Mixed states: the most common outpatient presentation of bipolar depressed adolescents?

BACKGROUND: The purpose of this study was to determine the rate of bipolar disorder in adolescent outpatients presenting with DSM-IV major depressive episode (MDE) and, among the bipolar group, to find out what proportion were in a mixed state.
METHODS: 247 MDE Hispanic adolescents presenting to a community mental health clinic received structured screens for hypomania/mania by history. One hundred met the criteria for bipolar I or II disorder, depressed. Patients meeting the full DSM-IV criteria for both MDE andhypomania/mania simultaneously for at least 1 continuous week during the index episode were classified as being in a mixed state.
RESULTS: One hundred of the 247 adolescents were bipolar (40.5%). Of these bipolars, 58 (58.0%) were boys. The mean age of the bipolar patients was 14.6 (+/-1.5) years. Eighty-two (82.0%) were in a mixed state. Of those in mixed states, 46 (56.1%) were boys, 45 (54.9%)had psychotic features, 40 (48.8%) had family histories of either major depressive disorder or of bipolar disorders, 26 (31.7%) had family histories of bipolar disorder, 55 (67.1%) had suicidal ideation and 42 (51.2%) had a history of a physically self-destructive act such as wrist cutting or overdoses. DISCUSSION: The mixed state was the most common presentation for bipolar adolescents who were in the midst of an MDE at the time of presentation to a mental health clinic. Such presentation dictates different treatments. Although this clinic caters to Hispanic youth with relatively severe affective illness, we submit that our data can be generalized to other settings in light of the fact that the unavailability of psychiatric beds for such destitute patients is driving them to ambulatory clinics. To the best of our knowledge, this is the first report of such a high prevalence of mixed states in adolescent bipolar patients evaluated in the course of routine clinical practice in an outpatient setting.