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5


Recurrent brief depression as an indicator of
severe mood disorders
Jules Angst, Alex Gamma, Valadeta Ajdacic, Dominique Eich,
¨
Lukas Pezawas and Wulf Rossler
Zurich University, Psychiatric Hospital, Zurich, Switzerland




Introduction
Bipolar spectrum
The bipolar spectrum is currently the focus of very intensive research, which is
hampered by two interrelated biases, one methodological and one commercial.
Epidemiological and clinical research in the field of bipolar disorders deals with
disorders/syndromes defined according to the diagnostic manuals and uses meth-
ods tailored to them, which are not suitable for assessing subthreshold morbidity
(minor and recurrent brief depression, recurrent and brief hypomania). This has
significant implications for the differentiation between depression and bipolar
disorder. As a consequence, major depressive disorders (MDD) are overdiagnosed
and heterogeneous; they include many bipolar II (BP-II) cases, of which the
hypomanic component does not reach the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV: American Psychiatric Association, 1994) or ICD-10
Classification of Mental and Behavioural Disorders (World Health Organization,
1992) diagnostic threshold for hypomania. This means that drug trials selecting
patients on the basis of an MDD diagnosis are also dealing with heterogeneous
groups, which include hidden BP-II subjects prone to switch into hypomania.
Moreover, current bipolar research is biased towards mania and neglects bipolar
depression. The large majority of modern treatment studies on mood stabilizers
select patients with mania and exclude those with BP-II disorders, although the
latter are much more prevalent than the former both in clinical practice and
among relatives of bipolar patients. In addition, BP-II patients have traditionally
been excluded from drug trials using modern antidepressants.
As we have found, bipolar subjects identified by diagnostic criteria of
DSM-IV (American Psychiatric Association, 1994) or ICD-10 (World Health
Organization, 1992) form only the tip of the iceberg of the bipolar spectrum;
below the diagnostic threshold are a large number of subjects with unidentified
Cambridge University Press, 2005.
#
110 J. Angst et al.


Zurich: Zurich:
DSM-IV hard criteria soft criteria

BP-I 0.5% BP-I 0.5% BP-I 0.5%
BP-II 0.4%

BP-II 5.3%

BP-II 11.0%



MDD 21.3%
MDD 11.4%
MDD 17.1%
Major Major 3.3%
3.3%

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