Several studies have shown that residual mood symptoms affect the psychosocial functioning of patients with bipolar disorder (BD) in euthymia.

To evaluate specific areas of functioning in this population and to explore the relationship with residual mood symptoms.

This is a descriptive and analytical cross-sectional study including patients with BD (DSM V) in euthymia followed on ambulatory basis to the Mood Disorders Unit of the Psychiatry A Department at Hedi Chaker Hospital in Sfax between January and April 2019. Patients were considered euthymic if they scored below 7 on the Young Mania Assessment Scale (YMRS) and under 8 on the Hamilton Depression scale (HDRS-17). Residual manic and depressive mood symptoms were assessed using YMRS and HDRS-17. The Short Function Evaluation Test (FAST) was used to evaluate the overall and specific functionning domains.The alteration of the domain-specific functioning is defined by the following thresholds: autonomy>1, professional functioning>1, cognitive functioning>2, financial problems>1, interpersonal relations>3 and leisure time>3.

We recruited 62 patients with a mean age of 45.65 years (SD = 13.3) and a sex ratio 1.13.The medians of YMRS and HDRS scores were respectively 2[0-5] and 2[0-7]. Global functionning impairment was observed in 85.5% of patients. Marked impairment of professional and cognitive functioning was observed in 98.4% and 77.4%, respectively. Alteration of the relational sphere was significantly more frequent in patients with residual depressive symptoms (p=0.009); impairment of autonomy was significantly more frequent in subjects with manic residual symptoms (p=0.005).

Residual symptoms should be considered as specific targets of treatment to improve functioning.

Attention deficit and hyperactivity disorder (ADHD) and bipolar disorder (BD) are two of the most prevalent psychiatric disorders presenting in children and adults, respectively. Reported co-occurrence of ADHD and BD in adulthood is higher than would be expected by chance, with great impact on prognosis and treatment. Since features of both entities can overlap, careful assessment of these patients is crucial.

To understand the relation between BD and ADHD, and how co-occurrence impacts clinical evaluation.

Bibliographic research was made through the PubMed/NCBI database. No time limit was specified on the search. Pertinent manuscripts were individually reviewed for additional relevant citations.

ADHD influences the course and manifestations of BD, regardless of its presence later in adulthood. There is a 3-fold increase of ADHD co-occurrence in individuals with BD when compared to normal population, and ADHD seems to co-occur in about 20% of BD patients (even after correction for overlapping symptoms). Features which may suggest simultaneous diagnosis are: earlier occurrence of BD-related symptoms (especially manic or hypomanic states), more severe course of the mood disorder, less adherence to treatment and higher functioning impact. This makes for a worse prognosis, with increased suicidal risk in these patients.

The co-occurrence of BD and ADHD may represent a distinct clinical phenotype, with recent findings highlighting the presence of common neurobiological mechanisms. Accordingly, patients with BD should be screened for ADHD and viceversa. There is no consensus for treatment of ADHD-BD patients, with further studies being necessary to better define and define possible therapeutic approaches.

Bipolar disorders (BD) are associated with a high degree of impulsivity especially during manic and depressive episodes. However, there is little information on impulsivity during remission phase.

Our objective was to assess impulsivity in patients with BD in remission compared to healthy controls (HC).

This was a comparative, cross-sectional and analytical study, conducted in the outpatient psychiatry department of Hedi Chaker University Hospital in Sfax (Tunisia), from July to September 2019, among 30 patients with BD in remission compared to 34 HC. Data were collected on a pre-established questionnaire. Impulsivity was assessed with the Barratt Impulsiveness Scale (BIS-11).

Mean ages of BD patients and HC were 44.17 and 40.1 years, respectively. The sex ratio was 1.7 in BD patients and 0.9 in HC groups. Age of onset of BD was 30 years. Impulsivity scores of the BD patients were higher than HC on total (66.27 vs 53.53) and three subscales measures; motor (21.83 vs 16.15), attentional (15.83 vs 13.53) and non planning impulsivity (28.93 vs 23.71). High degree of impulsivity was noted in 33.3% of BD patients. BD patients scored significantly higher than the HC on total, motor, and non planning impulsivity scores (p = 0.001; p = 0.001; p=0.000, respectively)

Our study found that patients with BD had a high degree of impulsivity outside the critical period compared to healthy individuals. Would this impulsivity be a vulnerability marker to the risk of early onset of the disease or the risk of its relapse?

