346–353CrossRefGoogle ScholarPubMed
Dilsaver, S.C., Chen, Y.R., Shoaib, A.M., Swann, A.C.Phenomenology of mania: evidence for distinct depressed, dysphoric, and euphoric presentations. Am J Psychiatry 1999;156:426–430Google ScholarPubMed
Dilsaver, S.C., Benazzi, F., Akiskal, H.S.Mixed states: the most common outpatient presentation of bipolar depressed adolescents?. Psychopathology 2005;38:268–272CrossRefGoogle ScholarPubMed
Ducrey, S., Gex-Fabry, M., Dayer, A., Pardos, E.R., Roth, L., Aubry, J.-M.et al.A retrospective comparison of inpatients with mixed and pure depression. Psychopathology 2004;36:292–298CrossRefGoogle Scholar
Dunner, D.L., Goodwin, F.K., Gershon, E.S., Murphy, D.L., Bunney, W.E. Jr.Excretion of 17-OHCS in unipolar and bipolar depressed patients. Arch Gen Psychiatry 1972;26:360–363CrossRefGoogle ScholarPubMed
Faedda, G.L., Baldessarini, R.J., Glovinsky, I.P., Austin, N.B.Pediatric bipolar disorder: phenomenology and course of illness. Bipolar Disord 2004;6:305–313CrossRefGoogle ScholarPubMed
Fava, M., Rosenbaum, J.F., Pava, J.A., McCarthy, M.K., Steingard, R.J., Bouffides, E.Anger attacks in unipolar depression, Part 1. Clinical correlates and response to fluoxetine treatment. Am J Psychiatry 1993;150:1158–1163Google ScholarPubMed
Fava, M., Rosenbaum, J.F.Anger attacks in patients with depression. J Clin Psychiatry 1999;60(Suppl 15):21–24Google ScholarPubMed
Feske, U., Frank, E., Mallinger, A.G., Houck, P.R., Fagiolini, A., Shear, M.K.et al.Anxiety as a correlate of response to the acute treatment of bipolar I disorder. Am J Psychiatry 2000;157:956–962CrossRefGoogle ScholarPubMed
First, M.B., Pincus, H.A., Levine, J.B., Williams, J.B., Ustun, B., Peele, R.Clinical utility as a criterion for revising psychiatric diagnoses. Am J Psychiatry 2004;161:946–954CrossRefGoogle ScholarPubMed
Frye, MA, McElroy, SL, Hellemann, G, Nolen, WA, Suppes, T, Grunze, HC, et al.Clinical correlates associated with antidepressant-related mania (abstract NR215). Toronto: Program and Abstracts of the American Psychiatric Association Annual Meeting; 2006.Google Scholar
Geller, B., Tillman, R., Bolhofner, K., Zimerman, B., Strauss, N.A., Kaufmann, P.Controlled, blindly rated, direct-interview family study of a prepubertal and early-adolescent bipolar I disorder phenotype: morbid risk, age at onset, and comorbidity. Arch Gen Psychiatry 2006;63:1130–1138CrossRefGoogle ScholarPubMed
Goldberg, J.F., Harrow, M., Whiteside, J.E.Risk for bipolar illness in patients initially hospitalized for unipolar depression. Am J Psychiatry 2001;158:1265–1270CrossRefGoogle ScholarPubMed
Goldberg, JF, Perlis, RH, Ghaemi, N, Calabrese, JR, Bowden, CL, Wisniewski, S, et al. Adjunctive antidepressant use and symptomatic recovery among bipolar depressed patients with concomitant manic symptoms: findings from the STEP-BD. Am J Psychiatry (in press).Google Scholar
Goodwin, F.K., Jamison, K.R.Manic-depressive illness. 2nd ed.Oxford: Oxford University Press; 2007Google Scholar
Goodwin, F.K., Ghaemi, S.N.The course of bipolar disorder and the nature of agitated depression. Am J Psychiatry 2003;160:2077–2079CrossRefGoogle ScholarPubMed
Hantouche, E.G., Angst, J., Akiskal, H.S.Factor structure of hypomania: interrelationships with cyclothymia and the soft bipolar spectrum. J Affect Disord 2003;73:39–47CrossRefGoogle ScholarPubMed
Hantouche, E.G., Akiskal, H.S.Toward a definition of a cyclothymic behavioral endophenotype: which traits tap the familial diathesis for bipolar II disorder?. J Affect Disord 2006;96:233–237CrossRefGoogle Scholar
