Back to table of contents Previous article Next article Letter to the EditorFull AccessEvidence of Depressive Mixed StatesTETSUYA SATO, M.D., Ph.D., RONALD BOTTLENDER, M.D., MARCUS SIEVERS, M.D., and HANS-JÜRGEN MÖLLER, M.D., TETSUYA SATO, M.D., Ph.D., RONALD BOTTLENDER, M.D., MARCUS SIEVERS, M.D., and HANS-JÜRGEN MÖLLER, M.D., Munich, GermanyPublished Online:1 Jan 2005https://doi.org/10.1176/appi.ajp.162.1.193-aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: The article on agitated depression in bipolar depression by Mario Maj, M.D., Ph.D., et al. (1) is a considerable contribution to our understanding of the nature and clinical implications of depressive mixed states in bipolar I disorder. The authors reported that manic symptoms during a depressive episode are considerably overlapping with agitated depression in bipolar I depressives. The data also implied that bipolar I depressives with and without depressive mixed states may require differential acute therapeutic strategies and may present differential long-term outcomes.However, there are two limitations in the data presentations. First, the results on anxiety symptoms were not reported. Agitation during a depressive episode has sometimes been related to extremely severe anxiety, while many studies have reported that subjects with bipolar I depression less frequently show anxiety symptoms than unipolar depressives (2). It is important to know how three symptom clusters—agitation, mania, and anxiety symptoms—are related in bipolar I depressives. The relationship among the three symptom clusters may have led to a definitive answer to the longstanding question of whether agitation during a bipolar I depressive episode is related more to severe anxiety or to admixed manic symptoms, as the classic authors recognized it. Second, the lack of data on patients with unipolar and bipolar II depression may lead to readers' failure to take a general view of manic symptoms during a depressive episode since two separate research groups already started to observe manic symptoms during a depressive episode in both unipolar and bipolar depressives. Benazzi (3) reported that manic symptoms during a depressive episode were more frequent in outpatients with bipolar II disorder than unipolar depressive disorder. However, more than 10% of unipolar depressives had considerable manic symptoms. Our Munich study (4, 5), which included subjects with bipolar I depression as well, provided similar results. The Munich study also factor-analyzed a broad range of depressive and manic symptoms, including anxiety symptoms. In the analysis, the agitated manic factor, which is composed of psychomotor/thought excitement and irritability, was extracted separately from the anxiety factor in 95 subjects with bipolar disorder and 863 subjects with unipolar depression combined, a finding suggesting that agitation and manic symptoms compose one salient syndrome independent of anxiety in depressive disorders. Consistent with the results of Dr. Maj et al., euphoria and grandiosity did not load on our agitated manic factor.As the authors acknowledged, more appropriate treatment strategies might be developed in the future when one takes depressive mixed states into account. The therapeutic implications of depressive mixed states would be more important in patients who have not ever experienced a hypomanic or manic episode. Patients with depressive mixed states are likely to be diagnosed as suffering from unipolar depression, according to DSM-IV. However, there is some evidence suggesting that these patients have a bipolar nature in terms of age at first onset of mood disorder and family history of bipolar disorder (5, 6). Evidence of depressive mixed states, emerging in unipolar as well as bipolar I depressives, seems to necessitate a reconsideration of the DSM-IV boundary between unipolar and bipolar disorders.References1. Maj M, Pirozzi R, Magliano L, Bartoli L: Agitated depression in bipolar I disorder: prevalence, phenomenology, and outcome. Am J Psychiatry 2003; 160:2134–2140Link, Google Scholar2. Mitchell P, Wilhelm K, Parker G, Austin M-P, Rutgers P, Malhi GS: The clinical features of bipolar depression: a comparison with matched major depressive disorder patients. J Clin Psychiatry 2001; 62:212–216Crossref, Medline, Google Scholar3. Benazzi F: Depressive mixed states: unipolar and bipolar II. Eur Arch Psychiatry Clin Neurosci 2000; 250:249–253Crossref, Medline, Google Scholar4. Sato T, Bottlender R, Kleindienst N, Möller H-J: Irritable psychomotor elation in depressed inpatients: a factor validation of depressive mixed states. J Affect Disord (in press)Google Scholar5. Sato T, Bottlender R, Schröter A, Möller H-J: Frequency of manic symptoms during a depressive episode and unipolar "depressive mixed state" as bipolar spectrum. Acta Psychiatr Scand 2003; 107:268–274Crossref, Medline, Google Scholar6. Akiskal HS, Benazzi F: Family history validation of the bipolar nature of depressive mixed states. J Affect Disord 2003; 73:113–122Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByJournal of Affective Disorders, Vol. 143, No. 1-3International Journal of Psychiatry in Clinical Practice, Vol. 16, No. 2Bipolar Disorders, Vol. 10, No. 1p2Adjunctive Antidepressant Use and Symptomatic Recovery Among Bipolar Depressed Patients With Concomitant Manic Symptoms: Findings From the STEP-BDJoseph F. Goldberg, M.D.Roy H. Perlis, M.D.S. Nassir Ghaemi, M.D., M.P.H.Joseph R. Calabrese, M.D.Charles L. Bowden, M.D.Stephen Wisniewski, Ph.D.David J. Miklowitz, Ph.D.Gary S. Sachs, M.D.Michael E. Thase, M.D.1 September 2007 | American Journal of Psychiatry, Vol. 164, No. 9 Volume 162Issue 1 January 2005Pages 193-a-194 Metrics PDF download History Published online 1 January 2005 Published in print 1 January 2005

