Posted by jrbecker on February 11, 2005, at 11:57:06
Journal of Affective Disorders
Volume 84, Issues 2-3 , February 2005, Pages 127-132
Bipolar Depression: Focus on Phenomenology
doi:10.1016/j.jad.2004.01.017
Copyright © 2004 Published by Elsevier B.V.
Research report
Bipolar II vs. unipolar depression: psychopathologic differentiation by dimensional measures
Elie G. Hantouche , a, , and Hagop S. Akiskalba Adult Psychiatry, Mood Center, Psychiatry Department, Pitiè-Salpêtrière Hôpital, 47 Bd de l'Hôpital, 75013, Paris, France
b International Mood Center, University of California at San Diego, La Jolla, CA, USAReceived 15 October 2003; accepted 15 January 2004. Available online 23 June 2004.
Abstract
Background: Clinical presentations of depression in bipolar disorder are varied, inconsistent and often confusing. Most previous studies have focused on bipolar I (BP-I). Given that bipolar II (BP-II) is the more common bipolar phenotype, which is often confused with unipolar (UP), the aim of the current analyses is to delineate the symptomalogic differences between BP II vs. UP MDD in a large national sample. Methods: The data derived from the French National EPIDEP study (n=452 DSM-IV major depressives), subdivided into BP-II (n=196) and UP (n=256). The BP II group included major depressives with both spontaneous and antidepressant-associated hypomania based on our finding of similarity in rates of familial bipolarity in the two subgroups. At index presentation, depression was assessed by the clinician (using HAM-D and the Rosenthal Atypical Depression Scale) and by the patient (using the Multi-Visual Analog Scale of Bipolarity, MVAS-BP). Principal component analyses (PCA with varimax rotation) were conducted on HAM-D and MVAS-BP in the total population and separately in BP-II and UP. We performed inter-group comparative tests (UP vs. BP-II) on factorial scores derived from PCAs and correlation tests between these factorial scores. Results: The PCA on "HAM-D+Rosenthal scale" showed the presence of nine major factors: F1-2 "weight changes", F3-4 "sleep disturbances", F5 "sadness–guilt", F6 "retardation–fatigue", F7 "somatic", F8 "diurnal variation" and F9 "insight–delusion". The PCA on MVAS-BP revealed the presence of eight principal components: F1 "psychomotor retardation", F2 "central pain", F3 "somatic", F4 "social contact", F5 "worry", F6 "loss of interest", F7 "guilt" and F8 "anger". Despite uniformity in global intensity of depression, significant differences were observed as follows: higher score on "psychomotor retardation" (p=0.03), "loss of interest" (p=0.057) and "insomnia" (p=0.05) in the UP group, and higher score on "hypersomnia" (p=0.008) in the BP-II group. Correlation analyses between clinician- and self-rating revealed the presence of higher number of significant coefficients in the UP vs. BP-II group (p≤0.001). Limitation: A three-way comparison between BP-I, BP-II and UP may have yielded somewhat different results. Conclusion: Our data indicate greater psychomotor retardation, stability and uniformity in the clinical picture of strictly defined UP depression. By contrast, bipolar II depression appeared to be characterized, despite the hypersomnic tendency, by psychomotor activation. This would indicate greater mixed features than those observed in UP. Moreover, in BP-II, there was less agreement between clinician vs. self-rating on the presence of various features of depression. Taken together, these findings explain why BP-II depression is missed by clinicians as a genuine depression.
Author Keywords: Bipolar II depression; Unipolar depression; Psychopathologic differentiation
Article Outline
1. Introduction
2. Methodology
3. Results
4. Discussion
Acknowledgements
References
1. Introduction
The debate on the clinical picture of bipolar depression is ongoing. For some, there is no difference between unipolar (UP) and bipolar (BP) depressions (Joffe et al., 1999). Previous studies, which have largely focused on bipolar I (BI-I), have suggested that psychomotor retardation is pathognomonic in comparison with UP (Akiskal, 1981; Akiskal, 1983; Akiskal and Mallya, 1987 and Mitchell et al., 2001). Other studies, which have largely derived from bipolar II (BP-II) samples, have concluded that bipolar depression has a distinct phenomenology with anxious, agitated, impulsive, irritable, and mixed features, as well as greater atypical manifestations such as reverse vegetative symptoms (Perugi et al., 1998 and Benazzi and Akiskal, 2003). In addition, hypersomnia is often considered the main sleep pathology in bipolar disorder (Detre et al., 1972 and Akiskal, 1983). The debate on these issues cannot be resolved unless bipolar I and II are considered separately (Akiskal, 1983 and Akiskal et al., 1995); and the unipolar group is "cleansed" by excluding depressives with antidepressant associated-hypomania, because the latter are familially bipolar (Akiskal et al., 2003a).
