Shefali Miller1, Trisha Suppes1, Jim Mintz1, Gerhard Hellemann1, Mark A Frye1, Susan L McElroy1, Willem A Nolen1, Ralph Kupka1, Gabriele S Leverich1, Heinz Grunze1, Lori L Altshuler1, Paul E Keck1, Robert M Post1. 1. From the VA Palo Alto Health Care System, Palo Alto, and the Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center, Stanford, Calif.; the Department of Psychiatry, University of Texas Health Science Center, San Antonio; the Department of Psychiatry, UCLA, Los Angeles; the Department of Psychiatry, Mayo Clinic, Rochester, Minn.; the Lindner Center of HOPE, University of Cincinnati, Mason, Ohio; University Medical Center Groningen, University of Groningen, the Netherlands; the Altrecht Institute for Mental Health Care, Utrecht, and VU University Medical Centre Amsterdam, VU University Amsterdam, the Netherlands; the Biological Psychiatry Branch, NIMH, Bethesda, Md.; the Department of Psychiatry and Psychotherapy, Paracelsus Medical University, and Christian Doppler Klinik, Salzburg, Austria; and the School of Medicine and Health Sciences, George Washington University, Washington, D.C.
Abstract
OBJECTIVE: DSM-5 introduced the "with mixed features" specifier for major depressive episodes. The authors assessed the prevalence and phenomenology of mixed depression among bipolar disorder patients and qualitatively compared a range of diagnostic thresholds for mixed depression. METHOD: In a naturalistic study, 907 adult outpatients with bipolar disorder participating in the Stanley Foundation Bipolar Network were followed longitudinally across 14,310 visits from 1995 to 2002. The Inventory of Depressive Symptomatology-Clinician-Rated Version (IDS-C) and the Young Mania Rating Scale (YMRS) were administered at each visit. RESULTS: Mixed depression, defined as an IDS-C score ≥15 and a YMRS score >2 and <12 at the same visit, was observed in 2,139 visits (14.9% of total visits, and 43.5% of visits with depression) by 584 patients (64.4% of all patients). Women were significantly more likely than men to experience subthreshold hypomania during visits with depression (40.7% compared with 34.4%). Patients with one or more mixed depression visits had more symptomatic visits and fewer euthymic visits compared with those with no mixed depression visits. DSM-5-based definitions of mixed depression (ranging from narrower definitions requiring ≥3 nonoverlapping YMRS items concurrent with an IDS-C score ≥15, to broader definitions requiring ≥2 nonoverlapping YMRS items) yielded lower mixed depression prevalence rates (6.3% and 10.8% of visits, respectively) but were found to have similar relationships to gender and longitudinal symptom severity. CONCLUSIONS: Among outpatients with bipolar disorder, concurrent hypomanic symptoms observed during visits with depression were common, particularly in women. The DSM-5 diagnostic criteria for depression with mixed features may yield inadequate sensitivity to detect patients with mixed depression.
OBJECTIVE: DSM-5 introduced the "with mixed features" specifier for major depressive episodes. The authors assessed the prevalence and phenomenology of mixed depression among bipolar disorderpatients and qualitatively compared a range of diagnostic thresholds for mixed depression. METHOD: In a naturalistic study, 907 adult outpatients with bipolar disorder participating in the Stanley Foundation Bipolar Network were followed longitudinally across 14,310 visits from 1995 to 2002. The Inventory of Depressive Symptomatology-Clinician-Rated Version (IDS-C) and the Young Mania Rating Scale (YMRS) were administered at each visit. RESULTS: Mixed depression, defined as an IDS-C score ≥15 and a YMRS score >2 and <12 at the same visit, was observed in 2,139 visits (14.9% of total visits, and 43.5% of visits with depression) by 584 patients (64.4% of all patients). Women were significantly more likely than men to experience subthreshold hypomania during visits with depression (40.7% compared with 34.4%). Patients with one or more mixed depression visits had more symptomatic visits and fewer euthymic visits compared with those with no mixed depression visits. DSM-5-based definitions of mixed depression (ranging from narrower definitions requiring ≥3 nonoverlapping YMRS items concurrent with an IDS-C score ≥15, to broader definitions requiring ≥2 nonoverlapping YMRS items) yielded lower mixed depression prevalence rates (6.3% and 10.8% of visits, respectively) but were found to have similar relationships to gender and longitudinal symptom severity. CONCLUSIONS: Among outpatients with bipolar disorder, concurrent hypomanic symptoms observed during visits with depression were common, particularly in women. The DSM-5 diagnostic criteria for depression with mixed features may yield inadequate sensitivity to detect patients with mixed depression.
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