Background: The bipolar nature of unipolar depression with depressive mixed sates (DMX) needs further validation studies. The seasonality of depressive episodes is indicated to be different between unipolar and bipolar depressions. We therefore explored the seasonal pattern of depressive episodes in unipolar depressive patients with DMX.Methods: The subjects were 958 consecutive depressive inpatients for a 6-year period. For defining DMX, previously validated operational criteria were used (2 or more of 8 manic or mania-related symptoms: flight of idea, logorrhea, aggression, excessive social contact, increased drive, irritability, racing thoughts, and distractibility). Onsets of the index depressive episodes during each of the 12 calendar months were summed up over the 6-year for bipolar depressive patients (N= 95). and unipolar depressive patients with (N= 77) and without DMX (N= 786) separately. An appropriate statistic was used for testing seasonality.Results: A significant seasonal variation with a large peak in spring was recognized in unipolar depression without DMX, while both bipolar depression and unipolar depression with DMX had a significant fall peak. The monthly distribution of depressive episodes was significantly different between unipolar depression without DMX and other 2 diagnostic categories. Similar results were obtained in separate analyses for each gender.Limitations: Further replication study using an epidemiological or outpatient sample is needed. Bipolar I and II patients were combined due to a small number of bipolar II patients in this sample.Conclusion: Unipolar depression with DMX has a seasonal pattern similar to bipolar depression. The finding provides further evidence of the bipolar nature of unipolar depression with DMX. (c) 2005 Elsevier B.V. All rights reserved.

BACKGROUND:Early authors described hypomanic symptoms as mixed features in depressive episode, but this syndrome has not been sufficiently explored in previous studies.METHODS:958 consecutive depressed patients were assessed by using a standardized method in terms of 43 psychiatric symptoms at hospitalization.RESULTS:A principal component analysis, followed by varimax rotation, extracted six interpretable factors: typical vegetative symptoms, depressive retardation/loss of feeling, hypomanic syndrome, anxiety, psychosis, and depressive mood/hopelessness. The extracted factor structure was relatively stable among several patient groups. There was no evidence that the hypomanic factor was exaggerated by antidepressant pretreatments before hospitalization. Bipolar diagnoses were associated with higher scores on depressive retardation and hypomanic symptoms, and a lower score on anxiety.LIMITATIONS:Psychiatric syndromes and their interrelationships, found in the present study, may be strongly influenced by the rating instrument used. The sample of this study was depressed inpatients. The results should not be generalized for depressed outpatients or epidemiological depressed populations.CONCLUSIONS:Hypomanic symptoms, as characterized by the flight of ideas, racing thought, increased drive, excessive social contact, irritability, and aggression are a salient syndrome in acutely ill depressed patients, lending support to the factor validity of mixed depression. The symptoms may not be related to pretreatments with antidepressants, or comorbidity of substance abuse, suggesting that they reflect various natural phenomenological manifestations of depressive episodes. Anxiety is unlikely to play a major role in the core phenomenological features of mixed depression. Hypomanic symptoms during a depressive episode were more represented in bipolar disorders, which may serve for further clarifications of latent bipolarity in unipolar depression, and prediction of switch into maniform states under biological depression treatments.

