Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders

Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. They are based explicitly on the available evidence and presented, similar to previous Clinical Practice guidelines, as recommendations to aid clinical decision-making for practitioners. They may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment.

The clinical use of gabapentin in bipolar spectrum disorders

BACKGROUND

with increasing awareness of lithium's limitations, several new anticonvulsants had been tested for their mood stabilisation during recent years. Among the innovative third generation mood stabilizing anticonvulsants, gabapentin (GBP) seems to have a broad spectrum of efficacy, although no certain data are available as to its efficacy and use in clinical practice. Accordingly, an extensive review on this subject has been carried out.

METHODS

A computer-generated search of the biomedical literature and abstract books of the more important scientific psychiatric congresses until June 2000 was undertaken to identify all pertinent case reports, case series and studies of GBP as monotherapy or adjunctive therapy in mood disorders. We identified 40 open-label studies on the use of GBP in at least 600 patients with bipolar disorder (BP), manic, depressed, or mixed episodes and unipolar depression and four controlled studies.

RESULTS

The 40 open-label studies and two of the controlled trials suggested that GBP may have a role as adjunctive agent in the treatment of patients with bipolar disorders particularly when complicated by co-morbid anxiety disorder or substance abuse. GBP is usually very well tolerated and has no pharmacological interference with other mood stabilisers. However, in the other two double-blind studies GBP has not been found to be efficacious in the treatment of refractory mania or refractory bipolar depression.

CONCLUSIONS

Although failing to show clear antimanic efficacy in randomized trials, gabapentin still remains a clinically useful agent when it comes to combination treatment in refractory and co-morbid patients.

When do antidepressants worsen the course of bipolar disorder?

Bipolar disorder may be more prevalent than previously believed. Because a substantial number of patients with bipolar disorder present with an index depressive episode, it is likely that many are misdiagnosed with unipolar major depression. Even if a correct diagnosis is made, depressive symptoms in bipolar disorder are notoriously difficult to treat. Patients are often treated with antidepressants, which, if used improperly, are known to induce mania and provoke rapid cycling. This article explores diagnostic conundrums in bipolar depression and their possible solutions, based on current research evidence. It also elucidates current evidence regarding the risks and benefits associated with antidepressant use and evaluates alternative treatment regimens for the depressed bipolar population, including the use of traditional mood stabilizers such as lithium, novel anticonvulsants such as lamotrigine, and atypical antipsychotics.

Difficult-to-treat depression: the role of contexts and comorbidities

In this review, we examine several special psychosocial contexts, including pregnancy and motherhood, that may seriously interfere with depressed patients' ability or willingness to engage and remain in treatment for their depression. We also explore the kinds of often-unrecognized subsyndromal comorbidities, such as panic-agoraphobic spectrum, that may complicate conventional treatments for depression or prevent depressed patients from remaining engaged long enough to fully benefit from treatment. We argue that psychotherapy can play a crucial role in addressing the special psychosocial contexts and the kinds of comorbidities experienced by the patient with difficult-to-treat depression. For difficult-to-treat depression during pregnancy and motherhood, preliminary data from several studies suggest that 8-24 sessions of weekly interpersonal psychotherapy (IPT), often followed by monthly maintenance IPT, is a promising long-term treatment for both middle- and low-income women. For difficult-to-treat depression with panic-agoraphobic subsyndromal features, preliminary results suggest that an integrated treatment approach, combining IPT for depression and cognitive-behavioral treatment for coexisting symptoms of panic, leads to higher depression response rates. These data imply that tailoring treatments to patients' specific needs and circumstances may be the real key to making depression less difficult to treat.

Treatment research in bipolar disorder: issues and recommendations

Bipolar (manic-depressive) disorder is one of the most common of the severe mental illnesses. Officially recognised forms comprise type I (with mania), type II (with hypomania), cyclothymia and a rapid-cycling subtype. International lifetime prevalence estimates are 1 to 5% of the general population, and bipolar disorder accounts disproportionately for idiopathic psychoses. Psychiatric and substance-abuse comorbidities are common complications, and mortality rates are increased as a result of high suicidal risks, accidents, complications of substance abuse and increased fatality of stress-sensitive medical illnesses. Complex and labile symptomatic presentations, a tendency for patients to deny illness and reject treatment, and diagnostic heterogeneity severely complicate the design, conduct and interpretation of experimental treatment trials in bipolar disorder. Progress in the short-term treatment of mania with certain antiepileptic drugs and atypical antipsychotic agents has advanced greatly in recent years; however, long-term treatment trials other than with lithium remain rare, as are studies of type II disorder, bipolar depression and mixed states, and there is limited information on treatment effectiveness against comorbidity, dysfunction and mortality. There is a growing realisation that bipolar disorder represents a major, largely unmet, international public health challenge and that innovative methods for carrying out reliable and generalisable long-term pharmacological treatment trials, alone and in combination with cost-effective psychosocial and rehabilitative interventions, are urgently required.

