Trends in Psychiatry and Psychotherapy
Trends in Psychiatry and Psychotherapy
Original Article

Mood versus energy/activity symptoms in bipolar disorder: which cluster of Hamilton Depression Rating Scale better distinguishes between mania, depression, and euthymia?

Sintomas de humor versus sintomas de energia/atividade no transtorno bipolar: qual grupo da Escala de Depressão de Hamilton distingue melhor entre mania, depressão e eutimia?

Elie Cheniaux; Rafael de Assis da Silva; Cristina M. T. Santana; Antonio Egidio Nardi; Alberto Filgueiras

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Abstract Introduction Although bipolar disorder (BD) is traditionally included among mood disorders, some authors believe that changes in energy and motor activity, rather than mood changes, represent the true cardinal symptoms in mania and depression. The aim of the current study was to identify which cluster of the Hamilton Depression Rating Scale (HAM-D) better distinguishes between mania, depression and euthymia. Method A group of 106 patients with BD were followed for 13 years and repeatedly assessed with the HAM-D as well as with other clinical scales. To perform a comparison, HAM-D items were classified according to clinical criteria into three clusters: energy/activity symptoms, mood symptoms, and other symptoms. Item response theory (IRT) analyses were performed to provide a test information curve for those three clusters. We measured the prevalence of one cluster of symptoms over the other two throughout the latent trait. Results Considering HAM-D items individually, the IRT analysis revealed that there was a mixture of mood and energy/activity symptoms among the most discriminative items, both in depression and in euthymia. However, in mania, only energy/activity symptoms – i.e., general somatic symptoms and retardation – were among the most informative items. Considering the classification of items, both in depression as in mania, the energy/activity cluster was more informative than the mood cluster according to the IRT analysis. Conclusion Our data reinforce the view of hyperactivity and motor retardation as cardinal changes of mania and depression, respectively.


Bipolar disorder, Hamilton Depression Rating Scale, mood change, hyperactivity, factor analysis, item response theory


Resumo Introdução Embora o transtorno bipolar (TB) seja tradicionalmente incluído entre os transtornos do humor, alguns autores acreditam que as alterações na energia e na atividade motora, em vez das alterações no humor, representam os verdadeiros sintomas cardinais na mania e na depressão. O objetivo do presente estudo foi identificar qual grupo da Escala de Depressão de Hamilton (HAM-D) distingue melhor entre mania, depressão e eutimia. Método Um grupo de 106 pacientes com TB foram acompanhados por 13 anos e avaliados repetidamente com a HAM-D e com outras escalas clínicas. Para realizar uma comparação, os itens da HAM-D foram classificados de acordo com critérios clínicos em três grupos: sintomas de energia/atividade, sintomas de humor e outros sintomas. Foram realizadas análises da teoria da resposta ao item (TRI) para fornecer uma curva de informações de teste para esses três grupos. Medimos a prevalência de um grupo de sintomas em comparação aos outros dois através do traço latente. Resultados Considerando os itens da HAM-D individualmente, a análise da TRI revelou que havia uma mistura de sintomas de humor e de energia/atividade entre os itens mais discriminativos, tanto na depressão quanto na eutimia. No entanto, na mania, apenas os sintomas de energia/atividade – ou seja, sintomas somáticos gerais e retardo – estavam entre os itens mais informativos. Considerando a classificação dos itens, tanto na depressão quanto na mania, o grupo energia/atividade foi mais informativo que o grupo humor, de acordo com a análise da TRI. Conclusão Nossos dados reforçam a visão da hiperatividade e do retardo motor como as alterações cardinais de mania e depressão, respectivamente.


Transtorno bipolar, Escala de Depressão de Hamilton, alterações de humor, hiperatividade, análise fatorial, teoria da resposta ao item


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