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Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 23-27

Bipolarity and temperament in depression: Making the right diagnosis

Department of Psychiatry, H. B. T. Medical College and Dr. R. N. Cooper Municipal General Hospital, Mumbai, Maharashtra, India

Date of Web Publication24-May-2019

Correspondence Address:
Dr. Suyog Vijay Jaiswal
Department of Psychiatry, H. B. T. Medical College and Dr. R. N. Cooper Municipal General Hospital, Juhu, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_40_18

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Background: Diagnosis of bipolar disorder is often missed clinically in cases presenting in depression, and temperament is an important clue to correct it. We, therefore, studied cases diagnosed as depression to see the evidence of undiagnosed bipolar disorder as well as temperament. Materials and Methods: Patients of a depressive episode (ICD-10, F32), between 18 and 60 years of age and within mild or normal range on Hamilton Depression Rating Scale at the time of interview were included in this study. The patients were diagnosed retrospectively using mini-international neuropsychiatric interview (MINI) mania hypomania scale to look for missed diagnoses of mania or hypomania episodes. Bipolar spectrum diagnostic scale (BSDS) was used to evaluate bipolar spectrum, and temperament assessment scale and Temperament Evaluation of Memphis, Pisa and San Diego Auto questionnaire (TEMPS-A) was used to assess affective temperament of participants. Chi-square test was used to compare the cases. Results: Out of 100 patients, 35 cases were diagnosed with hypomania and two cases with mania. BSDS was positive in 16% cases whereas it was positive in 9% cases with past episodes of hypomania and 1% case of mania. On TEMPS-A, 12% of cases had depressive or dysthymic temperament, 37% of cases had cyclothymic temperament, 21% of cases had hyperthymic temperament, and 5% of cases had irritable temperament. Cases with irritable or dysthymic temperament had no evidence of bipolar disorder on MINI and were statistically significant (P < 0.001). Limitations: Consecutive sampling, cross-sectional design, retrospective diagnosis. Conclusion: The misdiagnosis of Bipolar II disorder and bipolar spectrum disorder can happen as depression. Temperament can help assert evidence for bipolar disorder in cases presenting as depression and using standardized tools like MINI can help correct diagnosis and management.

Keywords: Bipolar disorder, depressive disorder, diagnosis, temperament

How to cite this article:
Soni A, Jaiswal SV, Sawant VA, Sinha D. Bipolarity and temperament in depression: Making the right diagnosis. Ann Indian Psychiatry 2019;3:23-7

How to cite this URL:
Soni A, Jaiswal SV, Sawant VA, Sinha D. Bipolarity and temperament in depression: Making the right diagnosis. Ann Indian Psychiatry [serial online] 2019 [cited 2023 Mar 30];3:23-7. Available from: https://www.anip.co.in/text.asp?2019/3/1/23/259089

  Introduction Top

Depression is a complex, polygenic, heterogeneous, and multifactorial brain disorder. Depressive episode is often the first mood syndrome at the onset of bipolar disorder occurring before the first episode of mania[1] and depressive phases occur more frequently than hypomanic or manic phases.[2] As many as 40% of both inpatients and outpatients diagnosed with depression are subsequently found to have bipolar disorders.[3] Despite low patient reporting rates and low physician pick-up rates, screening for bipolar disorders in patients presenting with depressive symptoms is seldom conducted, even in patients with a high risk of bipolar disorders.[4] Most patients with depressive onset get diagnosed to bipolar disorder within 5–9 years with an average of 6.4 years.[5] Bipolar disorder is thought to lie on a spectrum of disorders which may include depression at one end and mania at the opposite end.[6] Bipolar spectrum disorder has been described and defined in several ways, but it usually includes Bipolar I, Bipolar II, cyclothymia, and bipolar not otherwise specified. The lifetime prevalence of bipolar spectrum disorder has been found to be between 2.6% and 6.5%.[7] A significant proportion of patients with depression experience mild or brief episodes of hypomania which fall below the threshold for a formal diagnosis of bipolar affective disorder.[8] The substantial proportion of the bipolar spectrum that is undetected has been attributed both to the narrow diagnostic criteria for Bipolar II disorder as well as to the inherent difficulty in detecting milder forms of hypomania.[9] This problem is potentially greatest for depressive disorder, which may include heterogeneous conditions. Clinical studies indicate that 30%–55% of those with depression may be characterized by symptoms of hypomania,[10] and that those with subthreshold hypomania are less likely to respond adequately to usual treatments for depression.[11] These “bipolar spectrum” patients often have patterns of depressive episodes, co-morbidities, and treatment responses that differ from those with more simple depression and which, therefore, require a different approach to diagnosis and management.[12] Considering these aspects, this study was designed to gain further insight into bipolar spectrum disorders and ease the way for swift diagnosis of missed out and mistreated cases of bipolar spectrum disorder thereby to improve the prognosis and quality of life of these patients. Also, doing detailed diagnostic assessment could potentially identify who may be at risk of bipolar disorder. We, therefore, investigated the patients of the depressive episode for the evidence of undiagnosed bipolar mood disorder in terms of undiagnosed mania, hypomania as well as temperament.

