Depressive Symptoms in Patients With Unipolar and Bipolar Affective Disorder David
L. Dunner.
Ted Dwyer.
and Ronald
R. Fieve
T
HE STUDY of biologic differences in patients with affective illness is dependent in part on a clinical classification which separates depressed patients into subgroups of greater homogeneity. The unipolar-bipolar classification is one such system, and the use of this classification has been supported by clinical, biologic, genetic, and pharmacologic studies of affective disorder.’ This paper is part of a series of studies to determine if patients with depression and hypomania (“bipolar II”) can be distinguished from patients with depression and severe mania (“bipolar I”) and patients with depression without hypomania (unipolar).2-4 In this paper, symptoms of depression, as measured with the use of a modified Hamilton depression rating scale,5 a nurses’ global rating scale, and self-administered adjective check list, will be examined in moderately to severely depressed patients who were admitted to a clinical metabolic research unit. MATERIALS
AND
METHODS
All patients included in this study had been admitted to the metabolic clinical research unit at the New York State Psychiatric Institute over a 3-year period beginning July 1971. All patients met the criteria of Feighner et al.” for primary affective disorder and were studied during the depressive phase of their illness. Patients had been further classified on the basis of their psychiatric history as bipolar I, if they had ever been previously hospitalized for mania; bipolar II, if they had been hospitalized for depression only but had symptoms of hypomania of at least greater than 2 days duration; and unipolar, if they had histories of depression but not of mania or hypomania.’ Additional inclusion criteria for purposes of this report were that the patient evidenced depressive symptoms of at least moderate severity (as determined by several depression rating scales) but, in particular, had a total score on the modified Hamilton scale ofgreater than I5 points. All medications were discontinued from the time of admission while patients were undergoing a complete physical and laboratory examination in preparation for later research protocols. During this initial 2-week period of hospitalization, patients were evaluated by a nurse rating team trained in the use of a modified Hamilton depression rating scale” and global depression rating scales. On the same day, patients completed the Multiple Alfect Adjective Check List (MAACL)X and gave a self-rating of depression using a global depression scale. Data were analyzed from the items in the Hamilton scale, the nurses’ global depression ratings on a 0- SO scale (50 indicating euthymia, lower scores indicating greater severity of depression), from the patients self-rating using the same global depression scale, and from the MAACL. Scoring of the MAACL scale was achieved by separating adjectives into six groups. D’ contained words suggestive of depression: D-. suggestive of lack of depression; H+ indicated feelings of hostility: H- indicated lack of
From the New York State Psychiatric institute and Columbia University College oJPhysicians and Surgeons, New York, N. Y. David L. Dunner, M.D.: Psychiatrist, New York State Psychiatric Institute and Assistant ProJessor oJ’Clinical Psychiatry, Columbia University College ofPh_vsicians and Surgeons; Ted Dwyer: Research Assistant, Columbia University College of Physicians and Surgeons; Ronald R. Fieve. M.D.: ChieJoJ Research, Department of Internal Medicine. New York State Psychiatric Institute and ProJessor oJ Clinical Psychiatrv, Columbia University College of Physicians and Surgeons. Reprint requests should be addressed to Dr. David L. Dunner. 722 W. I6Rth Street. New: York, N. Y. 10032. t’ 1976 bv Grune & Stratton, Inc. Comprehensive Psychiatry, Vol 17. No. 3 (May/June). 1976
447
448
DUNNER,
Table 1. Depressive Symptoms (Mean Ratings: Modified
in Bipolar and Unipolar
Hamilton
Maximal I tern
Depression
I
Bipolar N=6
SCOW
DWYER. AND FIEVE
Patients
Rating Scale) Bipolar II N= 17
Unipolar N= 12
4
4.0
3.9
Sleep disturbance
3
1.6
1.6
1.2
Psychomotor
3
1 .o
1.0
0.2
0.2
Difficulties
in daily functioning retardationt
4.0
Hypochondriasis
3
I.911 0.3
Appetite
3
1.6
1.2
1.4
Agitation
3
1.3
1.6
1.3
Personal appearance’
3
2.1 II
1.1
1.2
Withdrawal
3
2.35
1.6
1.3
Indecisiveness
3
2.2
1.9
1.8
Concentration
3
1.8$
1.9$
1.4
Anxiety
3
1.9
2.0
2.0
Irritability
3
0.4
0.8
1.0
mood
4
3.2q
2.8
2.5
3
1.4
1.5
1.7
ideation
4
1.2
1 .I
1.3
Negative self-esteem
4
2.2
2.4
2.1
Negative expectation
3
1.8
2.0
1.8
Hyposexuality
2
t.911
1.5
1.3
30.1
28.6
Depressed Guilt Suicidal
Mean Total
33.2
*Statistically
significant,
AN0VA.p
tStatistically
significant,
ANOVA,
< 0.05. p < 0.01.
