Published in Bipolar Disorders, results from a clinical study identified 4 distinct trajectories of depressive symptoms among individuals with bipolar disorder. Patients with bipolar type I were more likely to experience a worse trajectory compared with patients with bipolar type II.

Data were abstracted from the Bipolar Clinical Health Outcomes Initiative in Comparative Effectiveness (CHOICE) trial, a 6-month randomized controlled trial that assessed the relative efficacy of lithium and quetiapine treatment among 482 adult patients with bipolar disorder type I (68.3%) or type II (31.7%). The study was conducted across 11 sites in the United States over the course of 3 years (2010-2013). At study entry, patients provided sociodemographic and clinical information to research coordinators. Bipolar disorder symptomatology was monitored at baseline and across 8 follow-up visits over the study course. Depressive symptoms were assessed per the Montgomery-Asberg Depression Rating Scale; remission was defined as a score ≤12 at the conclusion of follow-up. Growth Mixture Modeling was used to identify depressive symptom trajectories among patients.

Four depressive symptom trajectories were identified among participants. The responding class (60.3%) was characterized by a rapid reduction in symptoms and subsequent maintenance of low depression symptomatology. The partial-responding class (18.4%) experienced an initial symptom reduction followed by an increase during the remaining weeks. The fluctuating class (11.6%) experienced a fluctuation in depressive symptoms across the study course, whereas the nonresponding class (9.7%) displayed sustained moderate to severe depressive symptoms throughout follow-up. Bipolar type I predicted membership in the nonresponding class, and random assignment to quetiapine predicted membership in either the responding class or the nonresponding class.

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The responding and fluctuating classes had the highest proportion of patients in remission at the end of the follow-up period, at 95.9% and 52.5%, respectively. Just 15.9% of partial-responders experienced remission compared with no individuals in the nonresponding group. In addition, an average 7% increase in Montgomery-Asberg Depression Rating Scale score from baseline to week 24 was reported for the nonresponding group. According to multivariable analysis, patients with bipolar disorder type I (vs type II) had 3-fold greater odds of membership in the nonresponding class compared with the responding class (P =.04). In addition, patients randomly assigned to quetiapine treatment compared with patients randomly assigned to lithium had higher odds of membership in the responding class compared with the nonresponding class (P =.023).

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These data suggest that depression trajectory may be more severe among patients with bipolar disorder type I compared with bipolar disorder type II. Although no differences in overall outcome were observed between treatment groups, patients who received lithium had a more variable trajectory. Further research should investigate the specific factors that may affect treatment response and subsequent outcome in depressive symptoms.


Behrendt-Møller I, Madsen T, Sørensen HJ. Patterns of changes in bipolar depressive symptoms revealed by trajectory analysis among 482 patients with bipolar disorder [published online November 1, 2018]. Bipolar Disord. doi: 10.1111/bdi.12715