The association between suicidality and diagnoses of mixed mania, as defined using both DSM-IV and Cincinnati criteria, was studied in 576 consecutive manic inpatients. Of the whole sample, 51 (8.9%) had suicidal ideation and 13 (2.3%) attempted suicide during the index episode. Suicidality was significantly more frequent in patients with a diagnosis of mixed mania, whether the diagnosis was made by DSM-IV or Cincinnati criteria. A multiple logistic regression analysis revealed that an additive combination of a diagnosis of mixed mania, the depression severity, and the Global Assessment of Functioning (GAF) score was significant in predicting suicidal ideation, when using the DSM-IV criteria. A diagnosis of mixed mania alone was significant in a similar analysis, when using the Cincinnati criteria. The adjusted odds ratio for a diagnosis of mixed mania to having suicidality was much higher when using the latter criteria (4.0 v 14.0). A subsequent logistic regression analysis indicated that the Cincinnati mixed mania alone, rather than an additive combination of the DSM-IV mixed mania and the depression severity, achieved the most appropriate prediction of suicidal ideation in the sample. These findings did not differ, even when suicidality was defined as having a suicide attempt during the index episode. Our finding that suicidality was more strongly associated with Cincinnati mixed mania than with DSM-IV mixed mania is probably due to that suicidal patients who do not meet DSM-IV criteria for mixed mania are classified into mixed mania, or/and that the depressive syndrome, related to suicidality, is more appropriately assessed among manic patients, when using the Cincinnati criteria. There was no evidence that marital status, employment, a lifetime history of alcohol or substance abuse, or a history of suicide attempts before the index episode was significantly associated with suicidality in the sample. Manic patients with suicidality may have a greater severity of residual depressive symptoms at discharge.

Background: Depressive mixed state (DMX) is understudied, although this diagnostic concept may be of clinical and theoretical importance. Our goal was to provide preliminary evidence of the inter-episode stability of DMX. The inter-episode stability is known to be an important validator for establishing a distinct clinical entity. Methods: Out of depressive patients consecutively hospitalized at our institute, those who experienced two or more hospitalizations due to discrete depressive recurrences during a 6-year period were selected. All depressive episodes were directly observed and assessed using a standardized rating instrument in terms of eight intra-episode manic symptoms (flight of idea, logorrhea, aggression, excessive social contact, increased drive, irritability, racing thoughts, and distractibility). Assessments for subsequent episodes were performed blindly to those for previous episodes within each patient. Results: The inter-episode stability of categorical DMX diagnoses and the number of intra-episode manic symptoms was moderate but significantly high. Approximately 50% of patients with DMX in the index episode obtained a DMX diagnosis in the second episode. Approximately 40% of the total variance of the number of intra-episode manic symptoms was explained by agreements across several depressive episodes. Depressive patients who experienced a diagnostic switch from unipolar to bipolar disorder had a higher frequency of DMX and a greater number of intra-episode manic symptoms in the index as well as subsequent episodes. Limitations: All consecutive patients were not followed up. Bipolar I and II patients were combined due to a small number of bipolar II patients in this sample. Conclusion: The inter-episode stability of DMX may not be so high as is required for establishing a distinct clinical entity. However, the findings strongly suggest that some depressive patients have a long-lasting liability to DMX. It is important to determine whether such a liability to DMX is mediated by affective temperaments, as was originally hypothesized by Akiskal [J. Clin. Psychopharmacol. 16 (1996) 4S–14S]. DMX may be a risk factor to the diagnostic switch from unipolar to bipolar disorder.

Reports of potential differences in psychopathological presentations between early and late-onset schizophrenia have been controversial. However, such differences in first-episode neuroleptic-naive schizophrenic patients have not been discussed. The authors evaluated symptom profiles in 473 neuroleptic-naive schizophrenic patients before and after first-admission treatments. Both before and after treatment, (1) late-onset schizophrenia had a lower score on affective flattening/social withdrawal than did the earlier-onset counterpart of the illness, even after controlling for potential secondary sources of negative symptoms; (2) systematic persecutory delusion was more severe in patients with late-onset schizophrenia; and (3) the overall effect of age of onset on the psychopathological presentations was greater than the gender-related effects, including the interaction between age of onset and gender. Consideration of late-onset schizophrenia may be important in order to develop an etiologically and clinically reasonable conceptualization of the subtypes of schizophrenia. A factor–analytical study that attempts to compare directly the structure of broad psychopathological presentations in early and late-onset schizophrenia may be a reasonable approach to investigate the longstanding unsolved controversy as to whether or not the neurobiological backgrounds underlying the psychopathological presentations are comparable.