$Significantly
different
by t test from unipolar
SSignificantly
different
by t test from bipolar
II (p < 0.001);
tp < 0.01).
\\Significantly
different
by t test from bipolar
I I (p < 0.001);
(Significantly
different
by t test from bipolar
II (p < 0.05);
from unipolar from unipolar from unipolar
(p < 0.01). (p < 0.001). (p < 0.001).
feelings; A+ indicated anxiety; A- indicated calm or lack of tension. The “filler” adjectives, which did not reflect a particular affect, were not scored.” Data were analyzed with an analysis of variance (ANOVA) to determine if there were overall statistically significant differences for the three diagnostic groups. Differences between groups were evaluated by means of student’s t tests. A total of 35 patients were evaluated. There were 6 bipolar I patients (3 men and 3 women), I7 bipolar II patients (IO men and 7 women), and I2 unipolar patients (3 men and 9 women). Bipolar patients in both groups were older than unipolar patients. The mean age (* SD) of bipolar I patients was 48 i 9.5 years, for bipolar II patients, 51 f 9.1 years, and for unipolar patients, 40 =t 10.5 years (F = 5.23,~ < 0.05). However, there was no correlation with symptomatology and age. hostile
RESULTS
The ratings for the depressive symptoms from the modified Hamilton depression rating scale are tabulated in Table 1. Only two of these symptoms (psychomotor retardation and personal appearance) demonstrated overall statistical significance with the ANOVA. Further tests of significance, using t tests, demonstrated that for these two items, ratings for bipolar I patients were significantly different from either bipolar II or unipolar patients, whereas, no statistical significance was demonstrable between bipolar II and unipolar patients. Additional t tests were performed for those items where the ANOVA was not statistically significant, but where F was at least 2.0. Most of these items showed statistically significant differences in mean ratings for bipolar I patients as com-
UNIPOLAR
AND
BIPOLAR
AFFECTIVE
Table 2.
DISORDER
Ratings of Global Severity Bipolar
Mean nurses’
ratings
Mean patients’ There
ratings
were no significant
449
differences
of Depression
I
Bipolar
II
Unipolar
22.9
25.9
29.2
30.0
22.6
31.3
among
the patient
groups
for nurses’ or patients’
ratings.
pared to either bipolar II or unipolar patients (withdrawal, depressed mood, hyposexuality). Only one item-concentration-demonstrated statistical significance between bipolar II and unipolar patients. The ratings for suicidal ideation did not show significant differences overall or for the three diagnostic subgroups. Data regarding global depression ratings are presented in Table 2. There were no significant differences overall (by ANOVA) for the mean nurses’ ratings on the global scale. Furthermore, although the bipolar II patients had the lowest mean ratings on this scale, their ratings were not significantly different from either unipolar or bipolar I patients. However, whereas the mean of the nurses’ ratings for bipolar I and unipolar patients indicated greater severity of depression than these patients’ self-ratings, the bipolar II patients tended to rate themselves as more depressed (lower mean rating) than the nurses rated them. These data were analyzed for patients individually by means of a 3 x 3 chi square analysis (diagnostic groups versus staff rating higher, equal to, or lower than each of the patient’s self-ratings). Chi square for this analysis was 14.8, p < 0.01, suggesting that bipolar II patients rated themselves as more severely ill than the nurse rating team. The results from the MAACL are presented in Table 3. The mean number of adjectives checked by each patient was not significantly different for the diagnostic groups. Furthermore, no statistically significant differences emerged when the data were analyzed by subscales. Overall, patients tended to check adjectives which indicated they felt depressed and anxious (D+ and A+) rather than checking the “minus” adjectives. DISCUSSION
Dlxerentiation of Bipolar II Patients
The data from the Hamilton rating scale suggest that the symptoms of depression in patients classified as bipolar II are more similar to unipolar than to Table 3.
