The road to DSM-V. Bipolar disorder episode and course specifiers

There is general agreement that DSM-IV and ICD-10 require major improvements in format and content to make them more valid, evidence-based and clinically useful. DSM-IV-TR currently includes a series of clinical features that provide potentially useful information on cross-sectional and longitudinal courses of bipolar disorder. This conceptual and data-driven review proposes changes in the current classification by removing, modifying and adding bipolar episode and course specifiers in DSM-V. Specifiers to be maintained would be 'with catatonic features', 'with melancholic features', 'with atypical features' and 'with rapid cycling'. The 'seasonal pattern' modifier should be amended to allow manic, hypomanic and mixed episodes to be included in the description. Some specifiers should likely be substantially reconceptualized ('severity/psychosis/remission') or removed ('with post-partum onset'). Age at onset (early, intermediate or late onset) and predominant polarity (manic, depressive) should be added for their relevance for course and outcome.