Re labeling Depressive Symptoms as Manic Symptoms by Fiat

They look alike.  Madonna must really be a goat.

Another cartoonishly mischaracterized study described in a journal article was recently published in the Journal of Affective Disorders.  One of the editors of this journal is Hagop Akiskal  (I have discussed my opinion of Dr. Hagop Akiskal’s work in a previous blog post).  The article's title is Prevalence and clinical significance of subsyndromal manic symptoms, including irritability and psychomotor agitation, during bipolar major depressive episodes.  


The authors are Lewis L. Judd, Pamela J. Schettler, Hagop Akiskal [the very same], William Coryell, Jan Fawcett, Jess G. Fiedorowicz , David A. Solomon, and Martin B. Keller.

These authors suggest that the presence of something that they label as subsyndromal manic symptoms (that is, symptoms that they believe are the same as those that are usually seen in mania episodes but which are “below the threshold for mania" - whatever that means) are seen in the major depressive episodes (MDE’s) that are also characteristic of bipolar disorder.  

For those unfamiliar, patients with true bipolar disorder have both manic and major depressive episodes, obviously at different times, that are separated by relatively long periods of normal moods called euthymia.

They discuss how some other authors reported that “the most common manic symptom during bipolar MDEs was irritability (present in 73.1% of the sample), followed by distractibility (37.2%), psychomotor agitation (31.2%), flight of ideas or racing thoughts, (20.6%), and increased speech (11.0%). 

Now, of course, they do not mention that these very same symptoms are also seen in the major depressive episodes of people who never have had or will have a manic episode. And who respond to antidepressant medication and have no response at all to lithium (which is highly effective in bipolar disorder). Back in ancient history (the 70’s and 80’s) we labeled depressed patients who show such symptoms as having an agitated depression.  

Other patients with depression who are not agitated but are in fact extremely slowed down - as if on heavy sedatives - were said to have a retarded depression.  We stopped making this distinction between agitated and retarded major depressive episodes because we found that both types of depression usually respond to the same medications, (although agitated depressions seemed to have, on average, a somewhat worse prognosis for medication response).

This authors of this article state that irritable and agitated qualities of MDEs, defined in various ways, are prominent in the clinical and research literature on bipolar patients with yet another clinical entity called a mixed depressive state. In the opinion of a lot of psychiatrists like myself, a mixed state is something better characterized by the name dysphoric mania. The patient has all the symptoms of mania but, instead of the highly elevated, euphoric mood as most people in a manic state have, they feel awful.

I find I cannot use the definition of a "mixed state" that is used in the official diagnostic manual, the DSM, because it is actually impossible.  To have a mixed state according to DSM criteria, “The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day.”  This is impossible since many of the symptoms of mania and depression are polar opposites of one another, so that one cannot have both at the same time!

Anyway, the authors of the article under discussion described their study population thusly:

 “Subjects entered the NIMH CDS at five academic medical centers from 1978 to 1981, while seeking treatment for a major affective episode. Intake research diagnoses were made using Research Diagnostic Criteria (RDC) based on the Schedule for Affective Disorders and Schizophrenia (SADS) interviews ... as well as available medical and research records. Patients with bipolar disorder (type I or II) entering the CDS in a major depressive episode (MDE) were selected for these analyses. We excluded from the analysis all patients who were manic at intake (N=60), along with a small group of patients (N=5) who met DSM-IV-TR criteria for a mixed episode at intake (i.e., had full concurrent MDE plus mania).” 

Notice that they "found" and then excluded anyone that might possibly meet the contradictory DSM criteria for a “mixed state,” which is what they were talking about earlier as if it were the population of patients who were about to be described in their study, which in fact it was not.

52  of their patients were diagnosed as bipolar I and 90 were bipolar II.  As most of my readers know, I think bipolar II is a phony diagnosis in the first place. 

They go on: “Irritability and psychomotor agitation are included in the SADS interview not only as manic/hypomanic symptoms, but also in the depression section of the interview, as qualifiers for the MDE (i.e., specifically for periods of the intake MDE when the subject did not have evidence of a manic syndrome).”

“We have included these two characteristics of intake MDEs as subsyndromal manic symptoms because we believe they are clinically indistinguishable from criteria A-2 and B-6 for mania and may, therefore, represent a subtle and little recognized form of mixed bipolar MDE.”

The authors are subtly defining by fiat any depressed person with irritability as having a “subthreshold” manic symptom!  Sez who??  This is especially interesting considering that they used what is essentially a symptom checklist to make their diagnosis in the first place, and were not really using clinical judgment to tease out differences in the presentation, pervasiveness, and persistence of symptoms that may just look alike during evaluations done at one point in time.

The similar symptoms are, in fact, clinically distinguishable, precisely because the symptoms occur in different clinical states – that is, manic episodes and depressive episodes.  The authors use the word “may” in the sentence about the symptoms being a little recognized form of mixed bipolar, and then proceed entirely from the assumption that they are just that. 

To really sort this out, maybe they should have compared a sample of patients with bipolar depressive episodes to patients with unipolar depressive episodes (patients who get depressive episodes but not manic episodes).  But of course, if these authors found these symptoms in unipolar depressives, they could easily redefine the unipolars as bipolars because of the symptoms.  


Voila! Almost anyone who has a depressive episode is immediately re-categorized as bipolar!  Because they define it that way.

Actually, retarded depression is more common in bipolar patients than agitated depression.  

About the only valid conclusion one can draw from the data presented in the article is that bipolar patients who have an agitated depressive episode may have a somewhat worse prognosis, and may be more likely to experience a quick shift into a manic state, than bipolar patients who have retarded depressive episodes.


Of course, we knew that decades ago.