Recurrent Depressive Episodes Research Articles

Re-Engagement into Care: The Role of Social Support on Service Use for Recurrent Episodes of Mental Health Distress Among Primary Care Patients.

Given high rates of relapse of depression, understanding mechanisms that provide long-term benefits and optimal outcomes for depressed individuals is crucial. The current study examines social support as a relevant component in service use to manage mental health needs for individuals with recurrent depression over a 5-year period. Conducting a secondary data analysis from a randomized clinical trial titled Partners in Care, the study examines direct and moderating effects over two time points of reported 12-month social support on service use for mental health needs at 57-months for an adult sample (n = 991). Direct effects were supported for demographic and need variables. Increased social support at 12-months positively moderated the relationship between health impairment and service use at 57-months. Findings inform and extend the understanding of social support as an important mechanism to care to integrate into the treatment experience, encouraging service use to manage recurrent depressive episodes.

Hair cortisol as a marker of hypothalamic-pituitary-adrenal Axis activity in female patients with major depressive disorder.

Hair cortisol is regarded as a promising marker of hypothalamic-pituitary-adrenal axis (HPAA) activity alterations due to stress, somatic and mental health conditions. Hair cortisol was previously reported to be elevated in patients with depression, however the data related to remission and recurrent depressive episodes are different. In this study, levels of hair cortisol were assessed in female patients with major depressive disorder (MDD) and the validity of hair cortisol as a marker of HPAA activity in this condition was evaluated. Hair cortisol was measured in 1cm hair segments of 21 female patients with MDD and 22 female age-matched controls using enzyme-immunoassay analysis. Concurrently, serum cortisol was assessed and psychological status was evaluated using 17-item Hamilton Depression Rating Scale (HAMD-17), Beck Depression Inventory (BDI) and the Spielberger state trait anxiety inventory (STAI). The levels of hair cortisol were significantly lower in the MDD group, while serum cortisol levels were significantly higher in patients, as compared with controls. A significant negative correlation was found between HAMD-17 scores and hair cortisol. Decreased hair cortisol found in female patients with MDD as compared to controls suggests downregulation of HPAA activity during the preceding month. Further studies are needed to investigate the profiles of hair cortisol at different stages of depressive disorder to establish this parameter as a handy clinical tool.

M36 - CO-EXPRESSED TRANSCRIPTOME ANALYSES REVEAL CONSISTENT BIOLOGICAL PATHWAYS FOR MANIC EPISODE

Background Bipolar disorder (BD) is a highly heritable psychiatric disorder with recurrent episodes of depression and mania. Despite progress made for identifying genetic variants for BD, limited studies focus on its episodic feature in nature. In the current study, we aimed to investigate the mechanisms underlying manic episodes at a genome-wide level to identify potential molecular targets, in particular the gene/transcript expression patterns. Methods Two sets of transcriptome data were analyzed for manic episode. First, we enrolled 6 BD patients and followed them from manic episode to remission. The Young Mania Rating Scale (YMRS) score was assessed to evaluate the severity of manic-state (YMRS score >20 as acute phase and Results In the discovery samples, most of the transcripts were down-regulated in manic state comparing with remission. The top significant DE transcripts were DLC1, NFASC, and CLMN. Their expression patterns were validated by qRT-PCR with the same direction in HTA-array. Using WGCNA, six and three modules were found to be significantly related to manic episode in GSE46416 and ours data, respectively. Among these modules, results from intra-module pathway analysis revealed consistent pathways in the two datasets. The common pathways that were positively correlated with manic state included actin cytoskeleton, nervous system development, and response to redox state. On the other hand, calcium ion binding, synaptic transmission, and adaptive immune system were negatively correlated with manic-state. Discussion Genome-wide high-throughput transcriptome analyses are useful in identifying biomarkers for manic state in BD patients. In addition to DE transcripts analysis, network analysis based on transcripts co-expression might provide more biological insights for etiology study. In conclusion, our network and functional pathway-level analyses identify consistent modules and pathways for manic episode. These findings have potential to assist conducting therapeutic studies and to explore pathologic mechanisms underlying bipolar disorder in the future.

“Does Age Affect Treatment of Depressive Disorders? A systematic review of antidepressants versus placebo studies.”

“Does Age Affect Treatment of Depressive Disorders? A systematic review of antidepressants versus placebo studies.”

Clinical Practice Guidelines for the management of Depression.

