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Objectives: High rates of some depressive symptoms occur in both mixed and pure manic episodes. This study examined whether manic subjects identify these depressive symptoms by self-report consistently with observer ratings, whether dysphoric symptoms are self-rated differently in mixed compared to pure manic episodes, and whether discriminative self-rated dysphoric symptom sets agree with those established by observer ratings., Methods: Ninety-four inpatients meeting DSM-IV criteria for mania were classified as in pure or mixed episodes. Dysphoric symptoms were evaluated with the Hamilton Depression Rating Scale (HDRS) and the self-rated Carroll Depression Scale (CDS). Total scores and individual symptom scores on the two scales were compared, as were differences between the manic and mixed subtypes. Positive predictive values (PPV) of individual CDS statements for a diagnosis of a mixed bipolar episode were calculated. Those with a PPV of 0.5 or greater were summed across all subjects and the distributions within the bipolar manic and mixed groups inspected., Results: Self-rated depressive symptoms were highly concordant with observer-rated depressive symptoms in mania. Differences were demonstrated between mixed and pure manic subjects based on self-report, and these differences were similar to those observed with HDRS evaluations. A group of 8 dysphoric symptoms discriminated mixed from pure manic episodes on both scales. These symptoms were depressed mood, pathological guilt, suicidal tendency, anhedonia, psychomotor agitation, psychic and somatic anxiety, and general somatic symptoms (fatigue)., Conclusions: Manic patients report depressive symptoms consistently with observer ratings. Self-rated dysphoric symptoms differ significantly between mixed and pure manic episodes. Patient self-rating is another tool which may help in the diagnosis of mixed mania and the recognition of depressive symptoms during manic episodes., Limitations: The current study included patients who were evaluated during inpatient hospitalization only. The study included only subjects capable and willing to give written informed consent. Generalizability to other bipolar patients is not established.

Background: Although seasonal patterns of manic episodes have been reported, the seasonal variation of mixed states of bipolar disorder has received little attention. In the current report we address that concern as well as the overall seasonality of manic episodes., Methods: The seasonal pattern of 304 psychiatric hospital admissions for treatment of mixed or manic bipolar episodes over a 3-year period were analyzed employing two definitions of mixed manic states: DSM-III-R and an ROC derived definition., Results: The frequency of all manic episodes combined peaked in early spring, with a nadir in late fall. Pure manic admissions showed a similar pattern. Mixed manic admissions had a significantly different pattern, with a peak in late summer and a nadir in November. The differences between pure and mixed manic admissions were demonstrated with the use of the ROC definition for mixed states., Limitations: Effects of medications and medication non-compliance may dampen natural seasonal patterns of episodes., Conclusions: The different seasonal pattern of mixed and pure manic episodes support the separation of mixed episodes as a distinct clinical subtype.

Background: Few studies have compared symptom presentations across manic or mixed episodes in manic-depressive patients., Methods: In the current study we report on symptom presentations of 68 prospectively-evaluated subjects diagnosed with Bipolar Disorder during two discrete manic or mixed episodes. Each episode was categorized using DSM-IIIR criteria for Bipolar Disorder, manic or mixed, as well as a less restrictive definition for manic and mixed states derived from receiver operating characteristic (ROC) analysis of symptoms., Results: The occurrence of mixed bipolar episodes was not random using either the DSM-IIIR or ROC-derived definitions of mixed episodes., Limitations: Subjects were not all fully medication-free at the time of evaluation which may have altered symptom presentation. The total duration of the study was limited, with the longest inter-episode interval under 6 years., Conclusions: Although there was variability in mixed symptomatology between episodes, the occurrence of mixed episodes was not random. Manic and mixed episodes tend to recur true to type.