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Evidence-Based Definitions of Bipolar-I and Bipolar-II Disorders

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Evidence-Based Definitions of Bipolar-I and Bipolar-II Disorders View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by RERO DOC Digital Library Eur Arch Psychiatry Clin Neurosci (2013) 263:663–673 DOI 10.1007/s00406-013-0393-4 ORIGINAL PAPER Evidence-based definitions of bipolar-I and bipolar-II disorders among 5,635 patients with major depressive episodes in the Bridge Study: validity and comorbidity J. Angst • A. Gamma • C. L. Bowden • J. M. Azorin • G. Perugi • E. Vieta • A. H. Young Received: 15 May 2012 / Accepted: 17 January 2013 / Published online: 31 January 2013 Ó Springer-Verlag Berlin Heidelberg 2013 Abstract The definitions of bipolar-I (BP-I) and bipolar- with major depressive episodes from 18 countries (Europe, II (BP-II) disorders are currently under revision by the North Africa, Near East and Far East) leading psychiatrists APA and by the WHO. We provide evidence of a revised in each country assessed a pre-specified group of symp- set of criteria for bipolar disorders and major depressive toms, illness course, family history and duration of epi- disorder (MDD) which could serve to strengthen the con- sodes; these data allowed tests of several definitions of struct and predictive validity of both disorders and enable bipolarity. The primary revised specifier diagnosis of BP-I more incisive studies of treatments and courses of both disorder included manic episodes based on an additional disorders. In the diagnostic Bridge Study of 5,635 patients category A criterion (increased activity/energy) and did not apply any exclusion criteria. The revised BP-II disorders included hypomanic episodes of 1–3 days. Family history and illness course validators (history of mania/hypomania The study was conducted for the Bridge Study Group. among first degree relatives, 2 or more lifetime episodes and first symptoms having occurred before age 30) dis- J. Angst (&) Á A. Gamma criminated clearly between patients with bipolar-I or Zu¨rich University Psychiatric Hospital, Lenggstrasse 31, bipolar-II disorders meeting bipolarity specifier criteria and P.O. Box 1931, 8032 Zurich, Switzerland e-mail: [email protected] those with MDD. Specifier definitions provided better discrimination between MDD and the two bipolar sub- A. Gamma e-mail: [email protected] groups. Patterns of concurrent comorbidities also differed significantly between patients meeting criteria for MDD C. L. Bowden compared with those meeting bipolar specifier criteria. University of Texas Health Center, San Antonio, TX, USA Comorbidity patterns differed between bipolar-I and e-mail: [email protected] bipolar-II patients. This study provides evidence for the J. M. Azorin validity of modified (specifier) BP-I and BP-II definitions Hoˆpital de Sainte-Marguerite, Marseille, France that incorporate illness course and family history which e-mail: [email protected] reduce ambiguities of major depressive episodes between G. Perugi bipolar-I and bipolar-II disorders and MDD. University of Pisa, Pisa, Italy e-mail: [email protected] Keywords Bipolar-II Á Bipolar-I Á Hypomania Á Definitions Á Validity Á Comorbidity E. Vieta Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain e-mail: [email protected] Introduction A. H. Young Imperial College, London, UK The diagnostic classification of mood disorders is in a state e-mail: [email protected] of flux. Three recent epidemiological studies from both 123 664 Eur Arch Psychiatry Clin Neurosci (2013) 263:663–673 Europe and the United States [1–3] which applied criteria Methodology for bipolarity under the diagnostic threshold of DSM-IV and ICD-10 have reported that over 40 % of persons with Sample and assessment major depressive episodes meet modified criteria for bipolar disorders (BDs). With the exception of the Zurich The methodology of the Bridge Study has been described Study [4], most psychiatric epidemiological data were in detail [5]. In summary, it is a cross-sectional diagnostic collected with instruments tailored to the current diagnostic investigation of 5,635 depressed patients conducted in 18 manuals (e.g. the CIDI), which did not include sub- countries in Europe, Asia and North Africa between April threshold psychopathology. 2008 and May 2009. Community- and hospital-based In the diagnostic Bridge Study [BDs: Improving Diag- psychiatrists recruited consecutively all adult patients nosis, Guidance, and Education] of 5,635 patients from 18 seeking treatment with a diagnosis of MDE according to countries presenting for treatment with major depressive DSM-IV criteria [7]. At this evaluation, participating psy- episodes, the duration and symptoms of mania were chiatrists completed a questionnaire on patients’ clinical assessed using a descriptive, bottom-up approach which features, sociodemographic variables, diagnosis, medical allows testing of multiple definitions of bipolarity. A first history, treatment and simultaneously comorbid psychiatric article of the Bridge Study compared the validity and disorders. Separate sections on hypomania/mania, and the comorbidity of DSM-IV definitions of bipolarity with a MINI International Neuropsychiatric Interview (MINI ‘‘specifier’’ definition that adds increased activity as a gate DSM-IV) diagnostic interview [8], were applied. These criterion and eliminates exclusions associated with use of methods enabled a diagnosis of BD to be assigned, using an antidepressant or other medical conditions [5]. A second two different diagnostic algorithms: DSM-IV-TR and the article assessed the validity of the diagnostic criteria for bipolarity specifier [5, 7]. Patients meeting all inclusion mania/hypomania [6], that is, gate questions, duration of criteria except for those for BP-I or BP-II were classed as episodes, number of symptoms and exclusions criteria. having MDD. Concurrent comorbid conditions were also This analysis compares patients with bipolar-I (BP-I) or assessed by the MINI [8]. The study was carried out by bipolar-II (BP-II) disorders with patients with major Sanofi-Aventis in co-operation with an advisory board. depressive disorders (MDD) defined by DSM-IV versus those defined by evidence-based bipolar specifier criteria Definitions of subgroups of mood disorders and consideration of concurrent comorbidities [1]. We also consider the relevance of these results for the diagnosis and Table 1 presents the DSM-IV definitions for BP-I and BP- classification of both BDs and MDDs, as well as their II disorders and the specifier definitions (S) for bipolarity implications for future studies and the clinical management (BP-I-S and BP-II-S); the specifier criteria included of these discrete disorders. hypomanic episodes of 1 or more days, added increased Table 1 Definitions of BP-I and BP-II disorders DSM-IV BP-I BP-I-S DSM-IV BP-II BP-II-S (specifier) (specifier) Distinct period (days) 7? days 7? days 4? days 1? days A.1. Elated/irritable mood ?? ? ? 2. Increased activity or energy -? - ? B. Seven symptoms 3?/4? 3?/4? 3?/4? 3?/4? C. Symptoms not meeting mixed episode Not assessed - Not assessed – D. Marked impairment or hospitalisation ?? - - or psychotic Marked impairment - or hospitalisation E. Episode not due to somatic treatment ?- ? - Criterion A2: new valid gate question (see Bridge Study paper on diagnostic criteria [6]) Criterion B: 3?/4? symptoms as in DSM-IV mania Criterion C: not assessed in the Bridge Study Criterion D: psychotic symptoms of mania were not assessed in the Bridge Study Criterion E: not applied on the basis of results of paper on diagnostic criteria [6] 123 Eur Arch Psychiatry Clin Neurosci (2013) 263:663–673 665 activity/energy as a gate question in addition to elated disorders but also yielded stronger differences between mood or irritability and did not apply the exclusion crite- bipolar and MDD-S disorders, therefore providing rion E of DSM-IV-TR (manic/hypomanic episode not due improved validity compared with DSM-IV diagnoses. to the direct physiological effects of a substance or a Removing ‘‘sub-threshold’’ bipolars from the DSM-IV general medical condition). The Bridge Study did not MDD group led to substantive decreases in the rates of assess concurrent mixed syndromes and psychotic symp- bipolar characteristics among MDD-S patients. For exam- toms of mania. All DSM-IV MDE patients without a BP-I ple, family history for mania decreased from 13.7 to 6.2 %. or BP-II diagnosis were classified as having MDD or Similar changes occurred among MDD-S defined patients MDD-S, respectively. for illness course variables: age at onset, number of epi- sodes, illness progression and seasonality. Statistical methods Concurrent comorbidity of BP-I, BP-II and MD The association between an assigned diagnosis of MDD or disorders BD according to two sets of diagnostic concepts was measured by odds ratios. As validators we used demo- Comorbidity patterns differed markedly between DSM-IV graphic, family history, illness course, as well as clinical BP-I and BP-II patients (Table 3): BP-II patients had sig- and comorbidity characteristics. Stepwise multiple logistic nificantly greater comorbidity with most subgroups of regression analyses were then conducted on those variables anxiety disorders, except panic disorder and social phobia. which proved significant in the bivariate analyses. Comorbidity rates for substance use disorders were similar for BP-I and BP-II patients. Compared to DSM-IV MDD, patients with DSM-IV BP- Results I did not differ in comorbidity for any of the assessed other disorders. Only suicide attempters were more common BP-I and BP-II comparisons with MDD among BP-I patients (35.6 vs. 27.1 %) among MDD patients. DSM-IV BP-II patients showed significant Table 2 compares the three subgroups of major mood comorbidity with anxiety disorders (especially OCD, panic disorders defined by the criteria listed in Table 1. DSM-IV with agoraphobia and social phobia) and binge eating but classified 12.2 % of MDE patients as having BP-I, 3.8 % not with suicide attempts (Table 2).
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