Switching From 'Unipolar' to Bipolar II: An 11-Year Prospective Study of Clinical and Temperamental Predictors in 559 Patients

doi:10.1001/archpsyc.1995.03950140032004

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Vol. 52 No. 2, February 1995

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Switching From 'Unipolar' to Bipolar II

An 11-Year Prospective Study of Clinical and Temperamental Predictors in 559 Patients

Hagop S. Akiskal, MD; Jack D. Maser, PhD; Pamela J. Zeller, PhD; Jean Endicott, PhD; William Coryell, MD; Martin Keller, MD; Meredith Warshaw, MS; Paula Clayton, MD; Frederick Goodwin, MD

Arch Gen Psychiatry. 1995;52(2):114-123.

Abstract

Background
Given the therapeutic and prognostic importance of the unipolar-bipolardichotomy, predicting which patients will become bipolar subsequentto index diagnosis of major depressive disorder (MDD) is ofparamount clinical significance. We sought to characterize theprofile of patients with MDD who would convert to the more subtlebipolar subtype (known as BPII) on the basis of clinical andpersonality variables obtained during MDD episodes.

Methods
A total of 559 patients, comprehensively evaluated with theSchedule of Affective Disorders and Schizophrenia and "unipolar"MDD at entry, were administered 17 self-report personality measures.Hypomanic and manic episodes were systematically recorded overa prospective observation period of up to 11 years. We compared48 converters to BPII (8.6%) with 22 converters to bipolar I(BPI) (3.9%) and the remaining larger group of unipolar patients.

Results
Except for greater acuteness, severity, and psychotic symptomatology,BPI converters were essentially similar to MDD nonconverters.By contrast, BPII converters were robustly distinguished fromthose with MDD who remained unipolar on the basis of self-reportmeasures along the newly derived factors of Mood Lability, Energy-Activity,and Daydreaming. This profile was associated with early ageat onset of MDD and pleomorphic psychopathology beyond the usualaffective realm, high rates of substance abuse, as well as educational,marital, and occupational disruption and minor antisocial actsprior to discrete hypomanic episodes. Overall, BPII switchershad a more protracted and tempestuous course with shorter wellintervals. "Habitual self" descriptions of temperamental instabilityduring MDD episodes provided useful clinical information forpredicting which depressed patients will switch to BPII, attaininga sensitivity of 91% for all three factors combined (23 items);Mood Lability alone (nine items) was the most specific predictor(86%), though of lower sensitivity (42%).

Conclusions
The BPII subtype is best understood by such lability intrudinginto, and possibly its accentuation during, depressive episodes,thereby creating an intimate interweaving of trait and state.Clinicians must note that the foregoing temperamental profileappears more fundamental in defining the affective dysregulationof the BPII subtype than hypomanic episodes emphasized in DSM-IV.

Author Affiliations

From the National Institute of Mental Health (NIMH) Collaborative Program on the Psychobiology of Depression (Clinical Studies) (Drs Akiskal, Maser, Endicot, Coryell, Keller, Clayton, and Goodwin and Ms Warshaw) and DataMax, Inc, Rockville, Md (Dr Zeller). For other members of the NIMH Collaborative Program on the Psychobiology of Depression, see box at the end of the article.

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