Avanços no diagnóstico do transtorno do humor bipolar

Atualmente, vemos transformações no diagnóstico do Transtorno de Humor Bipolar (THB). A prática clínica exige conhecimento mais detalhado da correlação THB - outras doenças psiquiátricas. Nessa revisão não-sistemática, foram abordados aspectos diagnósticos do THB: a) histórico, b) Espectro Bipolar, c) Depressão Atípica (DeA) e Disforia Histeróide, d) Estados Mistos, e) relação THB-Transtornos de Ansiedade, f) relação com o diagnóstico de Transtorno de Personalidade Borderline (TPB), g) contraponto ao conceito de espectro bipolar. A doença é conhecida desde a Grécia Antiga. Os estudos baseados nas publicações de Hagop Akiskal expandem o diagnóstico para além dos critérios usualmente utilizados, criando o conceito de espectro bipolar. A alta prevalência de comorbidade entre THB e Transtornos de Ansiedade corroboram que ambos compartilham o mesmo substrato neurobiológico. O debate demonstra que não há consenso, expondo a fragilidade dos nossos métodos diagnósticos. Entretanto, a revisão mostra a utilidade de sempre considerar o THB como diagnóstico diferencial.

Response of patients with panic disorder and symptoms of hypomania to cognitive behavior therapy for panic

OBJECTIVES

The purpose of this cohort study was to determine in patients with Panic Disorder (PD): (1). the prevalence of subsyndromal symptoms of hypomania, and (2). whether subsyndromal hypomania symptoms affect the outcome of cognitive behavior therapy (CBT) for panic.

METHODS

Using the Diagnostic Interview Schedule, and DSM-III-R criteria we identified 18 individuals with a history of symptoms of hypomania among 56 patients with PD. Patients were treated in an open CBT group program. They were assessed before treatment and 6 and 12 months later. We used the Brief Symptom Inventory (BSI), the Perceived Stress Scale (PSS), the Pearlin-Schooler Mastery Scale (PMS), and the Social Adjustment Scale (SAS) at all assessments.

RESULTS

The total group significantly improved on all measures. The Clinically Significant Change was 71.4% and the Reliable Change Index 48.2%. Between 6 and 12 months, there was a trend for the hypomania symptom subgroup (PH) to continue to improve on the BSI Depression Scale, the Perceived Stress Scale, the Pearlin-Schooler Mastery Scale, and the Social Adjustment Scale but to lose gains on the BSI Phobic Anxiety and Somatization subscales compared with the group without symptoms of hypomania (PNH).

CONCLUSIONS

Thirty-two percent of patients with PD had symptoms of hypomania. With CBT for panic, patients with PD and symptoms of hypomania improve as much as those without hypomania symptoms. The presence or absence of symptoms of hypomania might help explain the inconsistent effects of depression and personality disorders on the treatment of PD.

Is there a link between atypical and early-onset "unipolar" depression and bipolar II disorder?

The aim of the present study was to determine whether there is a link between "unipolar" depression with atypical features and early onset, and bipolar II disorder, using atypical features and early onset as markers of bipolarity. A total of 158 consecutive unipolar and 234 bipolar II major depressive episode (MDE) outpatients were interviewed using the Structured Clinical Interview for DSM-IV (SCID). Patients were divided into those with and without atypical features, and into those with and without early onset. Comparisons were made on variables reported to distinguish bipolar from unipolar: age of onset, recurrences, atypical features, depressive mixed state (MDE plus three or more concurrent hypomanic symptoms [DMX3]), and bipolar II family history. Compared to bipolar II patients, patients with atypical unipolar were not significantly different regarding age of onset, DMX3, recurrences, and bipolar II family history. Compared to non-atypical unipolar patients, atypical unipolar patients had a significantly different age of onset. Nonatypical unipolar patients, versus bipolar II patients, were significantly different regarding age of onset, recurrences, DMX3, and bipolar II family history. Early onset unipolar, versus bipolar II, were not significantly different regarding atypical features, recurrences, DMX3, and bipolar II family history. Later onset unipolar patients, versus bipolar II patients, were significantly different regarding atypical features, recurrences, DMX3, and bipolar II family history. These results support a link of atypical and early-onset "unipolar" depression with bipolar II disorder, and support Pages and Dunner's suggestion to combine bipolar II and recurrent unipolar into a single group.

A new bipolar spectrum concept: a brief review

Research on the broad bipolar spectrum is dependent on the definition of hypomania. We recently proposed a new, softer syndromal definition with clinical validity. This broadens the diagnosis of bipolar II (BP-II) disorder at the expense of major depressive disorder (MDD). There is evidence for a third group of suspected BP-II manifesting major depression plus hypomanic symptoms. The two bipolar-II groups together are as prevalent as MDD. A new concept of minor bipolar disorder embracing dysthymia, minor and recurrent brief depression with hypomanic syndromes and symptoms is discussed. Some methodological pitfalls of research on drug-induced hypomania as an element of the bipolar spectrum are also summarized.

Depressive mixed state: dimensional versus categorical definitions

BACKGROUND

Recently, there has been a rebirth of studies on depressive mixed state (DMX), defined as a major depressive episode (MDE) plus few concurrent hypomanic symptoms. It is still unclear how to best define DMX. The study's aim was to test a categorical versus a dimensional definition of DMX.

METHODS

Consecutive 260 bipolar II disorder and 173 unipolar MDE outpatients were interviewed with the Structured Clinical Interview for DSM-IV, when presenting for MDE treatment (drug-free). Hypomanic symptoms during index MDE were systematically assessed and graded by a hypomania rating scale (Hypomania Interview Guide, HIG). Different cutoffs of the HIG to define DMX were tested versus a categorical definition of DMX (requiring more than two concurrent hypomanic symptoms, DMX3). Sensitivity and specificity for predicting bipolar II diagnosis were compared. The best definition of DMX based on the HIG was also compared to DMX3 versus typical bipolar variables (early onset, many recurrences, atypical features, bipolar family history).