Henry, C., M'bailara, K., Desage, A., Gard, S., Misdrahi, D., Vieta, E.Towards a reconceptualization of mixed states, based on an emotional-reactivity dimensional model. J Affect Disord 2007;101:35–41CrossRefGoogle ScholarPubMed
Himmelhoch, J.M., Mulla, D., Neil, J.F., Detre, T.P., Kupfer, D.J.Incidence and significance of mixed affective states in a bipolar population. Arch Gen Psychiatry 1976;33:1062–1066CrossRefGoogle Scholar
Houston, J.P., Ahl, J., Meyers, A.L., Kaiser, C.J., Tohen, M., Baldessarini, R.J.Reduced suicidal ideation in bipolar I disorder mixed-episode patients in a placebo-controlled trial of olanzapine combined with lithium or valproate. J Clin Psychiatry 2006;67:1246–1252CrossRefGoogle Scholar
http://www.fda.gov/cder/drug/advisory/SSRI20007.htm. (accessed 28 April 2006)Google Scholar
Joffe, R.T., Young, L.T., Cooke, R.G., Robb, J.The thyroid and mixed affective states. Acta Psychiatr Scand 1994;90:131–132CrossRefGoogle ScholarPubMed
Judd, L.L., Akiskal, H.S., Maser, J.D., Zeller, P.J., Endicott, J., Coryell, W.et al.A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders. Arch Gen Psychiatry 1998;55:694–700CrossRefGoogle ScholarPubMed
Judd, L.L., Akiskal, H.S., Schettler, P.J., Coryell, W., Endicott, J., Maser, J.D.et al.A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 2003;60:261–266CrossRefGoogle ScholarPubMed
Keller, M.B., Lavori, P.W., Coryell, W., Andreasen, N.C., Endicott, J., Clayton, P.J.et al.Differential outcome of pure manic, mixed/cycling, and pure depressive episodes in patients with bipolar illness. JAMA 1986;255:3138–3142CrossRefGoogle ScholarPubMed
Kendell, R., Jablensky, A.Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry 2003;160:4–12CrossRefGoogle ScholarPubMed
Kendler, K.S.The diagnostic validity of melancholic major depression in a population-based sample of female twins. Arch Gen Psychiatry 1997;54:299–304CrossRefGoogle Scholar
Kendler, K.S., Gardner, C.O. Jr.Boundaries of major depression: an evaluation of DSM-IV criteria. Am J Psychiatry 1998;155:172–177Google ScholarPubMed
Kendler, K.S.Toward a scientific psychiatric nosology. Strengths and limitations. Arch Gen Psychiatry 1990;47:969–973CrossRefGoogle Scholar
Koukopoulos, A., Koukopoulos, A.Agitated depression as a mixed state and the problem of melancholia. Psychiatr Clin North Am 1999;22:547–564CrossRefGoogle ScholarPubMed
Koukopoulos, A.Ewald Hecker's description of cyclothymia as a cyclical mood disorder: its relevance to the modern concept of bipolar II. J Affect Disord 2003;73:199–205CrossRefGoogle ScholarPubMed
Koukopoulos, K., Sani, G., Albert, M.J., Minnai, G.P., Koukopoulos, A.E.Agitated depression: spontaneous and induced. In: Marneros, A., Goodwin, F., Bipolar disorders 2005 Cambridge University Press Cambridge:157–186CrossRefGoogle Scholar
Koukopoulos, A., Albert, M.J., Sani, G., Koukopoulos, A.E., Girardi, P.Mixed depressive states: nosologic and therapeutic issues. Int Rev Psychiatry 2005;17:21–37.CrossRefGoogle ScholarPubMed
Krabbendam, L., Myin-Germeys, I., De Graaf, R., Vollebergh, W., Nolen, W.A., Iedema, J.et al.Dimensions of depression, mania and psychosis in the general population. Psychol Med 2004;34:1–10.CrossRefGoogle ScholarPubMed
Kraepelin, E.Manic-depressive insanity and paranoia. Edinburgh: E & S Livingstone; 1921.CrossRefGoogle Scholar
Kramlinger, K.G., Post, R.M.Ultra-rapid and ultradian cycling in bipolar affective illness. Br J Psychiatry 1996;168:314–323.CrossRefGoogle ScholarPubMed
Kupfer, D.J., Pickar, D., Himmelhoch, J.M., Detre, T.P.Are there two types of unipolar depression?. Arch Gen Psychiatry 1975;32:866–871.CrossRefGoogle ScholarPubMed
