Mania and bipolar depression: complementing not opposing poles—a post-hoc analysis of mixed features in manic and hypomanic episodes

Christoph Born, Heinz Grunze, Robert M. Post, Lori L. Altshuler, Ralph Kupka, Susan L. McElroy, Mark A. Frye, Trisha Suppes, Paul E. Keck, Willem A. Nolen, Lars Schaerer

Research output: Contribution to journalArticlepeer-review


Background: Depending on the classification system used, 5–40% of manic subjects present with concomitant depressive symptoms. This post-hoc analysis evaluates the hypothesis that (hypo)manic subjects have a higher burden of depression than non-(hypo)manic subjects. Methods: Data from 806 Bipolar I or II participants of the Stanley Foundation Bipolar Network (SFBN) were analyzed, comprising 17,937 visits. A split data approach was used to separate evaluation and verification in independent samples. For verification of our hypotheses, we compared mean IDS-C scores ratings of non-manic, hypomanic and manic patients. Data were stored on an SQL-server and extracted using standard SQL functions. Linear correlation coefficients and pivotal tables were used to characterize patient groups. Results: Mean age of participants was 40 ± 12 years (range 18–81). 460 patients (57.1%) were female and 624 were diagnosed as having bipolar I disorder (77.4%) and 182 with bipolar II (22.6%). Data of 17,937 visits were available for analyses, split into odd and even patient numbers and stratified into three groups by YMRS-scores: not manic < 12, hypomanic < 21, manic < 30. Average IDS-C sum scores in manic or hypomanic states were significantly higher (p <.001) than for non-manic states. (Hypo)manic female patients were likely to show more depressive symptoms than males (p <.001). Similar results were obtained when only the core items of the YMRS or only the number of depressive symptoms were considered. Analyzing the frequency of (hypo)manic mixed states applying a proxy of the DSM-5 mixed features specifier extracted from the IDS-C, we found that almost 50% of the (hypo)manic group visits fulfilled DSM-5 mixed features specifier criteria. Conclusion: Subjects with a higher manic symptom load are also significantly more likely to experience a higher number of depressive symptoms. Mania and depression are not opposing poles of bipolarity but complement each other.

Original languageEnglish (US)
Article number36
JournalInternational Journal of Bipolar Disorders
Issue number1
StatePublished - Dec 2021


  • Bipolar disorder
  • Depression
  • Hypomania
  • Mania
  • Mixed states

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Biological Psychiatry


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