RESULTS

An HIG cutoff of 8 had a specificity for predicting bipolar II diagnosis similar to that of DMX3. HIG>8 was strongly associated with bipolar family history (an important external diagnostic validator), and DMX3 was significantly associated with more bipolar variables (including bipolar family history).

LIMITATION

The interview was done by a single interviewer.

CONCLUSIONS

Similar specificity for predicting bipolar II disorder diagnosis and a similar strong association with bipolar family history suggest that a categorical and a dimensional definition of DMX could have similar validity. However, the dimensional definition (based on the scoring of a hypomania rating scale) could lead to a better assessment of hypomanic symptoms, resulting in more correct diagnoses of DMX.

Refining the evaluation of bipolar II: beyond the strict SCID-CV guidelines for hypomania

BACKGROUND

The prevalence of bipolar II disorder in depressed outpatients is much higher than previously reported, a finding probably related to systematic probing for past hypomania by trained clinicians. Our objective was to further refine the strict SCID-CV guidelines for hypomania in depressed outpatients.

METHODS

168 consecutive outpatients presenting with major depression were systematically interviewed with the SCID-CV about all past hypomanic behavior, irrespective of duration and initial negative response to the screening question on mood. Once typical hypomanic behaviors were elicited, the patient was re-questioned about mood change.

RESULTS

The prevalence of bipolar II was 61.3%. Bipolar II, so-defined, was indistinguishable at age of onset, recurrence, and atypical features from a previous sample of 251 BP-II patients interviewed by the same clinician (FB) without the present modification of the stem question on mood, and which had yielded a prevalence of 45% in the same outpatient clinic.

LIMITATIONS

Single interviewer, and cross-sectional assessment.

CONCLUSIONS

Systematic probing for all past hypomanic symptoms and behaviors, independently of the answer to the screening question on mood, can elicit hypomanic features that would otherwise be discarded by strict adherence to the SCID-CV. A net gain of 16% in the diagnosis of BP-II can thereby be achieved.

The role of cyclothymia in atypical depression: toward a data-based reconceptualization of the borderline-bipolar II connection

OBJECTIVE

Recent data, including our own, indicate significant overlap between atypical depression and bipolar II. Furthermore, the affective fluctuations of patients with these disorders are difficult to separate, on clinical grounds, from cyclothymic temperamental and borderline personality disorders. The present analyses are part of an ongoing Pisa-San Diego investigation to examine whether interpersonal sensitivity, mood reactivity and cyclothymic mood swings constitute a common diathesis underlying the atypical depression-bipolar II-borderline personality constructs.

METHOD

We examined in a semi-structured format 107 consecutive patients who met criteria for major depressive episode with DSM-IV atypical features. Patients were further evaluated on the basis of the Atypical Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list (HSCL-90), and the Hamilton Rating Scale for Depression (HRSD), coupled with its modified form for reverse vegetative features as well as Axis I and SCID-II evaluated Axis II comorbidity, and cyclothymic dispositions ('APA Review', American Psychiatric Press, Washington DC, 1992).

RESULTS

Seventy-eight percent of atypical depressives met criteria for bipolar spectrum-principally bipolar II-disorder. Forty-five patients who met the criteria for cyclothymic temperament, compared with the 62 who did not, were indistinguishable on demographic, familial and clinical features, but were significantly higher in lifetime comorbidity for panic disorder with agoraphobia, alcohol abuse, bulimia nervosa, as well as borderline and dependent personality disorders. Cyclothymic atypical depressives also scored higher on the ADDS items of maximum reactivity of mood, interpersonal sensitivity, functional impairment, avoidance of relationships, other rejection avoidance, and on the interpersonal sensitivity, phobic anxiety, paranoid ideation and psychoticism of the HSCL-90 factors. The total number of cyclothymic traits was significantly correlated with 'maximum' reactivity of mood and interpersonal sensitivity. A significant correlation was also found between interpersonal sensitivity and 'usual' and 'maximum' reactivity of mood.

LIMITATION

Correlational study.

CONCLUSIONS

Mood lability and interpersonal sensitivity traits appear to be related by a cyclothymic temperamental diathesis which, in turn, appears to underlie the complex pattern of anxiety, mood and impulsive disorders which atypical depressive, bipolar II and borderline patients display clinically. We submit that conceptualizing these constructs as being related will make patients in this realm more accessible to pharmacological and psychological interventions geared to their common temperamental attributes. More generally, we submit that the construct of borderline personality disorder is better covered by more conventional diagnostic entities.

Unique design issues in clinical trials of patients with bipolar affective disorder

Two National Institute of Mental Health-sponsored meetings of experts on bipolar illness (in 1989 and 1994) noted a paucity of clinical psychopharmacological trials in this illness which has now extended over the past two decades. One of the reasons elucidated for this neglect was a lack of agreement in the field as to what constituted an optimal clinical trial design, consequently resulting in low-priority scores for funding of studies in bipolar illness. In this paper, we note some of the characteristics of bipolar illness that make it particularly difficult to study and find such agreed upon trial designs. Some of the assets and liabilities of the well-accepted traditional parallel group, placebo-controlled, randomized clinical trial (RCT) are reviewed, and a series of other potential design options, such as crossover, enrichment, off-on-off-on (B-A-B-A), and N-of-1 trials, are discussed that may help to better address some of the unique clinical characteristics of bipolar illness. Finally, a variety of statistical approaches to analyzing data in off-on-off-on trial designs, and in helping to predetermine necessary durations of clinical trials in individual patients with bipolar disorders, are suggested. Acceptance of a wider variety of clinical trial designs may help facilitate the funding and accelerate the acquisition of new data on treatment of bipolar illness.