MacKinnon, D.F., Zandi, P.P., Gershon, E.S., Nurnberger, J.I. Jr., DePaulo, J.R. Jr.Association of rapid mood switching with panic disorder and familial panic risk in familial bipolar disorder. Am J Psychiatry 2003;160:1696–1698.CrossRefGoogle ScholarPubMed
MacKinnon, D.F., Zandi, P.P., Gershon, E., Nurnberger, J.I. Jr., Reich, T., DePaulo, J.R.Rapid switching of mood in families with multiple cases of bipolar disorder. Arch Gen Psychiatry 2003;60:921–928.CrossRefGoogle ScholarPubMed
Mackinnon, D.F., Potash, J.B., McMahon, F.J., Simpson, S.G., Raymond Depaulo, J. Jr.et al.the National Institutes of Mental Health Bipolar Disorder Genetics Initiative. Rapid mood switching and suicidality in familial bipolar disorder. Bipolar Disord 2005;7:441–448.CrossRefGoogle ScholarPubMed
Maj, M., Pirozzi, R., Formicola, A.M., Tortorella, A.Reliability and validity of four alternative definitions of rapid-cycling bipolar disorder. Am J Psychiatry 1999;156:1421–1424.Google ScholarPubMed
Maj, M., Pirozzi, R., Magliano, L., Bartoli, L.Agitated depression in bipolar I disorder: prevalence, phenomenology, and outcome. Am J Psychiatry 2003;160:2134–2140.CrossRefGoogle ScholarPubMed
Maj, M., Pirozzi, R., Magliano, L., Fiorillo, A., Bartoli, L.Agitated ‘unipolar’ major depression: prevalence, phenomenology, and outcome. J Clin Psychiatry 2006;67:712–719.CrossRefGoogle ScholarPubMed
Mammen, O.K., Pilkonis, P.A., Chengappa, K.N., Kupfer, D.J.Anger attacks in bipolar depression: predictors and response to citalopram added to mood stabilizers. J Clin Psychiatry 2004;65:627–633.CrossRefGoogle ScholarPubMed
Mantere, O., Suominen, K., Leppamaki, S., Valtonen, A., Arvilommi, P., Isometsa, E.The clinical characteristics of DSM-IV bipolar I and II disorders: baseline findings from the Jorvi Bipolar Study (JoBS). Bipolar Disord 2004;6:395–405.CrossRefGoogle Scholar
Marneros, A., Rottig, S., Wenzel, A., Bloink, R., Brieger, P.Affective and schizoaffective mixed states. Eur Arch Psychiatry Clin Neurosci 2004;254:76–81.CrossRefGoogle ScholarPubMed
McElroy, S.L., Keck, P.E. Jr., Pope, H.G. Jr., Hudson, J.I., Faedda, G.L., Swann, A.C.Clinical and research implications of the diagnosis of dysphoric or mixed mania or hypomania. Am J Psychiatry 1992;149:1633–1644.Google ScholarPubMed
McElroy, S.L., Strakowski, S.M., Keck, P.E. Jr., Tugrul, K.L., West, S.A., Lonczak, H.S.Differences and similarities in mixed and pure mania. Compr Psychiatry 1995;36:187–194.CrossRefGoogle ScholarPubMed
McElroy, S.L., Altshuler, L.L., Suppes, T., Keck, P.E. Jr., Frye, M.A., Denicoff, K.D.et al.Axis I psychiatric comorbidity and its relationship to historical illness variables in 288 patients with bipolar disorder. Am J Psychiatry 2001;158:420–426.CrossRefGoogle ScholarPubMed
McElroy, S.L.Diagnosing and treating comorbid (complicated) bipolar disorder. J Clin Psychiatry 2004;65(suppl 15):35–44.Google ScholarPubMed
McIntyre, R.S., Konarski, J.Z., Yatham, L.N.Comorbidity in bipolar disorder: a framework for rational treatment selection. Hum Psychopharmacol 2004;19:369–386.CrossRefGoogle ScholarPubMed
Nunn, C.M.Mixed affective states and the natural history of manic-depressive psychosis. Br J Psychiatry 1979;134:153–156.CrossRefGoogle ScholarPubMed
Nurnberger, J.I. Jr., Adkins, S., Lahiri, D.K., Mayeda, A., Hu, K., Lewy, A.et al.Melatonin suppression by light in euthymic bipolar and unipolar patients. Arch Gen Psychiatry 2000;57:572–579.CrossRefGoogle ScholarPubMed