Depressive Symptoms
as Determined
From an Adjective
Bipolar
Adjectives
I
N=5
Check
Bipolar I I N= 17
List Unipolar N = 11
Depression+
10
5.8
10.6
9.4
Depression-
10
0.6
0.9
2.6
Hostility+
16
1.6
3.2
3.4
Hostility
12
2.4
2.1
2.2
Anxiety+
11
6.0
6.4
6.6
Anxiety-
10
1.4
0.8
1.3
Mean number Data from
checked
23.0
31.2
34.1
the MAACL.
No significant
differences
were determined
for diagnostic
groups
overall
or between
groups.
450
DUNNER,
DWYER.
AND FIEVE
bipolar I patients. Although few of these symptoms achieved overall significance, bipolar I and unipolar patients showed significant differences by t tests on the mean ratings of several symptoms (psychomotor retardation, personal appearance, withdrawal, concentration, depressed mood, and hyposexuality). For all of these symptoms, except concentration, there also was significance between bipolar I and bipolar II patients. Bipolar II patients were rated significantly higher in inability to concentrate than unipolar patients, which was the only symptom where there was a significant difference between bipolar II and unipolar patients. These data suggest that, regarding depressive symptoms, bipolar II patients are indistinguishable from unipolar patients. The mean ratings of depression in the global scale showed no group differences. However, bipolar II patients rated themselves as more severely ill as compared to how the nurses rated them, whereas, the other depressed patients tended to be rated by the nurses as more severely ill than they rated themselves. One inference from this may be that bipolar II patients (as compared to other depressed patients) are in some way unable to convey to others how depressed they feel. An alternate interpretation of these data is that the levels of severity in the global scale may not be sufficiently anchored or explained to patients. Although no differences regarding suicidal ideation were demonstrable, previous studies have suggested that a history of suicide attempt and death from suicide may both be observed more frequently in patients classified as bipolar II as compared to bipolar I and unipolar patients. I*’ It is tempting to speculate that the suicidal behavior seen in bipolar II patients may be related to their not conveying the severity of their depression to their therapists. It is our clinical impression that during clinical interviews many bipolar II depressed patients demonstrate appropriate, nondepressed affects when discussing happier occasions in their lives. Often these bipolar II patients are not diagnosed as depressed because of their seeming lack of depressed affect. Regardless of whether or not this phenomenon is characteristic of the bipolar II depressive, the treatment implications of it require further investigation, as does the data regarding suicide and suicide attempts. The adjective check list data were analyzed to provide another index of depressive symptoms which might differentiate bipolar II patients. However, these data failed to reveal differences among patient groups. A previous study of this scale from our unit revealed that the MAACL was useful in discriminating the depressed state from normal9 Diflerentiation of Bipolar I patients
Our Hamilton rating scale data support previous studies which demonstrate differences in depressive symptomatology (particularly in psychomotor retardation) between bipolar and unipolar patients. Beige1 and MurphylO reported clinical characteristics of 25 age- and sex-matched pairs of unipolar and bipolar patients. Their unipolar patients were characterized by greater physical activity, overt expression of anger, and as having more somatic complaints as compared to bipolar patients who had greater psychomotor withdrawal. The bipolar patients reported by Beige1 and Murphy’” are bipolar I by the criteria of our study which also demonstrates that bipolar I patients have greater psychomotor withdrawal than other depressed patient groups. In addition, Kupfer and Foster” measured
UNIPOLAR
AND
BIPOLAR
AFFECTIVE
DISORDER
451
psychomotor activity by means of a telemetric mobility sensing system and reported that patients with bipolar depression had less psychomotor activity than unipolardepressives. Unlike the study of Beige1 and Murphy,“’ we could not demonstrate unipolar-bipolar differences in somatic complaints or hostility, The mean ratings for “hypochondriasis” on the Hamilton scale were uniformly low in all three diagnostic groups. Although bipolar II and unipolar patients had higher mean ratings than bipolar I patients for irritability and hostility on the Hamilton scale and the MAACL, respectively, these differences failed to achieve statistical significance. Several studies of unipolar and bipolar affective states support this separation of affectively ill patients, using genetic, clinical, and pharmacologic criteria.‘-.‘,: In those studies where data from bipolar II patients have been separately analyzed, the bipolar II patients have not been consistently more similar to either bipolar I or unipolar patients. For example, the mean urinary excretion of 17 hydroxycorticosteroids (17 OHCS) during depression was significantly reduced for bipolar I patients as compared to both unipolar and bipolar II patients who had similar levels.:’ However, studies of evoked cortical response reveal bipolar II patients to be more similar to bipolar I patients and significantly different from unipolar patients.& The present study supports the overall unipolar--bipolar separation and suggests that, on the basis of depressive symptoms, bipolar II patients are more similar to unipolar patients than to bipolar I patients. ACKNOWLEDGMENT We
appreciate
performed
the
assistance
by the nursing
of
Dr.