The EPIDEP French study showed that the rate of BP-II disorder nearly doubled from 21% at intake to 39.7% in a month's time, after systematic search for hypomania according to DSMIV criteria (Hantouche et al., 1998 and Allilaire et al., 2001). Without this prospective assessment of BP-II on at least two points in time, nearly 50% of all BP-II would have been misclassified as UP. In line with the reason given above, we also subsumed depressions with antidepressant-associated hypomania under BP-II. In the present analyses, we thereby succeeded to constitute appropriately defined groups of BP-II and UP patients, which enabled us to compare these groups on psychometric and phenomenological grounds.
2. Methodology
The EPIDEP is a national French multi-site study (15 sites and 48 trained investigators) conducted in a cohort of 537 patients with major depression (DSM-IV criteria). The aim of EPIDEP is to show the feasibility of validating the spectrum of BP-II. The full methodology can be found elsewhere (Hantouche et al., 1998; Akiskal et al., 2003b and Allilaire et al., 2001). From a total inclusion of 537 patients presenting a major depressive episode (DSM-IV), 493 (91,8%) completed the study (at least two visits 1 month apart). Cases presenting with BP-I disorder, with at least one manic episode (N=41) were excluded from the present analyses. Thus, the size of the current validated sample (UP+BP-II) was 452.
During the two visits, depression was assessed by the Hamilton Depression Rating Scale (21 items) plus additive Rosenthal Scale (8 items) for atypical features, and the multiple VAS of Bipolarity (MVAS-B; Ahearn and Carroll, 1996), which were filled out by patients. The definite categorization of mood disorder was obtained at the second visit according to a systematic screening of hypomania: 196 patients were ranked in the "BP-II" group (all cases with hypomania according to DSM-IV criteria; hypomania associated with antidepressant were also subsumed in this sub-population), and 256 in the "UP" sub-group, which included all the remaining patients.
Psychometric data on depression were obtained during intake (in other words, during the acute current depression). Principal component analyses (PCA) were separately conducted on the HAM-D (29 items) and the MVAS-BP (26 items), by using the varimax rotation method. Comparative tests of factorial scores of HAM-D and those of MVAS-BP were applied in UP vs. BP-II sub-groups (with a significance level at p≤0.05). Correlation tests (Pearson method) between the factorial scores of HAM-D and those of MVAS-BP were performed in the total sample, then separately in UP, and BP-II sub-populations (with significance level set at p≤0.001).
3. Results
The PCA conducted on "HAM-D+Rosenthal scale" (29 items) showed the presence of nine major factors: F1"weight loss" (two items: gastro-intestinal (GI) symptoms, weight loss), F2 "hyperphagia" (four items: weight gain, augmented appetite, hyperphagia, craving for carbohydrates), F3 "insomnia" (three items: initial, midnight and late insomnias), F4 "hypersomnia" (one item: hypersomnia), F5 "sadness–guilt" (five items: depressed mood, GI symptoms, guilt feelings, suicide thoughts, psychic anxiety), F6 "retardation–fatigue" (four items: work-activities, social withdrawal, fatigue, retardation) , F7 "somatic" (three items: general somatic symptoms, somatic anxiety, hypochondriasis), F8 "diurnal variation" (two items: diurnal variation types 1 and 2), and F9 "insight–delusion" (two items: insight, delusion).
The PCA on MVAS-BP revealed the presence of eight principal components that are clinically meaningful: F1 "psychomotor retardation" (eight items), F2 "central pain" (seven items), F3 "somatic" (three items), F4 "social contact" (three items), F5 "worry–anxiety" (two items), F6 "loss of interest" (two items), F7 "guilt" (one item) and F8 "anger" (one item).
Despite uniformity in global intensity of depression (equivalent global scores on HAM-D; Allilaire et al., 2001), significant differences (Table 1) were observed as follows: the UP group was characterized by higher score on the "psychomotor retardation," "loss of interest", and "insomnia"; by contrast, higher score on "hypersomnia" characterized the BP-II group.Correlation analyses between clinician- and self-ratings revealed in the combined UP–BP-II population the presence of significant coefficients (14 significant coefficients at p≤0.001), mainly between "sadness" and "retardation" (from HAM-D) and factors derived from MVAS-BP (Table 2).
