Are There Two

Types

David J. Kupfer, MD; David Pickar, MD; Jonathan

of

M.Himmelhoch, MD;

Personality traits and clinical characteristics in psychiatric outpatients with affective disorder were examined.Two groups of unipolar patients, divided on the basis of treatment response to tricyclic antidepressants, were compared to a bipolar group. While the unipolar-T (tricyclic responder) group showed premorbid personality traits of chronic anxiety and obsessiveness, neither the bipolar nor unipolar-L (tricyclic nonresponder,lithium carbonate responder) groups showed such findings. In fact, the unipolar-L and bipolar groups were similar not only with regard to personality variables, but also in terms of both drug response and certain family history features. These findings cast doubt on the homogeneity of unipolar depression and suggest the possibility of a subtype of unipolar depression with psychobiologic and personality features resembling bipolar affective disorder.

Unipolar Depression? Thomas P.Detre,MD

it not for such biased

selection, as may result when only inpatients are studied, the distinction between unipolar and bipolar illness would be less sharp than it appears to be. The contradictory results obtained in the controlled treatment trials of recurrent depressions would also sug¬ gest that there may be more than one type of unipolar or bipolar disorder. We have previously noted that the method proposed by Perris5 for the identification of "true" unipolar disorders (at least three consecutive episodes without a hypomanic or manic episode) is of little help for the clinician who sees the patient in the course of his (or her) first or second de¬ pressive episode. This report examines the notion that personality traits might also be used in the classification of these disorders.

for a schema for affective has gone on for a cen¬ it affective syndromes tury. suspected might really be a collection of heterogeneous disorders, in¬ vestigators have always been reluctant to divide the pie into more than two pieces. From Kraepelin,1 Mapother,2 and others,3·4 who divided depressions into endoge¬

search clinically useful classificatory TheWhile disorders nearly has been that

nous/reactive, psychotic/neurotic types to Perris,5 Angst,6

and Winokur and Clayton7 who described the differences between unipolar and bipolar depression, the assumption has been that the subtypes within these classificatory schemes are homogeneous. Yet despite the detail provided on age of onset,8 course, sex distribution, and genetic in¬ heritance911 in the more recent studies, almost all these nosologie systems were based on clinical data derived pri¬ marily from the study of inpatients. Recently, however, there has been one attempt to delineate the phenomena of depression and develop a conceptual model based primar¬ ily on outpatient data.12 Indeed, one could argue that were

Accepted for publication March 25,1975. From the Department of Psychiatry, University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic. Reprint requests to the Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic,3811 O'Hara St, Pittsburgh, PA 15261 (Dr.Kupfer).

METHODS

Psychiatric outpatients from the Dana Pyschiatric Outpatient Division at the Yale-New Haven Hospital were selected for this retrospective study of affective disorders. All patients in this investigation had received an extensive psychiatric evaluation based on the KDS System and the Feighner criteria, and each clinical visit was recorded in a standardized manner.1319 Thus, the information used for the chart review was fairly extensive and systematic. A minimum of two episodes of affective disease severe enough to require psychiatric treatment was required for inclu¬ sion in the study. All charts were individually reviewed and the patients were initially divided into two diagnostic groups consist¬ ing of bipolar and unipolar affective disease, respectively. To be considered bipolar, patients were required to have had at least one documented episode of hypomania or mania and at least one episode of clinical depression. In view of the many am¬ biguities that surround the symptoms that are regarded as typical of manic-depressive disease, if the history clearly indicated that symptom-free intervals and socially competent functioning oc¬ curred between mood swings, the patient was then considered a true manic-depressive. Individuals whose manic-depressive diag¬ nosis was in question, in particular those who had delusions and were considered possible schizoaffective type schizophrenics, were excluded.20 To be considered unipolar, it was required that the rea¬ son for seeking psychiatric care was for the treatment of depres¬ sion, that the past history was negative for hypomania and mania, and that the patients had had at least two previous episodes of

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DO YOUR MUSCLES TIGHTEN UP WHEN YOU BECOME ANXIOUS?

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DO YOU LIKE BEING IN THE MIDST OF EXCITEMENT?

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DO YOU OFTEN FEEL YOU ARE POSING OR PRETENDING?

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DO YOU FEEL MORE RELAXED INDOORS?

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DO YOU FEAR BEING LEFT ALONE?

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DO YOU FEEL PANICKY IN CROWDS?

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DO YOU OFTEN HAVE PERIODS DURING WHICH EVERYTHING AND EVERYBODY SEEMS UNREAL AND

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FAR AWAY? DO YOU TEND TO BE LATE FOR APPOINTMENTS? HAVE YOU OFTEN ASKED YOURSELF"HAVE I DONE THE RIGHT THING?"