Joseph
staff of the 4 North
Fleiss
and
Metabolic
Dr.
Clinical
Frank
Stallone.
Research
The
ratings
were
Goodwin
FK.
Unit.
REFERENCES I.
Dunner
Heritable
DL,
Gershon
factors
2. Gershon al:
tyrosine, Plenum,
BT.
and DL,
Excretion
of
and
FK,
illness:
alpha-methyl-paraWM
(eds):
Disease.
Brain
New
York.
ES, Goodwin
depressed
primary
evoked
Psycho1 6:278 6. Feighner Diagnostic Arch
in
patients. FK,
Arch
Murphy
responses 128:19-25,
M: Development depressive
et
1972
Am J Psychiatry
>_ Hamilton
FK.
l7-hydroxycorticosteroids
M. Goodwin
Average
disorders.
Gershon
26:360-363,
4. Buchsbaum
search.
affective
Mclsaac
bipolar
Gen Psychiatry
for
and
Mental
3. Dunner
al:
WE Jr, Goodwin
1971, pp 135 I61
unipolar
et
ill-
in
DL,
affective 1971
of a rating
illness.
Br
scale
J Sot
Clin
296, 1967 JP,
criteria
use
Gen Psychiatry
DL.
factors
Cershon
ES,
in the severity
E, Guze in
SB,
et al:
psychiatric
26:57-63.
1972
re-
of affective
Assoc
123:187
ill188.
I970 Lubin
B: Manual
Multiple
8. Zuckerman Affective
Adjective
Check
Diego,
Educational
and
Service,
1965
9. Plutchik
M,
R, Platman
tion of manic-depressive
Industrial
for List.
the San
Testing
SR, Fieve RR: Evaluastates
with
an adjective
check list. J Clin Psycho1 27:310 ~314, 1971 IO. bipolar
Beige1
A,
affective
Murphy illness:
DL:
accompanying
Gen Psychiatry
24:215-220,
I I.
Kupfer
DJ,
search Section, Psychiatric 1974
Foster
in depression. Annual
Association,
Unipolar
Differences
characteristics
activity
Robins for
7. Dunner Heritable
ness. Sci Proc Am Psychiatr
and
L-DOPA
in Ho
Chemistry
al:
ES, Bunney
with
FK:
of affective
(in press)
Catecholamines
Studies
Goodwin
in the severity
ness. Biol Psychiatry et
ES,
and
in clinical
depression.
Arch
197 1 FG:
Presented Meeting Detroit,
Psychomotor at the New Reof the American Mich.,
May
L. Dunner.
Ted Dwyer.