BACKGROUND:Neurobiological studies implicate serotonergic dysfunction in suicidal behavior. Tryptophan hydroxylase (TPH), the rate-limiting enzyme in the biosynthesis of serotonin, plays a vital role in serotonin metabolism. Thus, variations in the TPH gene have been regarded as prime candidates in the susceptibility to suicidal behavior. The most widely studied genetic variations in the TPH gene, which are located in intron 7, yielded conflicting results in individual studies on suicide-related behavior.METHODS:We performed a meta-analysis on a total of 898 patients and 1179 control subjects, in addition to our local association study in consecutively recruited suicide attempters (n=147) and healthy control subjects of German descent (n=326).RESULTS:We observed a nonsignificant higher frequency of the TPH intron 7 A218 allele in our local group. The meta-analysis showed a weak yet highly significant increase in the frequency of the A218 allele (odds ratio [OR]: 1.33; 95% confidence interval [CI]: 1.17-1.50; p=.00002) and an over-representation of A-carriers (OR: 1.48; 95% CI: 1.22-1.79; p=.00005) in Caucasian suicide attempters/victims.CONCLUSIONS:Our meta-analysis provides strong evidence for an association of suicide-related behavior with an A218 single-nucleotide polymorphism in the TPH gene in Caucasians. Because this variation do not seem to alter functional properties of the TPH gene or protein, functional variations remain to be identified and subsequently tested for association with suicide-related behavior.

OBJECTIVE:To explore the stability of diverse manic presentations across manic recurrences.METHOD:A total of 253 bipolar patients who experienced two or more hospitalizations, because of consecutive manic (or mixed) episodes, during a 20-year period were included. All patients had second hospitalizations with an mean interval of 773 days, while 126 and 91 patients had third and fourth hospitalizations with mean intervals of 1559 and 2237 days from the index hospitalization, respectively. Seven symptom scores, previously factor-validated, were calculated.RESULTS:Depressive mood, irritable aggression, psychomotor/thought inhibition, mania, emotional lability/agitation and psychosis were moderately correlated across the index and subsequent hospitalizations.CONCLUSION:A majority of diverse manic presentations were stable across manic recurrences. The stability was not restricted to two consecutive recurrences but appeared widespread over the long-term course of bipolar disorder. The finding may serve for the development of more effective long-term treatment strategies and a clinically more reasonable subtyping of mania.

A genetic susceptibility to suicide attempts has been repeatedly suggested by family-, twin-, and adoption-studies. Because elevated impulsive aggression is one of the most prominent characteristics of suicide attempters and aggressive behavior has been reported in 5-HT1B receptor gene knockout mice, the serotonin receptor 1B gene (5-HT1B) is an attractive candidate. The distribution of a polymorphism (G861C) in the 5-HT1B gene was examined in 148 consecutively hospitalized German suicide attempters, and 327 German healthy volunteers randomly recruited from the general population. The controls and their first degree relatives had no history of mental disorders or suicidal behavior. We found no significant difference in allele or genotype frequency between patients and controls. The results did not differ when the patients were divided into several subgroups (gender, suicide attempters with a violent method or suicide attempters with unipolar-, bipolar-, borderline personality-, and schizophrenia spectrum disorders). These findings suggest that the 5-HT1B polymorphism is unlikely to play a major role in the genetic susceptibility to suicide attempts.

OBJECTIVE:To report the frequency of intra-episode manic symptoms in depressive episodes, and to evaluate unipolar depressive mixed state (DMS) as bipolar spectrum.METHOD:A total of 958 (863 unipolar, 25 bipolar II, and 70 bipolar I) depressive in-patients were assessed in terms of manic symptoms at admission, and several clinical variables using standardized methods.RESULTS:The frequency of manic symptoms (flight of idea, logorrhea, aggression, excessive social contact, increased drive, irritability, racing thoughts, and distractibility) was significantly higher in bipolar depressives than in unipolar depressives. Unipolar depressives with DMS - defined as having two or more manic symptoms - had more similarities to bipolar depressives than to other unipolar depressives in clinical variables such as onset age, family history of bipolar disorder, and possibly suicidality.CONCLUSION:Depressive mixed state is frequent, particular in bipolar depressives. Unipolar depressives with DMS may be better classified into bipolar spectrum.

