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30-09-2013 | Mental health | Article

Multiple aspects to severe bipolar mixed states


Free abstract

medwireNews: Researchers have identified four subgroups of severe bipolar mixed states, characterized by distinct symptomatologic presentations.

The straightforward view of a mixed state as being concurrent mania and depression is an “over-simplification,” say lead study author Giulio Perugi (University of Pisa, Italy) and team.

Based on their findings in 202 patients who were referred for electroconvulsive therapy (ECT), they believe that “[a]nxiety and psychosis have a remarkable role in the definition of the clinical picture and should be considered for proper identification of the syndrome.”

Psychosis affected about 70% of the patients and partly defined three of the four subgroups, while anxiety was rarely a predominant feature but was present in all subgroups.

These were among six factors that accounted for 55.9% of the variance in clinical presentation, supporting the idea that mixed states are not characterized merely by mania and depression. When entered into a cluster analysis, the factors generated four symptom profiles with very little overlap in presentation.

Two profiles were predominantly depressive – Agitated-Irritable Mixed-Depression (31.2% of patients) and Psychotic-Retarded Mixed-Depression (31.2%) – and two were broadly manic – Psychotic Mixed-Mania (29.2%) and Anxious-Irritable-Psychotic Mixed-Mania (8.5%).

Patients with the Anxious-Irritable-Psychotic Mixed-Mania profile had anxiety, activation and psychosis, with panic/anxiety-related comorbidities and a high number of past episodes and hospitalizations. Although the least frequent, this profile was “probably the most severe in terms of global symptomatology,” write Perugi et al in the Journal of Affective Disorders.

The Psychotic Mixed-Mania group, on the other hand, had the fewest past episodes and comorbidities of all the groups.

By contrast, the Agitated-Irritable Mixed-Depression group had the highest number of previous episodes of all the symptom groups, and the most comorbidities, most notably panic/agoraphobic and eating disorders. They also had the highest number of past suicide attempts.

Patients in the Retarded-Psychotic Mixed-Depression group had motor inhibition, and psychosis with thought acceleration, in addition to depression. They had a low number of past episodes, suicide attempts, and comorbidities, but the longest duration of current episode.

The four symptom groups differed somewhat in their response to ECT, but all appeared to derive some benefit, with remission rates ranging from 0% to 27% and response rates from 64% to 82%.

“ECT seems to be effective in a substantial number of patients with severe drug resistant [mixed states] and, to our view, remains an important treatment option,” observes the team.

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013

By Eleanor McDermid, Senior medwireNews Reporter