and Ronald
R. Fieve
T
HE STUDY of biologic differences in patients with affective illness is dependent in part on a clinical classification which separates depressed patients into subgroups of greater homogeneity. The unipolar-bipolar classification is one such system, and the use of this classification has been supported by clinical, biologic, genetic, and pharmacologic studies of affective disorder.’ This paper is part of a series of studies to determine if patients with depression and hypomania (“bipolar II”) can be distinguished from patients with depression and severe mania (“bipolar I”) and patients with depression without hypomania (unipolar).2-4 In this paper, symptoms of depression, as measured with the use of a modified Hamilton depression rating scale,5 a nurses’ global rating scale, and self-administered adjective check list, will be examined in moderately to severely depressed patients who were admitted to a clinical metabolic research unit. MATERIALS
AND
METHODS
All patients included in this study had been admitted to the metabolic clinical research unit at the New York State Psychiatric Institute over a 3-year period beginning July 1971. All patients met the criteria of Feighner et al.” for primary affective disorder and were studied during the depressive phase of their illness. Patients had been further classified on the basis of their psychiatric history as bipolar I, if they had ever been previously hospitalized for mania; bipolar II, if they had been hospitalized for depression only but had symptoms of hypomania of at least greater than 2 days duration; and unipolar, if they had histories of depression but not of mania or hypomania.’ Additional inclusion criteria for purposes of this report were that the patient evidenced depressive symptoms of at least moderate severity (as determined by several depression rating scales) but, in particular, had a total score on the modified Hamilton scale ofgreater than I5 points. All medications were discontinued from the time of admission while patients were undergoing a complete physical and laboratory examination in preparation for later research protocols. During this initial 2-week period of hospitalization, patients were evaluated by a nurse rating team trained in the use of a modified Hamilton depression rating scale” and global depression rating scales. On the same day, patients completed the Multiple Alfect Adjective Check List (MAACL)X and gave a self-rating of depression using a global depression scale. Data were analyzed from the items in the Hamilton scale, the nurses’ global depression ratings on a 0- SO scale (50 indicating euthymia, lower scores indicating greater severity of depression), from the patients self-rating using the same global depression scale, and from the MAACL. Scoring of the MAACL scale was achieved by separating adjectives into six groups. D’ contained words suggestive of depression: D-. suggestive of lack of depression; H+ indicated feelings of hostility: H- indicated lack of
From the New York State Psychiatric institute and Columbia University College oJPhysicians and Surgeons, New York, N. Y. David L. Dunner, M.D.: Psychiatrist, New York State Psychiatric Institute and Assistant ProJessor oJ’Clinical Psychiatry, Columbia University College ofPh_vsicians and Surgeons; Ted Dwyer: Research Assistant, Columbia University College of Physicians and Surgeons; Ronald R. Fieve. M.D.: ChieJoJ Research, Department of Internal Medicine. New York State Psychiatric Institute and ProJessor oJ Clinical Psychiatrv, Columbia University College of Physicians and Surgeons. Reprint requests should be addressed to Dr. David L. Dunner. 722 W. I6Rth Street. New: York, N. Y. 10032. t’ 1976 bv Grune & Stratton, Inc. Comprehensive Psychiatry, Vol 17. No. 3 (May/June). 1976
447
448
DUNNER,
Table 1. Depressive Symptoms (Mean Ratings: Modified
in Bipolar and Unipolar
Hamilton
Maximal I tern
Depression
I
Bipolar N=6
SCOW
DWYER. AND FIEVE
Patients
Rating Scale) Bipolar II N= 17
Unipolar N= 12
4
4.0
3.9
Sleep disturbance
3
1.6
1.6
1.2
Psychomotor
3
1 .o
1.0
0.2
0.2
Difficulties
in daily functioning retardationt
4.0
Hypochondriasis
3
I.911 0.3
Appetite
3
1.6
1.2
1.4
Agitation
3
1.3
1.6
1.3
Personal appearance’
3
2.1 II
1.1
1.2
Withdrawal
3
2.35
1.6
1.3
Indecisiveness
3
2.2
1.9
1.8
Concentration
3
1.8$
1.9$
1.4
Anxiety
3
1.9
2.0
2.0
Irritability
3
0.4
0.8
1.0
mood
4
3.2q
2.8
2.5
3
1.4
1.5
1.7
ideation
4
1.2
1 .I
1.3
Negative self-esteem
4
2.2
2.4
2.1
Negative expectation
3
1.8
2.0
1.8
Hyposexuality
2
t.911
1.5
1.3
30.1
28.6
Depressed Guilt Suicidal
Mean Total
33.2
*Statistically
significant,
AN0VA.p
tStatistically
significant,
ANOVA,
< 0.05. p < 0.01.
$Significantly
different
by t test from unipolar
SSignificantly
different
by t test from bipolar
II (p < 0.001);
tp < 0.01).