Back to table of contents Previous article Next article Letter to the EditorFull AccessDr. Sato and Colleagues ReplyTETSUYA SATO, M.D., Ph.D., RONALD BOTTLENDER, M.D., NIKOLAUS KLEINDIENST, M.S., ANDREAS SCHRÖTER, M.S., and HANS-JÜRGEN MÖLLER, M.D., TETSUYA SATOSearch for more papers by this author, M.D., Ph.D., RONALD BOTTLENDERSearch for more papers by this author, M.D., NIKOLAUS KLEINDIENSTSearch for more papers by this author, M.S., ANDREAS SCHRÖTERSearch for more papers by this author, M.S., and HANS-JÜRGEN MÖLLERSearch for more papers by this author, M.D., Munich, GermanyPublished Online:1 Feb 2003https://doi.org/10.1176/appi.ajp.160.2.392-aAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: After we submitted our article, two other research groups, using multivariate analyses, reported on manic subtypes (1, 2; Cassidy et al., 2001). Surprisingly, all reports, including ours, proposed almost the same subtypings. Similarities and minor differences between the Duke study (Cassidy et al., 2001) and ours are summarized by Drs. Cassidy and Carroll. Their letter calls into question our conclusion that atypical manic features, such as aggression, psychosis, and depression, are likely to separately characterize several manic subtypes since “the factor scores have extremely large standard deviations, denoting a wide overlap of scores among the identified clusters.” It should be noted, however, that standardized factor scores were used in our study. The mean factor score and its standard deviation were set at 0.0 and 1.0, respectively. As shown in Table 2 of our article, it is not true that the factor scores reported “have extremely large standard deviations.” Our factors, called depressive mood and psychomotor/thought inhibition, have relatively large standard deviations in our mixed subtype. This reflects a large variance of these syndromes within this subgroup, suggesting the possibility that this subtype consists of several lower-order subgroups. It would be interesting to determine whether these lower-order subtypes are similar to the two mixed subtypes proposed by Dr. Cassidy et al. and whether the depressive inhibition factor identified in our study plays a role in describing these lower-order subtypes. Until these issues are clarified, it is too early to state that our “cluster analysis does not positively support Kraepelin’s subclassification of mixed states.”Swann and colleagues (1, 2) proposed four manic subtypes that more strikingly resemble our subtypes. Their depressive, delusional, classical, and irritable subtypes appear exactly to correspond to our mixed, psychotic, pure, and aggressive subtypes, respectively. While the aggressive factor characterized several manic subtypes in the study by Dr. Cassidy et al., that factor was reported in the study by Swann et al. as only prominent in one subtype (irritable mania), as was found in our study. Furthermore, the report on their multicenter placebo-controlled trial implied that their four groups had differential treatment responses to placebo, divalproex, and lithium (2). This suggests that both their and our manic subtypes may be validated in terms of acute treatment response.An agreement of results derived from cross-sectional phenomenological data is only the first step in identifying clinically meaningful manic subtypes, although this agreement was reached by three independent studies. Further studies are required to determine the differential long-term natural history of the proposed manic subtypes. Differential responses to available maintenance treatments should also be investigated.References1. Swann AC, Janicak PL, Calabrese JR, Bowden CL, Dilsaver SC, Morris DD, Petty F, Davis JM: Structure of mania: depressive, irritable, and psychotic clusters with different retrospectively assessed course patterns of illness in randomized clinical trial participants. J Affect Disord 2001; 67:123-132Crossref, Medline, Google Scholar2. Swann AC, Bowden CL, Calabrese JR, Dilsaver SC, Morris DD: Pattern of response to divalproex, lithium, or placebo in four naturalistic subtypes of mania. Neuropsychopharmacology 2002; 26:530-536Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByPsychological Medicine, Vol. 45, No. 10Long-term inter-episode stability of syndromes underlying mania2 September 2003 | Acta Psychiatrica Scandinavica, Vol. 108, No. 4 Volume 160Issue 2 February 2003Pages 392-a-393 Metrics History Published online 1 February 2003 Published in print 1 February 2003

