Abstract
BackgroundDepending on the classification system used, 5–40% of manic subjects present with concomitant depressive symptoms. This post-hoc analysis evaluates the hypothesis that (hypo)manic subjects have a higher burden of depression than non-(hypo)manic subjects.MethodsData from 806 Bipolar I or II participants of the Stanley Foundation Bipolar Network (SFBN) were analyzed, comprising 17,937 visits. A split data approach was used to separate evaluation and verification in independent samples. For verification of our hypotheses, we compared mean IDS-C scores ratings of non-manic, hypomanic and manic patients. Data were stored on an SQL-server and extracted using standard SQL functions. Linear correlation coefficients and pivotal tables were used to characterize patient groups.ResultsMean age of participants was 40 ± 12 years (range 18–81). 460 patients (57.1%) were female and 624 were diagnosed as having bipolar I disorder (77.4%) and 182 with bipolar II (22.6%). Data of 17,937 visits were available for analyses, split into odd and even patient numbers and stratified into three groups by YMRS-scores: not manic < 12, hypomanic < 21, manic < 30. Average IDS-C sum scores in manic or hypomanic states were significantly higher (p < .001) than for non-manic states. (Hypo)manic female patients were likely to show more depressive symptoms than males (p < .001). Similar results were obtained when only the core items of the YMRS or only the number of depressive symptoms were considered. Analyzing the frequency of (hypo)manic mixed states applying a proxy of the DSM-5 mixed features specifier extracted from the IDS-C, we found that almost 50% of the (hypo)manic group visits fulfilled DSM-5 mixed features specifier criteria.ConclusionSubjects with a higher manic symptom load are also significantly more likely to experience a higher number of depressive symptoms. Mania and depression are not opposing poles of bipolarity but complement each other.
Highlights
Depressive symptomatology during a manic episode is commonly seen in daily practice (Vieta and Valenti 2013) and, compared to pure mania, predicts a course of bipolar disorder (BD) with a younger age at onset, more frequentBorn et al Int J Bipolar Disord (2021) 9:36 and longer episodes, more treatment resistance with delayed symptomatic remission, more frequent relapses, suicidality and suicidal acts, irritability, anxiety and substance abuse comorbidity (Grunze et al 2018)
Six hundred twenty-four were diagnosed with bipolar I disorder (77.4%) and 182 with bipolar II (22.6%). 17,937 visits of these subjects were available with corresponding Young Mania Rating Scale (YMRS) and Inventory of Depressive Symptoms—Clinician Version (IDS-C), both rated at the same occasion
Applying the 4-item-YMRS core score to group subjects, we found that 652 visits in the hypomanic group (47.7%) and 121 visits in the manic group (48%) fulfilled Diagnostic and statistical manual (DSM)-5 criteria for amanic episode with mixed features specifier (≥ 3 depressive symptoms)
Summary
Depressive symptomatology during a manic episode ( termed mixed, depressive, or dysphoric mania) is commonly seen in daily practice (Vieta and Valenti 2013) and, compared to pure mania, predicts a course of bipolar disorder (BD) with a younger age at onset, more frequentBorn et al Int J Bipolar Disord (2021) 9:36 and longer episodes, more treatment resistance with delayed symptomatic remission, more frequent relapses, suicidality and suicidal acts, irritability, anxiety and substance abuse comorbidity (Grunze et al 2018). Older studies applying research-based categorial definitions of mixed mania (Cincinnati criteria, Pisa criteria) indicate that relevant depressive symptoms, i.e. fulfilling the respective mixed features criteria, are present in about 30–40% of acutely manic patients (Akiskal et al 2000; Hantouche et al 2006; McElroy et al 1992) whereas using full Diagnostic and Statistical manual, 4th edition (DSM-IV TR) criteria (American Psychiatric Association 1994) brings the prevalence down to 6.7% (Hantouche et al 2006). Acknowledging that categorial DSM-IV criteria of mixed mania are too restrictive for deriving meaningful clinical implications, Diagnostic and Statistical manual, 5th edition (DSM-5) (American Psychiatric Association 2013) introduced a more dimensional approach defining depressive symptoms in manic patients and manic symptoms in depression as specifier, requiring ≥ 3 core symptoms of the opposite polarity. This post-hoc analysis evaluates the hypothesis that (hypo)manic subjects have a higher burden of depression than non-(hypo)manic subjects
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