Arguments for the genetic basis of the bipolar spectrum

Family members of bipolar probands have been repeatedly shown to have an increased risk for mood disorders. However, a range of different syndromes in the bipolar spectrum are commonly observed in these relatives. This suggests the hypothesis that these different syndromes may be genetically related. It further suggests that bipolar disorder may be better conceptualized from a genetic standpoint as a quantitative trait. In such a model, the same genes may predispose to a variety of phenotypes ranging from schizoaffective disorder to cyclothymic temperament. Previous attempts to test such a multifactorial model have provided some limited support. However, other studies argue that some forms of bipolar disorder such as bipolar II may be genetically distinct. In this review, various quantitative and categorical models of illness are considered and the data supporting them reviewed. It is proposed that the existing data may best fit a model in which different sets of genes predispose to overlapping phenotypes that are in part both quantitative and distinct in nature.

Family history validation of the bipolar nature of depressive mixed states

BACKGROUND

Recent data indicate that depressive mixed states (DMX), major depressive episode (MDE) plus few concurrent hypomanic symptoms are common in clinical practice but omitted in DSM-IV. Our aims were to find the sensitivity and specificity of DMX for the diagnosis of bipolar II disorder, and validate it against familial bipolarity.

METHODS

377 consecutive private outpatients presenting with psychoactive drug-free MDE were interviewed with the Structured Clinical Interview for DSM-IV (Clinician Version). History of past hypomanic episodes and presence of hypomanic symptoms during the index MDE were systematically recorded. Of these, 226 were bipolar II and 151 unipolar. DMX3 was defined as an MDE plus three or more intra-episodic hypomanic symptoms.

RESULTS

DMX3 was present in 58.4% of bipolar II, and 23.1% of unipolar patients. It was significantly associated with variables distinguishing bipolar from strictly defined unipolar disorders (younger age at onset, more MDE recurrence, more atypical features, more bipolar II family history). Unipolar DMX3 (MDE with documented hypomania solely intra-episodically) was not significantly different from bipolar II MDE on age at onset, atypical features, and bipolar II family history.

CONCLUSIONS

Results support the inclusion of DMX3 (bipolar II and 'unipolar') into the bipolar spectrum. Adding the 23% of the UP-DMX3 to the roster of less-than-manic outpatient depressives will boost the rate of bipolarity in this outpatient depressive population to a respectable 70%, the highest rate yet reported for the bipolar spectrum below the threshold of mania.

The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases

BACKGROUND

Despite emerging international consensus on the high prevalence of the bipolar spectrum in both clinical and community samples, many skeptics contend that narrowly defined bipolar disorder with a lifetime rate of about 1% represents a more accurate estimate of prevalence. This may in part be due to the fact that higher figures proposed for the bipolar spectrum (5-8%) have not been based on national data and have not included all levels of manic symptom severity. In the present secondary analyses of the US National Epidemiological Catchment Area (ECA) database, we provide further clarification on this fundamental public health issue.

METHODS

All respondents in the first wave (first interview) of the ECA household five site sample (n=18252) were classified on the basis of DSM-III criteria into lifetime manic and hypomanic episodes, as well as those with at least two lifetime manic/hypomanic symptoms below the threshold for at least 1 week duration (subsyndromal manic symptoms [SSM] group). Odds ratios were calculated on lifetime service utilization for mental health problems, measures of adverse psychosocial outcome, and suicidal behavior compared to subjects with no mental disorders or manic symptoms.

RESULTS

As originally reported nearly two decades ago by the primary investigators of the ECA, the lifetime prevalence for manic episode was 0.8%, and for hypomania, 0.5%. What is new here is the inclusion of subthreshold SSM subjects, which accounted for 5.1%, yielding a total of 6.4% lifetime prevalence for the bipolar spectrum. All three (manic, hypomanic and SSM) groups had greater marital disruption. There were significant increases in lifetime health service utilization, need for welfare and disability benefits and suicidal behavior when the SSM, hypomanic and manic subjects were compared to the no mental disorder group. Suicidal behavior was non-significantly highest in the hypomanic (bipolar II) group. Otherwise, hypomanic and manic groups had comparable level of service utilization and social disruption.

LIMITATIONS

Comorbid disorders, which might influence functioning, were not included in the present analyses.

CONCLUSION

These secondary analyses of the US National ECA database provide convincing evidence for the high prevalence of a spectrum of bipolarity in the community at 6.4%, and indicate that subthreshold cases are at least five times more prevalent than DSM-based core syndromal diagnoses at about 1%. These SSM subjects, who met the criteria of "caseness" from the point of view of harmful dysfunction, are of great theoretical and public health significance.

Bipolar II with and without cyclothymic temperament: "dark" and "sunny" expressions of soft bipolarity

BACKGROUND

In the present report deriving from the French national multi-site EPIDEP study, we focus on the characteristics of Bipolar II (BP-II), divided on the basis of cyclothymic temperament (CT). In our companion article (Hantouche et al., this issue), we found that this temperament in its self-rated version correlated significantly with hypomanic behavior of a risk-taking nature. Our aim in the present analyses is to further test the hypothesis that such patients-assigned to CT on the basis of clinical interview-represent a more "unstable" variant of BP-II.