Pasquini, M., Picardi, A., Biondi, M., Gaetano, P., Morosini, P.Relevance of anger and irritability in outpatients with major depressive disorder. Psychopathology 2004;37:155–160.CrossRefGoogle ScholarPubMed
Perlis, R.H., Beasley, C.M. Jr., Wines, J.D. Jr., Tamura, R.N., Cusin, C., Shear, D.et al.Treatment-associated suicidal ideation and adverse effects in an open, multicenter trial of fluoxetine for major depressive episodes. Psychother Psychosom 2007;76:40–46.CrossRefGoogle Scholar
Perugi, G., Akiskal, H.S., Micheli, C., Toni, C., Madaro, D.Clinical characterization of depressive mixed state in bipolar-I patients: Pisa-San Diego collaboration. J Affect Disord 2001;67:105–114.CrossRefGoogle Scholar
Post, R.M., Rubinow, D.R., Uhde, T.W., Roy-Byrne, P.P., Linnoila, M., Rosoff, A.et al.Dysphoric mania. Clinical and biological correlates. Arch Gen Psychiatry 1989;46:353–358.CrossRefGoogle ScholarPubMed
Posternak, M.A., Zimmerman, M.Anger and aggression in psychiatric outpatients. J Clin Psychiatry 2002;63:665–672.CrossRefGoogle ScholarPubMed
Raskin, A., Schulterbrandt, J., Reatig, N., McKeon, J.J.Replication of factors of psychopathology in interview, ward behavior and self-report ratings of hospitalized depressives. J Nerv Ment Dis 1969;148:87–98.CrossRefGoogle ScholarPubMed
Robins, E., Guze, S.B.Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry 1970;126:983–987.CrossRefGoogle Scholar
Salvatore, P., Baldessarini, R.J., Centorrino, F., Egli, S., Albert, M., Gerhard, A.et al.Weygandt's On the Mixed States of Manic-Depressive Insanity: a translation and commentary on its significance in the evolution of the concept of bipolar disorder. Harv Rev Psychiatry 2002;10:255–275.CrossRefGoogle ScholarPubMed
Sato, T., Bottlender, R., Kleindienst, N., Moller, H.J.Syndromes and phenomenological subtypes underlying acute mania: a factor analytic study of 576 manic patients. Am J Psychiatry 2002;159:968–974.CrossRefGoogle ScholarPubMed
Sato, T., Bottlender, R., Sievas, M., Schroter, A., Hecht, S., Moller, H.J.Long-term inter-episode stability of syndromes underlying mania. Acta Psychiatr Scand 2003;108:310–313.CrossRefGoogle ScholarPubMed
Sato, T., Bottlender, R., Schroter, A., Moller, H.-J.Frequency of manic symptoms during a depressive episode and unipolar ‘depressive mixed state’ as bipolar spectrum. Acta Psychiatr Scand 2003;107:268–274.CrossRefGoogle ScholarPubMed
Sato, T., Bottlender, R., Sievers, M., Schroter, A., Kleindienst, N., Moller, H.J.Evaluating the inter-episode stability of depressive mixed states. J Affect Disord 2004;8:103–113.CrossRefGoogle Scholar
Sato, T., Bottlender, R., Kleindienst, N., Moller, H.J.Irritable psychomotor elation in depressed inpatients: a factor validation of mixed depression. J Affect Disord 2005;84:187–196.CrossRefGoogle ScholarPubMed
Schatzberg, A.F., DeBattista, C.Phenomenology and treatment of agitation. J Clin Psychiatry 1999;60(suppl 15):17–20.Google ScholarPubMed
Sedler, M.J.Falret's discovery: the origin of the concept of bipolar affective illness. Am J Psychiatry 1983;140:1127–1133.Google ScholarPubMed
Serretti, A., Olgiati, P.Profiles of “manic” symptoms in bipolar I, bipolar II and major depressive disorders. J Affect Disord 2005;84:159–166.CrossRefGoogle ScholarPubMed
Suppes, T., McElroy, S.L., Altshuler, L.L., Kupka, R.W., Frye, M.A., Keck, P.E.et al.Mixed hypomania in 908 patients with bipolar disorder evaluated prospectively in the Stanley Bipolar Treatment Network: a gender-specific phenomenon. Arch Gen Psychiatry 2005;62:1089–1096.CrossRefGoogle Scholar