The same analyses conducted separately in UP and BP-II sub-populations revealed the presence of higher number of significant coefficients (at p≤0.001) in the UP group: 13 vs. only 8 in the BP-II group (Table 3 and Table 4). Moreover, the "sadness" and "retardation" factors from HAM-D revealed 10 significant correlations with self-report in the UP group vs. only 5 in the BP-II group.
4. Discussion
Conservatively, it is difficult to differentiate unipolar from bipolar depressions on solely the clinical picture during acute depressive episode, without getting information about the patient's course of illness and the presence of prior hypomanic episodes (Akiskal, 1983; Akiskal et al., 1995; Angst and Preisig, 1995 and Swann, 1997). In fact, there is considerable overlap to render the two types of depression essentially indistinguishable. However, some clinical hints could help to differentiate between UP and BP depressions. For example, bipolar depressions tend to have shorter duration and are associated with greater anergy (Katz et al., 1982; Thase et al., 1992 and Himmelhoch, 1998). However, few studies separated BP-I, BP-II and related soft bipolar conditions, which may have contributed to this clinical impression of BP "retardation."
Data from past analyses in the EPIDEP study have revealed that, while clinically depressed, global depressive intensity is equivalent between UP and BP-II groups (Allilaire et al., 2001). However, the rate of certain depressive symptoms is differentially represented in the two groups: guilt feelings, suicide thoughts and psychomotor restlessness are more frequently observed in BP-II depression, and psychic anxiety and initial insomnia in the UP group. In the present analyses, we report on different clinical dimensions obtained from the HAM-D (filled out by clinicians) and the self-rated MVAS-BP. Factorial scores on dimensions such as psychomotor retardation, sleep and appetite disturbances did differentiate between UP (in which levels of retardation, loss of interest and insomnia were high) and BP-II (high level on hypersomnia, which is just one of the major features of atypical depression). These data are against prior observations that bipolar depression is globally more retarded or anergic (Akiskal, 1983; Himmelhoch et al., 1991 and Mitchell et al., 2001). In the latter studies the focus was on BP-I and not BP-II depression. In the present EPIDEP data, BP-II is activated, as if it were a mixed state, as suggested by Akiskal et al. (1995) and Benazzi and Akiskal (2003).
Hypersomnia appears more specifically related to bipolar depression, as observed in Perugi et al. (1998) in atypical depression that contained a very high rate of soft bipolar disorders. In related research (Benazzi and Akiskal, 2003), such features as irritability, racing or crowded thoughts, and inner tension characterized the mixed depressive episode, which was considered as prima facie evidence for the presence of soft bipolarity.
Interrelationships between clinician and patient ratings are rarely considered in clinical research. Our study showed more significant correlations between clinician's and patient's ratings in the UP group, than in the BP-II group, mainly on the assessment of sadness. Thus, in the UP group, the factor "sadness" from HAM-D was correlated with five factors from self-reporting vs. only two in the BP-II group. The assessment of "retardation" (clinician) and "central pain" (patient) was related only in the UP group. The discrepancy between depressive feelings, sadness and psychomotor function is then greater in BP-II (probably because of activation; Benazzi and Akiskal, 2003 and Koukopoulos and Koukopoulos, 1999). These findings suggest greater stability in the clinical picture of UP depression (greater congruency between depressive feelings and sadness, GI symptoms, guilt feelings, suicide thoughts, and psychic anxiety). By contrast, BP-II depression appeared to be characterized by "mood-incongruent" psychomotor disturbance (less retardation). However, hypersomnia, which is an atypical feature, we found more prevalent in bipolar II. Thus, clinical complexity, mood instability, and psychomotor activation despite hypersomnia would be the signatures of bipolar depression.
Bipolar depression is, by its very nature, more unstable and intense, and therefore misleading in everyday clinical practice. Many patients presenting bipolar II depression would be considered as "histrionic" or other personality disorder and the authenticity of depression would often appear questionable to the external observer. Previous data from EPIDEP (Hantouche et al., 1998) suggested that the clinical picture of BP-II disorder is best characterized by instability. This feature should be added to the clinical portrait of this disorder. Presently, clear-cut hypomania is the only cue to recognize soft bipolarity (Akiskal and Pinto, 1999); in clinical practice, it is often difficult to have access to this information (when obtained by history, hypomania is highly specific (Rice et al., 1986), but when absent, it does not rule out BP-II). Besides hypomania, the clinical interviewer should look for clinical instability of depressive manifestations and lesser conformity between clinician and patient's reporting (mainly on "sadness").