METHODS

From a total major depressive population of 537 psychiatric patients, 493 were re-examined on average a month later; after excluding 256 DSM-IV MDD and 41 with history of mania, the remaining 196 were placed in the BP-II spectrum. As mounting international evidence indicates that hypomania associated with antidepressants belongs to this spectrum, such association per se did not constitute a ground for exclusion. CT was assessed by clinicians using a semi-structured interview based on in its French version; as two files did not contain full interview data on CT, the critical clinical variable in the present analyses, this left us with an analysis sample of 194 BP-II. Socio-demographic, psychometric, clinical, familial and historical parameters were compared between BP-II subdivided by CT. Psychometric measures included self-rated CT and hypomania scales, as well as Hamilton and Rosenthal scales for depression.

RESULTS

BP-II cases categorically assigned to CT (n=74) versus those without CT (n=120), were differentiated as follows: (1). younger age at onset (P=0.005) and age at seeking help (P=0.05); (2). higher scores on HAM-D (P=0.03) and Rosenthal (atypical depressive) scale (P=0.007); (3). longer delay between onset of illness and recognition of bipolarity (P=0.0002); (4). higher rate of psychiatric comorbidity (P=0.04); (5). different profiles on axis II (i.e., more histrionic, passive-aggressive and less obsessive-compulsive personality disorders). Family history for depressive and bipolar disorders did not significantly distinguish the two groups; however, chronic affective syndromes were significantly higher in BP-II with CT. Finally, cyclothymic BP-II scored significantly much higher on irritable-risk-taking than "classic" driven-euphoric items of hypomania.

CONCLUSION

Depressions arising from a cyclothymic temperament-even when meeting full criteria for hypomania-are likely to be misdiagnosed as personality disorders. Their high familial load for affective disorders (including that for bipolar disorder) validate the bipolar nature of these "cyclothymic depressions." Our data support their inclusion as a more "unstable" variant of BP-II, which we have elsewhere termed "BP-II 1/2." These patients can best be characterized as the "darker" expression of the more prototypical "sunny" BP-II phenotype. Coupled with the data from our companion paper (Hantouche et al., 2003, this issue), the present findings indicate that screening for cyclothymia in major depressive patients represents a viable approach for detecting a bipolar subtype that could otherwise be mistaken for an erratic personality disorder. Overall, our findings support recent international consensus in favoring the diagnosis of cyclothymic and bipolar II disorders over erratic and borderline personality disorders when criteria for both sets of disorders are concurrently met.

Validating 'hard' and 'soft' phenotypes within the bipolar spectrum: continuity or discontinuity?

The unitary Kraepelian concept of manic-depressive illness which incorporated attenuated forms, personal dispositions to mood instability, as well as much of the terrain of remitting depressions, may be considered by many to be too broad. On the other hand, the presently preferred unipolar-bipolar dichotomy in official nosology fails to account for the very common occurrence of clinical and subclinical conditions in the interface of major depressive disorders and bipolarity. The emerging concept of the bipolar spectrum represents a provocative working hypothesis to account for these conditions.

The dual factor structure of self-rated MDQ hypomania: energized-activity versus irritable-thought racing

BACKGROUND

Bipolar II is diagnosed in a clinically depressed patient by documenting history of hypomania. Therefore, it is of great significance for both clinical and research purposes to characterize the factor structure of hypomania.

METHODS

Among consecutive depressive outpatients-126 major depressives and 187 bipolar II-diagnosed by the Structured Clinical Interview for DSM-IV (Clinician Version), 181 who had clinically recovered from depression were administered the Mood Disorder Questionnaire (MDQ of. Am. J. Psychiatry 157, 1873). The MDQ is a newly developed, psychometrically validated self-report screening instrument for bipolar spectrum disorders. It screens for lifetime history of manic/hypomanic symptoms by including yes/no items covering all DSM-IV symptoms of mania/hypomania. The MDQ symptom interrelationships were studied by principal component analysis with varimax rotation.

RESULTS

Hypomanic symptoms occurring in >50% were racing thoughts, increased energy and social activity, and irritability. Factor analysis revealed two factors: 'Energized-Activity' (eigenvalue=3.1) and 'Irritability-Racing Thoughts' (eigenvalue=1.5).

LIMITATIONS

Cross-sectional assessment.

CONCLUSIONS

Self-assessment of past hypomanic symptoms by patients, during clinical remission from depression, revealed two independent hypomanic factors, neither of which comprised euphoria. Hypomanic behavior appears to be more fundamental for the diagnosis of hypomania than elated mood accorded priority in DSM-IV; of hypomanic moods, irritability had greater significance than elation. It would appear that self-report of euphoria is less likely when hypomanias are brief (>or=2 vs. >or=4 days). The main implication for busy clinical practice is that energized activity and irritable mood associated with racing thoughts represent the modal experiences of hypomania among bipolar II outpatients; euphoria is neither sensitive, nor pathognomonic, in the diagnosis of these patients. These conclusions accord with recommendations made many years ago for the diagnosis of hypomania among cyclothymic patients [. Am. J. Psychiatry 134, 1227].

Identifying bipolar disorders in individuals with intellectual disability

OBJECTIVE

The aim of the present study was to characterize adults with intellectual disability (ID) and concomitant clinical diagnoses of bipolar disorder (BPD), and determine whether DSM-IV criteria would distinguish individuals with BPD from patients with other psychiatric diagnoses.

