Mania and bipolar depression: complementing not opposing poles-a post-hoc analysis of mixed features in manic and hypomanic episodes

Christoph Born; Heinz Grunze; Robert M Post; Lori L Altshuler; Ralph Kupka; Susan L McElroy; Mark A Frye; Trisha Suppes; Paul E Keck; Willem A Nolen; Lars Schaerer

doi:10.1186/s40345-021-00241-5

Mania and bipolar depression: complementing not opposing poles-a post-hoc analysis of mixed features in manic and hypomanic episodes

Int J Bipolar Disord. 2021 Nov 16;9(1):36. doi: 10.1186/s40345-021-00241-5.

Authors

Christoph Born^{1

2}, Heinz Grunze^{3

4}, Robert M Post^{5

6}, Lori L Altshuler^{7

8}, Ralph Kupka⁹, Susan L McElroy^{10

11}, Mark A Frye¹², Trisha Suppes^{13

14}, Paul E Keck^{10

11}, Willem A Nolen¹⁵, Lars Schaerer¹⁶

Affiliations

¹ Paracelsus Medical University, Nuremberg, Germany.
² Psychiatrie Schwäbisch Hall, Ringstrasse 1, 74523, Schwäbisch Hall, Germany.
³ Paracelsus Medical University, Nuremberg, Germany. heinz.grunze@icloud.com.
⁴ Psychiatrie Schwäbisch Hall, Ringstrasse 1, 74523, Schwäbisch Hall, Germany. heinz.grunze@icloud.com.
⁵ Bipolar Collaborative Network, Bethesda, MD, USA.
⁶ Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, DC, USA.
⁷ Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
⁸ Department of Psychiatry, VA Greater Los Angeles Healthcare System, West Los Angeles Healthcare Center, Los Angeles, CA, USA.
⁹ Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
¹⁰ Lindner Center of HOPE, Mason, OH, USA.
¹¹ Biological Psychiatry Program, University of Cincinnati Medical College, Cincinnati, OH, USA.
¹² Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA.
¹³ Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA.
¹⁴ V.A. Palo Alto Health Care System, Palo Alto, CA, USA.
¹⁵ Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
¹⁶ Department of Psychiatry and Psychotherapy Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.

Abstract

Background: Depending on the classification system used, 5-40% of manic subjects present with concomitant depressive symptoms. This post-hoc analysis evaluates the hypothesis that (hypo)manic subjects have a higher burden of depression than non-(hypo)manic subjects.

Methods: Data from 806 Bipolar I or II participants of the Stanley Foundation Bipolar Network (SFBN) were analyzed, comprising 17,937 visits. A split data approach was used to separate evaluation and verification in independent samples. For verification of our hypotheses, we compared mean IDS-C scores ratings of non-manic, hypomanic and manic patients. Data were stored on an SQL-server and extracted using standard SQL functions. Linear correlation coefficients and pivotal tables were used to characterize patient groups.

Results: Mean age of participants was 40 ± 12 years (range 18-81). 460 patients (57.1%) were female and 624 were diagnosed as having bipolar I disorder (77.4%) and 182 with bipolar II (22.6%). Data of 17,937 visits were available for analyses, split into odd and even patient numbers and stratified into three groups by YMRS-scores: not manic < 12, hypomanic < 21, manic < 30. Average IDS-C sum scores in manic or hypomanic states were significantly higher (p < .001) than for non-manic states. (Hypo)manic female patients were likely to show more depressive symptoms than males (p < .001). Similar results were obtained when only the core items of the YMRS or only the number of depressive symptoms were considered. Analyzing the frequency of (hypo)manic mixed states applying a proxy of the DSM-5 mixed features specifier extracted from the IDS-C, we found that almost 50% of the (hypo)manic group visits fulfilled DSM-5 mixed features specifier criteria.

Conclusion: Subjects with a higher manic symptom load are also significantly more likely to experience a higher number of depressive symptoms. Mania and depression are not opposing poles of bipolarity but complement each other.

Keywords: Bipolar disorder; Depression; Hypomania; Mania; Mixed states.