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Comprehensive Psychiatry 54 (2013) 605 610

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Clinical differences between unipolar and bipolar depression: Interest of

BDRS (Bipolar Depression Rating Scale)
Filipe Galvo a, e,, Sarah Sportiche b, c , Jerome Lambert d , Marie Amiez b , Catherine Musa b, c ,
Isabel Nieto b, c , Caroline Dubertret e, f , Jean Pierre Lepine b, c, f, g
a

EA 4166, Service du Pr d'Amato, CH le vinatier, 95 bd Pinel 69677 Bron cedex France

Department of Psychiatry, Lariboisire Fernand Widal Hospital, Assistance Publique Hpitaux de Paris
c
FondaMental Foundation, Creteil 94010, France
d
University Pierre et Marie Curie-Paris, INSERM, UMR-S 707, Assistance Publique Hpitaux de Paris, Saint-Antoine Hospital, Paris, France
e
Department of Psychiatry, Louis-Mourier Hospital, APHP, Colombes, France
f
Faculty of Medicine, University Sorbonne Paris Cit, Denis-Diderot, Paris, France
g
Unit INSERM 705 CNRS UMR 8206, Paris, France
b

Abstract
Objectives: It is currently assumed that there are no important differences between the clinical presentations of unipolar and bipolar
depression. Failure to distinguish bipolar from unipolar depression may lead to inappropriate treatment and poorer outcomes. We hereby
compare unipolar and bipolar depressed subjects, in order to identify distinctive clinical specificities of bipolar depression.
Methods: Two independent samples of depressed patients (unipolar and bipolar) were recruited, with 55 patients in one sample, and 49 in the
other. In both samples, unipolar and bipolar patients were compared on a broad range of parameters, including sociodemographic
characteristics, comorbidities, Montgomery and Asberg Depression Scale (MADRS; assessing depression severity), CORE (assessing
psychomotor disturbance) and Bipolar Depression Rating Scale (assessing specific bipolar depression symptoms).
Results: Results were similar in both samples. MADRS scores were similar in bipolar and unipolar subjects (median score 33 vs 34;
p = 0.74). On the CORE, there was a trend to higher scores among the bipolar subjects. BDRS scores were higher in bipolar than in
unipolar subjects (median score 33 vs 27; p b 0.001). The difference was particularly marked on the mixed subscale of the BDRS. We
tested the ability of the mixed subscale of the BDRS to distinguish bipolar from unipolar depression, using different cut off points: a cut off
point of 3 can predict bipolar depression, with a sensibility of 62% and a specificity of 82%.
Conclusions: Presence of mixed symptoms during a depressive episode is in favour of bipolar depression. The BDRS scale should be
integrated in a probabilistic approach to distinguish bipolar from unipolar depression.
2013 Elsevier Inc. All rights reserved.

1. Introduction
Major depressive episodes (MDEs) are part of clinical
features in both bipolar disorder and major depressive
disorder (unipolar disorder), and current international
classifications (DSMIV-TR [1], and IDC-10, [2]) consider
MDE symptoms similar whether reported in unipolar or
bipolar disorder (BPD). In current clinical practice, differential diagnosis of MDD from BPD mainly depends on
absence of hypomanic or manic episodes in the past.

Corresponding author.
E-mail address: filipe.galvao@ch-le-vinatier.fr (F. Galvo).
0010-440X/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.comppsych.2012.12.023

A growing number of studies suggest that bipolar disorder

is under recognized in clinical practice, and often misdiagnosed as unipolar disorder [3,4]. Estimates of the mean
delay between first mood symptoms and the correct bipolar
diagnosis are 7 to 10 years [4,5]. These misdiagnoses lead to
inappropriate treatment, which can be associated with
detrimental consequences for patients, including switching
into mania or into mixed states [6,7], cycle acceleration [8],
and development of treatment resistance [9].
Some studies have attempted to discriminate bipolar and
unipolar depression. Most of them found that atypical
features, including mood reactivity, overeating or weight
gain, hypersomnia, interpersonal rejection sensitivity, and
melancholic or catatonic features were more common in