METHODS

A retrospective chart review was done of a convenience sample of adult patients seen over a 3-year period in a specialty clinic for adults with ID and psychiatric disorders. The DSM-IV criteria were used to differentiate individuals with clinical symptoms of BPD from groups of patients with other mood or thought disorders with behavioural symptoms which frequently overlap those of BPD. Behavioural symptoms were also catalogued and used to distinguish the diagnostic groups.

RESULTS

Subjects with clinical symptoms of BPD had significantly more DSM-IV mood-related and non-mood-related symptoms, as well as functional impairments, compared to individuals with major depression, depression with psychosis or schizophrenia/psychosis NOS (not otherwise specified). Likewise, behavioural profiles of the BPD group of patients differed significantly from patients in the other three groups.

CONCLUSIONS

Bipolar disorder can be readily recognized and distinguished from other behavioural and psychiatric diagnoses in individuals with ID, and DSM-IV criteria can be useful in the diagnosis of BPD.

Factor structure of hypomania: interrelationships with cyclothymia and the soft bipolar spectrum

BACKGROUND

No systematic data exists on the phenomenology and psychometric aspects of hypomania. In this report we focus on the factor structure of hypomania and its relationships with cyclothymic temperament in unipolar (UP) and bipolar II (BP-II) spectrum (soft bipolar) patients.

METHOD

The combined sample of UP and BP-II spectrum patients (n=427) derives from the French National multi-center study (EPIDEP). The study involved training 48 psychiatrists at 15 sites in France in a protocol based on DSM-IV phenomenological criteria for major depressive disorder, hypomania, and BP-II, as well as a broadened definition of soft bipolarity. Psychometric measures included Angst's Hypomania Checklist (HCA) and Akiskal's Cyclothymic Temperament (CT) Questionnaires.

RESULTS

In the combined sample of the UP and BP-II spectrum, the factor pattern based on the HCA was characterized by the presence of one hypomanic component. In the soft bipolar group (n=191), two components were identified before and after varimax rotation. The first factor (F-1) identified hypomania with positive (driven-euphoric) features, and the second factor (F-2) hypomania with greater irritability and risk-taking. In exploratory analyses, both factors of hypomania tentatively distinguished most soft BP subtypes from UP. However, F-1 was generic across the soft spectrum, whereas F-2 was rather specific for II-1/2 (i.e., BP-II arising from CT). CT, which was found to conform to a single factor among the soft bipolar patients, was significantly correlated only with irritable risk-taking hypomania (F-2).

LIMITATION

In a study conducted in a clinical setting, psychiatrists cannot be kept blind of the data revealed in the various clinical evaluations and instruments. However, the systematic collection of all data tended to minimize biases.

CONCLUSION

EPIDEP data revealed a dual structure of hypomania with 'classic' driven-euphoric contrasted with irritable risk-taking expressions distributed differentially across the soft bipolar spectrum. Only the latter correlated significantly with cyclothymic temperament, suggesting the hypothesis that repeated brief swings into hypomania tend to destabilize soft bipolar conditions.

Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania

BACKGROUND

The boundaries of bipolarity have been expanding over the past decade. Using a well characterized epidemiologic cohort, in this paper our objectives were: (1). to test the diagnostic criteria of DSM-IV hypomania, (2). to develop and validate criteria for the definition of softer expressions of bipolar-II (BP-II) disorder and hypomania, (3). to demonstrate the prevalence, clinical validity and comorbidity of the entire soft bipolar spectrum.

METHODS

Data on the continuum from normal to pathological mood and overactivity, collected from a 20-year prospective community cohort study of young adults, were used. Clinical validity was analysed by family history, course and clinical characteristics, including the association with depression and substance abuse.

RESULTS

(1). Just as euphoria and irritability, symptoms of overactivity should be included in the stem criterion of hypomania; episode length should probably not be a criterion for defining hypomania as long as three of seven signs and symptoms are present, and a change in functioning should remain obligatory for a rigorous diagnosis. (2). Below that threshold, 'hypomanic symptoms only' associated with major or mild depression are important indicators of bipolarity. (3). A broad definition of bipolar-II disorder gives a cumulative prevalence rate of 10.9%, compared to 11.4% for broadly defined major depression. A special group of minor bipolar disorder (prevalence 9.4%) was identified, of whom 2.0% were cyclothymic; pure hypomania occurred in 3.3%. The total prevalence of the soft bipolar spectrum was 23.7%, comparable to that (24.6%) for the entire depressive spectrum (including dysthymia, minor and recurrent brief depression).

LIMITATION

A national cohort with a larger number of subjects is needed to verify the numerical composition of the softest bipolar subgroups proposed herein.

CONCLUSION

The diagnostic criteria of hypomania need revision. On the basis of its demonstrated clinical validity, a broader concept of soft bipolarity is proposed, of which nearly 11% constitutes the spectrum of bipolar disorders proper, and another 13% probably represent the softest expression of bipolarity intermediate between bipolar disorder and normality.

Validating antidepressant-associated hypomania (bipolar III): a systematic comparison with spontaneous hypomania (bipolar II)

BACKGROUND

According to DSM-IV and ICD-10, hypomania which occurs solely during antidepressant treatment does not belong to the category of bipolar II (BP-II).

METHODS

As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 144 (29.2%) fulfilled the criteria for bipolar II with spontaneous hypomania (BP-II Sp), and 52 (10.5%) had hypomania associated solely with antidepressants (BP-H AA).

