Dr. Maj and Colleagues Reply

To the Editor: We are grateful to Dr. Sato et al. for their letter, which confirms the current revival of interest in agitated bipolar depression as a possible mixed state. Dr. Sato et al. state that in our article we did not report on anxiety symptoms in our bipolar I patients with an index episode of agitated depression. This is not correct. In Table 3 of our article, we did report the mean score on the item “inner tension” of the Comprehensive Psychopathological Rating Scale (defined in the scale as “mental tension mounting to panic, dread, and anguish”). This score was significantly higher in patients with agitated depression (mean=1.40, SD=0.49) than in those with nonagitated depression (mean=0.95, SD=0.56) (F=21.5, df=1, 120, p<0.001) and in those with mania (mean=0.46, SD=0.50) (F=107.6, df=1, 120, p<0.0001). Of the eight patients with agitated depression who showed both three symptoms of factor 2 and all of the symptoms of factor 5 of Cassidy et al. (1) for mania, six (75%) had a score of at least 1 on the “inner tension” item. In line with these findings, Koukopoulos et al. (2) used the expression “anxious-excited depression” to identify the mixed depressive state and listed “intense inner tension” as one of the symptoms characterizing the condition, whereas Akiskal and Mallya (3) mentioned “refractory anxiety” among the symptoms of mixed depression. Perhaps the current characterization of the “new” psychopathology of mania (reflected in our current assessment instruments) is not sophisticated enough to allow a clear demarcation between “anxiety” and “nonclassic manic” symptoms.

We agree with Dr. Sato et al. that the issue of agitated depression as a possible mixed state is also relevant to bipolar II and unipolar depression, and we are currently studying two cohorts of bipolar II and unipolar patients with an index episode of agitated depression, along with appropriate comparison groups.