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Objective: To estimate the frequency of mixed states in patients diagnosed with major depressive episode (MDE) according to conceptually different definitions and to compare their clinical validity., Method: This multicenter, multinational cross-sectional Bipolar Disorders: Improving Diagnosis, Guidance and Education (BRIDGE)-II-MIX study enrolled 2,811 adult patients experiencing an MDE. Data were collected per protocol on sociodemographic variables, current and past psychiatric symptoms, and clinical variables that are risk factors for bipolar disorder. The frequency of mixed features was determined by applying both DSM-5 criteria and a priori described Research-Based Diagnostic Criteria (RBDC). Clinical variables associated with mixed features were assessed using logistic regression., Results: Overall, 212 patients (7.5%) fulfilled DSM-5 criteria for MDE with mixed features (DSM-5-MXS), and 818 patients (29.1%) fulfilled diagnostic criteria for a predefined RBDC depressive mixed state (RBDC-MXS). The most frequent manic/hypomanic symptoms were irritable mood (32.6%), emotional/mood lability (29.8%), distractibility (24.4%), psychomotor agitation (16.1%), impulsivity (14.5%), aggression (14.2%), racing thoughts (11.8%), and pressure to keep talking (11.4%). Euphoria (4.6%), grandiosity (3.7%), and hypersexuality (2.6%) were less represented. In multivariate logistic regression analysis, RBDC-MXS was associated with the largest number of variables including diagnosis of bipolar disorder, family history of mania, lifetime suicide attempts, duration of the current episode > 1 month, atypical features, early onset, history of antidepressant-induced mania/hypomania, and lifetime comorbidity with anxiety, alcohol and substance use disorders, attention-deficit/hyperactivity disorder, and borderline personality disorder., Conclusions: Depressive mixed state, defined as the presence of 3 or more manic/hypomanic features, was present in around one-third of patients experiencing an MDE. The valid symptom, illness course and family history RBDC criteria we assessed identified 4 times more MDE patients as having mixed features and yielded statistically more robust associations with several illness characteristics of bipolar disorder than did DSM-5 criteria., (© Copyright 2015 Physicians Postgraduate Press, Inc.)

Objective: The study focuses on the controversial relationship between borderline personality disorder (BPD) and bipolar disorder (BD), defined according to different criteria set, in a world-wide sample of patients with a current major depressive episode (MDE)., Method: A total of 5635 patients with an MDE were enrolled in a multinational study, designed to assess varying definition of hypo/mania and familial and clinical variables associated with bipolarity. Patients with (BPD+) and without (BPD-)comorbid BPD were compared on sociodemographic, familial and clinical characteristics., Results: Five hundred and thirty-two patients (9.3%) met criteria for BPD. A diagnosis of BD was more frequent in BPD+ than in BPD- using either DSM-IVTR-modified criteria or the bipolar specifier. BPD+ were younger than BPD- depressives with regard to age and age at onset. They also showed more hypomania/mania in first-degree relatives in comparison to BPD- as well as more psychiatric comorbidity, psychotic symptoms, mixed states, atypical features, seasonality of mood episodes, suicide attempts, prior mood episodes and antidepressants-induced hypo/manic switches., Conclusion: In our sample, selected on the basis of the presence of a mood disorder, the BD-BPD connection is confirmed by the high prevalence of bipolarity in depressive patients with BPD and by the significant association with familial and clinical features classically considered as external validators of bipolarity., (© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Context: Major depressive disorder, the most common psychiatric illness, is often chronic and a major cause of disability. Many patients with major depressive episodes who have an underlying but unrecognized bipolar disorder receive pharmacologic treatment with ineffective regimens that do not include mood stabilizers., Objective: To determine the frequency of bipolar disorder symptoms in patients seeking treatment for a major depressive episode., Design: Multicenter, multinational, transcultural, cross-sectional, diagnostic study. The study arose from the initiative Bipolar Disorders: Improving Diagnosis, Guidance and Education (BRIDGE)., Setting: Community and hospital psychiatry departments., Patients: Participants included 5635 adults with an ongoing major depressive episode., Main Outcome Measures: The frequency of bipolar disorder was determined by applying both DSM-IV-TR criteria and previously described bipolarity specifier criteria. Variables associated with bipolarity were assessed using logistic regression., Results: A total of 903 patients fulfilled DSM-IV-TR criteria for bipolar disorder (16.0%; 95% confidence interval, 15.1%-17.0%), whereas 2647 (47.0%; 95% confidence interval, 45.7%-48.3%) met the bipolarity specifier criteria. Using both definitions, significant associations (odds ratio > 2; P < .001) with bipolarity were observed for family history of mania/hypomania and multiple past mood episodes. The bipolarity specifier additionally identified significant associations for manic/hypomanic states during antidepressant therapy, current mixed mood symptoms, and comorbid substance use disorder., Conclusions: The bipolar-specifier criteria in comparison with DSM-IV-TR criteria were valid and identified an additional 31% of patients with major depressive episodes who scored positive on the bipolarity criteria. Family history, illness course, and clinical status, in addition to DSM-IV-TR criteria, may provide useful information for physicians when assessing evidence of bipolarity in patients with major depressive episodes. Such an assessment is recommended before deciding on treatment.