  Materials and Methods Top

Study design

The study was conducted in psychiatry outpatient department of a tertiary care municipal-run teaching hospital in suburban Mumbai. Consecutive sampling was used to collect the study sample. The sample size was calculated as follows:[13]

Z1 − 2α= 1.96 (value for 95% confidence level); p = 0.045 (4.5% prevalence,[14] expressed as decimal); and C = 0.05 (confidence interval, expressed as decimal). The estimated sample comes around 60.

A sample of 100 follow-up outpatients fulfilling the inclusion and exclusion criteria were interviewed for the purpose of study between April 2015 and March 2016.


The study protocol was presented to Institutional Ethics Committee and was approved before commencement of the study. The participants were briefed about the study and assured confidentiality. Written informed consent was obtained from willing participants before commencing the interview. Confidentiality was maintained using unique identifiers.

Selection criteria

Newly diagnosed and follow-up patients of depressive episode (ICD-10, F32), between 18 and 60 years of age were included in this study. Patients diagnosed with any chronic and debilitating medical or neurological illness and intellectual disability, any current or past psychiatric condition apart from a depressive episode (ICD-10, F32); were not included in the study. The patients with Hamilton Depression Rating Scale (HDRS) score more than 14 (moderate or severe depression) were deferred from inclusion and interview. They were evaluated on fortnightly follow-up and were included if their score was below 14 (mild or no depression category on HDRS) after treatment to avoid recall bias for retrospective data collection. Furthermore, the patients of comorbid substance use disorder in dependence pattern other than nicotine and caffeine were excluded from the study.

Data collection

The patients who were included in the study were given appointment as per their convenience and called for interview. The data were obtained from the patient, caregivers, and case records wherever available. Specially designed case record forms were used to collect sociodemographic and clinical data. HDRS was used to assess the severity of depression. The patients were diagnosed retrospectively using mini-international neuropsychiatric interview (MINI) mania hypomania scale to look for missed diagnoses of mania or hypomania episodes. Bipolar spectrum diagnostic scale (BSDS) was used to evaluate the presence or absence of bipolar spectrum disorder. Temperament evaluation of Memphis, Pisa, and San Diego auto questionnaire (TEMPS-A) was used to assess affective temperament of participants and classified them into dysthymic, cyclothymic, hyperthymic, irritable, or with no specific temperament type. Data were carefully collected, and the case record form of each participant was coded serially to ensure the confidentiality.

