Hantouche E G, Akiskal H S, Lancrenon S, Allilaire J F, Sechter D, Azorin J M, Bourgeois M, Fraud J P, Châtenet-Duchêne L
Université Paris VI, Hôpital Pitié-Salpetrière, France.
J Affect Disord. 1998 Sep;50(2-3):163-73. doi: 10.1016/s0165-0327(98)00112-8.
This paper presents the methodology and clinical data in mid-stream from a French multi-center study (EPIDEP) in progress on a national sample of patients with DSM-IV major depressive episode (MDE). The aim of EPIDEP is to show the feasibility of validating the spectrum of soft bipolar disorders by practising clinicians. In this report, we focus on bipolar II (BP-II).
EPIDEP involves training 48 French psychiatrists in 15 sites; construction of a common protocol based on the criteria of DSM-IV and Akiskal (Soft Bipolarity), as well as criteria modified from the work of Angst (Hypomania Checklist), the Ahearn-Carroll Bipolarity Scale, HAM-D and Rosenthal Atypical Depression Scale; Semi-Structured Interview for Evaluation of Affective Temperaments (based on Akiskal-Mallya), self-rated Cyclothymia Scale (Akiskal), family history (Research Diagnostic Criteria); and prospective follow-up.
Results are presented on 250 (of the 537) MDE patients studied thus far during the acute phase. The rate of BP-II disorder which was 22% at initial evaluation, nearly doubled (40%) by systematic evaluation. As expected from the selection of MDE by uniform criteria, inter-group comparison between BP-II vs unipolar showed no differences on the majority of socio-demographic parameters, clinical presentation and global intensity of depression. Despite such uniformity, key characteristics significantly differentiated BP-II from unipolar: younger age at onset of first depression, higher frequency of suicidal thoughts and hypersomnia during index episode, higher scores on Hypomania Checklist and cyclothymic and irritable temperaments, and higher switching rate under current treatment. Eighty-eight percent of cases assigned to cyclothymic temperament by clinicians (with a cut-off of 10/21 items on self-rated cyclothymia) were recognized as BP-II. Evaluation of this temperament by clinician and patient correlated at a highly significant level (r=0.73; p <0.0001). Cyclothymia and hypomania were also correlated significantly (r=0.51; p < 0.001).
In a study conducted in diverse clinical settings, it was not possible to assure that clinicians making affective diagnoses were blind to the various temperamental measures. However, bias was minimized by the systematic and/or semi-structured nature of all evaluations.
With a systematic search for hypomania, 40% of major depressive episodes were classified as BP-II, of which only half were known to the clinicians at study entry. Cyclothymic temperamental dysregulation emerged as a robust clinical marker of BP-II disorder. These data indicate that clinicians in diverse practice settings can be trained to recognize soft bipolarity, leading to changes in diagnostic practice at a national level.
本文介绍了一项正在进行的法国多中心研究（EPIDEP）的方法和中期临床数据，该研究以患有DSM-IV重度抑郁发作（MDE）的全国患者样本为对象。EPIDEP的目的是证明执业临床医生验证软双相情感障碍谱系的可行性。在本报告中，我们重点关注双相II型（BP-II）。
EPIDEP包括在15个地点对48名法国精神科医生进行培训；根据DSM-IV和阿基斯卡尔（软双相情感障碍）标准，以及从安格斯特（轻躁狂检查表）、阿赫恩 - 卡罗尔双相情感障碍量表、汉密尔顿抑郁量表和罗森塔尔非典型抑郁量表的工作中修改的标准构建通用方案；情感气质评估的半结构化访谈（基于阿基斯卡尔 - 马利亚）、自评环性心境障碍量表（阿基斯卡尔）、家族史（研究诊断标准）；以及前瞻性随访。
展示了迄今为止在急性期研究的537名MDE患者中250名患者的结果。初始评估时BP-II障碍的发生率为22%，通过系统评估几乎翻倍（40%）。正如通过统一标准选择MDE所预期的那样，BP-II与单相抑郁之间的组间比较在大多数社会人口统计学参数、临床表现和抑郁的总体严重程度方面没有差异。尽管如此统一，但关键特征显著区分了BP-II与单相抑郁：首次抑郁发作的年龄较小、在索引发作期间自杀念头和嗜睡的频率较高、轻躁狂检查表得分较高以及环性心境障碍和易怒气质得分较高，以及当前治疗下的转换率较高。临床医生根据自评环性心境障碍量表10/21项的临界值判定为环性心境障碍气质的病例中，88%被认定为BP-II。临床医生和患者对这种气质的评估具有高度显著的相关性（r = 0.73；p < 0.0001）。环性心境障碍和轻躁狂也具有显著相关性（r = 0.51；p < 0.001）。
在不同临床环境中进行的一项研究中，无法确保做出情感障碍诊断的临床医生对各种气质测量结果不知情。然而，所有评估的系统性和/或半结构化性质将偏差最小化。
通过系统地寻找轻躁狂，40%的重度抑郁发作被归类为BP-II，其中只有一半在研究开始时临床医生已知。环性心境障碍气质失调成为BP-II障碍的一个有力临床标志。这些数据表明，不同执业环境中的临床医生可以接受培训以识别软双相情感障碍，从而在国家层面导致诊断实践的改变。
