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Mixed Hypomania in 908 Patients With Bipolar Disorder Evaluated Prospectively in the Stanley Foundation Bipolar Treatment Network
A Sex-Specific Phenomenon
Trisha Suppes, MD, PhD;
Jim Mintz, PhD;
Susan L. McElroy, MD;
Lori L. Altshuler, MD;
Ralph W. Kupka, MD;
Mark A. Frye, MD;
Paul E. Keck, Jr, MD;
Willem A. Nolen, MD;
Gabriele S. Leverich, MSW;
Heinz Grunze, MD;
A. John Rush, MD;
Robert M. Post, MD
Arch Gen Psychiatry. 2005;62:1089-1096.
Context The prevalence of depressive symptoms co-occurring with hypomanic symptoms has not been quantified. Whether there is a greater likelihood for women to experience mixed symptoms has not been resolved.
Objectives To determine whether mixed hypomania is observed more frequently than euphoric hypomania and whether a sex effect exists in patients with bipolar disorder.
Setting Academic research settings in the United States (4 sites) and Europe (3 sites).
Participants Subjects were enrolled in a naturalistic prospective study after providing written informed consent.
Main Outcome Measures Mixed hypomania was defined at a given visit as a Young Mania Rating Scale score of 12 or higher and an Inventory of Depressive Symptomatology–Clinician-Rated Version score of 15 or higher. Given partial overlap of items from these scales, exploratory analyses were completed assessing instrument overlap affecting the findings.
Results In 908 patients, 14 328 visits over 7 years were evaluated. Patients with bipolar I disorder were significantly more likely to experience hypomania than those with bipolar II disorder. Of all 1044 visits by patients with hypomanic symptoms, 57% met criteria for mixed hypomania. The likelihood of depression was significantly greater for women during hypomania (P<.001). For women, the probability of mixed symptoms increased with the severity of hypomania and then decreased at the most severe levels of hypomania or mania. When a modified Inventory of Depressive Symptomatology–Clinician-Rated Version was evaluated by removing the 5 overlapping Young Mania Rating Scale items, a significant sex effect persisted for women (P<.001) but not for men (P = .95), owing to the elimination of the items "irritability" and "agitation."
Conclusions Mixed hypomania is common in patients with symptoms of hypomania and particularly common in women. Potential overlap of clinical symptom scales should be assessed before study of patients with bipolar disorder symptoms is undertaken.
Author Affiliations: Bipolar Disorder Research Program, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas (Drs Suppes and Rush); Biostatistics Core, University of California Neuropsychiatric Institute, Los Angeles (Dr Mintz); Mood Disorder Clinic, University of California, Los Angeles (Drs Altshuler, and Frye); Psychopharmacology Research Program, Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio (Drs McElroy and Keck); Altrecht Institute for Mental Health Care, Utrecht, the Netherlands (Dr Kupka); General Clinical Research Center and Mental Health Care Line, Cincinnati Veterans Affairs Medical Center, Cincinnati (Dr Keck); Department of Psychiatry, University Hospital Groningen, Groningen, the Netherlands (Dr Nolen); Biological Psychiatry Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Md (Ms Leverich and Dr Post); Department of Psychiatry, University of Munich, Munich, Germany (Dr Grunze).
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