BACKGROUND:The present study evaluated differences in negative symptoms between schizophrenic and depressive patients and investigated whether a consideration of the nature of negative symptoms (enduring vs. nonenduring) can help to improve their specificity for schizophrenia.METHOD:Patients enrolled in the study were consecutively hospitalized with an acute exacerbation of schizophrenia (N = 33) or major depressive disorder (N = 43) (DSM-IV). Negative and depressive symptoms were assessed with the Scale for the Assessment of Negative Symptoms (SANS) and the Montgomery-Asberg Depression Rating Scale, respectively. Duration of negative symptoms was assessed through a semistructured interview with the patients and their closest relatives. On the basis of the assessed duration of symptoms, negative symptoms were categorized as enduring or nonenduring.RESULTS:Analyses revealed high SANS ratings for both diagnostic groups. Negative symptoms in depressive patients (p =.01), but not in schizophrenic patients, were significantly associated with the presence or the emergence of depressive symptoms. The prevalence of enduring negative symptoms was significantly higher in schizophrenic patients than in depressive patients (p <.01). A consideration of enduring negative symptoms significantly increased the discriminative power of negative symptoms for schizophrenia (p =.02).CONCLUSION:The present findings suggest that negative symptoms in most depressive patients are just an epiphenomenon of depressive symptoms and can be distinguished from schizophrenic negative symptoms.

BACKGROUND:Case observations imply that depressed patients with mixed features are of high risk for maniform switch during acute treatment.METHODS:The medical records of 158 bipolar I depressives were examined with respect to mixed depressive features at admission, naturalistic medications, and maniform switch during inpatient treatment.RESULTS:Besides pharmacological variables, the number of mixed depressive symptoms (flight of ideas, racing thoughts, logorrhea, aggression, excessive social contact, increased drive, irritability, and distractibility) at admission was associated with a higher risk for, and the acceleration of, maniform switch during inpatient treatment.LIMITATIONS:This was a retrospective study in patients receiving naturalistic treatment. The cohort was hospital based and thus not representative of the full range of bipolar affective disorder.CONCLUSIONS:In line with recent studies, our results underline the factors inherent in subjects at a higher risk of switch. Investigation of the relationships between several inherent factors and their interactions with pharmacological treatments may be important in resolving the controversy surrounding antidepressant-induced mania. Further validation studies on mixed depression are warranted.

OBJECTIVE:The aim of the study was to investigate the association between the duration of untreated psychosis, premorbid functioning and outcome from first inpatient treatment in schizophrenic or schizoaffective patients.METHOD:The data of 196 first-hospitalized patients with a schizophrenic or schizoaffective disorder according to the ICD-10 criteria were analyzed using univariate and multivariate methods. Patients' characteristics were prospectively assessed using standardized instruments at the time of first admission and discharge.RESULTS:The analyses revealed that a duration of untreated psychosis longer than 12 months was independently and significantly associated with a poorer outcome from first inpatient treatment. Premorbid functioning might have an additional influence on outcome, but this influence seems to be dependent on the diagnostic category.CONCLUSIONS:The findings suggest that the duration of untreated psychosis is an independent prognostic factor for the outcome in schizophrenic and schizoaffective disorders.

Although many retrospective, prospective and family studies have consistently found that neuroticism characterizes the premorbid personality of depression, there is still a controversy as to whether obsessionality is also related to the premorbid personality of depression. The authors emphasized that two different conceptualizations of obsessionality were used in previous studies in this field; and that a soft form of obsessionality, represented by the melancholic type of personality (Tellenbach), but not obsessionality based on the psychoanalytical conceptualization, was consistently related to premorbid personality of depression. In this paper, the authors focused on cultural invariance of the relationship between the soft obsessionality and premorbid personality of depression by presenting results of a direct matched comparison of personality between depressive patients and controls from two countries, Germany and Japan. The study found that in both countries, depressive patients scored higher on neuroticism and rigidity (the conceptual origin of this dimension is the melancholic type of personality) and lower on frustration tolerance than did controls, indicating cultural invariance of the relationship between the soft obsessionality and premorbid personality of depression. Some hypotheses on the role of the soft obsessionality in the etiology of depression were introduced. Furthermore, potential clinical implications of this personality dimension were discussed.

OBJECTIVE:To investigate the boundary between ICD-10 mixed and manic episodes, which has apparently remained understudied.METHOD:In-patients with ICD-10 mixed (n=36) and manic episodes (n=145) were compared in terms of demographic, clinical, therapeutical and outcome variables.RESULTS:Of in-patients with manic episode, 26 (18%) had several depressive symptoms at admission. These patients (dysphoric manic patients) were very similar to patients with ICD-10 mixed episode in terms of current symptomatic presentations and several clinical and therapeutic variables, which were significantly different from those in patients with pure mania.CONCLUSION:The ICD-10 boundary between mixed and manic episodes is unlikely to be effective although experienced clinicians made the diagnoses. The system may have a high probability of diagnosing dysphoric manic patients as having manic episode, despite their great similarities to patients with mixed episode in terms of current psychopathological presentations as well as clinically important variables.