Depression is a common disorder, which often leads to poor quality of life and impaired role functioning. It is known to be a major contributor to the global burden of diseases and according to World Health Organization (WHO), depression is the fourth leading cause of disability worldwide and it is projected that by 2020, it will be the second most common leading cause of disability. Depression is also associated with high rates of suicidal behaviour and mortality. When depression occurs in the context of medical morbidity, it is associated with increased health care cost, longer duration of hospitalization, poor cooperation in treatment, poor treatment compliance and high rates of morbidity. Depression is also known to be associated with difficulties in role transitions (e.g., low education, high teen child-bearing, marital disruption, unstable employment) and poor role functioning (e.g., low marital quality, low work performance, low earnings). It is also reported to be a risk factor for the onset and persistence of a wide range of secondary disorders. Available data also suggests that between one-third and one-half of patients also experience recurrence of depressive episodes.

Adult ADHD: Questioning Diagnosis and Treatment in a Patient with Multiple Psychiatric Comorbidities

Adult Attention-Deficit/Hyperactivity Disorder (ADHD) is a contentious diagnostic issue, which has been increasing in prevalence in recent years, and is often comorbid with other psychiatric disorders. This report presents a detailed account of a clinical case involving a middle-aged man with a history of recurrent depressive episodes and an unsubstantiated diagnosis of ADHD, treated with stimulants. There is persistent debate around the use of psychostimulants both in adult ADHD and in the treatment of depression. Despite promising activating properties, psychostimulants carry significant risks of misuse and substance use disorder. In this report, we consider the potential benefits and adverse effects of stimulants in the treatment of adult ADHD and mood disorders and review the learning points of this complicated, but not uncommon, clinical case.

Investigation of associations between recurrence of major depressive disorder and spinal posture alignment: A quantitative cross-sectional study

The aim of this study was to investigate associations between poor spinal posture and the recurrence of major depressive episodes and severity of symptoms in patients with major depressive disorder (MDD). This was a cross-sectional quantitative study of MDD patients. Outpatients were recruited from consecutive admissions at a mood disorders unit of a tertiary psychiatric hospital. Of 136 MDD patients, 72 (53 women, 19 men; mean age, 42.4±9.1years) met all the criteria and completed the study. Forty-one patients were classified with a recurrent episode (RE) of MDD and 31 with a single episode (SE). Quantitative assessments of postural deviations were made using photogrammetry, including kyphosis, shoulder protraction, and head inclination. The severity of depressive episodes was assessed using the Hamilton Depression Rating Scale. The diagnosis and classification of patients were performed according to DSM-IV-TR and SCID criteria. Multivariate analysis of variance indicated that the RE group had greater anterior head inclination (35.39; SD: 1.57), greater scapular abduction (1.69; SD: 0.93), and worse thoracic kyphosis (139.38; SD: 1.19) than the SE group (p<0.001 for all). Multivariate analysis of covariance showed an interaction between the severity of depressive symptoms and the degree of thoracic kyphosis (p=0.002). Recurrence of depressive episodes is associated with measures of postural misalignment.

Secondary to excessive melatonin synthesis, the consumption of tryptophan from outside the blood-brain barrier and melatonin over-signaling in the pars tuberalis may be central to the pathophysiology of winter depression

Seasonal affective disorder is defined as recurrent episodes of major depression, mania, or hypomania with seasonal onset and remission. In this class of mood disturbances, a unipolar major depressive disorder known as winter depression is common in populations living in northern latitudes far from the equator. Winter depression repeatedly occurs in the autumn or winter and remits in the spring or summer, and its etiopathogenesis is currently unknown. However, one can surmise that excessive melatonin production during the reduced duration of daily sunlight in the autumn and winter plays a role in its pathophysiology. Melatonin is synthesized from tryptophan within the pineal gland, which is located outside the blood-brain barrier, and overproduction of melatonin may lead to augmented consumption of tryptophan, from which serotonin is synthesized. As tryptophan is captured from the blood and excessively utilized by the pineal gland, tryptophan blood levels may decline; as such, it is more difficult for tryptophan to pass through the blood-brain barrier and reach the serotonergic neurons as the ratio of tryptophan to the other amino acids that compete for the same transporter to enter the brain is diminished. As such, less tryptophan is available for serotonin synthesis. Moreover, melatonin is known to modulate thyrotropin expression in the thyrotrophic cells of the pars tuberalis of the pituitary gland, and overproduction of melatonin in the autumn or winter months may cause excessive signaling in the pars tuberalis, diminishing its release of thyrotropin and resulting in central hypothyroidism. Both conditions reduced serotonin production and central hypothyroidism may cause depression. Furthermore, the excessive synthesis of melatonin during the autumn and winter may negatively affect the expression of neuromedin U in the pars tuberalis, causing an increased appetite, which is common in winter depression patients. The hypersomnia common in winter depressive patients can be ascribed to excessive circulating melatonin, a hormone that increases the propensity for sleep. Furthermore, central hypothyroidism may also increase sleepiness, as it is known that hypothyroid patients usually experience excessive somnolence. In this theoretical article, we also propose studies to evaluate winter depression patients with regard to the necessity, or not, of offering them an increased amount of tryptophan in their diets during the autumn and winter. We also suggest that the administration of triiodothyronine to winter depressive patients may mitigate their central hypothyroidism.