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DO YOU FEEL COMPELLED TO COUNT THINGS?

Y-ES



DO YOU STOP AND THINK BEFORE DOING THE SMALLEST THING ?

yes

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DO YOU LIKE MAKING QUICK DECISIONS?

MES

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DO YOU TEND TO LOSE YOUR TEMPER WHEN YOU DON'T GET YOUR WAY? DO YOU OFTEN GET A HEADACHE WHEN YOU FEEL TENSE?

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DO YOU OFTEN WORRY THAT SOMETHING BAD IS GOING TO HAPPEN?

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DO YOU GET ANXIOUS WHEN YOU HAVE TO ASK SOMEONE FOR A FAVOR?

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DO YOU GET ANXIOUS WHEN YOU HAVE TO MEET NEW PEOPLE OR GO TO A NEW PLACE?

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DO YOU USUALLY TRY TO BE THE CENTER OF ATTENTION OR THE LIFE OF THE PARTY?

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ARE YOU CONCERNED THAT PEOPLE THINK YOU ARE UNATTRACTIVE?

yes

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20. 21

DO YOU BECOME EASILY ENTHUSIASTIC AND JUST AS EASILY DISAPPOINTED ABOUT PEOPLE?

yes

«ta

DO YOU FEEL BAD FOR A LONG TIME WHEN SOMEBODY CRITICIZES YOU?

yes

«ta

22. 23

DO YOU FEEL THAT YOUR LIFE IS IN A RUT AND THAT YOU ARE UNABLE TO CHANGE IT? DO YOU FIND THAT MOST PEOPLE DEEP DOWN ARE FULL OF HATRED?

mes

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24. 25. 26.

DO YOU BECOME TIRED AND EXHAUSTED EASILY?

yes

«ta

DO YOU THINK PEOPLE FIND YOU SEXUALLY ATTRACTIVE?

yes

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DO YOU GET INTO FIGHTS WITH PEOPLE YOU LOVE?

mes «ta

27 28. 29. 30. 31. 32. 33. 34 35

DO YOU OFTEN FEEL ANNOYED WITH PEOPLE WHO ARE NOT ORDERLY?

yes «ta

CAN YOU EASILY BE CHEERED UP EVEN WHEN YOU GET VERY UPSET?

yes

DO YOU OFTEN WORRY ABOUT YOUR PHYSICAL HEALTH?

MES

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ARE YOU ALWAYS AFRAID OF CATCHING SOMEBODY'S ILLNESS OR BEING CONTAMINATED?

mes

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DO YOU OFTEN THINK ABOUT THINGS THAT HAPPENED WHEN YOU WERE A CHILD? ARE YOU OFTEN CONCERNED THAT SOMEHOW YOU ARE GOING TO LOSE CONTROL AND HURT YOURSELF OR SOMEBODY ELSE? DO YOU TEND TO GET INTO ACCIDENTS?

YES

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WHEN THINGS GO WRONG IN YOUR LIFE. DO YOU THINK OF IT AS SOME SORT OF PUNISHMENT?

MES

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DO YOU FIND IT DIFFICULT TO GET CLOSE TO PEOPLE?

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DO YOU GET BORED WITH ALMOST EVERYTHING YOU DO?

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OVER THE YEARS, WITHOUT ANY APPARENT REASON HAVE YOU SOMETIMES FELT.

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REMAIN UNCHANGED ("":)

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Table

1.—Demographic Characteristics Unipolar-L

Unipolar-T

43.3 ±2.1

43.6 ±2.6

56.1

80.0 20.0

64.7 35.3

19.0 60.3

12.0 68.0

14.7 61.8

Bipolar Age, yr_42.8 ±1.5* Sex, % Female 43.9| Male Martital status, %

Single

Married

Separated or 19.0 1.7

16.0 4.0

20.6 2.9

62.5

21.6$

Three or more

psychiatric hospitalizations, %_42J_50J)_18.2

§

Standard error. t < .01 when compared to unipolar-T group. t < .05 when compared to unipolar-T group. § < .05 when compared to bipolar-T group. *

Table

as or

RESULTS

lege degree, %_ 31.5J

2.—Family History Bipolare

Unipolar-L

Unipolar-T

History of mood swings

50.0*

13.8t

Bankruptcy Psychiatric hospi-

33.3

42.1 44.4

27.8

42.4

54.1 30.6 34.3

15.6J:

22.2_21.2 38.9

33.3

Percentage of patient's families with at least one member having the group characteristic, t P< .01 when compared to bipolar group or unipolar-T group. t < .05 when compared to unipolar-T group. *

depression severe enough to warrant antidepressant medication. Unipolar patients were excluded if they had a concomitant chronic medical disease or if they had received psychiatric care in the past for reasons other than depression. There was a minimum time span of two months (much longer in most cases) between the time the patients completed the questionnaires used in the study and the time their charts were reviewed for inclusion. Any patient who during this time period was hospitalized or whose clinical pic¬ ture substantially worsened, as verified by the symptom rating scales, was also excluded from the study. Out of the original sample of 135 patients, the final sample in¬ cluded a total of 117 patients (58 bipolare and 59 unipolars). In ad¬ dition to the conventional admission data, the chart contained in¬ formation on history of psychological symptoms in childhood; difficulties with impulse control; previous suicide attempts; previ¬ ous hospitalizations; history of alcoholism; family history of mood swings, alcoholism, drug history, and bankruptcy; life-long per¬ sonality traits; and current symptom states. Patient family his¬ tories were gathered from a number of sources. Family members were considered to be grandparents, parents, aunts, uncles, sib¬ lings, and offspring. The personality traits and current symptom profiles were measured by self-administered rating scales (KDS-1, 2, and SA).11" The data in the three groups were examined using chi-squares, t tests, and multiple regression techniques. For pur¬ poses of data analysis, the subgroup of patients with hypomania of insufficient size to be treated as a separate cell. The unipolar patients were further subdivided into two groups on the basis of their prior treatment response to tricyclic antidepressants. The first group consisted of 34 depressed patients who had been successfully treated with tricyclic antidepressant medication and were receiving this treatment in a medication was

Disorders Clinic. Success of treatment in all groups was defined return to social and work functioning at a level similar to greater than the levels in the premorbid condition. a

divorced Widowed Attainment of col-

talizations Suicide attempts Alcohol abuse

maintenance clinic. This group will subsequently be referred to as unipolar-T. The second group consisted of 25 patients who had been unsuccessfully treated for their depression with tricyclic antidepressants and who had subsequently been referred for lithium carbonate treatment (unipolar-L). These patients were receiving lithium carbonate because of a lack of clinical response to tricyclic antidepressants and not because of a family history of "mood swings." The bipolar group of patients consisted of 58 patients who were being treated with lithium carbonate in the affective

There were no significant differences in age among the three groups (Table 1). When women and men were com¬ pared to each other, no significant differences between men and women on any of the measurements under inves¬ tigation were found. Because of these findings, the data were combined and treated as three groups for additional analysis. As shown in Table 1, while the age and marital status of the three groups were fairly similar, there were more women in both unipolar groups than in the bipolar group. Interestingly, the unipolar-L group had a much larger number of individuals who had a college degree, but this may be explained by the fact that patients who knew about the availability of lithium carbonate treatment (or whose physicians referred them) were by definition better informed and from a higher socioeconomic class. Although the groups were also similar in regard to the number of prior depressive episodes, incidence of suicide attempts, and use of alcohol or other drugs, or both, patients in both the bipolar and unipolar-L groups had a greater number of psychiatric hospitalizations than in the unipolar-T group

(P < .05).

As shown in Table 2, there were significantly more fam¬ ily members with a history of mood swings in both the bipolar and unipolar-L groups than in the unipolar-T group (P < .01). Family history of bankruptcy was higher in both the unipolar-L and bipolar groups than in the unipolar-T group but reached statistical significance only when the unipolar-T and unipolar-L groups were com¬ pared (P < .05). With regard to such items as psychiatric hospitalization, suicide attempts, alcohol abuse, incidence of postpartum psychosis, and the frequency of color blind¬ ness in the family, no statistically significant differences were found. Since we were primarily interested in the possible dif¬ ferences in personality traits and since personality traits have been shown to vary to some extent with current symptomatology, we first had to ascertain whether or not the three groups were comparable in regard to their cur¬ rent symptoms. Using the cluster scores derived from our previous clinical studies,16·18·21 no significant differences were found between the unipolar-T and unipolar-L groups or between unipolar-L and bipolar groups for levels of cur¬ rent anxiety, but there was a significantly higher current anxiety level in the unipolar-T group when compared to the bipolar group (P < .01). With regard to current levels of depression, there was no difference between the two unipolar groups, but both unipolar groups reported signif-

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icantly more depressive symptoms than the bipolar group (P

Are there two types of unipolar depression?

Personality traits and clinical characteristics in psychiatric outpatients with affective disorder were examined. Two groups of unipolar patients, div...
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