\\Significantly
different
by t test from bipolar
I I (p < 0.001);
(Significantly
different
by t test from bipolar
II (p < 0.05);
from unipolar from unipolar from unipolar
(p < 0.01). (p < 0.001). (p < 0.001).
feelings; A+ indicated anxiety; A- indicated calm or lack of tension. The “filler” adjectives, which did not reflect a particular affect, were not scored.” Data were analyzed with an analysis of variance (ANOVA) to determine if there were overall statistically significant differences for the three diagnostic groups. Differences between groups were evaluated by means of student’s t tests. A total of 35 patients were evaluated. There were 6 bipolar I patients (3 men and 3 women), I7 bipolar II patients (IO men and 7 women), and I2 unipolar patients (3 men and 9 women). Bipolar patients in both groups were older than unipolar patients. The mean age (* SD) of bipolar I patients was 48 i 9.5 years, for bipolar II patients, 51 f 9.1 years, and for unipolar patients, 40 =t 10.5 years (F = 5.23,~ < 0.05). However, there was no correlation with symptomatology and age. hostile
RESULTS
The ratings for the depressive symptoms from the modified Hamilton depression rating scale are tabulated in Table 1. Only two of these symptoms (psychomotor retardation and personal appearance) demonstrated overall statistical significance with the ANOVA. Further tests of significance, using t tests, demonstrated that for these two items, ratings for bipolar I patients were significantly different from either bipolar II or unipolar patients, whereas, no statistical significance was demonstrable between bipolar II and unipolar patients. Additional t tests were performed for those items where the ANOVA was not statistically significant, but where F was at least 2.0. Most of these items showed statistically significant differences in mean ratings for bipolar I patients as com-
UNIPOLAR
AND
BIPOLAR
AFFECTIVE
Table 2.
DISORDER
Ratings of Global Severity Bipolar
Mean nurses’
ratings
Mean patients’ There
ratings
were no significant
449
differences
of Depression
I
Bipolar
II
Unipolar
22.9
25.9
29.2
30.0
22.6
31.3
among
the patient
groups
for nurses’ or patients’
ratings.
pared to either bipolar II or unipolar patients (withdrawal, depressed mood, hyposexuality). Only one item-concentration-demonstrated statistical significance between bipolar II and unipolar patients. The ratings for suicidal ideation did not show significant differences overall or for the three diagnostic subgroups. Data regarding global depression ratings are presented in Table 2. There were no significant differences overall (by ANOVA) for the mean nurses’ ratings on the global scale. Furthermore, although the bipolar II patients had the lowest mean ratings on this scale, their ratings were not significantly different from either unipolar or bipolar I patients. However, whereas the mean of the nurses’ ratings for bipolar I and unipolar patients indicated greater severity of depression than these patients’ self-ratings, the bipolar II patients tended to rate themselves as more depressed (lower mean rating) than the nurses rated them. These data were analyzed for patients individually by means of a 3 x 3 chi square analysis (diagnostic groups versus staff rating higher, equal to, or lower than each of the patient’s self-ratings). Chi square for this analysis was 14.8, p < 0.01, suggesting that bipolar II patients rated themselves as more severely ill than the nurse rating team. The results from the MAACL are presented in Table 3. The mean number of adjectives checked by each patient was not significantly different for the diagnostic groups. Furthermore, no statistically significant differences emerged when the data were analyzed by subscales. Overall, patients tended to check adjectives which indicated they felt depressed and anxious (D+ and A+) rather than checking the “minus” adjectives. DISCUSSION
Dlxerentiation of Bipolar II Patients
The data from the Hamilton rating scale suggest that the symptoms of depression in patients classified as bipolar II are more similar to unipolar than to Table 3.
Depressive Symptoms
as Determined
From an Adjective
Bipolar
Adjectives
I
N=5
Check
Bipolar I I N= 17
List Unipolar N = 11
Depression+
10
5.8
10.6
9.4
Depression-
10
0.6
0.9
2.6
Hostility+
16
1.6
3.2
3.4
Hostility
12
2.4
2.1
2.2
Anxiety+
11
6.0
6.4
6.6
Anxiety-
10
1.4
0.8
1.3
Mean number Data from
checked
23.0
31.2
34.1
the MAACL.
No significant
differences
were determined
for diagnostic
groups
overall
or between
groups.
450
DUNNER,
DWYER.
