Clinical Issues™

Clinical Issues in Bipolar Depression

Consensus and Controversies Across the Spectrum of Patient Presentations

Meeting Slides


Diagnostic and Statistical Manual of Mental Disorders (Fifth edition). 2013.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (Fifth edition). Arlington, VA: American Psychiatric Publishing

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults (Third edition). 2016.

Arlington, VA: American Psychiatric Publishing.

2015 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults.

The University of South Florida, Florida Medicaid Drug Therapy Management Program for Behavioral Health.


Patient Resources

Depression and Bipolar Support Alliance

The Depression and Bipolar Support Alliance (DBSA) offers resources for patients, materials for clinicians, information on mental health research, as well as listings of patient support groups across the United States.

Clinical Assessment Tools

Clinically Useful Depression Outcome Scale with questions for the DSM-5 mixed features specifier (CUDOS-M)

This self-administered assessment scale detects the presence of mixed features in patients with major depressive disorder. With a rating scale of 0-4, where 0 is not at all true and 4 is almost always true, patients endorse the frequency of each symptom experienced during the prior week (Zimmerman M, et al. J Affect Disord. 2014;168:357-362).

Montgomery-Asberg Depression Rating Scale (MADRS)

This clinician-scored questionnaire assesses the severity of patient depression over the prior week on a scale of 0-6, where 0 denotes no symptoms and 6 indicates the most severe symptoms (Montgomery SA, Asberg M. Brit J Psychiatry. 1979;134:382-389).

The Bipolarity Index

This clinician-rated scale aims to provide diagnostic confidence when evaluating a patient with suspected bipolar disorder. Five sections evaluating the 5 illness dimensions are each scored from 0-20, with a final score ≥50 indicative of bipolar disorder (Sachs GS. Acta Psychiatr Scand. 2004;422(suppl):S7-S17; Aiken CB, et al. J Affect Disord. 2015;177:59-64).

The Mood Disorder Questionnaire (MDQ)

This self-administered assessment scale is intended to help clinicians screen patients for bipolar disorder. The 5-question evaluation can be completed in less than 5 minutes and provides important insight into diagnosis and treatment. A positive screen is noted if a patient answers YES to ≥7 out of 13 items in question 1, YES to question 2, and MODERATE or SERIOUS to question 3 (Hirschfeld RMA. Prim Care Companion J Clin Psychiatry. 2002;4(1):9-11).

Young Mania Rating Scale (YMRS)

This clinician-guided assessment is intended to identify the severity of patient abnormalities. The 11-statement assessment is used to describe the patient’s symptoms over the prior week through scoring on a 0-4 scale, where 0 is absence of symptoms (feeling normal) and 4 indicates the most severe symptoms (Young RC, et al. Br J Psychiatry. 1978;133(5):429-435).

Suggested Readings

Major depressive disorder and bipolar disorder predispose youth to accelerated atherosclerosis and early cardiovascular disease: a scientific statement from the American Heart Association.

Goldstein BI, et al. Circulation. 2015;132(10):965-986. 2015;8(4):206-220

Mixed specifier for bipolar mania and depression: highlights of DSM-5 changes and implications for diagnosis and treatment in primary care.

Hu J, et al. Prim Care Companion CNS Disord. 2014;16(2).

The prevalence and illness characteristics of DSM-5-defined “mixed feature specifier” in adults with major depressive disorder and bipolar disorder: Results from the International Mood Disorders Collaborative Project.

McIntyre RS, et al. J Affect Disord. 2015;172:259-264.

Lurasidone in the treatment of bipolar depression with mixed (subsyndromal hypomanic) features: post hoc analysis of a randomized placebo-controlled trial.

McIntyre RS, et al. J Clin Psychiatry. 2015;76(4):398-405.

Mixed depression in bipolar disorder: prevalence rate and clinical correlates during naturalistic follow-up in the Stanley Bipolar Network.

Miller S, et al. Am J Psychiatry. 2016; Apr 15. [Epub ahead of print].

A 6 week randomized double-blind placebo-controlled trial of ziprasidone for the acute depressive mixed state.

Patkar A, et al. PLoS One. 2012;7(4):e34757.

Predictors of recurrence in bipolar disorder: primary outcomes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

Perlis RH, et al. Am J Psychiatry. 2006;163(2):217-224.0

Mixed features in patients with a major depressive episode: the BRIDGE-II-MIX study.

Perugi G, et al. J Clin Psychiatry. 2015;76(3):e351-e358.

Factors related to suicidal behavior in patients with bipolar disorder: the effect of mixed features on suicidality.

Seo HJ, et al. Gen Hosp Psychiatry. 2016;39:91-96.

Efficacy of olanzapine monotherapy in the treatment of bipolar depression with mixed features.

Tohen M, et al. J Affect Disord. 2014;164:57-62.

Heterogeneity of DSM-IV major depressive disorder as a consequence of subthreshold bipolarity.

Zimmermann P, et al. Arch Gen Psychiatry. 2009;66(12):1341-1352.

