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26]

Original Article

Bipolarity and Temperament in Depression: Making the

Right Diagnosis
Abhijeet Soni, Suyog Vijay Jaiswal, Vishal A. Sawant, Deoraj Sinha
Department of Psychiatry, H. B. T. Medical College and Dr. R. N. Cooper Municipal General Hospital, Mumbai, Maharashtra, India

Abstract
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

Introduction ways, but it usually includes Bipolar I, Bipolar II, cyclothymia,

and bipolar not otherwise specified. The lifetime prevalence of
Depression is a complex, polygenic, heterogeneous, and
bipolar spectrum disorder has been found to be between 2.6%
multifactorial brain disorder. Depressive episode is often the
and 6.5%.[7] A significant proportion of patients with depression
first mood syndrome at the onset of bipolar disorder occurring
experience mild or brief episodes of hypomania which fall
before the first episode of mania[1] and depressive phases occur
below the threshold for a formal diagnosis of bipolar affective
more frequently than hypomanic or manic phases.[2] As many
disorder.[8] The substantial proportion of the bipolar spectrum
as 40% of both inpatients and outpatients diagnosed with
that is undetected has been attributed both to the narrow
depression are subsequently found to have bipolar disorders.[3]
diagnostic criteria for Bipolar II disorder as well as to the
Despite low patient reporting rates and low physician pick‑up
inherent difficulty in detecting milder forms of hypomania.[9]
rates, screening for bipolar disorders in patients presenting
This problem is potentially greatest for depressive disorder,
with depressive symptoms is seldom conducted, even in
which may include heterogeneous conditions. Clinical studies
patients with a high risk of bipolar disorders.[4] Most patients
with depressive onset get diagnosed to bipolar disorder within
Address for correspondence: Dr. Suyog Vijay Jaiswal,
5–9 years with an average of 6.4 years.[5] Bipolar disorder is Department of Psychiatry, H. B. T. Medical College and Dr. R. N. Cooper
thought to lie on a spectrum of disorders which may include Municipal General Hospital, Juhu, Mumbai, Maharashtra, India.
depression at one end and mania at the opposite end.[6] Bipolar E‑mail: suyogjaiswal@gmail.com
spectrum disorder has been described and defined in several
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DOI: How to cite this article: Soni A, Jaiswal SV, Sawant VA, Sinha D. Bipolarity
10.4103/aip.aip_40_18 and temperament in depression: Making the right diagnosis. Ann Indian
Psychiatry 2019;3:23-7.

© 2019 Annals of Indian Psychiatry | Published by Wolters Kluwer - Medknow 23

[Downloaded free from http://www.anip.co.in on Friday, May 24, 2019, IP: 10.232.74.26]
Soni, et al.: Bipolarity and temperament in depression
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
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]
z 2 × p × (1 − p )
Samplesize = 1− 2a
d2
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.
Ethics
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
24
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]
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Soni, et al.: Bipolarity and temperament in depression