Many researches addressing quality of life (QOL) has been demonstrated its impairment during acute episodes of bipolar disorder (BD) and major depressive disorder (MDD).

To compare QOL between patients with remitted MDD and remitted BD and healthy controls (HC).

A comparative and analytical study, conducted over 3 months in the outpatient psychiatric department of Hedi Chaker University Hospital in Sfax (Tunisia) among 30 patients with remitted BD, 30 patients with remitted MDD and 34 HC. QOL was assessed with the «36 item Short-Form Health Survey» (SF-36).

Compared with HC, the MDD and the BD groups had significantly lower scores for the total of the SF-36 and its sub-domains (table 1). Physical scores were lower in patients with MDD, compared with patients with BD (table 1). Table 1: Comparison of SF-36 sub-domain scores between MDD, BD patients, and HC.

QOL of patients with mood disorders such as MDD and BD suffered damage even in euthymic periods.

Euthymic patients with bipolar I and II disorder (BD) often have comorbid insomnia, which is associated with worse outcome. Cognitive behavioral therapy for insomnia (CBT-I) is rarely offered to this population, though preliminary research indicates CBT-I to be safe and helpful to improve sleep and mood stability.

The present study investigates if CBT-I for euthymic BD patients is feasible and acceptable when offered in a group format.

14 euthymic bipolar disorder I or II participants participated in a 7-session group CBT-I with BD-specific modifications (CBT-I-BD), preceded by one individual session. Feasibility and acceptability were assessed by recruitment, treatment drop-out and participants’ and therapists’ evaluations, while sleep quality, mood and sleep medication were assessed at baseline, end of treatment, 3 and 6 months later.

31 of 539 patients with bipolar disorder were referred, 14 were included and one dropped out of treatment. Group CBT-I-BD was acceptable as shown by high session attendance and good homework compliance. Participants highly appreciated the treatment, the group format and learning effect. Insomnia severity decreased significantly between baseline and post-treatment. Group CBT-I-BD did not cause mood episodes during treatment and although not requested, the total number of nights with sleep medication decreased.

Group CBT-I-BD seems to be a feasible, acceptable and therefore viable treatment for euthymic patients with bipolar disorder suffering from persistent insomnia. The small sample size, resulting in small CBT-I-BD groups was a main limitation of the study.

The main factors that are involved in a correct adherence to the therapeutic recommendations in Bipolar Disorder includes aspects related to age, sex, ethnicity, socioeconomic level and characteristics of the illness associated with the severity, comorbidity and adverse effects related to previous medicine.

To analyse the individual perception that the patient with Bipolar Disorder has regarding the positive and negative aspects of taking the recommended medication.

Descriptive and interpretative observational study under the qualitative paradigm of research, extracting the data through the completion of four focus groups with ten patients everyone. To complete the codification of the content of the participant’s discourses, we rely on the QRS NVivo 10 computer program.

In the participant’s discourse concerning the main barriers to pharmacological treatment, for example “It’s because we live in a society and, because of that, we don’t go without medicine; if we didn’t live in society, we wouldn’t take medicine because we wouldn’t bother anyone”. Some examples of patient’s discourse, about perceived facilitators were: “I have to take medicine for my bipolar disorder, that’s it, I have a treatment, my illness has a name”.

The main facilitators regarding the use of pharmacological treatment in Bipolar Disorder are the perceived need for treatment in the acute phase and the recognition of the illness, the shared clinical decision and the causal biological attribution in the chronic phase. About perceived barriers, social control is identified in both phases, adverse effects in the acute cases and the absence of effective treatment in the chronic state.

Prescribing antidepressants in the treatment of bipolar depression remains highly controversial due to the inconsistency between routine clinical practice and the results of controlled trials.

To assess the validity of antidepressants use in bipolar depression from the point of view of evidence-based medicine.

Database search (Scopus and MEDLINE) followed by analysis of studies concerning the efficacy and safety of antidepressants in the bipolar depression treatment.