Relevant Resources

Reducing the Burden of Bipolar Depression

Improved Diagnostic and Management Strategies

Improving Outcomes in Bipolar Depression

Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

Comprehensive Management of Bipolar Depression

New Approaches to Optimizing Patient Outcomes

A Focus on Bipolar Depression

Overcoming Diagnostic Barriers and Optimizing Long-Term Patient Outcomes

Acute Management of Migraine Attacks

Overcoming Pain and Gastrointestinal Distress to Improve Patient Outcomes

Multidisciplinary Management of Bipolar Disorder

Accelerating Diagnosis, Achieving Remission, and Encouraging Adherence

Clinical Updates on the Management of Gout

Evidence-Based Strategies for Improved Patient Outcomes

Opioid-Induced Constipation

Proactive Diagnosis and Targeted Management

Chronic Obstructive Pulmonary Disease, Asthma, or Both

Differential Diagnosis and Comprehensive Management Strategies

Improving Outcomes in Chronic Obstructive Pulmonary Disease

Optimizing Maintenance Therapy Across Healthcare Settings

Managing Gout in Primary Care

Evolving Strategies for Diagnosis and Long-Term Management

Clinical Issues in Chronic Pain

Consensus and Controversies for Responsible Opioid Prescribing

Mixed Features in Depressive Episodes

Managing Patients Across the Disease Spectrum

Noninsulin Approaches to Managing Type 2 Diabetes

Best Practices in Combination Therapy

Hitting the Target in Type 2 Diabetes

Evolving Approaches to Insulin Based Therapy

Agitation and Psychiatric Disease

Best Practices for Emergency Care

Clearing the Air

Improving Outcomes for Patients with COPD

Clinical Updates in Type 2 Diabetes

New Strategies for Insulin Replacement Therapy

How Low Do You Go?

Clinical Updates in LDL-C Management

Incretin-Based Therapies For Type 2 Diabetes

Improving Comprehensive Patient Care

Improving Outcomes in Non–24-Hour Sleep-Wake Disorder

Identifying Patients and Tailoring Therapy

Comprehensive Management of Chronic Obstructive Pulmonary Disease

Collaborative Approaches to Guideline-Concordant Patient Care

Clinical Updates in the Management of Severe Asthma

New Strategies for Individualizing Long-term Care

Comprehensive Chronic Pain Management

A Focus on Patients With Opioid-Induced Constipation

Clinical Updates in Rheumatoid Arthritis

Evolving Treatment Algorithms and Expert Perspectives on Biosimilars

Caring for Patients with Severe Asthma

Evolving Best Practices to Optimize Outcomes

Can You Spot Axial Spondyloarthritis?

The PCP’s Role in Timely Recognition and Referral

Advancing the Care of Severe Asthma

Differential Diagnosis, Multidisciplinary Management, and Patient Engagement

Updates in HCV Screening and Treatment

Key Issues Impacting OB/GYN Practice

Evolving Models of HIV Care

Volume II: Expanding Evidence for the Role of Rapid ART Initiation in HIV Practice

Clearing the Air in Severe Asthma Management

Improving Patient Outcomes Through Shared Clinical Decision Making

GLP-1 Receptors Agonists in Type 2 Diabetes

Mechanistic Insights and Evolving Treatment Options

Airing It Out

A Case-Based Conversation on Managing Asthma and Chronic Rhinosinusitis With Nasal Polyposis

COPD in Managed Care

The Clinical and Utilization Benefits of Exacerbation Prevention

Assimilating the Evidence in T2DM

Cardiovascular and Renal Outcomes With SGLT2 Inhibitors

Demystifying New Evidence for COPD Management

Best Practices for Primary Care

Finding Relief in Osteoarthritis

New Paths to Chronic Pain Management

The Changing Landscape of HIV Prevention

What the Pharmacist Needs to Know about PrEP

What’s New in Systemic Lupus Erythematosus?

Unlocking Novel Paths to Patient Care

Expert Views on the Changing Landscape in RA

The Increasing Role of JAK Inhibitors

COPD Cases & Conversations

Preventing COPD Exacerbations to Improve Outcomes

Comprehensive Management in COPD

A Whole Patient Case Series

Maybe It’s NOT Mechanical Back Pain

Getting on the Fast Track to Identify AxSpA

Treating Hepatitis C in the Primary Care Setting

Establishing Clinical Readiness Through Mentored Learning

Finding the Path in Eosinophilic Esophagitis

Interdisciplinary Strategies for Adult and Pediatric Patients

Answering the Call

Interdisciplinary Management of Eosinophilic Esophagitis and Hereditary Angioedema

Getting Low in Familial Hypercholesterolemia

Reducing LDL-C and a Lifetime of Cardiovascular Risk

Expert Consult Series in Multiple Sclerosis

Updates, Clinical Scenarios, and Future Directions

Putting a Spotlight on Systemic Mastocytosis

A Multidisciplinary Look at Early Diagnosis and Management

Is It Systemic Mastocytosis?

Best Practices for Diagnosis and Management

Monoclonal Antibodies for COVID-19

An Update on Best Practices

Monoclonal Antibodies for COVID-19

New Avenues to Pre-Exposure Prophylaxis

Early Cancer Detection in Primary Care:

Are You Aware of New Blood-Based Multi-Cancer Screening Tools

Buffing Up on New and Emerging ART

A Look at the Changing HIV Playing Field

Pharmacy PrEP Education

A “How To” Series Spanning Policy to Practice


Building Bridges to Reach People who Inject Drugs with the Goal of Employing PrEP for HIV Prevention

Flexing Your Early Cancer Detection Muscles

Strengthening Your Knowledge of Blood-Based Screening Tools

Long-Acting Injectable PrEP:

Bringing HIV Prevention to a New Level

PrEParing to End the Epidemic

Optimizing HIV Prevention in Primary Care

Multi-Cancer Early Detection in Primary Care

What You Need to Know About New Blood-Based Screening Tools

A Call to Action

Monoclonal Antibodies for the Prevention and Treatment of COVID-19

What’s Next

Exploring New Treatment Avenues in Nonadvanced Systemic Mastocytosis

Best Practices in COPD

Practical Updates on the 2023 GOLD Guidelines

Answers to Everyday Practice Challenges in HIV Medicine

A Phone-a-Friend CME Series – Volume 2

What’s New in the Management of COVID-19

Incorporating New Data and Updated Guidelines Into Daily Practice

Lifting the Bar in Relapsed or Refractory Multiple Myeloma

Capitalizing on BCMA-Directed Therapies