606

F. Galvo et al. / Comprehensive Psychiatry 54 (2013) 605610

bipolar than in unipolar depression [1015]. Other symptoms, such as psychotic symptoms, psychomotor agitation,
irritability and anxiety were also reported to be a strong
diagnostic validator of bipolar nature of MDE [14,1620].
Psychomotor retardation is an important symptom of
depression and considered by some authors as the core of
depression [21]. Many studies have found that this symptom
is very intense in bipolar depression and most of the time,
more common than in unipolar depression [13,22]. In
contrast, others authors didn't find any difference regarding
psychomotor retardation in unipolar and bipolar depression
[23,24]. Some clinical characteristics like family history of
BPD, early age of onset, greater number of previous
depressive episodes, and comorbidity of psychoactive drug
abuse tend to occur more frequently in BPD [19,2426].
Recently published guidelines from the International
Society for Bipolar Disorders (ISBD) Diagnostic Task
Force have argued for a dimensional rather than categorical
distinction between bipolar and unipolar depression, leading
to the development of a probabilistic approach to the
diagnosis of bipolar depression [27,28]. Based on these
works, Berk et al. developed a specific instrument for
clinical evaluation of bipolar depression: the Bipolar
Depression Rating Scale (BDRS) [29]. This instrument
showed strong correlation with classic depression scales
(MADRS and HAM-D). However, to our knowledge, the
use of this scale in unipolar depressed subjects has never
been reported.
Our main objective is to compare unipolar and bipolar
depressed subjects, in order to distinguish clinical
symptoms of bipolar depression from unipolar depression.
Our secondary objective is to assess the use of the
BDRS in a predictive model to distinguish bipolar from
unipolar depression.

2. Material and methods

Participants where inpatients, aged 1885 years, hospitalized for a major depressive episode (meeting DSMIV-TR
criteria). Two independent samples of patients (A, B) were
recruited in two hospitals, interviewed by two different
psychiatrists. The A sample includes 55 patients recruited
through the mood disorders psychiatry unit, in Fernand
Widal Hospital, Paris, between February 2009 and February
2010 by the first psychiatrist. The B sample includes 49
patients recruited through the psychiatry unit, in Louis
Mourier Hospital, Colombes, between November 2009 and
May 2010 by the second psychiatrist. Participants with
severe cognitive impairment, schizophrenia or other
psychotic disorder, and mixed states were excluded from
the study. All participants provided informed consent for
the study. All patients hospitalized for major depressive
episode during these periods, meeting the inclusion and
exclusion criteria, and having given their consent, were
included in the study.

Patients were interviewed by the psychiatrist during the

first week of hospitalization. The interview lasted 50 to
60 min, and included a structured assessment of sociodemographic characteristics and the Mini International
Neuropsychiatric Interview (MINI) to obtain DSM-IV
diagnoses [30], and assess substance use disorders and
anxiety disorders, which are the more frequent axis I
disorders among bipolar and unipolar subjects [31,32].
Three scales were used to assess MDE: the MADRS,
the BDRS and the CORE. The MADRS is a 10 item
rating instrument, developed for the assessment of
treatment induced changes in depressive symptoms
[33,34]. MADRS is designed to rate severity of the
depressive symptomatology, but several symptoms, as
psychomotor retardation or atypical features, are not
covered by this instrument.
The CORE is an 18 item rating scale, developed to
assess psychomotor disturbances of MDE: retardation,
agitation and non-interactivity [35,21]. A French version
of the CORE was developed, with a good inter-rater
reliability [36]. CORE is designed to rate psychomotor
disturbances, often found to be more common in bipolar
than in unipolar depression.
The BDRS is a 20 item rating scale, developed by Berk et
al. to specifically evaluate bipolar depression. The BDRS
showed strong correlation with MADRS and HAM-D [29].
The factor analysis of BDRS showed three factors describing
the scale: somatic depression, psychological depression and
mixed symptom clusters. Because of the lack of a French
version of the BDRS, the original scale was translated into
French by a native French psychiatrist, then back-translated
into English by a native English psychologist.
2.1. Statistical analyses
Categorical variables are presented with their frequency
and percentage and compared across bipolar and unipolar
patients using the Fisher exact test. Due to the skewed
distribution of several continuous variables, they are
presented with a median and interquartile range and
compared using the Wilcoxon sum rank test. Correlations
between the MADRS and the BDRS scale were estimated for
the whole sample and then separately for bipolar and
unipolar patients using the Spearman's rho statistic. All tests
Table 1
Sociodemographic features of subjects with bipolar disorder and subjects
with major depressive disorder.
Number (%) or median [IQR]