The search found 23 studies. There was a high degree of inconsistency in the results, apparently related to the methodology. Only two studies compared the effectiveness of antidepressants in monotherapy with placebo. No differences were found in the study with 740 participants but in the study with 70 participants with type 2 bipolar disorder antidepressants were found to be more effective than placebo. Nevertheless, both studies had significant methodological issues. In 6 studies comparing the effectiveness of the combination of antidepressants with mood stabilizers against the combination of mood stabilizers with placebo, only the effectiveness of fluoxetine in combination with olanzapine was confirmed, other antidepressants were ineffective. At the same time, studies where antidepressants were compared with each other in combination with mood stabilizers revealed a significant clinical response to therapy. Risk of the treatment emergency adverse events were relatively low for SSRI.

Despite the contradictory literature data, the use of antidepressants in bipolar depression is justified from the point of view of evidence-based medicine for certain groups of patients with taking into account risk factors.

Sleep is paramount in bipolar affective disorder and sleep disturbance can be a trigger or initial manifestation of an episode of illness. Changes in the circadian rhythm in bipolar affective disorder have consistently been recognized and reported, however, this feature can be overlooked in daily clinical practice.

We aim to review and summarize the literature regarding changes in circadian rhythm in patients with bipolar affective disorder.

We performed an updated review in the PubMed database using the terms “circadian rhythm” and “bipolar affective disorder”.

Irregularity of the sleep–wake rhythm, eveningness chronotype, abnormality of melatonin secretion, vulnerability of clock genes, and the irregularity of social time cues are circadian rhythm markers disrupted in bipolar affective disorder. Circadian rhythm dysfunction might be a trait marker of this illness and can act as a predictor for the first onset of bipolar affective disorder and the relapse of mood episodes. Achieving normalization of circadian rhythm in combination with pharmacological, psychosocial and chronobiological treatments can be a tool for managing bipolar affective disorder.

Recognizing patterns of changes in circadian rhythms is important to detect and diagnose bipolar disorder in clinical practice, also affecting treatment. These alterations are often overlooked and can lead to inadequate treatment and management.

Patients with bipolar disorder (BD) frequently experience residual symptoms, problems in psychosocial functioning, cognitive impairment, and poor quality of life (QOL).

* To evaluate the QOL of euthymic patients with BD compared to healthy controls (HC). * To identify factors associated with its deterioration.

This is a comparative and analytical study, conducted over 3 months, involving 30 euthymic patients with BD, followed up in the outpatient psychiatry department of Hedi Chaker University Hospital in Sfax (Tunisia). They were compared to 34 HC. General, clinical and therapeutic data were collected using a pre-established questionnaire. QOL was assessed with the «36 item Short-Form Health Survey» (SF-36).

The mean ages of BD patients and HC were 44.17 years and 40.1 years, respectively. Compared with HC, patients with BD had decreased overall SF-36 scores (53.73 vs 73.78; p=0.000) and decreased physical and psychological subdomain scores (p=0.001; p=0.000). The study of the relationship between the dimensional average scores and different variables revealed correlations between; physical health problems and somatic disease (p=0.021) and unemployment (p=0.001), impaired general health and somatic disease (p=0.02) and psychotropic association (p=0.021), emotional health problems and psychiatric family history (p=0.023), pain and psychotropic association (p=0.031), and impaired global QOL and psychiatric family history (p=0.05).

Our results confirm the impairment of the QOL of patients with BD even in euthymic periods. Many factors have been associated, including demographic and clinical variables. The improvement of QOL is to consider these factors in the management of these patients.

It is known that the peripartum period is a high-risk period of recurrence in bipolar disorder (BD). However, data on correlations between reproductive life events, such as age at menarche and peripartum period, are mixed in BD.

The aims of this retrospective study are to investigate the lifetime rate of peripartum mood episodes, the clinical correlates and the relationship between age at menarche and peripartum episode in a sample of women with BD.

The study focused on comparisons between women with vs. without peripartum mood episodes (n = 292). Socio-demographic and clinical characteristics between women with vs without BD peripartum episode were examined through descriptive statistics.Adjusted logistic regression analysis was run to examine the association between variables.

In our sample, 30% had at least one BD peripartum episode. Women with peripartum episode had significantly earlier age at menarche, earlier onset of BD and longer duration of untreated disorder compared to women without peripartum episode. After adjustment, the late menarche (>15 years) was associated with lower probability of BD episodes during the peripartum period compared to normal menarche (12-14 years).

Peripartum mood episodes are common in BD and are correlated with early onset of BD and long duration of untreated disorder. Moreover, age at menarche may be related to the risk of peripartum mood episodes. The results deserve to be deepened in further studies.