Negative Self-Referential Processing Predicts the Recurrence of Major Depressive Episodes

Most individuals who develop Major Depressive Disorder (MDD) will experience a recurrent depressive episode; we know little, however, about cognitive mechanisms that increase the likelihood of recurrence. In the current study we examined whether negatively biased self-referential processing, negative life events, baseline depressive symptoms, and psychotropic medication use predicted the onset of a subsequent depressive episode in a longitudinal study of women with a history of recurrent MDD. Higher levels of depressive symptoms at baseline predicted experiencing a greater number of negative life events which, in turn, tended to predict recurrence of depression. Importantly, after accounting for other associations, negatively biased self-referential processing contributed unique variance to the likelihood of experiencing a depressive episode over the next three years. Thus, negatively biased self-referential processing appears to be a significant risk factor for the recurrence of depressive episodes and may be an important target for interventions aimed at preventing future episodes.

A parallel-group, randomized controlled trial into the effectiveness of Mindfulness-Based Compassionate Living (MBCL) compared to treatment-as-usual in recurrent depression: Trial design and protocol

BackgroundMindfulness Based Cognitive Therapy (MBCT) has been shown to reduce the risk of relapse in patients with recurrent depression, but relapse rates remain high. To further improve outcome for this group of patients, follow-up interventions may be needed. Compassion training focuses explicitly on developing self-compassion, one of the putative working mechanisms of MBCT. No previous research has been done on the effectiveness of compassion training following MBCT in patients with recurrent depression. AimsTo investigate the effectiveness of Mindfulness-Based Compassionate Living (MBCL) in reducing (residual) depressive symptoms in patients with recurrent depression who previously participated in MBCT. Methods/designA randomized controlled trial comparing MBCL in addition to treatment as usual (TAU) with TAU only, in patients suffering from recurrent depressive episodes who completed an MBCT course in the past. Assessments will take place at baseline, post-treatment and at six months follow-up. After the control period, patients randomized to the TAU condition will be offered MBCL as well. Outcome measuresPrimary outcome measure is severity of depressive symptoms according to the Beck Depression Inventory-II (BDI-II) at post-treatment. Secondary outcome measures are presence or absence of DSM-IV depressive disorder, rumination, self-compassion, mindfulness skills, positive affect, quality of life, experiential avoidance and fear of self-compassion. DiscussionOur study is the first randomized controlled trial to examine the effectiveness of compassion training following MBCT in a recurrently depressed population. Trial registrationClinicalTrials.gov: NCT02059200, registered 30 January 2014.

A Molecular Model for Lithium’s Bioactive Form

Lithium carbonate, a drug for the treatment of bipolar disorder, provides mood stability to mitigate recurrent episodes of mania and/or depression. Despite its long-term and widespread use, the mechanism by which lithium acts to elicit these psychological changes has remained unknown. Using nuclear magnetic resonance (NMR) methods, in this study we characterized the association of lithium with adenosine triphosphate (ATP) and identified a bimetallic (Mg·Li) ATP complex. Lithium’s affinity to form this complex was found to be relatively high (Kd ∼1.6 mM) compared with other monovalent cations and relevant, considering lithium dosing and physiological concentrations of Mg2+ and ATP. The ATP·Mg·Li complex reveals, for the first time, to the best of our knowledge, that lithium can associate with magnesium-bound phosphate sites and then act to modulate purine receptor activity in neuronal cells, suggesting a molecular mode for in vivo lithium action.