Like Dunner et al. (1976), we observed less conformity between clinician judgment and self-reporting in patients with BP-II vs. UP depression. This discrepancy should be added to other cues, such as tempestuous course, mixity, complex comorbidity, cyclothymic traits, or long-standing mood lability (Akiskal et al., 1995; Vieta et al., 1997; Hantouche et al., 1998 and Perugi et al., 1998), that are helpful to detect BP-II during acute depressive episodes, especially when at intake, history of hypomania is not obtainable.
Acknowledgements
The EPIDEP National French Study was conducted with Pr HS Akiskal as its international advisor, in collaboration with a French scientific committee which included Prs JF Allilaire (Paris), JM Azorin (Marseille), ML Bourgeois (Bordeaux) and D Sechter (Besançon). The study was coordinated by Dr EG Hantouche (Paris) and Dr L Châtenet-Duchêne (Sanofi-Syntelabo France), and supported by a unrestricted grant from Sanofi-Syntelabo France. Data management, computer monitoring and statistics were conducted by Sylia-Stat (Mrs S Lancrenon).
References
Ahearn, E.P. and Carroll, B.J., 1996. Short-term variability of mood ratings in unipolar and bipolar depressed patients. J. Affect. Disord. 36, pp. 107–115. Abstract | Abstract + References | PDF (579 K)
Akiskal, H.S., 1981. Subaffective disorders: dysthymic, cyclothymic and bipolar II disorders in the "border-line" realm. Psychiatr. Clin. North Am. 4, pp. 25–46. Abstract-EMBASE | Abstract-MEDLINE
Akiskal, H.S., 1983. The bipolar spectrum: new concepts in classification and diagnosis. In: Grinspoon, L., Editor, 1983. Psychiatry Update: The American Psychiatric Association Annual Review vol. 2, American Psychiatric Press, Washington, DC, pp. 271–292.
Akiskal, H.S. and Mallya, G., 1987. Criteria for the "soft" bipolar spectrum: treatment implications. Psychopharmacol. Bull. 23, pp. 68–73. Abstract-EMBASE | Abstract-MEDLINE
Akiskal, H.S. and Pinto, O., 1999. The evolving bipolar spectrum: prototypes I, II, III and IV. Psychiatr. Clin. North Am. 22, pp. 517–534. Abstract-EMBASE | Abstract-PsycINFO
Akiskal, H.S., Maser, J.D., Zeller, P., Endicott, J., Coryell, W., Keller, M., Warshaw, M., Clayton, P. and Goodwin, F.K., 1995. Switching from "unipolar" to bipolar II: an 11-year prospective study of clinical and temperamental predictors in 559 patients. Arch. Gen. Psychiatry 52, pp. 114–123. Abstract-EMBASE | Abstract-MEDLINE | Abstract-PsycINFO
Akiskal, H.S., Hantouche, E., Allilaire, J.F., Sechter, D., Bourgeois, M., Azorin, J.M., Chatenêt-Duchêne, L. and Lancrenon, S., 2003. Validating antidepressant-associated hypomania (BP-III): systematic comparison with spontaneous hypomania (BP-II). J. Affect. Disord. 73, pp. 65–74. SummaryPlus | Full Text + Links | PDF (86 K)
Akiskal, H.S., Hantouche, E. and Allilaire, J.F., 2003. BP-II with and without cyclothymia: "dark" and "sunny" expressions of soft bipolarity. J. Affect. Disord. 73, pp. 49–57. SummaryPlus | Full Text + Links | PDF (80 K)
Allilaire, J.-F., Hantouche, E.G., Sechter, D., Lancrenon, S., Chatenêt-Duchêne, L. and Akiskal, H.S., 2001. Frequency and clinical aspects of BP-II: data from the French multi-site study EPIDEP. Encéphale 27, pp. 149–158. Abstract-EMBASE | Abstract-MEDLINE | Abstract-PsycINFO
Angst, J. and Preisig, M., 1995. Course of a clinical cohort of unipolar, bipolar, and schizo-affective patients: results of a prospective follow-up from 1959 to 1985. Schweiz. Arch. Neurol. Psychiatr. 146, pp. 5–16. Abstract-EMBASE | Abstract-MEDLINE | Abstract-PsycINFO
Benazzi, F. and Akiskal, H.S., 2003. Refining the evaluation of bipolar II: beyond the strict SCID-CV guidelines for hypomania. J. Affect. Disord. 73, pp. 33–383.