Unipolar
(n = 57)

Bipolar
(n = 47)

Number of previous
depressive episodes
Age of onset
Family History of bipolar disorder
Family History of major
depressive disorder

2 [13]

6 [49]

b0.001

39.5 [24.7554] 25 [2235]

2 (3.9%)
11 (25%)
21 (41.2%)
19 (43.2%)

0.003
0.005
1

F. Galvo et al. / Comprehensive Psychiatry 54 (2013) 605610

607

Table 2
Comparison of comorbidities between subjects with bipolar disorder and
subjects with major depressive disorder.

Table 4
Scores on the MADRS, the CORE and the BDRS in subjects with bipolar
disorder and subjects with major depressive disorder.

Comorbidity n (%)

Unipolar (n = 57)

Bipolar (n = 47)

Median [IQR]

Unipolar (n = 57)

Bipolar (n = 47)

Anxiety disorder
Addiction
Addiction and/or
anxiety disorder

20 (36.4)
13 (24.1)
27 (50)

16 (37.2)
17 (39.5)
28 (65.1)

1
0.124
0.154

MADRS
CORE
Non-interactiveness
Retardation
Agitation
BDRS
Psychological
Somatic
Mixed

34
9
3
4
2
27
14
12
1

33 [28.537]
12 [717]
3 [26]
5 [1.58]
2 [14]
33 [2836.5]
17 [1419]
13 [10.514]
3 [25]

0.74
0.13
0.49
0.39
0.15
b0.001
0.006
0.076
b0.001

were two-sided with p = 0.05 as the significance level. Data

analysis was performed using R 2.10.1 statistical software.

[2937]
[712]
[15]
[26]
[04]
[2331]
[1117]
[913]
[02]

3. Results
We included 55 subjects in the A group (23 bipolar and
32 unipolar), and 49 in the B group (24 bipolar and 25
unipolar). The two groups were similar concerning sociodemographic features. The total sample comprised 104
subjects (60 women and 44 men), 47 with bipolar depression
and 57 with unipolar depression.
As expected, compared with subjects with UPD, subjects
with BPD had an earlier age at first onset (25 vs. 40 years;
p = 0.002), and more prior depressive episodes (6 vs. 2
episodes; p b 0.001). Family history of major depressive
disorder did not differ significantly between the two groups,
but family history of bipolar disorder was more common
among bipolar subjects (Table 1).
Comorbidity of anxiety disorders and substance use
disorders did not differ significantly between the two groups.
Half of the unipolar subjects and 65.1% of the bipolar
subjects had at least one of those comorbidities (Table 2).
Comparison of scores in the two groups on MADRS,
CORE and BDRS are shown in Table 3. In both groups,
scores on the MADRS scale were similar. On the CORE
scale, in group 2, scores on the agitation subscale were
higher among bipolar subjects, but this result was not found
in group 1. Finally, on the BDRS scale, in both groups,
scores were higher among bipolar subjects. Regarding the
subscales' scores, bipolar subjects had significantly higher
scores on the mixed subscale, in both groups (Table 3).

