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Background: The bipolar nature of unipolar depression with depressive mixed states (DMX) needs further validation studies. The seasonality of depressive episodes is indicated to be different between unipolar and bipolar depressions. We therefore explored the seasonal pattern of depressive episodes in unipolar depressive patients with DMX., Methods: The subjects were 958 consecutive depressive inpatients for a 6-year period. For defining DMX, previously validated operational criteria were used (2 or more of 8 manic or mania-related symptoms: flight of idea, logorrhea, aggression, excessive social contact, increased drive, irritability, racing thoughts, and distractibility). Onsets of the index depressive episodes during each of the 12 calendar months were summed up over the 6-year for bipolar depressive patients (N = 95), and unipolar depressive patients with (N = 77) and without DMX (N = 786) separately. An appropriate statistic was used for testing seasonality., Results: A significant seasonal variation with a large peak in spring was recognized in unipolar depression without DMX, while both bipolar depression and unipolar depression with DMX had a significant fall peak. The monthly distribution of depressive episodes was significantly different between unipolar depression without DMX and other 2 diagnostic categories. Similar results were obtained in separate analyses for each gender., Limitations: Further replication study using an epidemiological or outpatient sample is needed. Bipolar I and II patients were combined due to a small number of bipolar II patients in this sample., Conclusion: Unipolar depression with DMX has a seasonal pattern similar to bipolar depression. The finding provides further evidence of the bipolar nature of unipolar depression with DMX.

Background: Case observations imply that depressed patients with mixed features are of high risk for maniform switch during acute treatment., Methods: The medical records of 158 bipolar I depressives were examined with respect to mixed depressive features at admission, naturalistic medications, and maniform switch during inpatient treatment., Results: Besides pharmacological variables, the number of mixed depressive symptoms (flight of ideas, racing thoughts, logorrhea, aggression, excessive social contact, increased drive, irritability, and distractibility) at admission was associated with a higher risk for, and the acceleration of, maniform switch during inpatient treatment., Limitations: This was a retrospective study in patients receiving naturalistic treatment. The cohort was hospital based and thus not representative of the full range of bipolar affective disorder., Conclusions: In line with recent studies, our results underline the factors inherent in subjects at a higher risk of switch. Investigation of the relationships between several inherent factors and their interactions with pharmacological treatments may be important in resolving the controversy surrounding antidepressant-induced mania. Further validation studies on mixed depression are warranted.

The association between suicidality and diagnoses of mixed mania, as defined using both DSM-IV and Cincinnati criteria, was studied in 576 consecutive manic inpatients. Of the whole sample, 51 (8.9%) had suicidal ideation and 13 (2.3%) attempted suicide during the index episode. Suicidality was significantly more frequent in patients with a diagnosis of mixed mania, whether the diagnosis was made by DSM-IV or Cincinnati criteria. A multiple logistic regression analysis revealed that an additive combination of a diagnosis of mixed mania, the depression severity, and the Global Assessment of Functioning (GAF) score was significant in predicting suicidal ideation, when using the DSM-IV criteria. A diagnosis of mixed mania alone was significant in a similar analysis, when using the Cincinnati criteria. The adjusted odds ratio for a diagnosis of mixed mania to having suicidality was much higher when using the latter criteria (4.0 v 14.0). A subsequent logistic regression analysis indicated that the Cincinnati mixed mania alone, rather than an additive combination of the DSM-IV mixed mania and the depression severity, achieved the most appropriate prediction of suicidal ideation in the sample. These findings did not differ, even when suicidality was defined as having a suicide attempt during the index episode. Our finding that suicidality was more strongly associated with Cincinnati mixed mania than with DSM-IV mixed mania is probably due to that suicidal patients who do not meet DSM-IV criteria for mixed mania are classified into mixed mania, or/and that the depressive syndrome, related to suicidality, is more appropriately assessed among manic patients, when using the Cincinnati criteria. There was no evidence that marital status, employment, a lifetime history of alcohol or substance abuse, or a history of suicide attempts before the index episode was significantly associated with suicidality in the sample. Manic patients with suicidality may have a greater severity of residual depressive symptoms at discharge.

Objective: There are no factor analytic studies specifically including symptoms representative of depressive inhibition among manic patients, although Kraepelin described several mixed affective states with depressive inhibition. There is controversy as to whether atypical manic features such as aggression, psychosis, and depression are likely to coexist among manic patients. The authors' goal was to examine this controversy., Method: They used a standardized instrument to assess the presence or absence of 37 psychiatric symptoms in 576 consecutive inpatients who were diagnosed as having DSM-IV manic episode, nonmixed or mixed., Results: A principal-component analysis followed by varimax rotation extracted seven independent interpretable factors (depressive mood, irritable aggression, insomnia, depressive inhibition, pure manic symptoms, emotional lability/agitation, and psychosis) that were relatively stable across several patient groups. A subsequent cluster analysis identified four phenomenological subtypes underlying acute mania: pure, aggressive, psychotic, and depressive (mixed) mania. Several variables, including gender, suicidality, and outcome of treatments, significantly differentiated the subtypes., Conclusions: In patients with mania, depressive inhibition may be a salient syndrome independent of depressive mood, lending some support to Kraepelin's classification of mixed manic states on the basis of the permutations of three elements-thought disorder, mood, and psychomotor activity. Depressive inhibition, together with depressive mood and emotional lability/agitation, appears to be an important phenomenological element of mixed states. Atypical manic features such as aggression, psychosis, and depression are not likely to coexist, but they are likely separately to characterize several different subtypes potentially underlying acute mania.

Replies to comments made on an article about symptom factors and clinical subtypes in mania. Atypical mania features such as aggression, psychosis and depression which are likely to separately characterize several manic subtypes; Deviations in the mixed subtype by factors called depressive mood and psychomotor/though inhibition.