***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Using a structured interview with 150 r and omly selected 14 - 16-year-olds and their parents , we found 20 who endorsed four or more manic symptoms of at least 2 days duration . Compared to the rest of the sample , these teenagers had significantly higher rates of attention deficit , conduct , and anxiety disorders and psychotic symptoms , and were seen as needing treatment by the interviewers . However , most of the pathology was endorsed by teenagers rather than parents . Other assessment s confirmed this group as dysphoric , impulsive and emotionally labile . We discuss the normative and diagnostic implication s of these findings though long-term follow-up is necessary to draw more certain conclusions Twenty percent of a cohort of 206 outpatient depressives with no past bipolar history switched during prospect i ve observation . These 41 prob and s developed manic periods on the average of 6.4 years ( median 4 , range 1 - 25 ) after their first depressive episode . The change in polarity occurred throughout the life span , but was most common in adolescence and early adulthood . The following variables were found useful in predicting this outcome : onset less than or equal to 25 years , bipolar family history , loaded pedigrees , precipitation by childbirth , hypersomnic-retarded phenomenology , and pharmacologically-mobilized hypomania . Although the respective sensitivities of these findings were relatively low ( 32 - 71 % ) , their specificities ranged from 69 % to 100 % for bipolar outcome ; the diagnostic specificity of any 3 of these variables when combined was 98 % . When compared with nonbipolar depression , bipolar disorder was seldom chronologically secondary to nonaffective psychiatric disorders . These findings suggest that many young depressives with lethargy and oversleeping are not manifesting a " neurotic " disorder , but rather a precursor of primary bipolar affective disorder . Finally , a psychotically depressed adolescent or young adult with positive bipolar family history should be observed for eventual bipolar outcome , especially when the clinical presentation is that of stupor CONTEXT There is growing evidence that major depressive disorder ( MDD ) might be overdiagnosed at the expense of bipolar disorder ( BPD ) . OBJECTIVES To identify a subgroup of subthreshold BPD among DSM-IV MDD , which is distinct from pure MDD regarding a range of validators of bipolarity , and to examine the pattern of these validators among different groups with affective disorders . DESIGN Ten-year prospect i ve longitudinal and family study including 3 follow-up waves . Data were assessed with the DSM-IV Munich Composite International Diagnostic Interview . SETTING Community sample in Munich , Germany . PARTICIPANTS A total of 2210 subjects ( aged 14 - 24 years at baseline ) who completed the third follow-up . MAIN OUTCOME MEASURES Cumulative incidence of pure MDD , BPD , and subthreshold BPD ( defined as fulfilling criteria for MDD plus having manic symptoms but never having met criteria for [hypo]mania ) . RESULTS Among 488 respondents with MDD , 286 ( 58.6 % ) had pure MDD and 202 ( 41.4 % ) had subthreshold BPD  ( cumulative incidence , 9.3 % ) . Compared with respondents who had pure MDD , respondents with subthreshold BPD were found to have a significantly increased family history of mania , considerably higher rates of nicotine dependence and alcohol use disorders , rates of panic disorder that were twice as high , and a tendency toward higher rates of criminal acts . Prospect i ve analyses showed that subthreshold BPD converted more often into BPD during follow-up , with DSM-IV criterion D ( symptoms observable by others ) being of critical predictive relevance . With increasing severity of the manic component , rates for diverse validators accordingly increased ( eg , alcohol use disorders , parental mania ) or decreased ( harm avoidance ) . CONCLUSIONS Data suggest that MDD is a heterogeneous concept including a large group with subthreshold BPD , which is clinical ly significant and shares similarities with BPD . Findings might support the need for a broader concept and a more comprehensive screening of bipolarity , which could be substantial for future research and adequate treatment of patients with bipolarity OBJECTIVES Significant questions remain regarding both the incidence patterns of mood episodes in adolescents and young adults from the community and the conversion rate from unipolar to bipolar disorders . We addressed these issues by examining data from a prospect i ve longitudinal community study to ( i ) determine the cumulative incidence of mood episodes and disorders in the first three decades of life ; ( ii ) determine the risk for first onset of depression among individuals with a previous history of hypomanic/manic episodes and vice versa ; and ( iii ) determine the clinical and treatment characteristics of these subjects . METHODS Using the Munich-Composite International Diagnostic Interview , clinical ly trained interviewers assessed mood episodes and mental disorders in 3,021 community subjects ( aged 14 - 24 at baseline and 21 - 34 at third follow-up ) . RESULTS The estimated cumulative incidence at age 33 was 2.9 % for manic , 4.0 % for hypomanic , 29.4 % for major depressive , and 19.0 % for minor depressive episodes ; overall , 26.0 % had unipolar major depression , 4.0 % bipolar depression , 1.5 % unipolar mania , and 3.6 % unipolar hypomania ( no major depression ) . Overall , 0.6 % and 1.8 % had unipolar mania or hypomania , respectively , without indication for even minor depression . A total of 3.6 % of the initial unipolar major depression cases subsequently developed (hypo)mania , with particularly high rates in adolescent onset depression ( < 17 years : 9 % ) . A total of 49.6 % of the initial unipolar mania cases subsequently developed major depression and 75.6 % major or minor depression . While bipolar cases had more adverse clinical and course depression characteristics and higher treatment rates than unipolar depressed cases , bipolar cases did not significantly differ in mania characteristics from unipolar mania cases . CONCLUSIONS Unipolar and bipolar mood disorders are more frequent than previously thought in adolescence and young adulthood , a time period when both the recognition and the intervention rates by the healthcare system are rather low . ' Conversion ' to bipolar disorder is limited in initial unipolar depression , but common in initial unipolar mania . The remaining unipolar mania cases appear to be significant in terms of clinical and course characteristics and thus require more research attention to replicate these findings OBJECTIVES To analyse the time course and some risk factors for a diagnostic change from major depression to bipolar disorders ( BP ) over an average of 20 years from the onset of the disorders . METHODS Patients ( 406 ) with major mood disorders hospitalised at some time between 1959 and 1963 were followed-up until 1985 . The analysis also included the course prior to hospitalisation .  