Comparisons of scores on MADRS, CORE and BDRS

for the total sample are shown in Table 4. On the MADRS
scale, scores were similar among unipolar and bipolar
subjects, with a median score of 34 for the unipolar subjects
and 33 for the bipolar subjects.
On the CORE scale, scores were also similar among
unipolar and bipolar subjects, even if there was a trend to
higher scores among the bipolar subjects, the difference was
not statistically significant. The comparison of the three
subscales' scores (non-interactiveness, retardation and
agitation) didn't show any difference between unipolar and
bipolar patients.
On the BDRS scale, median scores were higher in
bipolar subjects than in unipolar subjects (33 vs. 27;
p b 0.001). Observing the three subscales' scores, there was
a trend to higher scores among bipolar subjects on somatic
depression (13 vs. 12; p = 0.07). Bipolar subjects had
significantly higher scores on psychological depression
(17 vs. 14; p = 0.006), and particularly on the mixed
subscale (3 vs. 1, p b 0.001) (Table 4).
Correlation coefficients of the BDRS with the MADRS
indicated a strong positive correlation between these two
scales, in unipolar as in bipolar subjects, with r = 0.885 in the
bipolar and r = 0.935 in the unipolar subjects. Correlation
coefficients between total scores of BDRS and CORE also
indicated a positive correlation, with r = 0.643 in the unipolar
and r = 0.584 in the bipolar subjects.

Table 3
Comparison of scores on the MADRS, the CORE and the BDRS in the two samples.
Median [IQR]

MADRS
CORE
Non interactiveness
Retardation
Agitation
BDRS
Psychological
Somatic
Mixed

Group A

Group B

Unipolar (n = 32)

Bipolar (n = 23)

Unipolar (n = 25)

Bipolar (n = 24)

31 [25.533.5]
8.5 [412.5]
2.5 [15]
3 [15.5]
2.5 [14]
25.5 [20.528.5]
12 [1015.5]
11 [912.5]
1 [02]

30 [2833]
13 [8.518]
4 [1.56]
7 [2.59]
2 [24]
30 [2834]
16 [13.517]
13 [10.514]
2 [1.54]

0.88
0.07
0.29
0.07
0.63
0.002
0.04
0.03
0.003

37 [3440]
11 [712]
4 [35]
6 [37]
1[03]
28[2636]
14.5 [1318.5]
13 [1114]
1 [03]

35 [32.540.5]
10 [6.7517]
3 [26.25]
3.5 [18]
2.5 [14]
35.5 [30.539.5]
18 [1620]
12 [10.513]
4 [2.55.5]

0.23
0.9
0.66
0.54
0.04
0.02
0.06
0.79
b0.001

F. Galvo et al. / Comprehensive Psychiatry 54 (2013) 605610

0.6
0.4
0.0

0.2

Sensitivity

0.8

1.0

608

0.0

0.2

0.4

0.6

0.8

1.0

1-specificity
Fig. 1. ROC curve analyses using the mixed score of BDRS for
discriminating bipolar depression.

Scores on the mixed subscale of the BDRS can vary from

0 to 15. We tested the ability of the mixed subscale of the
BDRS to distinguish bipolar from unipolar depression. A cut
off point of 3 can predict bipolar depression, with a
sensitivity of 62% and a specificity of 82%. Using a cut of
point of 4, specificity reaches 93%, with a sensitivity of 47%.
The receiver operating characteristics (ROC) curve analysis
for the mixed subscale is presented in Fig. 1. The total area
under the receiver-operating characteristic curve was
estimated to be 0.78 (Fig. 1). The area under the curve
may be interpreted as the probability that the predictions and
outcomes are concordant; for example, a value of 0.50 means
that the predictions were no better than guessing, whereas a
value of 1.0 would indicate perfect prediction ability.

4. Discussion
Regarding sociodemographic features, our study shows
three significant differences between unipolar and bipolar
subjects: bipolar subjects have more prior depressive
episodes, more family history of bipolar disorder, and a
younger age of onset of the disorder than unipolar subjects.
These results are consistent with previous findings [28].
Family history of major depressive disorder was as frequent
in unipolar as in bipolar subjects. In bipolar subjects, family
history of major depressive disorder was more frequent than
family history of bipolar disorder. We assessed comorbidity
of depression with substance use disorders and anxiety
disorders. Our study didn't find any difference between
bipolar and unipolar subjects in terms of comorbidities.
Previous results are contradictory: some studies showed
more substance use disorder in bipolar than in unipolar
subjects [37,38], but other find no differences [39].