Detre, T., Himmelhoch, J., Swartzburg, M., Anderson, C.M., Byck, R. and Kupler, D.J., 1972. Insomnia and manic-depressive disease. Am. J. Psychiatry 128, pp. 1303–1305. Abstract-MEDLINE | Abstract-PsycINFO
Dunner, D.L., Dwyer, T. and Fieve, R.R., 1976. Depressive symptoms in patients with unipolar and bipolar affective disorder. Comp. Psychiatry 17, pp. 447–451. Abstract
Hantouche, E.G., Akiskal, H.S., Lancrenon, S., Allilaire, J.F., Sechter, D., Azorin, J.M., Bourgeois, M., Fraud, J.P. and Châtenet-Duchêne, L., 1998. Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multisite study (EPIDEP). J. Affect. Disord. 50, pp. 163–173. SummaryPlus | Full Text + Links | PDF (87 K)
Himmelhoch, J.M., 1998. Social anxiety, hypomania and the bipolar spectrum: data, theory and clinical issues. J. Affect. Disord. 50, pp. 203–213. SummaryPlus | Full Text + Links | PDF (85 K)
Himmelhoch, J.M., Thase, M.E., Mallinger, A.G. and Houck, P., 1991. Tranylcypromine versus imipramine in anergic bipolar depression. Am. J. Psychiatry 148, pp. 910–916. Abstract-EMBASE | Abstract-MEDLINE | Abstract-PsycINFO
Joffe, R.T., Young, L.T. and MacQueen, G.M., 1999. A two-illness model of bipolar disorder. Bipolar Disord. 1, pp. 25–30. Abstract-MEDLINE | Full Text via CrossRef
Katz, M.M., Robins, E., Croughan, J., Secunda, S. and Swann, A.C., 1982. Behavioral measurement and drug response characteristics of unipolar and bipolar depression. Psychol. Med. 12, pp. 25–36. Abstract-EMBASE | Abstract-MEDLINE | Abstract-PsycINFO
Koukopoulos, A. and Koukopoulos, A., 1999. Agitated depression as a mixed state and the problem of melancholia. Psychiatr. Clin. North Am. 22, pp. 547–564. Abstract-EMBASE | Abstract-MEDLINE
Mitchell, P.B., Wilhelm, K., Parker, G., Austin, M.P., Rutgers, P. and Malhi, G.S., 2001. The clinical features of bipolar depression: a comparison with matched major depressive disorder patients. J. Clin. Psychiatry 62, pp. 212–216. Abstract-EMBASE | Abstract-PsycINFO
Perugi, G., Akiskal, H.S., Lattanzi, L., Cecconi, D., Mastrocinque, C., Patronelli, A., Vignoli, S. and Beni, E., 1998. The high prevalence of ‘soft’ bipolar (II) features in atypical depression. Compr. Psychiatry 39, pp. 63–71. SummaryPlus | Full Text + Links | PDF (787 K)
Rice, J.P., McDonald-Scott, P., Endicott, J., Coryell, W., Grove, W.M., Keller, M.B. and Altis, D., 1986. The stability of diagnosis with an application to bipolar II disorder. Psychiatry Res. 19, pp. 285–296. Abstract
Swann, A.C., 1997. Is bipolar depression a specific biological entity?. In: Young, L.T. and Joffe, R.T., Editors, 1997. Bipolar Disorder: Biological Models and their Clinical Applications, Marcel Dekker, New York, pp. 255–288.
Thase, M.E., Mallinger, A.G., McKnight, D. and Himmelhoch, J.M., 1992. Treatment of imipramine-resistant recurrent depression: IV. A double-blind cross-over study of tranylcypromine for anergic bipolar depression. Am. J. Psychiatry 149, pp. 195–198. Abstract-EMBASE | Abstract-MEDLINE | Abstract-PsycINFO
Vieta, E., Gasto, C., Otero, A., Nieto, E. and Vallejo, J., 1997. Differential features between bipolar I and bipolar II disorder. Compr. Psychiatry 38, pp. 98–101. SummaryPlus | Full Text + Links | PDF (346 K)
Corresponding author. Tel.: +33-1-43-25-08-07; fax: +33-1-43-25-06-35.
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