Affective disorders as potential complication of anti-acne treatment with isotretinoin: A case series

ObjectiveTo analyse cases of 9 patients (18-27 yo) who were consequently admitted to our department and treated with affective disorders (AD) while undergoing isotretinoin (INN) therapy. MethodsA semi-structured questionnaire designed by the authors was used to analyse many variables related to demographic characteristics, dermatologic and psychiatrics symptoms, AD course and treatment, family history of mental disorders, building on medical histories of patients and their families, and available medical records. ResultsPatients were diagnosed (DSM-IV-TR) with: a major depressive episode (4 patients), a recurrent major depressive episode (3), a bipolar mixed episode (1), and rapid cycling bipolar I disorder (1). The mean time from the first use of INN to: I. the onset of mental disorders was approximately 2 months (1–6 months), II. a visit with a psychiatrist was about 12 months (1–38 months). The predictors of occurrence of AD included a family history of AD and a prior episode of mental disorders. The onset of AD was in most cases preceded by prodromal symptoms such as headaches, sleep disorders, fatigue, drowsiness, or general weakness. Five patients reported suicidal ideation, four patients showed suicidal tendencies, and two persons attempted to commit suicide during the treatment. ConclusionsPsychiatrists should pay special attention to isotretinoin as a drug that may trigger episodes of AD, particularly in patients with a family history of AD or prior episodes of mental disorders. Isotretinoin therapy of patients with acne and a family history of AD or prior episodes of mental disorders requires special care and, if symptoms of depression develop or worsen during the INN treatment, collaboration between a dermatologist and a psychiatrist is needed.

Staging Models in Bipolar Disorder: A Systematic Review of the Literature.

Bipolar disorder is manifested as severe dysregulation of mood with recurrent manic and major depressive episodes. It is associated with psychiatric and medical comorbidities, inadequate response to currently available pharmacological agents and a progressively deteriorating course in many patients. The index episode is often depressive in nature, while the first manic or hypomanic episode may occur several years later in the course of the disorder causing delay in diagnosis and use of inappropriate treatment strategies. Staging has been used to great advantage in other branches of medicine like cardiology and oncology. There is growing realization that major mental disorders are fundamentally progressive, with simpler treatment requirements and better prognosis during initial stages of the illness. Defining these conditions into clinically applicable stages not only helps in better understanding the trajectory of a particular disorder, but also assists in management. Patients with a chronic, recalcitrant condition like bipolar disorder are likely to greatly benefit from this approach. If the illness is correctly identified early in its course, proper treatment can be instigated arresting progression to latter phases which are associated with myriad complications in the biopsychosocial realm. With these considerations, a search of the MEDLINE data base was conducted to seek out literature pertaining to staging models in bipolar disorder. A thorough scrutiny of the existing research work revealed that a number of investigators have endeavored to stage define bipolar disorder. This paper outlines staging proposals for bipolar disorder which have the greatest supporting evidence in the literature.

The relation between chronotype and treatment outcome with light therapy on a fixed time schedule

BackgroundSeasonal affective disorder (SAD) is characterized by recurrent episodes of major depression in a seasonal pattern. The therapy of choice is light therapy (LT). It is suggested that LT should be administered relative to the chronotype of the patient, with the optimal timing earlier for morning than for evening types. This study aims to retrospectively investigate the relation between chronotype and the effect of LT on a fixed time in the morning in a population of SAD patients. MethodsData from four different studies conducted at the University Center of Psychiatry in Groningen, the Netherlands was used. Data from 132 patients was used (103 women). Depression score was determined by a structured interview (SIGH-SAD) prior to LT and after LT. Prior to LT morningness/eveningness preference of the patient was determined by the ‘Morningness/Eveningness Questionnaire’ (MEQ). All patients received LT at 8:00 AM at the clinic, independent of chronotype. ResultsPatients had an average MEQ score of 51.5±8.2. There was no significant relationship between MEQ score and therapy success as measured with the SIGH-SAD (F2,129=0.05, ns). When patients were divided by chronotype (ranging from definite morning to moderate evening) no significant relation between MEQ score and therapy success was found (F2,129=0.02, ns). LimitationsRetrospective design. ConclusionsThe lack of a significant relationship between chronotype, as measured with the MEQ, and therapy success with LT at a fixed timepoint may indicate that the anti-depressive effect of morning light in SAD patients is not explained by a phase shift of the biological clock.

