Possible Bipolar Nature of Irritability in Major Depressive Disorder

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Sir: Perlis et al.¹ found that irritability was present in 40% ofoutpatients with major depressive disorder (MDD). The findingmirrors DSM-IV-TR,² which lists irritability not only as a coresymptom of mania and hypomania, but also as a commonsymptom of MDD. Kraepelin³ classified irritability as a manic(excitement) symptom. The bipolar nature of irritability inMDD can have an important impact on treatment of MDD.Although a study⁴ on MDD with irritability showed that fluoxetinewas effective in reducing irritability, clinical observationssuggest adding mood-stabilizing agents to antidepressantsin MDD with irritability because antidepressants alone mayworsen irritability.^5-9‘ ‹