RESULTS

BP-II Sp group had earlier age at onset, more hypomanic episodes, and higher ratings on cyclothymic and hyperthymic temperaments, and abused alcohol more often. The two groups were indistinguishable on the hypomania checklist score (12.2+/-4.0 vs. 11.4+/-4.4, respectively, P=0.25) and on rates of familial bipolarity (14.1% vs. 11.8%, respectively, P=0.68). But BP-H AA had significantly more family history of suicide, had higher ratings on depressive temperament, with greater chronicity of depression, were more likely to be admitted to the hospital for suicidal depressions, and were more likely to have psychotic features; finally, clinicians were more likely to treat them with ECT, lithium and mood stabilizing anticonvulsants.

LIMITATION

Naturalistic study, where treatment was uncontrolled.

CONCLUSION

BP-H AA emerges as a disorder with depressive temperamental instability, manifesting hypomania later in life (and, by definition, during pharmacotherapy only). By the standards of clinicians who have taken care of these patients for long periods of time, BP-H AA appears as no less bipolar than those with prototypical BP-II. We submit that familial bipolarity ('genotypic' bipolarity) strongly favors their inclusion within the realm of bipolar II spectrum, as a prognostically less favorable depression-prone phenotype of this disorder, and which is susceptible to destabilization under antidepressant treatment. These considerations argue for revisions of DSM-IV and ICD-10 conventions. BP-HAA may represent a genetically less penetrant expression of BP-II; phenotypically; it might provisionally be categorized as bipolar III.

The soft bipolar spectrum redefined: focus on the cyclothymic, anxious-sensitive, impulse-dyscontrol, and binge-eating connection in bipolar II and related conditions

The bipolar II spectrum represents the most common phenotype of bipolarity. Numerous studies indicate that in clinical settings this soft spectrum might be as common--if not more common than--major depressive disorders. The proportion of depressive patients who can be classified as bipolar II further increases if the 4-day threshold for hypomania proposed by the DSM-IV is reconsidered. The modal duration of hypomanic episodes is 2 days; highly recurrent brief hypomania is as short as 1 day, and when complicated by major depression, it should be classified as a variant of bipolar II. Another variant of the bipolar II pattern is represented by major depressive episodes superimposed on cyclothymic or hyperthymic temperamental characteristics. The literature is unanimous in supporting the idea that depressed patients who experience hypomania during antidepressant treatment belong to the bipolar II spectrum. So-called alcohol- or substance-induced mood disorders may have much in common with bipolar II spectrum disorders, in particular when mood swings outlast detoxification. Finally, many patients within the bipolar II spectrum, especially when recurrence is high and the interepisodic period is not free of affective manifestations, may meet criteria for personality disorders. This is particularly true for cyclothymic bipolar II patients, who are often misclassified as borderline personality disorder because of their extreme mood instability. Subthreshold mood lability of a cyclothymic nature seems to be the common thread that links the soft bipolar spectrum. The authors submit this to represent the endophenotype likely to be informative in genetic investigations. Mood lability can be considered the core characteristics of the bipolar II spectrum, and it has been validated prospectively as a sensitive and specific predictor of bipolar II outcome in major depressives. In a more hypothetical vein, cyclothymic-anxious-sensitive temperamental disposition might represent the mediating underlying characteristic in the complex pattern of anxiety, mood, and impulsive disorders that bipolar II spectrum patients display throughout much of their lifetimes. The foregoing conclusions, based on clinical experience and the research literature, challenge several conventions in the formal classificatory system (i.e., ICD-10 and DSM-IV). The authors submit that the enlargement of classical bipolar II disorders to include a spectrum of conditions subsumed by a cyclothymic-anxious-sensitive disposition, with mood reactivity and interpersonal sensitivity, and ranging from mood, anxiety, impulse control, and eating disorders, will greatly enhance clinical practice and research endeavors. Prospective studies with the requisite methodologic sophistication are needed to clarify further the relationship of the putative temperamental and developmental variables to the complex syndromic patterns described herein. The authors believe that viewing these constructs as related entities with a common temperamental diathesis will make patients in this realm more accessible to pharmacologic and psychological approaches geared to their common temperamental attributes. The authors submit that the use of the term "spectrum" is distinct from a simple continuum of subthreshold and threshold cases. The underlying temperamental dimensions postulated by the authors define the disposition for soft bipolarity and its variation and dysregulation in anxious disorders and dyscontrol in appetitive, mental, and behavioral disorders, much beyond affective disorders in the narrow sense.

Conceptual underpinnings and empirical support for the mood spectrum

This article presents an overview of the conceptual basis and empirical support for a unitary view of mood disturbance. The authors consider this general conceptualization of psychiatric disturbance as consisting of an array of related symptoms and behavioral features that define the "spectrum" of each disorder. They discuss how this conceptual framework aids in overcoming what they believe to be the false dichotomy between unipolar and bipolar mood disorders and in evaluating subthreshold and unusual presentations. They also describe the structured clinical interview and self-report instrument that they have developed to facilitate systematic assessment of the proposed mood spectrum. Finally, they summarize the clinical utility of such an approach to the description and assessment of patients with mood disorders.