Maladaptive mood repair, atypical respiratory sinus arrhythmia, and risk of a recurrent major depressive episode among adolescents with prior major depression.

Because depressive illness is recurrent, recurrence prevention should be a mainstay for reducing its burden on society. One way to reach this goal is to identify malleable risk factors. The ability to attenuate sadness/dysphoria (mood repair) and parasympathetic nervous system functioning, indexed as respiratory sinus arrhythmia (RSA), are impaired during depression and after it has remitted. The present study therefore tested the hypothesis that these two constructs also may mirror risk factors for a recurrent major depressive episode (MDE). At time 1 (T1), 178 adolescents, whose last MDE had remitted, and their parents, reported on depression and mood repair; youths' RSA at rest and in response to sad mood induction also were assessed. MDE recurrence was monitored until time 2 (T2) up to 2 years later. Mood repair at T1 (modeled as a latent construct), and resting RSA and RSA response to sadness induction (RSA profile), served to predict onset of first recurrent MDE by T2. Consistent with expectations, maladaptive mood repair predicted recurrent MDE, above and beyond T1 depression symptoms. Further, atypical RSA profiles at T1 were associated with high levels of maladaptive mood repair, which, in turn, predicted increased risk of recurrent MDE. Thus, maladaptive mood repair mediated the effects of atypical RSA on risk of MDE recurrence. This study documented that a combination of behavioral and physiological risk factors predicted MDE recurrence in a previously clinically referred sample of adolescents with depression histories. Because mood repair and RSA are malleable, both could be targeted for modification to reduce the risk of recurrent depression in youths.

Cognitive Behavioral Therapy in Primary Care for Youth Declining Antidepressants: A Randomized Trial.

Health care providers have few alternatives for youth depression other than antidepressants. We examined whether brief cognitive behavioral therapy (CBT) is a viable alternative in primary care. A total of 212 adolescents aged 12 to 18 with major depression who had recently declined or quickly discontinued new antidepressant treatment were randomized to self-selected treatment as usual (TAU) control condition or TAU plus brief individual CBT. Blinded evaluators followed youth for 2 years. The primary outcome was time to major depression diagnostic recovery. CBT was superior to the control condition on the primary outcome of time to diagnostic recovery from major depression, with number needed to treat from 4 to 10 across follow-up. A similar CBT advantage was found for time to depression diagnosis response, with number needed to treat of 5 to 50 across time points. We observed a significant advantage for CBT on many secondary outcomes over the first year of follow-up but not the second year. Cohen's d effect sizes for significant continuous measures ranged from 0.28 to 0.44, in the small to medium effect range. Most TAU health care services did not differ across conditions, except for psychiatric hospitalizations, which occurred at a significantly higher rate in the control condition through the first year of follow-up. Observed results were consistent with recent meta-analyses of CBT for youth depression. The initial year of CBT superiority imparted an important clinical benefit and may reduce the risk of future recurrent depression episodes.

Expressional profile of the diacylglycerol kinase eta gene DGKH.

Bipolar disorder (BPD) is a genetically complex mental disorder, which is characterized by recurrent depressive and manic episodes, occurring with a typical cyclical course. In a recent study, we were able to identify a risk haplotype for BPD, as well as for unipolar depression and adult attention-deficit/hyperactivity disorder (ADHD), within the DGKH gene. DGKH codes for the eta (η) isoform of diacylglycerol kinase, which is involved in the phosphoinositol pathway. In the present study, we determined the expressional profile of Dgkh using quantitative real-time PCR (qPCR), in situ hybridization and immunohistological staining in the human and in the mouse brain. Expression studies showed that two different Dgkh transcripts exhibited distinct occurrence in a variety of murine tissues and also differed in their expression levels. The proteins encoded by those transcripts differ in functional protein domains suggesting distinct biochemical and cell biological properties and functions. qPCR analyses revealed an increase in Dgkh expression during mouse brain development indicating a possible role of this kinase in late developmental stages. Immunostainings revealed strong Dgkh expression in neurons of the hippocampus and the cerebellum of the murine brain, whereas highest expression levels of DGKH in the human brain were found in the striatum. Taken together, our studies revealed expressional changes during mouse brain development and occurrence of Dgkη in neurons of regions that have been linked to BPD as well as ADHD in humans providing evidence for the implication of DGKH in those disorders.

