Anger in Depressive Mixed States

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Sir: Mammen et al.,¹ in an article on anger attacks in bipolar (I and II) depression, reported that anger attacks responded to citalopram and had no relationship to depressive symptoms or hypomanic symptoms within depressive episodes in a secondary analysis of data. The small sample they used, which included only 15 bipolar II disorder patients, could lead to type II error. The mean score on the Young Mania Rating Scale (YMRS), used to assess hypomanic symptoms within depressive episodes, was only 3.3 (scale range, 0-60), meaning few symptoms were present and few of the patients’ depressive episodes included hypomanic symptoms.