Swann, A.C., Stokes, P.E., Casper, R., Secunda, S.K., Bowden, C.L., Berman, N.et al.Hypothalamic-pituitary-adrenocortical function in mixed and pure mania. Acta Psychiatr Scand 1992;85:270–274.CrossRefGoogle ScholarPubMed
Swann, A.C., Secunda, S.K., Katz, M.M., Croughan, J., Bowden, C.L., Koslow, S.H.et al.Specificity of mixed affective states: clinical comparison of dysphoric mania and agitated depression. J Affect Disord 1993;28:81–89.CrossRefGoogle ScholarPubMed
Swann, A.C., Stokes, P.E., Secunda, S.K., Maas, J.W., Bowden, C.L., Berman, N.et al.Depressive mania versus agitated depression: biogenic amine and hypothalamic-pituitary-adrenocortical function. Biol Psychiatry 1994;35:803–813.CrossRefGoogle ScholarPubMed
Swann, A.C., Bowden, C.L., Morris, D., Calabrese, J.R., Petty, F., Small, J.et al.Depression during mania. Treatment response to lithium or divalproex. Arch Gen Psychiatry 1997;54:37–42.CrossRefGoogle ScholarPubMed
Swann, A.C., Janicak, P.L., Calabrese, J.R., Bowden, C.L., Dilsaver, S.C., Morris, D.D.et al.Structure of mania: depressive, irritable, and psychotic clusters with different retrospectively-assessed course patterns of illness in randomized clinical trial participants. J Affect Disord 2001;67:123–132.CrossRefGoogle ScholarPubMed
Swann, A.C., Gerard Moeller, F., Steinberg, J.L., Schneider, L., Barratt, E.S., Dougherty, D.M.Manic symptoms and impulsivity during bipolar depressive episodes. Bipolar Disord 2007;9:206–212.CrossRefGoogle ScholarPubMed
Tandon, R., Channabasavanna, S.M., Greden, J.F.CSF biochemical correlates of mixed affective states. Acta Psychiatr Scand 1988;78:289–297.CrossRefGoogle ScholarPubMed
Tollefson, G.D., Greist, J.H., Jefferson, J.W., Heiligenstein, J.H., Sayler, M.E., Tollefson, S.L.et al.Is baseline agitation a relative contraindication for a selective serotonin reuptake inhibitor: a comparative trial of fluoxetine versus imipramine. J Clin Psychopharmacol 1994;14:385–391.CrossRefGoogle ScholarPubMed
Zarate, C.A., Tohen, M., Zarate, S.B.Thyroid function tests in first-episode bipolar disorder manic and mixed types. Biol Psychiatry 1997;42:302–304.CrossRefGoogle ScholarPubMed
Vieta, E., Colom, F., Corbella, B., Martinez-Aran, A., Reinares, M., Benabarre, A.et al.Clinical correlates of psychiatric comorbidity in bipolar I patients. Bipolar Disord 2001;3:253–258.CrossRefGoogle ScholarPubMed
Wada, K., Sasaki, T., Jitsuiki, H., Yoshimura, Y., Erabi, H., Hada, Y.et al.Manic/hypomanic switch during acute antidepressant treatment for unipolar depression. J Clin Psychopharmacol 2006;26:512–515.CrossRefGoogle ScholarPubMed
Watson, S., Gallagher, P., Ritchie, J.C., Ferrier, I.N., Young, A.H.Hypothalamic-pituitary-adrenal axis function in patients with bipolar disorder. Br J Psychiatry 2004;184:496–502.CrossRefGoogle ScholarPubMed
Williams, J.B.W., Terman, M., Link, M.J., Amira, L., Rosenthal, N.E.Hypomania interview guide (including hyperthymia). Current assessment version (HIGH-C). Clinical Assessment Tools Packet Norwood, NJ: Center for Environmental Therapeutics; 1994.Google Scholar
Woods, S.W., Money, R., Baker, C.B.Does the manic/mixed episode distinction in bipolar disorder patients run true over time?. Am J Psychiatry 2001;158(8):1324–1326. J Neuropsychopharmacol 2006;9 (suppl 1):s147.CrossRefGoogle ScholarPubMed
World Health Organization. The ICD-10 classification of mental and behavioural disorders. Geneva: World Health Organization; 1992.Google Scholar
Young, R.C., Biggs, J.T., Ziegler, V.E., Meyer, D.A.A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978;133:429–435.CrossRefGoogle ScholarPubMed
Submit a response

Comments

No Comments have been published for this article.