In the last decade, literature reports evidences of a growing number of patients diagnosed with Bipolar Disorders (BD), however, only few data are available regarding the distribution of BD diagnosis in the two genders. In fact, although many studies show differences in presentation and comorbidities of BD in the two genders, BD are commonly perceived as equally affecting both women and men. On the other hand, BD in female patients can often be misdiagnosed as MDD, especially because of the higher number of depressive episodes that characterize BD in women.

We aimed to analyse the gender composition of large samples, recently published studies on BD, in order to evaluate a possible modification of representation of BD in the two genders.

An electronic review of literature was conducted, and results were filtered by year of publication (2011-2020) and number of patients (> 1,000).

Our results show a higher number of female patients in every study evaluated (N=10). Of note, we found a higher number of females also in BD-I subsamples, in contradiction with previously published literature.

Even if with limitations connected to the design of the study, our study supports the hypothesis of a gender specific increment in BD diagnosis, and could lead the way for large epidemiological studies assessing gender specific prevalence of BD in the general population. Given the risks connected with untreated BD, and with antidepressants monotherapy, a better understanding of BD epidemiology could help physicians adequately diagnose and treat affected subjects.

Bipolar disorder is associated, in popular belief, with violence as any psychiatric pathology. Studies in recent years have found an increased risk of violence in patients with bipolar disorder.

To describe the socio-demographic characteristics of bipolar patients and identify the various risk factors for violence.

We conducted a retrospective descriptive, analytical study, including patients with bipolar disorder type I and II in the CHU HEDI CHAKER Sfax psychiatry department whose reason for hospitalization was hetero-aggressiveness during a period of 6 months ranging from 1 January to 30 June 2019.

We’ve collected 32 patients. The average age of our sample is 36 years. Half of the patients (50%) were single. Most of these patients were unemployed. The type of bipolar disorder was dominated by type I (90.3%) in a manic episode. These patients had antisocial pathological personality in 18.8% and borderline personality in 20%. Siblings and ascendants accounted for 68.7% of victims of violence. Our study showed that comorbidity to the use of psychoactive substances was present in 65.6%. The exaltation of mood was intense in 78.1% with a bad insight in 75%. Patients with violent behaviour were discontinued in 96.9% of cases with poor therapeutic adherence in 90.6% and irregular follow-up in 68.8%. Violence was significantly associated with psychoactive substance use with p=0.037.

The risk of violence in patients with bipolar disorder is higher than in the general population. This risk is particularly high if there was an association with substance abuse and personality disorders.

Impulsivity is a psychiatric symptom that seems to be more prevalent in some mental disorders such as bipolar disorders (BD). It is a trait that seems to be influenced by many socio-demographic variables across BD.

The aim of our study is to examine the relationship between impulsivity and these variables.

We performed a cross sectional study on 30 patients diagnosed with BD and consulting at the Psychiatric department of Hedi Chaker Hospital. Patients were euthymic during the time of the study confirmed by administration Young Mania Rating Scale (YMRS) and Montgomery Depression Rating Scale (MDRS). The socio-demographic data was obtained. Impulsivity was evaluated using the Barratt Impulsiveness Scale (BIS-11)

The study sample consisted of 30 patients (10 men and 20 women). The mean age of the sample was 45.83 years (SD= 11. 63). Seventeen patients (56.7%) were married. More than half of the subjects (76.7%) were unemployed and 26.7% were not educated. Of the studied patients 83.3% were drug free, 43.3% were smoker and 16.7% were alcoholic. The mean BIS11 score was 75. 60 (SD=5.51) and 76.7% had a high level of impulsivity. No correlation was found between the level of impulsivity (BIS-11 scores) and age, gender, marital status, being a current smoker, using drug or alcohol or job status (p=0.082; p=0.760; p=0.087: p=0.977; p=0.847; p=0.708).

Further studies should be realized to fully characterize impulsivity in BD and, therefore, make it a target for future therapeutic models.

Bipolar disorder (BD) is a serious and extremely recurrent illness frequently associated with cognitive and functional deterioration that poses many treatment challenges. However, over the years, with the evolution of more and more mood stabilizers and neuroleptics, there were controversies surrounding the use of electroconvulsive therapy (ECT).

The present study was an attempt at studying the clinical profile of BD patients who receive ECT and to study its effectiveness.

