Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

139 Atypical depression and bipolar spectrumBP-II males versus UP males. Female gender was significantly associated with ADbut not with diagnosis (by logistic regression). The higher frequency of AD infemales versus males was not related to the higher frequency of AD in BP-II versusUP, but to an association between female gender and AD (Benazzi, 1999e).Findings are in line with studies showing more females than males in AD(Agosti and Stewart, 2001; Angst et al., 2002, Posternak and Zimmerman, 2002,and other studies reviewed by Angst et al., 2002).Is AD a moderate-severity depression?In a 536 MDE sample (BP-II n ¼ 241, UP n ¼ 295), severe MDE (n ¼ 219) (defined asa Global Assessment of Funtioning (GAF) scale score of 50 or less) had AD in 34.7%,and non-severe MDE had AD in 37.5% (P ¼ 0.5022; Benazzi, 1999f). No BP-II versusUP differences were found. The GAF severity cut-off of 50 followed the depressionseverity definition of Elkin et al.(1989). This finding runs against the report that AD isoften a moderate-severity depression (Kendler et al., 1996), but is in line with thereport that severe AD is not uncommon (35.6% of AD; Sullivan et al., 1998).Is there a link between depressive mixed state and AD?Depressive mixed state (defined as a BP-II and UP MDE plus more than twoconcurrent hypomanic symptoms) was significantly more common (50.0% versus20.3%) in AD versus non-AD (BP-II þ UP sample, n ¼ 87), and the associationpersisted when controlled for BP-II by logistic regression (BP-II could be aconfounding factor because it was associated with both AD and depressivemixed state). Among the DSM-IV hypomanic symptoms, AD had significantlymore talkativeness, distractibility, and psychomotor agitation (Benazzi, 2001g).In a second, larger study, depressive mixed state was highly associated with AD(odds ratio ¼ 3.1, P ¼ 0.000). UP depressive mixed state (n ¼ 35) versus BP-IIMDE (n ¼ 226) did not have a significantly different age of onset, frequency ofAD, or BP-II family history, while UP depressive mixed states versus UP nondepressivemixed state MDE (n ¼ 116) had a significantly higher frequency of BP-II family history. These findings suggest a link between BP-II and UP depressivemixed state, including a similar frequency of AD (Akiskal and Benazzi, 2003).Is there a link between female gender and AD in depressive mixed state?In a depressive mixed-state outpatient sample (n ¼ 205), female gender was significantlyassociated with atypical features (odds ratio ¼ 2.1, P ¼ 0.021; Benazzi,2003d).