Statistical analysis Table 1: Sociodemographic details among samples

Statistical Package for Social Sciences version 18.0 (IBM
Corp, Armonk, NY, USA) was applied to obtain the statistical Variable n (total sample size=100)
significance of the data thus collected. Descriptive statistics has Gender
been used to describe the sample in terms of sociodemographic Male 29
and clinical characteristics. Chi‑square test was used to Female 71
Marital status
compare between groups based on gender, family history of
Married 91
psychiatric disorder, presence or absence of bipolarity (hypo/
Unmarried 09
mania), temperament types, and presence or absence of bipolar
Socioeconomic status
spectrum (BSDS). In this study, a level of significance (α) of
Middle 89
0.05 (two‑tailed) has been taken to consider a result statistically
Lower 11
significant. Habitat
Rural 26
Results Urban 74
We interviewed 100 patients for the purpose of the study, and Family history of psychiatric disorder
Significant 13
the mean age of our sample was 37.03 ± 7.17 years ranging
Not significant 87
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
Table 2: Comparison of clinical variables and
retrospective assessment using MINI, 35% cases had a history
mini‑international neuropsychiatric interview and bipolar
of hypomania (12 males and 23 females) and 2% had mania
spectrum diagnostic scale with temperament types
(both females) whereas BSDS suggested 16 patients (4 males and
12 females) with evidence of bipolarity. Bipolarity (BSDS) was Variables Temperament P
positive in 9% cases with past episodes of hypomania (MINI) N D C H I
and 1% case of mania (MINI). On TEMPS‑A, 12% cases had Gender
depressive or dysthymic temperament, 37% had cyclothymic Male (n=29) 9 2 13 5 0 0.346
temperament, 21% had hyperthymic temperament, and 5% Female (n=71) 16 10 24 16 5
had irritable temperament. Table 2 shows an association of Family history of psychiatric disorder
temperament with different study variables. Table 3 shows the Positive (n=13) 2 2 8 1 0 0.274
number of patients as per Akiskal classification. Negative (n=87) 23 10 29 20 5
Evidence of bipolar disorder (MINI)
Hypomania/mania (n=37) 6 0 22 9 0 0.000*
Discussion None (n=63) 19 12 15 12 5
Unrecognized hypomania or mania and bipolar spectrum BSDS
in depression Positive (n=13) 3 0 9 4 0 0.232
In our study, the finding of undiagnosed cases of bipolar Negative (n=62) 22 12 28 17 5
disorder in diagnosed cases with depression is in keeping *<0.05 (significance at 5%). n: None, D: Dysthymic, C: Cyclothymic,
H: Hyperthymic, I: Irritable, MINI: Mini‑International Neuropsychiatric
with several studies that have found that bipolar disorder Interview, BSDS: Bipolar Spectrum Diagnostic Scale
is often misdiagnosed as depressive disorder. In a previous
study done by Hu et al.[22] similar findings were noted in to the narrow diagnostic criteria for Bipolar II disorder as
patients being treated for depression who were diagnosed with
well as to the inherent difficulty in detecting milder forms of
bipolar disorder after administering the MINI. Another older
hypomania.[10] Ghaemi et al. also reiterates similar findings
clinical study by Akiskal et al. indicates that 30%–55% of
with BSDS.[19] However, bipolar spectrum was not as clearly
those with depression may be characterized by symptoms of
emphasized on as was the concept on missing the hypomanic
hypomania.[9] These findings suggest that although individuals
episode in a case that were diagnosed to be a depressive
within hypomania represent the most common bipolar
phenotype, they are often unrecognized as the presence of disorder. Bipolar spectrum disorder argues to be a longitudinal
hypomanic or manic episode(s) is required to meet criteria for diagnosis included various mood states ranging from
a diagnosis of bipolar disorders, and until that seminal episode depression to mania including mixed states and hyperthymic
occurs, it would be virtually impossible to diagnose anything temperament.[23]
other than depression. Comparison of temperament types
Bipolar disorder is hypothesized to lie on a spectrum of Cases diagnosed wherein past episode of hypomania or mania
disorders which may include depression at one end and could be traced, had either cyclothymic or hyperthymic
mania at the opposite end.[5] The substantial proportion of the temperament types. A previous study done by Henry
bipolar spectrum that is undetected has been attributed both et al.[24] found that depressive temperament may prevail

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Soni, et al.: Bipolarity and temperament in depression
Table 3: Division of bipolar disorder according to Akiskal
classification
Akiskal Clinical characteristics
classification
Bipolar I Full blown mania
Bipolar I ½ Depression with protracted hypomania
Bipolar II Depression with hypomanic episodes
Bipolar II ½ Depression associated with cyclothymic
temperament
Bipolar III Hypomania due to antidepressant drugs
Bipolar III ½ Hypomania and/or depression associated with
substance use
Bipolar IV Depression associated with hyperthymic
temperament
Bipolar V Recurrent depressions that are admixed with
dysphoric hypomania
Bipolar VI Late‑onset depression with mixed mood features,
progressing to a dementia‑like syndrome.
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.
26
Akiskal classification
Akiskal classification was based on affective temperaments
which can constitute the subclinical and subaffective
n manifestation of affective illnesses and used a spectrum
approach to classify bipolar disorder into six subtypes.[30]
2
The affective spectrum is described as a continuum ranging
0
from subclinical manifestations to full‑blown bipolar
6
disorder which includes cyclothymia [31,32] as well as
35
subsyndromal depression, mild depression, dysthymia,
0 and moderate‑to‑severe depression.[33] Studies show that
0 depressive temperament is usually more prevalent among
depressive patients, and hyperthymic as well as cyclothymic
21 temperament is a particular effective characteristic for
bipolar illness.[34] In few other studies, it was found that
0
Bipolar II disorder is more specifically related to cyclothymic
0 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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Soni, et al.: Bipolarity and temperament in depression
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