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Diagnostic criteria for bipolarity based on an international sample of 5,635 patients with DSM-IV major depressive episodes


To assess the clinical validity of individual DSM-IV criteria for hypomania. In an international sample of 5,635 patients with major depressive episodes (Bridge Study), DSM-IV criteria for hypomania (stem questions, number and quality of symptoms, duration and exclusion criteria) were systematically assessed and their validity analysed on the basis of clinical data including family history, course, and other clinical characteristics. Three stem questions for hypomania, irritability, elevated mood and the added question of increased activity, showed comparable validity. The results support the current DSM-IV requirement for a higher symptom threshold (4 of 7 hypomanic symptoms) in cases of irritable mood. Longer durations of hypomanic episodes were associated with higher scores on all validators. The results did not support the DSM-IV durational requirements for hypomanic episodes (4 days) and manic episodes (7 days). Brief hypomanic episodes of 1, 2 or 3 days were valid and would meet validity criteria for inclusion. The three exclusion criteria in DSM-IV (hypomania due to the use of antidepressants or of other substances, or to other medical conditions) were found to exclude patients with bipolar depression and should therefore not be retained. These results support several revisions of the DSM-IV concept of hypomanic episodes: specifically, the inclusion of increased activity as a gate question, the inclusion of 1 or 2 to 3-day episodes and the elimination of all exclusion criteria.

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The diagnostic Bridge Study was organised and sponsored by Sanofi-Aventis. We thank them for providing us with all data and derived variables for analyses without any restrictions.

Conflict of interest statement

Prof. Dr. Jules Angst has served on the advisory board for Eli Lilly & Company, Janssen Cilag, Lundbeck, on the speakers’ bureau for Eli Lilly & Company and AstraZeneca, and as a consultant for Sanofi Aventis.

J.M.A. has undertaken consultancy work for Lilly, Janssen, Sanofi-Aventis, Lundbeck, Astra Zeneca, and Bristol-Myers-Squibb; and has received honoraria form Lilly, Janssen, Lundbeck, Sanofi-Aventis, Bristol-Myers-Squibb, Pfizer, and Novartis in relation to conference presentations.

A.G. is a statistician of JA and has no conflict of interest to declare.

C.L.B. has acted as a consultant for Pfizer, Bristol Myers Squibb, Repligen, and Merck. He has served on an advisory board of sanofi-aventis. He has received grant support from NIMH, Johnson and Johnson, and Bristol Myers Squibb.

G.P. has acted as consultant of Sanofi Aventis, Bristol Myers Squibb, Astra Zeneca, Eli Lilly, Boehringer Ingheleim; received grant/research support from Eli lilly, Astra Zeneca, Boehringer Ingheleim, Glaxo-SmithKline; is on the speaker/advisory board of Sanofi Aventis, Bristol Myers Squibb, Astra Zeneca, Eli Lilly, Boehringer Ingheleim, Glaxo-SmithKline, Pfyzer, Wyeth, Jannsen-Cilag, Lundbeck.

E.V. has acted as consultant, received grant/research support or honoraria from Almirall, Astra-Zeneca, Bristol-Myers-Squibb, Eli Lilly, Forest Research Institute, Geodon Richter, Glaxo-Smith-Kline, Janssen-Cilag, Jazz, Johnson & Johnson, Lundbeck, Merck Sharpe and Dohme, Novartis, Organon, Otsuka, Pierre-Fabre, Pfizer, Sanofi Aventis, Servier, Shering-Plough, Takeda, United Biosource Corporation, and Wyeth.

A.H.Y. has acted as a consultant, received grant/research support or honoraria from, and/or has been on the advisory boards of Sanofi-aventis, Eli-Lilly, Bristol-Myers Squibb, BCI, AstraZeneca, GSK, Janssen, Pfizer and Servier.

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Correspondence to J. Angst.

Additional information

For the Bridge Study Group.

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Angst, J., Gamma, A., Bowden, C.L. et al. Diagnostic criteria for bipolarity based on an international sample of 5,635 patients with DSM-IV major depressive episodes. Eur Arch Psychiatry Clin Neurosci 262, 3–11 (2012).

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  • Hypomania
  • Diagnosis
  • DSM criteria
  • Validity
  • Bridge study