  1. HDRS: The clinician-rated questionnaire for assessing the severity of symptoms observed in depression such as low mood, insomnia, agitation, anxiety, and weight loss. The scale contains 17 variables and score is calculated by adding the score on each variable. Score <8 is normal, 8–13 is suggestive of mild depression, 14–18 of moderate depression, 19–22 of severe depression, and more than 22 of very severe depression. Internal consistency is reported 0.83[15] and validity ranges from 0.65 to 0.90[16]
  2. The MINI is a short structured diagnostic interview for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 min, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a first step in outcome tracking in nonresearch clinical settings.[17] Sensitivity is 0.91 and specificity is 0.70[18]
  3. BSDS is a psychiatric screening rating scale for bipolar disorders. The BSDS has two sections. The first part includes a series of 19 sentences that describe the main symptoms of bipolar spectrum disorders. Each sentence is linked to a blank space that should be checked by patients who decide that the statement is an accurate description of their feelings or behaviors. Each checked statement is assigned 1 point. Sensitivity 0.76 and specificity 0.85[19]
  4. TEMPS-A contains 110 items, measuring affective temperament traits occurring throughout the life of the subject, as represented by five dimensions: depressive, cyclothymic, hyperthymic, irritable, and anxious. Questions about the various types are grouped together.[20] Indian adaption of TEMPS-A was used in the study, which contains 50 questions in Hindi language.[21]

Statistical analysis

Statistical Package for Social Sciences version 18.0 (IBM Corp, Armonk, NY, USA) was applied to obtain the statistical significance of the data thus collected. Descriptive statistics has been used to describe the sample in terms of sociodemographic and clinical characteristics. Chi-square test was used to compare between groups based on gender, family history of psychiatric disorder, presence or absence of bipolarity (hypo/mania), temperament types, and presence or absence of bipolar spectrum (BSDS). In this study, a level of significance (α) of 0.05 (two-tailed) has been taken to consider a result statistically significant.

  Results Top

We interviewed 100 patients for the purpose of the study, and the mean age of our sample was 37.03 ± 7.17 years ranging from 19 to 49 years. Mean duration of illness was 43.74 ± 32.03 months. Predominant population in our sample was female. Sociodemographic details are as depicted in [Table 1]. On a retrospective assessment using MINI, 35% cases had a history of hypomania (12 males and 23 females) and 2% had mania (both females) whereas BSDS suggested 16 patients (4 males and 12 females) with evidence of bipolarity. Bipolarity (BSDS) was positive in 9% cases with past episodes of hypomania (MINI) and 1% case of mania (MINI). On TEMPS-A, 12% cases had depressive or dysthymic temperament, 37% had cyclothymic temperament, 21% had hyperthymic temperament, and 5% had irritable temperament. [Table 2] shows an association of temperament with different study variables. [Table 3] shows the number of patients as per Akiskal classification.
Table 1: Sociodemographic details among samples

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Table 2: Comparison of clinical variables and mini-international neuropsychiatric interview and bipolar spectrum diagnostic scale with temperament types

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Table 3: Division of bipolar disorder according to Akiskal classification

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  Discussion Top

Unrecognized hypomania or mania and bipolar spectrum in depression

In our study, the finding of undiagnosed cases of bipolar disorder in diagnosed cases with depression is in keeping with several studies that have found that bipolar disorder is often misdiagnosed as depressive disorder. In a previous study done by Hu et al.[22] similar findings were noted in patients being treated for depression who were diagnosed with bipolar disorder after administering the MINI. Another older clinical study by Akiskal et al. indicates that 30%–55% of those with depression may be characterized by symptoms of hypomania.[9] These findings suggest that although individuals within hypomania represent the most common bipolar phenotype, they are often unrecognized as the presence of hypomanic or manic episode(s) is required to meet criteria for a diagnosis of bipolar disorders, and until that seminal episode occurs, it would be virtually impossible to diagnose anything other than depression.

