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Toward a validation of a new definition of agitated depression as a bipolar mixed state (mixed depression)
- F. Benazzi, A. Koukopoulos, H.S. Akiskal
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- Journal:
- European Psychiatry / Volume 19 / Issue 2 / April 2004
- Published online by Cambridge University Press:
- 16 April 2020, pp. 85-90
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Purpose
As psychotic agitated depression is now a well-described form of mixed state during the course of bipolar I disorder, we sought to investigate the diagnostic validity of a new definition for agitated (mixed) depression in bipolar II (BP-II) and major depressive disorder (MDD).
Materials and methodsThree hundred and thirty six consecutive outpatients presenting with major depressive episodes (MDE) but without history of mania were evaluated with the Structured Clinical Interview for DSM-IV when presenting for the treatment of MDE. On the basis of history of hypomania they were assigned to BP-II (n = 206) vs. MDD (n = 130). All patients were also examined for hypomania during the current MDE. Mixed depression was operationally defined by the coexistence of a MDE and at least two of the following excitatory signs and symptoms as described by Koukopoulos and Koukopoulos (Koukopoulos A, Koukopoulos A. Agitated depression as a mixed state and the problem of melancholia. In: Akiskal HS, editor. Bipolarity: beyond classic mania. Psychiatr Clin North Am 1999;22:547–64): inner psychic tension (irritability), psychomotor agitation, and racing/crowded thoughts. The validity of mixed depression was investigated by documenting its association with BP-II disorder and with external variables distinguishing it from unipolar MDD (i.e., younger age at onset, greater recurrence, and family history of bipolar disorders). We analyzed the data with multivariate regression (STATA 7).
ResultsMDE plus psychic tension (irritability) and agitation accounted for 15.4%, and MDE plus agitation and crowded thoughts for 15.1%. The highest rate of mixed depression (38.6%) was achieved with a definition combining MDE with psychic tension (irritability) and crowded thoughts: 23.0% of these belonged to MDD and 76.9% to BP-II. Moreover, any of these permutations of signs and symptoms defining mixed depression was significantly and strongly associated with external validators for bipolarity. The mixed irritable-agitated syndrome depression with racing-crowded thoughts was further characterized by distractibility (74–82%) and increased talkativeness (25–42%); of expansive behaviors from the criteria B list for hypomania, only risk taking occurred with some frequency (15–17%).
ConclusionsThese findings support the inclusion of outpatient-agitated depressions within the bipolar spectrum. Agitated depression is validated herein as a dysphorically excited form of melancholia, which should tip clinicians to think of such a patient belonging to or arising from a bipolar substrate. Our data support the Kraepelinian position on this matter, but regrettably this is contrary to current ICD-10 and DSM-IV conventions. Cross-sectional symptomatologic hints to bipolarity in this mixed/agitated depressive syndrome are virtually absent in that such patients do not appear to display the typical euphoric/expansive characteristics of hypomania—even though history of such behavior may be elicited by skillful interviewing for BP-II. We submit that the application of this diagnostic entity in outpatient practice would be of considerable clinical value, given the frequency with which these patients are encountered in such practice and the extent to which their misdiagnosis as unipolar MDD could lead to antidepressant monotherapy, thereby aggravating it in the absence of more appropriate treatment with mood stabilizers and/or atypical antipsychotics.
Exclusion of overlapping symptoms in DSM-5 mixed features specifier: heuristic diagnostic and treatment implications
- Gin S Malhi, Yulisha Byrow, Tim Outhred, Kristina Fritz
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- Journal:
- CNS Spectrums / Volume 22 / Issue 2 / April 2017
- Published online by Cambridge University Press:
- 21 November 2016, pp. 126-133
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This article focuses on the controversial decision to exclude the overlapping symptoms of distractibility, irritability, and psychomotor agitation (DIP) with the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mixed features specifier. In order to understand the placement of mixed states within the current classification system, we first review the evolution of mixed states. Then, using Kraepelin’s original classification of mixed states, we compare and contrast his conceptualization with modern day definitions. The DSM-5 workgroup excluded DIP symptoms, arguing that they lack the ability to differentiate between manic and depressive states; however, accumulating evidence suggests that DIP symptoms may be core features of mixed states. We suggest a return to a Kraepelinian approach to classification—with mood, ideation, and activity as key axes—and reintegration of DIP symptoms as features that are expressed across presentations. An inclusive definition of mixed states is urgently needed to resolve confusion in clinical practice and to redirect future research efforts.
1 - Bipolar disorders beyond major depression and euphoric mania
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- By Andreas Marneros, Martin-Luther University Halle-Wittenberg, Halle, Germany, Frederick K. Goodwin, George Washington University Medical Center, Washington, DC, USA
- Edited by Andreas Marneros, Martin Luther-Universität Halle-Wittenburg, Germany, Frederick Goodwin, George Washington University, Washington DC
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- Book:
- Bipolar Disorders
- Published online:
- 10 August 2009
- Print publication:
- 06 October 2005, pp 1-44
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Summary
The early descriptions and roots of mixed states are very closely connected with the history and development of concepts regarding bipolar disorders. These concepts have their roots in the work and theories of the Greek physicians of the classical period, especially of the school of Hippocrates and, later, of the school of Aretaeus of Cappadocia. Most of the studies of the families of patients with rapid-cycling bipolar disorder show no difference between rapid- and non-rapid-cycling patients. Schizoaffective disorders present as unipolar or bipolar forms in a way similar to mood disorders, as is reflected in both diagnostic and statistical manual of mental disorders (DSM-IV) and tenth revision of the international classification of diseases (ICD-10). ICD-10 and DSM-IV handle the definition of schizoaffective disorder differently. These differences present a difficulty for cross-national research. For a long time, agitated depression has been considered to be a type of mixed state.
7 - Agitated depression: spontaneous and induced
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- By Athanasios Koukopoulos, Centro Lucio Bini Center for the Treatment and Research of Affective Disorders Rome Italy, Gabriele Sani, Centro Lucio Bini Center for the Treatment and Research of Affective Disorders Rome Italy, Matthew J. Albert, Centro Lucio Bini Center for the Treatment and Research of Affective Disorders Rome Italy, Gian Paolo Minnai, Centro Lucio Bini Center for the Treatment and Research of Affective Disorders Rome Italy, Alexia E. Koukopoulos, Centro Lucio Bini Center for the Treatment and Research of Affective Disorders Rome Italy
- Edited by Andreas Marneros, Martin Luther-Universität Halle-Wittenburg, Germany, Frederick Goodwin, George Washington University, Washington DC
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- Book:
- Bipolar Disorders
- Published online:
- 10 August 2009
- Print publication:
- 06 October 2005, pp 157-186
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Summary
Depression is understood as a morbid entity and every physician is entitled to offer antidepressant treatment to nearly all patients with despondent mood diagnosed as meeting the DSM-III criteria for a major depressive episode with or without agitation. Normal human behavior, and especially behavior during affective episodes, has created the impression that good mood is allied with good drive and fluent thinking and vice versa. Hypomania with euphoric mood with hyperactivity, and depression with retardation are typical examples of this parallelism. It is ironic that today agitated depression has lost its status as a mixed state, whereas manic stupor and dysphoric mania are still considered as such. Clinical forms of agitated depression include psychotic agitated depression, agitated depression with psychomotor agitation, and minor agitated depression. The anxiety observed in agitated depression seems to be of a different kind, inherent in the agitation itself.