Anger in Bipolar Depression

Letter to the Editor

Sir: Koh et al. reported that anger was more likely in depressive disorders than in anxiety and somatoform disorders, that anger was found in 30% to 40% of depressive disorders, and that comparative data were scarce among other mental disorders. My comment is that anger is even more likely in bipolar depression than in major depressive disorder (MDD). Finding a higher frequency of anger in bipolar depression has an important impact on the treatment of depression, because misdiagnosis of bipolar depression as MDD is high (at least 40%), and treatment of bipolar depression with antidepressants without concurrent mood stabilizers (and even with mood stabilizers) can induce mania/hypomania, mixed states, and rapid cycling. The importance for clinical practice of this finding is supported by the high frequency of bipolar II disorder in major depressive episode (MDE) outpatients (up to 60%) and in the community (11%, vs. 11% of MDD), found by improving the probing for past hypomania.