Risk factors for a new cardiac event after a first acute coronary syndrome

IntroductionDepression is an established risk factor for acute coronary syndrome (ACS), nonetheless the mechanisms underlying this association are still unclear and literature disagrees on the role played by anxiety. Moreover, most of the studies included subjects with a long lasting history of heart disease or recurrent depressive episodes that could bias the results.ObjectivesWe performed serial assessments of anxiety, depression and new cardiac events in a cohort of never-depressed patients in the two years after their first ACS.AimsClarify the role of anxiety and depression in predicting new cardiac events.MethodsTwo hundred and fifty-one consecutive patients completed the two-years follow-up. The presence of depression was evaluated with the Primary Care Evaluation of Mental Disorders (PRIME-MD) and its severity with the Hospital Anxiety and Depression Scale (HADS). Evaluations were collected at baseline, when GRACE-score was calculated, and at 1, 2, 4, 6, 9, 12 and 24-months follow-ups.ResultsForty-two patients (16.7%) developed a second cardiac event and, of these, eighteen (42.9%) had a previous depressive episode. At Cox Regression, controlling for confounding clinical variables (e.g. GRACE-score), developing a first-ever depressive episode was a significant risk factor (OR = 2.38; 95%CI = 1.11–5.14; P = 0.027) whereas baseline anxiety was protective (OR = 0.56; 95%CI = 0.38–0.81; P= 0.002). The latter, moreover, moderated the effect of incident depression on new cardiac events.ConclusionOur results confirm the well-established detrimental effect of depression on cardiac prognosis and suggest clinicians to keep in mind anxious symptoms when facing a patient at his/her first ACS.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Prevalence of depressive disorders in andalusia: Results from the PISMA-ep study

IntroductionDepressive disorders are the most prevalent mental diseases and they cause a major impact in our society.ObjectivesThe objective of this study is to establish the prevalence of depressive disorders in Andalusia.AimsThe aim is to provide useful information regarding this prevalent and disabling condition, in order to contribute to its prevention and treatment.MethodsOur results proceed from the PISMA-ep study, undertook in Andalusia. In this cross-sectional community based study, 4507 participants between 18 and 75 years of age were interviewed by fully trained professionals. The main diagnostic tool was the Spanish version of the MINI Neuropsychiatric International Interview.ResultsOur sample consists of 4507 participants. 50.9% of them were females. Mean age was 42.8 years. The estimated one-month prevalence of any mood disorder was 7.9% (7.1–8.6). The estimated one-month prevalence of major depression was 6, 4% (5.6–7.1). The prevalence of the other measured depressive disorders were as follows: Recurrent depressive episode: 3.7% (3.2–4.3), Melancholic depression: 3% (2.5–3.5), Severe depressive episode with psychotic symptoms: 1.4% (1.1–1.8).ConclusionsThe PISMA-ep is the first large mental health epidemiological study ever developed in the largest region of Spain. The results obtained in this region show a higher prevalence of depressive disorders in Andalusia, when compared with prior studies that used a nationally representative sample (i.e. the ESEMeD study). The reasons for this higher prevalence are yet to be explored.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Determining the cut-off for recurrent depressive episode to predict diagnostic conversion from unipolar depression to bipolar disorder: 5-year retrospective study in one university hospital

ObjectivesThe aim of this study was to determining the cut-off for recurrent depressive episode to predict diagnostic conversion from unipolar depression to bipolar disorder by means of retrospective reviews of medical records.MethodsThe medical records of 250 patients with a diagnosis of major depressive disorder for at least 5 years were retrospectively reviewed for this study. We reviewed DSM-IV diagnosis and detailed clinical information at the index admission with assessments made every year after discharge to determining the cut-off for recurrent depressive episode to predict diagnostic conversion from unipolar depression to bipolar disorder.ResultsReceiver operating characteristic curve analysis indicated cut-off scores for recurrent depressive episode of more than three times (area under curve = 0.647, sensitivity = 0.435, specificity = 0.819, positive predictive value = 0.351, negative predictive value = 0.865).ConclusionsThese findings suggest that it could predict the best diagnostic conversion from unipolar depression to bipolar disorder when depressive episodes are recurrent more than three times. Based on these findings, it will be able to promote the accuracy of diagnosis and the efficiency of treatment.Disclosure of interestThe authors have not supplied their declaration of competing interest.