Approximately one third of unipolar and bipolar subjects

had a comorbid anxiety disorder, without differences
between the two groups. These prevalences are lower than
in other studies [40,41].
Our main hypothesis was that bipolar and unipolar
patients would have different clinical profiles. Regarding
MADRS or CORE scores, we didn't find any difference
between bipolar and unipolar depressed subjects. This lack
of difference on MADRS scores between unipolar and
bipolar depressed subjects is in favour of similar severity of
depression in these two groups. Likewise, the lack of
difference between unipolar and bipolar depressed subjects
on CORE scores, suggests that psychomotor retardation may
not be a reliable symptom of bipolar depression. Nevertheless, this clinical feature is often reported to be more
common in patients with bipolar depression, and is included
in the probabilistic approach proposed by Mitchell and
colleagues [28]. BDRS was the only scale showing
statistically significant differences, with higher scores in
bipolar than in unipolar subjects.
The BDRS is well correlated with the MADRS, among
unipolar (r = 0.935) and bipolar subjects (r = 0.885). Considering that that the MADRS is a well validated depression
scale, this good correlation is in favour of the BDRS as a
useful instrument to assess depression, whether unipolar or
bipolar. Berk and colleagues also found a robust correlation
coefficient between the MADRS and the BDRS (r = 0.906),
in a population of bipolar depressed subjects [29]. But in
addition to evaluating depression, the BDRS assesses
specific symptoms of bipolar depression, as shown by the
significant difference of scores on the BDRS between
unipolar and bipolar subjects. The comparisons of the three
sub scores described in the factor analysis of the BDRS
showed similar scores between unipolar and bipolar subjects
on somatic depression, but scores on psychological
depression, and especially on the mixed subscale were
significantly higher among bipolar subjects. The items
included in the mixed score are lability, increased motor
drive, increased speech, agitation and psychotic symptoms.
These symptoms are present in mixed or manic episodes, but
can also exist in depression [42,19]. These symptoms are not
included in other depression scales, usually used to assess
depression in bipolar subjects. These results are in favour of
clinical specificities of bipolar depression, essentially mixed
symptoms. These symptoms often exist in bipolar depression, even without a mixed episode [19].
This study illustrates the usefulness of BDRS in detecting
theses subtreshold symptoms. Previous findings show that
these symptoms, detected by BDRS, are associated with a
more morbid course of illness (more depressive episodes,
higher rates of comorbidity) [43]. Moreover, patients with
these subtreshold features have greater psychosocial and
quality of life impairments [44].
We assessed performance of the mixed subscale of the
BDRS to distinguish bipolar from unipolar depression.
Scores N3 on the mixed subscale of BDRS, could be good

F. Galvo et al. / Comprehensive Psychiatry 54 (2013) 605610

predictors of bipolar depression, with a sensibility of 62%

and a specificity of 82%. In addition to specific clinical
features, the score on the mixed subscale of the BDRS could
be integrated in a probabilistic approach to distinguish
bipolar from unipolar depression, as the one proposed by
Mitchell and colleagues [28].
The main limitation of the present study is the fact that the
assessors were not blind about the bipolar or unipolar nature
of depression. Furthermore, some participants included in
the unipolar group, particularly those having their first
depressive episode, could have been misdiagnosed, in case
of future manic , hypomanic or mixed episode.
To summarize, this is, to our knowledge, the first study
comparing unipolar and bipolar depression with three
depressions scales, the BDRS, the MADRS and the CORE.
MADRS and CORE scores were unable to distinguish
unipolar from bipolar depression, but BDRS scores were
significantly higher in bipolar depression. This difference was
particularly marked for the mixed subscore, suggesting that
presence of mixed symptoms in depression is in favour of
bipolar depression.
Further research is required on this finding, with larger
samples. Overall, this study supports the growing notion of
significant clinical differences between unipolar and bipolar
depression, and spurs the necessity to better characterize
these two types of depression.

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