Retrospective data were collected from all bipolar patients submitted to acute ECT treatment, between June 2015 and June 2016, at the Department of Psychiatry of the University Hospital of Mahdia, Tunisia.

During the study period, among all the patients who received ECT, 47% were diagnosed to have bipolar disorder. ECT was administered most commonly for mania with psychotic symptoms, followed by severe depression with psychotic symptoms. Most of patients showed more than 65% response (based on reduction in the standardized rating scales) with ECT. Few patients (18.7%) reported some kind of side effects.

ECT resulted very effective for all BD acute depressive and manic episodes not responding to conventional pharmacologic management.

Mood destabilization and induced manic episodes are well-known phenomenon under antidepressant medications. However, even with a cautious introduction of antidepressants, it’s important to be aware of possible pharmacological interactions. Terbinafine is a known inhibitor of CYP2D6, a major hepatic metabolizer of a full list of antidepressant medications, and so capable of raising their serum levels and potentiating their side effects.

With this case report we aim to emphasize the importance of cautious usage of Terbinafine when combined with antidepressant medications.

We present a clinical case of an induced first manic episode after the introduction of Terbinafine in a patient under antidepressant medication and a qualitative review on the topic, using PubMed database.

A 66-year-old woman, with an history of Major Depressive Disorder, previously medicated with Venlafaxine 75mg/day and Mirtazapine 30mg/day, was brought to the emergency department because of psychomotor agitation. She also had an history of seasonal fluctuating mood, although never fulfilling the criteria for Bipolar Disorder. At admission, her clinical status was compatible with a manic episode. This episode followed two months after the initiation of Terbinafine for onychomycosis.

There are few studies that have shown antidepressant toxicity mediated by an interaction with Terbinafine. As far as we know this is the first case of induced mania after the introduction of Terbinafine. Therefore, it is important to remind that Terbinafine is a potential interacting agent when combined with psychotropic medications.

While the links between cyclothymia and creativity are well documented, the experts have tried to determine whether temperament would influence the major choices of life such as career.

The study aims mainly to evaluate the temperaments of a sample of Tunisian students, and to look for the possible correlations between the temperament and the choice of studies.

The Tunisian version of the TEMPS-A which is a self-evaluation measure to assess affective temperaments was administered to 100 medical students and 100 humanities students.

Student populations differed in their socio-demographic and scholar variables such as age, sex ratio or socio-economic level, choice of studies and their religiosity. The temperamental prevalences were close between our two populations by considering the threshold score Mean +1standard deviation; they ranged between 13 and 18%. Hyperthymic and cyclothymic scores were significantly higher among humanities students (11.38 ± 4.385 versus 9.00 ± 4.192 and 11.96 ± 4.497 versus 9.63 ± 4.499 respectively) and irritable scores were higher in the latter, though not significant (6.45 ± 3.823 versus 5.39 ± 2.998). Depressive and anxious temperament scores were close in both groups. The study showed significant temperament differences within gender, socioeconomic status, high school marks, religiosity and political affiliation.

It is relevant and even necessary to include such studies in the selection of candidates who could adapt to a specific professional field on the basis of objective criteria such as conscientiousness, and privileging profile diversity.

Quality of life is a broad and complex concept, but essentially refers to an individual’s well-being in a spectrum of life domains.

The aim of the present study was to investigate the relationship between spirituality, religiosity (S/R) and quality of life (QOL) among bipolar disorder (BD) patients.

Data were collected between July and December 2017.Participants were enrolled from the Mood Consultation of the Psychiatry (A) Department of the University Hospital HediChaker. We assessed symptoms of mania [Young Mania Rating Scale (YMRS)], depression [Beck scale], quality of life [World Health Organization Quality of Life-Brief Version (WHOQOL-BREF)]andquality of life aspects related to spirituality, religiousness and personal beliefs [World Health Organization Quality Of Life –Spirituality, Religiousness and Personal Beliefs (WHOQOL-SRPB)]

Our sample included 60 patients. It consisted of 55% of female and the mean age was 44.94 (SD=12.76). The sample included 68% of participant diagnosed with BDI and 32% with BDII The median score of quality of live was 3 (minimum=1; maximum=5).The median of physic, psychic, social and environmental quality of life was respectively (25, 31, 81 and 19) (Minimum=0; Maximum=100). The mean score of WHOQOL-SPRB was 14.82 (Minimum=4, Maximum=20). S/R were correlated to psychic, social and environmental quality of life (p=0.006, p=0.011, p=0.016). We did not find a significant association between physic quality of life and S/R (p=0.234).