AND FIEVE
bipolar I patients. Although few of these symptoms achieved overall significance, bipolar I and unipolar patients showed significant differences by t tests on the mean ratings of several symptoms (psychomotor retardation, personal appearance, withdrawal, concentration, depressed mood, and hyposexuality). For all of these symptoms, except concentration, there also was significance between bipolar I and bipolar II patients. Bipolar II patients were rated significantly higher in inability to concentrate than unipolar patients, which was the only symptom where there was a significant difference between bipolar II and unipolar patients. These data suggest that, regarding depressive symptoms, bipolar II patients are indistinguishable from unipolar patients. The mean ratings of depression in the global scale showed no group differences. However, bipolar II patients rated themselves as more severely ill as compared to how the nurses rated them, whereas, the other depressed patients tended to be rated by the nurses as more severely ill than they rated themselves. One inference from this may be that bipolar II patients (as compared to other depressed patients) are in some way unable to convey to others how depressed they feel. An alternate interpretation of these data is that the levels of severity in the global scale may not be sufficiently anchored or explained to patients. Although no differences regarding suicidal ideation were demonstrable, previous studies have suggested that a history of suicide attempt and death from suicide may both be observed more frequently in patients classified as bipolar II as compared to bipolar I and unipolar patients. I*’ It is tempting to speculate that the suicidal behavior seen in bipolar II patients may be related to their not conveying the severity of their depression to their therapists. It is our clinical impression that during clinical interviews many bipolar II depressed patients demonstrate appropriate, nondepressed affects when discussing happier occasions in their lives. Often these bipolar II patients are not diagnosed as depressed because of their seeming lack of depressed affect. Regardless of whether or not this phenomenon is characteristic of the bipolar II depressive, the treatment implications of it require further investigation, as does the data regarding suicide and suicide attempts. The adjective check list data were analyzed to provide another index of depressive symptoms which might differentiate bipolar II patients. However, these data failed to reveal differences among patient groups. A previous study of this scale from our unit revealed that the MAACL was useful in discriminating the depressed state from normal9 Diflerentiation of Bipolar I patients
Our Hamilton rating scale data support previous studies which demonstrate differences in depressive symptomatology (particularly in psychomotor retardation) between bipolar and unipolar patients. Beige1 and MurphylO reported clinical characteristics of 25 age- and sex-matched pairs of unipolar and bipolar patients. Their unipolar patients were characterized by greater physical activity, overt expression of anger, and as having more somatic complaints as compared to bipolar patients who had greater psychomotor withdrawal. The bipolar patients reported by Beige1 and Murphy’” are bipolar I by the criteria of our study which also demonstrates that bipolar I patients have greater psychomotor withdrawal than other depressed patient groups. In addition, Kupfer and Foster” measured
UNIPOLAR
AND
BIPOLAR
AFFECTIVE
DISORDER
451
psychomotor activity by means of a telemetric mobility sensing system and reported that patients with bipolar depression had less psychomotor activity than unipolardepressives. Unlike the study of Beige1 and Murphy,“’ we could not demonstrate unipolar-bipolar differences in somatic complaints or hostility, The mean ratings for “hypochondriasis” on the Hamilton scale were uniformly low in all three diagnostic groups. Although bipolar II and unipolar patients had higher mean ratings than bipolar I patients for irritability and hostility on the Hamilton scale and the MAACL, respectively, these differences failed to achieve statistical significance. Several studies of unipolar and bipolar affective states support this separation of affectively ill patients, using genetic, clinical, and pharmacologic criteria.‘-.‘,: In those studies where data from bipolar II patients have been separately analyzed, the bipolar II patients have not been consistently more similar to either bipolar I or unipolar patients. For example, the mean urinary excretion of 17 hydroxycorticosteroids (17 OHCS) during depression was significantly reduced for bipolar I patients as compared to both unipolar and bipolar II patients who had similar levels.:’ However, studies of evoked cortical response reveal bipolar II patients to be more similar to bipolar I patients and significantly different from unipolar patients.& The present study supports the overall unipolar--bipolar separation and suggests that, on the basis of depressive symptoms, bipolar II patients are more similar to unipolar patients than to bipolar I patients. ACKNOWLEDGMENT We
appreciate
performed
the
assistance
by the nursing
of
Dr.
Joseph
staff of the 4 North
Fleiss
and
Metabolic
Dr.
Clinical
Frank
Stallone.
Research
The
ratings
were
Goodwin
FK.
Unit.
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