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

142 F. Benazzitreatment, were interviewed. MDD and MDD superimposed on dysthymicdisorder were combined in one group (Angst et al., 2000; Judd and Akiskal,2000). No psychopharmacotherapy before evaluation avoided the inclusion ofantidepressant-induced mixed states (Akiskal and Pinto, 1999). Current substanceabuse and patients with severe personality disorder were not included (Benazzi,2000i), as this would confound the diagnosis of BP-II and mixed states (Akiskalet al., 2000). Clinically significant general medical illness and dementia patientswere not included. All patients were interviewed during the first visit with theSCID-CV. The SCID-CV is partly semistructured and is based on clinical evaluation(not on simple yes/no answers to structured questions). Clinical evaluationby clinicians trained in BP-II diagnosis using semistructured interviews resultedin more correct diagnoses than strict structured interviewing (Dunner and Tay,1993;Brughaet al., 2001). All patients were systematically SCID-CV-interviewedfor a history of manic/hypomanic episodes, and for DSM-IV hypomanic symptomsduring the index MDE. The SCID-CV-structured question on racingthoughts was supplemented by the Koukopoulos and Koukopoulos’ definition(1999) of crowded thoughts (head continuously full of ideas that the patient isunable to stop). The SCID-CV skip-out instruction of the stem question aboutpast hypomanic mood was not followed, as a negative answer would not allowassessment of the other hypomanic symptoms. It was shown (Benazzi andAkiskal, 2003a) that systematic assessment of all past hypomanic symptomsincreased the frequency of BP-II diagnoses, as overactivity was easier to remember(by patient and family members/close friends) than hypomanic mood (diagnosisof hypomania always required hypomanic mood, which was easier toremember after having remembered overactivity). A history of mania/hypomaniawas always investigated soon after having made the diagnosis of MDE, before theassessment of study variables, to avoid a possible bias related to knowledge ofindicators of bipolarity. BP (I þ II) family history was investigated with the FamilyHistory Screen (Weissman et al., 2000), a structured interview for psychiatrichistory of first-degree relatives.Depressive mixed state (DMX) was defined as an MDE plus more than twoconcurrent hypomanic symptoms, following Benazzi and Akiskal (2001). Themore clinically useful definition of DMX was found to be one based on aminimum number of hypomanic symptoms(three)duringMDEversusonebased on the combination of specific hypomanic symptoms, by multivariateanalyses (Benazzi, 2002e, 2003b). Hypomanic symptoms during the MDE lastedat least 1 week, appeared during the MDE, and were present at the time of theinterview.The DSM-IV 4-days’ minimum duration of hypomania for BP-II diagnosis(a cut-off not based on data: Dunner, 1998) was not followed. Instead, at least 2