Angst J, Sellaro R, Stassen HH, Gamma A. Diagnostic conversion from depression to bipolar disorders: results of a long-term prospective study of hospital admissions

Epidemiological Research, Zurich University Psychiatric Hospital, Lenggstrasse 31, P.O. Box 68, 8029 Zurich, Switzerland.
Journal of Affective Disorders (Impact Factor: 3.38). 03/2005; 84(2-3):149-57. DOI: 10.1016/S0165-0327(03)00195-2
Source: PubMed


To analyse the time course and some risk factors for a diagnostic change from major depression to bipolar disorders (BP) over an average of 20 years from the onset of the disorders.
Patients (406) with major mood disorders hospitalised at some time between 1959 and 1963 were followed-up until 1985. The analysis also included the course prior to hospitalisation. Survival analyses and Cox regression models were applied.
A diagnostic change from depression to bipolar I occurred in about 1% of the patients per year and to bipolar II disorders in about 0.5% per year. Risk factors for a change from depression to BP-I disorder were male sex and an early onset of the disorder; risk factors for a change from depression to BP-II disorder were female sex, a later onset of the disorder and a positive family history of mania.
Across the entire lifetime, every new episode of depression brings a new risk for mania; more than half of our severe mood disorder cases became bipolars. The risk of depression developing into bipolar disorder remains constant lifelong.
The diagnostic classification of ICD-9 met RDC criteria for bipolar disorder in only 90% of cases. Part of the data collected in retrospect may be less reliable; the prospective data were only collected every 5 years from 1965 to 1985 using multiple sources; mild manifestations between the follow-ups may have been partially missed. The sample of subsequent hospital admissions for major depression and mania represents a severe group of patients and generalisations to ambulatory cases may not be possible. Not all risk factors for diagnostic conversion described in the literature could be assessed in this study.

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Available from: Alex Gamma, Dec 22, 2015
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    • "Jules Angst and others have convincingly proven that—based on epidemiologic criteria, such as family history, course, and comorbidity—up to 40% of patients with major depressive disorders diagnosed based on the DSM-IV criteria suffer from subsyndromal hypomania and should therefore be classified as bipolar spectrum disorder(Angst et al., 2011; Angst et al., 2010). As listed in Table 1, various clinical characteristics have been identified to predict bipolar spectrum disorders (Angst et al., 2005b; Dudek et al., 2013; Lapalme et al., 1997). "
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    ABSTRACT: In bipolar disorders, there are unclear diagnostic boundaries with unipolar depression and schizophrenia, inconsistency of treatment guidelines, relatively long trial-and-error phases of treatment optimization, and increasing use of complex combination therapies lacking empirical evidence. These suggest that the current definition of bipolar disorders based on clinical symptoms reflects a clinically and etiologically heterogeneous entity. Stratification of treatments for bipolar disorders based on biomarkers and improved clinical markers are greatly needed to increase the efficacy of currently available treatments and improve the chances of developing novel therapeutic approaches. This review provides a theoretical framework to identify biomarkers and summarizes the most promising markers for stratification regarding beneficial and adverse treatment effects. State and stage specifiers, neuropsychological tests, neuroimaging, and genetic and epigenetic biomarkers will be discussed with respect to their ability to predict the response to specific pharmacological and psychosocial psychotherapies for bipolar disorders. To date, the most reliable markers are derived from psychopathology and history-taking, while no biomarker has been found that reliably predicts individual treatment responses. This review underlines both the importance of clinical diagnostic skills and the need for biological research to identify markers that will allow the targeting of treatment specifically to sub-populations of bipolar patients who are more likely to benefit from a specific treatment and less likely to develop adverse reactions. Copyright © 2015. Published by Elsevier B.V.
    Full-text · Article · Jan 2015 · European neuropsychopharmacology: the journal of the European College of Neuropsychopharmacology
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    • "However, in the subanalysis that divided the conversion group into BP-I and BP-II patients, this difference in recurrent depression was significant in the BP-II, but not the BP-I, group. When the definition for recurrent major depressive episodes (43) used in the present study was applied, a significant difference was found for both the BP-I and BP-II groups in the univariate analysis, similar to Angst et al. (2005), but none in the multivariate analysis, as reported by Gan et al. (2011). Hence, the definition of 'recurrent' should be carefully considered in the interpretation of the results from relevant studies. "
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    ABSTRACT: The major aims of this study were to identify factors that may predict the diagnostic conversion from major depressive disorder (MDD) to bipolar disorder (BP) and to evaluate the predictive performance of the bipolar spectrum disorder (BPSD) diagnostic criteria. The medical records of 250 patients with a diagnosis of MDD for at least 5 years were retrospectively reviewed for this study. The diagnostic conversion from MDD to BP was observed in 18.4% of 250 MDD patients, and the diagnostic criteria for BPSD predicted this conversion with high sensitivity (0.870) and specificity (0.917). A family history of BP, antidepressant-induced mania/hypomania, brief major depressive episodes, early age of onset, antidepressant wear-off, and antidepressant resistance were also independent predictors of this conversion. This study was conducted using a retrospective design and did not include structured diagnostic interviews. The diagnostic criteria for BPSD were highly predictive of the conversion from MDD to BP, and conversion was associated with several clinical features of BPSD. Thus, the BPSD diagnostic criteria may be useful for the prediction of bipolar diathesis in MDD patients. Copyright © 2014 Elsevier B.V. All rights reserved.
    Full-text · Article · Nov 2014 · Journal of Affective Disorders
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    • "Moreover, patients with a major depressive episode and at least 2 manic/ hypomanic symptoms had higher rates of family history of bipolar I disorder (Maj et al., 2006). Lastly, patients with unipolar major depressive disorder with episodes of mixed depression are more likely than patients with episodes of non-mixed depression to convert or shift to a subsequent bipolar disorder diagnosis (Angst et al., 2005b). Therefore, identifying mixed symptoms in patients with depression now has a common lingua franca for diagnostic criteria and may aid in the proper selection of the pharmacological treatment (i.e. using mood stabilizers and possibly avoiding antidepressants (Pacchiarotti et al., 2013)). "
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    ABSTRACT: There are no self-report scales that assess manic/hypomanic symptoms in patients with depression. The aim of this study was to explore the use of a modified screening instrument for bipolar disorder to assess current manic/hypomanic symptoms in patients with a depressive episode.Methods The study sample consisted of 188 patients with Structured Clinical Interview for DSM-IV-TR disorders (SCID) confirmed bipolar or major depressive disorder. We modified the Hypomania Checklist-32 (mHCL-32) to assess current instead of lifetime symptoms. An Exploratory Factor Analysis (EFA) was conducted to identify clusters of mHCL-32 items that were endorsed concurrently. A Latent Class Analysis (LCA) was carried out to identify groups of patients with similar mHCL-32 item endorsement patterns.ResultsThe EFA identified 3 factors: factor #1 (“elation-disinhibition-increased goal directed activity”), factor #2 (“risk-taking-impulsivity-substance use”) and factor #3 (distractibility–irritability). The LCA yielded 3 classes (2 showing manic/hypomanic features). While class #1 patients endorsed more items related to disinhibition and racing thoughts, class #2 patients recognized more items associated with irritability and substance use.LimitationsLack of an adequate gold standard measure of mixed depression to compare to, the cross-sectional design and the lack of a validation sample.Conclusions The mHCL-32 scale allowed a comprehensive and convergent delineation of hypomanic/manic symptoms in depression. Further validation of these findings is needed.
    Full-text · Article · Oct 2014 · Journal of Affective Disorders
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