Skip to main content Accessibility help

Presence of Irritability During Depressive Episodes in Bipolar Disorder

  • Thilo Deckersbach, Roy H. Perlis, W. Gordon Frankle, Stephen M. Gray, Louisa Grandin, Darin D. Dougherty, Andrew A. Nierenberg and Gary S. Sachs...


Background:This study examined the prevalence of irritability in patients with bipolar I disorder during an episode of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) major depression who do not meet criteria for a mixed episode.

Method:A chart review of 111 patients with bipolar I disorder treated at the Massachusetts General Hospital Bipolar Clinic between 1998 and 2000 identified 34 patients who met criteria for a DSM-IV major depressive episode in the absence of (1) mood elevation and/or (2) irritability associated with any additional above threshold DSM-IV symptoms of mania. Data gathered from the charts utilized prospective ratings made routinely at each clinic visit using the Clinical Monitoring Form (CMF), a structured assessment instrument which includes modified versions of the mood modules of the Structured Clinical Interview for DSM-IV. Data from these 34 patients were reviewed to determine the presence of irritability.

Results:The frequency of abnormal irritability in these 34 patients followed a bimodal distribution: 26% of the patients showed abnormal irritability ≥75% of the time, compared with 68% of the patients with abnormal irritabihty ≤30% of the time. Of the high-irritability patients, psychomotor agitation was rated as definitely present to a significant degree in 44%. Talkativeness and distractibility were rated present but subthreshold in one patient each. All other symptoms of DSM-IV mania were absent.

Conclusion:Approximately 25% of patients with bipolar I disorder who meet criteria for a DSM-IV major depressive episode also experienced substantial irritability in the absence of associated symptoms of mania. Our results suggest that abnormal irritability is not limited to mania or mixed states.


Corresponding author

Please direct all correspondence to: Thilo Deckersbach, PhD, Psychiatric Neuroscience Program, Harvard Bipolar Research Program Department of Psychiatry, 149-2611, Massachusetts General Hospital, Bldg. 149, 13th St., Charlestown, MA 02129; Tel: 617-724-6300, ext. 1340183, Fax:, 617-726-4078; E-mail:


Hide All
1.Altman, EG, Hedeker, DR, Janicak, PG, et. al.The clinician-administered rating scale for mania (CARS-M): development, reliability, and validity. Biol Psychiatry. 1994;36:124134.
2.Perugi, G, Akiskal, HS, Micheli, C, et al.Clinical subtypes of bipolar mixed states: validating a broader European definition in 143 cases. J Affect Disord. 1997;43:169180.
3.Cassidy, F, Murry, E., Forest, Ket al.Signs and symptoms of mania and mixed episodes. J Affect Disord. 1998;50:187201.
4.Dilsaver, S, Chen, YR, Shoaib, AM, et al.Phenomenology of mania: Evidence for distinct depressed, dysphoric and euphoric presentations. Am J Psychiatry. 1999;156:426430.
5.Cassidy, F, Forest, K, Murry, E. et al.A factor analysis of the signs and symptoms of mania. Am J Psychiatry. 1998;155:2732.
6.Dayer, A, Aubry, J-M, Roth, L, et al.A theoretical reappraisal of mixed states: dysphoria as a third dimension. Bipolar Disord. 2000;2:16324.
7.Akiskal, HS, Benazzi, F. Family history validation of the bipolar nature of depressive mixed states. J Affect Disord. 2003;73:113122.
8.Perugi, G, Akiskal, HS, Micheli, C, Toni, C, Madaro, D. Clinical characterization of depressive mixed state in bipolar-1 patients: Pisa - San Diego collaboration. J Affect Disord. 2001;67:105114.
9.Winokur, G, Clayton, PJ, Reich, T. Manic Depressive Illness. St. Louis, Mo: CV Mosby; 1969.
10.Benazzi, F. Atypical depression with hypomanic symptoms. J Affect Disord. 2001;65:179183.
11.Benazzi, F. Major depressive disorder with anger: a bipolar spectrum disorder? Psychother Psychosom. 2003;72:300306.
12.Guille, C, Sachs, G, Demopulos, C. A clinical monitoring form for mood disorders (CMF-M), Paper presented at: Annual Meeting of the New Clinical Drug Evaluation Unit, June 1-4, 1999. Boca Raton, FL.
13.Diagnostic Statistical Manual of Mental Disease. 4th ed. Washington, DC: American Psychiatric Association; 1994.
14.First, MB, Spitzer, RL, Gibbon, M, et al.Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition. (SCID-I/D, Version 2.0). Washington, DC: American Psychiatric Association; 1995.
15.Koukopulos, A, Koukopoulos, A. Agitated depression as a mixed state and the problem of melancholia. Psychiatr Clin North Am. 1999;22:547564.
16.Fava, M, Anderson, K, Rosenbaum, J. “Anger attacks”: possible variants of panic and major depressive disorder. Am J Psychiatry. 1990;147:867870.
17.Guy, W. Assessment Manual for Psychopharmacology. Washington, DC: US Government Printing Office; 1976.


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed