Research reportClinical subtypes of bipolar mixed states:: Validating a broader European definition in 143 cases
Introduction
With few exceptions (Winokur et al., 1969, Kotin and Goodwin, 1972, Himmelhoch et al., 1976a, Akiskal and Puzantian, 1979, Nunn, 1979, Krishnan et al., 1983), bipolar mixed states were relatively neglected during the quarter century between 1960–1985. A momentum of research seems to have developed over the past decade (McElroy et al., 1992), giving rise to several interesting lines of investigation. Unlike the manic forms of bipolar disorder, which are more prevalent in males, mixed states are over-represented in females (Leibenluft, 1996). The prognosis of mixed states has been reported to be worse than that of depressive and manic forms (Keller et al., 1986). Better response to anticonvulsant medication is receiving increasing support (Prien et al., 1988, Swann et al., 1997) and innovative models (Post, 1992Akiskal, 1992Gottschalk et al., 1995) of mixed states have been proposed. Despite this increasing interest, clinical characterization and boundaries of mixed states remain inadequately defined. The present investigation addresses this challange.
Section snippets
Literature review
Since Kraepelin (1907), the term “mixed state” refers to an affective condition in which symptoms of both depressive and manic polarity are simultaneously present. Along with mania and depression, mixed state represents a major phase of manic-depressive illness (Goodwin and Jamison, 1990), yet it is often misdiagnosed because of its polymorphic symptomatological presentation and is underdiagnosed because of inadequate diagnostic delimitation (Akiskal and Puzantian, 1979, Nunn, 1979). Even in
Materials and methods
From January 1990 to September 1992, we studied 143 mixed states and 118 manic subjects that were consecutively admitted to the in-patient and day-hospital services of the Psychiatry Clinic at the University of Pisa. In prior publications from our Clinic (Dell'Osso et al., 1991, Dell'Osso et al., 1993), we reported on an independent and exclusively female sample of mixed states. As the primary objective of the present investigation was to test the validity of the broadened definition of mixed
Demographic data
As expected, our mixed state group had a sex ratio of 3:5, favoring females (n=86, 60.1%); by design, the manic group was chosen to reflect the same ratio (number of females=67, 56.8%). At index observation, the mixed state and mania had similar average age (respectively: mean=37.3, SD=11.9; range 17–69 vs. mean=39.3, SD=13.3; range 16–69; t=−1.24; df=259; p=0.22), and there was also great similarity among other sociodemographic characteristics such as marital status (X2=6.81; df=4; p=0.15),
Discussion
The major asset of this investigation is that, to the best of our knowledge, this is the first attempt to systematically validate Kraepelin's clinical subtypes of mixed states in a large representative clinical population. The major limitation of the present study is that our data on family history and course characteristics are not “blind”; frankly, we do not know how to arrange this for clinicians intimately involved in the care of the psychotically ill manic and mixed bipolar patients. The
References (47)
- Akiskal, H.S., Khani, M.K. and Scott-Strauss, A. (1979) Cyclothymic temperamental disorders. Psychiatr. Clin. North Am....
- Akiskal, H.S. and Puzantian, V.R. (1979) Psychotic forms of depression and mania. Psychiatr. Clin. North Am. 2,...
- Akiskal, H.S. and Mallya, G. (1987) Criteria for the “soft-bipolar spectrum”: treatment implications. Psychopharmacol....
- Akiskal, H.S. (1992) The mixed states of bipolar I, -II, -III. Clin. Neuropsychopharmacol. 15 (Suppl. 1a),...
- Akiskal, H.S. (1994) Dysthymic and cyclothymic depressions: therapeutic considerations. J. Clin. Psychiatry. 55/4...
- American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Rev....
- American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). APA,...
- Andreasen, N.C., Endicott, J., Spitzer, R.L. and Winokur, G. (1977) The family history method using diagnostic...
- Berner, P., Gabriel, E., Katschnig, H., Kieffer, W., Koehler, K., Lenz, G. and Simhandl, C. (1983) Diagnostic criteria...
- Berner, P., Gabriel, E., Katschnig, H., Kieffer, W., Koehlert, K., Lenz, G., Nutzinger, D., Schanda, H. and Simhandl,...
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2020, Psychiatric Clinics of North AmericaCitation Excerpt :These findings suggest that irritable traits be considered as risk factors for suicidal ideation and acts, and even more so when mixed features are present. In [hypo]mania, risk of suicidal behavior has been greater among patients with mixed symptoms than without.41–43,60–67 However, in [hypo]manias with or without depressive symptoms, treatment typically is based on use of antipsychotics and mood stabilizers, which are likely to be safe by avoiding use of antidepressants.