Bipolar disorder is hypothesized to lie on a spectrum of disorders which may include depression at one end and mania at the opposite end.[5] The substantial proportion of the bipolar spectrum that is undetected has been attributed both to the narrow diagnostic criteria for Bipolar II disorder as well as to the inherent difficulty in detecting milder forms of hypomania.[10] Ghaemi et al. also reiterates similar findings with BSDS.[19] However, bipolar spectrum was not as clearly emphasized on as was the concept on missing the hypomanic episode in a case that were diagnosed to be a depressive disorder. Bipolar spectrum disorder argues to be a longitudinal diagnosis included various mood states ranging from depression to mania including mixed states and hyperthymic temperament.[23]

Comparison of temperament types

Cases diagnosed wherein past episode of hypomania or mania could be traced, had either cyclothymic or hyperthymic temperament types. A previous study done by Henry et al.[24] found that depressive temperament may prevail among bipolar affective disorder patients with predominant depressive polarity, and hyperthymic temperament is commonly present in those bipolar affective disorder patients with manic predominant polarity. In study done by Perugi et al.[25] it was shown that in cases with depressive disorder, the presence of other affective temperaments besides the depressive temperament has a crucial role in determining the clinical picture, course, and bipolar conversion. They further state that the presence of cyclothymic temperament in these cases of depression has been related to atypical clinical features. Bipolar disorder patients with predominant cyclothymic and hyperthymic temperament are significantly different along several relevant clinical and course features, including gender ratio, episode polarity and number of episodes, hospitalizations, suicidality, comorbid anxiety disorders, and personality disorders.[26] The relationship between Bipolar II disorder and cyclothymic temperament and conversion from depression to Bipolar disorder was shown by studies done by Kochman et al. who suggest that the presence of depressive temperament can also help distinguishing between mixed and pure manic states.[27] Temperament can play a role in determining as well as modeling the emergence and evolution of affective disorders including several important disease characteristics such as predominant polarity, symptomatic expression, long-term course and, response and adherence to treatment, outcome as well.[28] Higher scores of hyperthymic temperament are associated with higher risks for antidepressant-induced mania in bipolar depressives.[29] These studies correlate with our findings when comparing cyclothymic and hyperthymic temperament and dysthymic temperament with the presence or absence of previous episodes of hypomania or mania and henceforth bipolar conversion. The temperament may not be important pertaining to diagnosis of bipolar disorder but arguably provide a clue toward the course of depression, possible bipolar conversion, and bipolarity of affect in general.

Akiskal classification

Akiskal classification was based on affective temperaments which can constitute the subclinical and subaffective manifestation of affective illnesses and used a spectrum approach to classify bipolar disorder into six subtypes.[30] The affective spectrum is described as a continuum ranging from subclinical manifestations to full-blown bipolar disorder which includes cyclothymia[31],[32] as well as subsyndromal depression, mild depression, dysthymia, and moderate-to-severe depression.[33] Studies show that depressive temperament is usually more prevalent among depressive patients, and hyperthymic as well as cyclothymic temperament is a particular effective characteristic for bipolar illness.[34] In few other studies, it was found that Bipolar II disorder is more specifically related to cyclothymic temperament,[35] and in cases of recurrent depressive episodes, it is also associated with earlier age of onset, a higher number of previous depressive episodes, more psychotic and melancholic features, as well as suicidal ideations and attempts, which are predictive factors of bipolarity in recurrent depression.[36] Application of these categories revealed considerable diversity in the clinical manifestations of mood disorders and indicated that bipolar spectrum disorders occur almost as frequently as “pure” unipolar depression and it is clinically difficult to define the border between a variant of normal behavior and the behaviors that are associated with “subthreshold bipolar disorder.”

Our study indicates a high incidence of bipolarity in cases diagnosed as unipolar depression. Adequate history, the use of standardized instruments and taking temperament types of patients into consideration can help to reach a correct diagnosis of bipolar depression. This gives us perspective to assert diagnosis of depression, especially in cases that are not responding or labeled as treatment resistant. We believe we are still away from clearly defining the spectrum approach and require further investigation in this area, albeit applying the structured interviews like MINI can take care of the undiagnosed case of bipolar disorder to do the course correction of management where being treated as depression. The clinician should take temperament into consideration while managing depression especially in cases which are not responding or labeled as treatment resistant.

Our study had few limitations such as its cross-sectional design and consecutive case selection. Few of our variables were based on retrospective recall, we, however, interviewed patients when their depression scores were mild or normal to minimize the recall bias. A long-term follow-up is needed for better knowledge on the course and outcome of bipolar disorder.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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