Our study suggests that spirituality, religiosity have an important influence on most aspects of the quality of life among bipolar patients.

Bipolar disorder (BD) has the highest suicide attempt rate among psychiatric disorders. Many factors are associated with the risk of suicide attempt in BD, but the relation between them has still not been explicitly stated.

This study aimed to examine the clinical variables characterizing patients with BD with prior suicide attempt (PSA).

This was a descriptive and analytical study, conducted over 3 months, involving 31 euthymic patients with BD, followed up in the outpatient psychiatry department of Hedi Chaker University Hospital in Sfax (Tunisia). General, clinical and therapeutic data were collected using a pre-established questionnaire. Quality of life (QOL) was assessed with the «36 item Short-Form Health Survey» (SF-36). Impulsivity was assessed with the Barratt Impulsiveness Scale (BIS-11).

The mean age was 47.25 years and the sex ratio was 1.6. Family history of suicide attempts was found in 25% of cases. Mean score of SF36 was 34 and high degree of impulsivity was noted in 62.5% of cases. The frequency of BD patients with PSA was 12.3% (N=8), with two of these (25%) having more than one PSA. Comorbid alcohol abuse (p=0.000), somatic illness (p=0.013), high degree of impulsivity (p=0.032), and impaired quality of live (p=0.003) were significantly more frequent in BD patients with PSA.

We found several clinical variables associated with PSA in BD patients. Even though these retrospective findings did not address causality, they could be clinically relevant to better understanding suicidal behavior in BD and adopting proper strategies to prevent suicide in higher risk patients.

Impulsivity is not a classical psychiatric diagnosis like schizophrenia, depression, bipolar or borderline personality disorder. It is a symptom that could occur in almost all psychiatric disorders and in some neurological or systemic diseases.

In this study we examine the influence of bipolar disorder’s (BD) treatment on the impulsivity.

We performed a cross sectional study on 30 patients diagnosed with BD and consulting at the Psychiatric department of HediChaker Hospital. Patients were euthymic during the time of the study confirmed by administration Young Mania Rating Scale (YMRS) and Montgomery Depression Rating Scale (MDRS). The socio-demographic data and treatment models were obtained. Impulsivity was evaluated using the Barratt Impulsiveness Scale (BIS-11).

The study sample consisted of 30 patients (10 men and 20 women). The mean age of the sample was 45.83 years (SD= 11. 63). Seventeen patients (56.7%) were married. Half of the participants were using an association of mood stabilizer (MS) and an antipsychotic (AP), 36.7% and 13.3% were receiving respectively only mood stabilizer or an antipsychotic. The mean BIS11 score was 75. 60 (SD=5.51) and 76.7% had a high level of impulsivity. No correlation was found between the level of impulsivity (BIS-11 scores) and using MS, AP or MS+AP (p=0.199; p=0.933; p=0.195).

Further studies should be realized to identify pharmacological treatment of impulsivity among people with BD.

The early diagnosis of bipolar II disorder remains difficult in clinical practice, hence the importance of psychometric tests.

To detect hypomania in patients followed for a major depressive disorder (MDD) and to determine factors which are correlated with it.

This was a cross-sectional, descriptive and analytical study. It involved 40 psychiatric outpatients, who were followed for MDD (isolated or recurrent episode) at the Hedi Chaker University Hospital in Sfax (Tunisia), from January 26 to February 10, 2020. The study was conducted using a questionnaire and the Angst Hypomania Checklist-20 (HCL-20).

The sex ratio (M/F) was 0.66 with an average age of 54.8 years. MDD started at an average age of 41.45 years. According to HCL-20, half of our sample had hypomania. The presence of hypomania was correlated with young age (p = 0.022), academic failure (p = 0.038) and smoking (p = 0.003). In addition, there was a statistically significant relationship between the presence of hypomania and the characteristics of the disease: number of depressive episodes ≥ 2 (p = 0.013), psychotic features (p = 0.038), melancholic features (p=0,025) and premature discontinuation of treatment (p = 0.003).

Our study confirmed that bipolar depression is still underdiagnosed and poorly treated. Questioning a patient about a history of hypomania would be a delicate task and would require the help of a scale, in particular the HCL -20.