Survival analyses and Cox regression models  were applied . RESULTS A diagnostic change from depression to bipolar I occurred in about 1 % of the patients per year and to bipolar II disorders in about 0.5 % per year . Risk factors for a change from depression to BP-I disorder were male sex and an early onset of the disorder ; risk factors for a change from depression to BP-II disorder were female sex , a later onset of the disorder and a positive family history of mania . CONCLUSIONS Across the entire lifetime , every new episode of depression brings a new risk for mania ; more than half of our severe mood disorder cases became bipolars . The risk of depression developing into bipolar disorder remains constant lifelong . LIMITATIONS The diagnostic classification of ICD-9 met RDC criteria for bipolar disorder in only 90 % of cases . Part of the data collected in retrospect may be less reliable ; the prospect i ve data were only collected every 5 years from 1965 to 1985 using multiple sources ; mild manifestations between the follow-ups may have been partially missed . The sample of subsequent hospital admissions for major depression and mania represents a severe group of patients and generalisations to ambulatory cases may not be possible . Not all risk factors for diagnostic conversion described in the literature could be assessed in this study INTRODUCTION We have developed ultra-high risk criteria for bipolar affective disorder ( bipolar at-risk - BAR ) which include general criteria such as being in the peak age range of the onset of the disorder and a combination of specific criteria including sub-threshold mania , depressive symptoms , cyclothymic features and genetic risk . In the current study , the predictive validity of these criteria were tested in help-seeking adolescents and young adults . METHOD This medical file-audit study was conducted at ORYGEN Youth Health ( OYH ) , a public mental health program for young people aged between 15 and 24years and living in metropolitan Melbourne , Australia .  BAR criteria were applied to the intake assessment s of all non-psychotic patients who were being treated in OYH on 31 January , 2008 . All entries were then checked for conversion criteria . Hypomania/mania related additions or alterations to existing treatments or initiation of new treatment by the treating psychiatrist served as conversion criteria to mania . RESULTS The BAR criteria were applied to 173 intake assessment s. Of these , 22 patients ( 12.7 % ) met BAR criteria . The follow-up period of the sample was 265.5days on average ( SD 214.7 ) . There were significantly more cases in the BAR group ( 22.7 % , n=5 ) than in the non-BAR group ( 0.7 % , n=1 ) who met conversion criteria ( p<.001 ) . CONCLUSIONS These findings support the notion that people who develop a first episode of mania can be identified during the prodromal phase . The proposed criteria need further evaluation in prospect i ve clinical trials OBJECTIVE To investigate the rate and predictors of onset of DSM-III bipolar I and bipolar II disorders among 6- to 12-year-old prepubertal subjects with DSM-III major depressive disorder ( MDD ) who were followed for a 2- to 5-year period . METHODS This was a prospect i ve , blindly rated study of 79 children with MDD and 31 normal control children matched for age , gender , and socioeconomic status . Subjects and a second informant were assessed at 4-month intervals using the Kiddie Schedule for Affective Disorders and Schizophrenia-Present Episode Version-1986 modified to include 4-month interval ratings and to include DSM-III diagnoses .  Family history ( FH ) was assessed using the FH- Research Diagnostic Criteria obtained from the mother about the subject 's first- and second-degree relatives . RESULTS Bipolarity developed in 31.7 % ( N = 25 ) of the children with MDD at a mean age of 11.2 + /- 2.0 years and 80 % were prepubertal . Loaded FH and multigenerational FH were significantly associated with bipolar I. Neither prior nor current use of tricyclic antidepressants nor atypical depressive features were predictive . CONCLUSIONS These findings strongly support the need to educate families of children with prepubertal-onset MDD about the possibility of the emergence of manic and hypomanic symptoms to encourage early recognition and appropriate treatment BACKGROUND To investigate whether ADHD is a risk factor for switches from unipolar to bipolar disorder over time . METHODS Data from two large controlled longitudinal family studies of boys and girls with and without ADHD and their siblings were used . Subjects ( n=168 ) were followed prospect ively and blindly over an average follow-up period of 7 years . Comparisons were made between youth with unipolar major depression who did and did not switch to full or subthreshold BP-I disorder at the follow-up assessment . Subjects were assessed at baseline and follow-up on multiple domains of functioning . Positive family history of parental psychiatric disorders was also compared between groups . RESULTS ADHD was associated with a significantly higher risk for switches from unipolar to bipolar disorder ( 28 % versus 6 % ; z=2.80 , p=0.005 ) . In subjects with ADHD , switches from unipolar to bipolar disorder were predicted by baseline comorbid conduct disorder , school behavior problems , and a positive family history of parental mood disorder . LIMITATIONS Psychosis was an exclusionary criterion in the original ascertainment of the studies of ADHD prob and s , so we were unable to test this as a predictor of switching to BPD . CONCLUSIONS ADHD is a risk factor for switches from unipolar to bipolar disorder , and switches could be predicted by the presence of baseline conduct disorder , school behavior problems , and a positive family history of a mood disorder in a parent . These characteristics can aid clinicians in their treatment of youth with MDD 
    Output:
    
These findings can aid clinicians in differentiating the two forms of MDD in youth