Clinical and demographic features of mood disorder subtypes

The aim of this study was to investigate demographic, clinical and symptomatologic features of the following mood disorder subtypes: bipolar disorder I (BP-I); bipolar disorder II (BP-II); major depressive disorder, recurrent (MDR); and major depressive episode, single episode (MDSE). A total of 1832 patients with mood disorders (BP-I=863, BP-II=141, MDR=708, and MDSE=120) were included in our study. The patients were assessed using structured diagnostic interviews and the operational criteria for psychotic illness checklist (n=885), the Hamilton depression rating scale (n=167), and the social adjustment scale (n=305). The BP-I patients were younger; had more hospital admissions; presented a more severe form of symptomatology in terms of psychotic symptoms, disorganization, and atypical features; and showed less insight into their disorder than patients in the other groups. Compared with the major depressive subgroups, BP-I patients were more likely to have an earlier age at onset, an earlier first lifetime psychiatric treatment, and a greater number of illness episodes. BP-II patients had a higher suicide risk than both BP-I and MDSE patients. MDSE patients presented less severe symptomatology, lower age at observation, and a higher number of males. The retrospective approach and the selection constraints due to the inclusion criteria are the main limitations of the study. Our data support the view that BP-I disorder is quite different from the remaining mood disorders from a demographic and clinical perspective, with BP-II disorder having an intermediate position to MDR and MDSE, that is, as a less severe disorder. This finding may help in the search for the biological basis of mood disorders.

Psychomotor changes in melancholic and atypical depression: unipolar and bipolar-II subtypes

Psychomotor changes are reported to be 'nearly always present' in the melancholic subtype of major depressive episode (MDE) in DSM-IV-TR, and are believed by some researchers to be markers of melancholia. The aim of this study was to compare melancholic and atypical forms of MDE and to determine whether psychomotor changes are core features of melancholic MDE. The Structured Clinical Interview of DSM-IV was used to consecutively assess 107 unipolar and 164 bipolar-II MDE outpatients. The criteria used to define melancholic and atypical MDE followed DSM-IV-TR. Melancholic MDE was present in 17.7% of patients; atypical MDE, in 35.0%. The group of patients with melancholic MDE had the following differences from the atypical group: higher age, higher age at onset, fewer females, more unipolar cases, fewer bipolar-II cases, lower Global Assessment of Functioning scores, more MDE symptoms, and more psychotic features. Percentages of observable and marked psychomotor changes (agitation and retardation combined) did not differ significantly between the two groups, though the melancholic group tended to have more symptoms. Retardation was significantly more common in melancholic MDE, but its frequency was very low in both melancholic and atypical cases (12.5 vs. 0.0%). Logistic regression controlling for age, gender and illness duration had little effect on the findings, which suggests that psychomotor changes are not core features of melancholic MDE.

Which could be a clinically useful definition of depressive mixed state?

Depressive mixed state (DMX) (major depressive episode [MDE] with few superimposed hypomanic symptoms) was reported to be common among depressed outpatients. Study aim was to find if the best clinically useful definition of DMX was one based on a minimum number of hypomanic symptoms, or instead one based on the combination of specific hypomanic symptoms.

METHODS

Consecutive 138 bipolar II and 83 unipolar MDE outpatients were interviewed with DSM-IV Structured Clinical Interview. DMX definitions tested were: MDE with three or more hypomanic symptoms (DMX3) and MDE with hypomanic symptoms irritability, distractibility and racing thoughts.

RESULTS

DMX3, and the combination of racing thoughts, irritability and distractibility, had the same significant and nonsignificant associations with study variables. DMX3, and the combination of the specific hypomanic symptoms, significantly predicted bipolar II diagnosis. For predicting bipolar II diagnosis, DMX3 had higher specificity (86.7% vs. 50.6%), while the combination of the specific hypomanic symptoms had higher sensitivity (76.8% vs. 51.4%).

CONCLUSIONS

A DMX definition with higher specificity (DMX3) for predicting bipolar II diagnosis may be more clinically useful because it may reduce misdiagnosis.

Depressive mixed state frequency: age/gender effects

Depressive mixed state (DMX), a major depressive episode (MDE) combined with few manic/hypomanic symptoms, is understudied. Age and gender are important variables in mood disorders. The aim of the present study was to determine whether age and gender had any effect on the frequency of DMX. Consecutive unipolar (n = 144) and bipolar II (n = 218) drug-free MDE out-patients were interviewed with the Structured Clinical Interview for DSM-IV when presenting for MDE treatment. The presence of hypomanic symptoms during the index MDE was assessed systematically. Depressive mixed state was defined as a MDE with three or more concurrent hypomanic symptoms (DMX3), following previous reports. Associations were tested by logistic regression. The results showed that the DMX3 frequency was 43.9% and that it affected more females than males. Frequency decreased with age. The lower frequency with age was related to the lower frequency of bipolar II disorder with age. Bipolar disorder family history of DMX3 patients did not change with age. In conclusion, the frequency of DMX3 was high and related to age. The high frequency of DMX3 supports the clinical usefulness of the definition, as well as observations that antidepressants may worsen its hypomanic symptoms, whereas antipsychotics and mood stabilisers may treat them. A bipolar vulnerability seems to be required for the appearance of DMX3 also in later life.

Laterality of pain in migraine with comorbid unipolar depressive and bipolar II disorders

OBJECTIVES

The purpose of the present study has been to examine differences in the laterality of pain in patients with migraine and comorbid unipolar depressive (UP) and bipolar II (BP II) disorders.

METHODS

Semi-structured interviews of 102 patients with major affective disorders were conducted, using DSM-IV criteria for affective disorders combined with Akiskal's criteria for affective temperaments and International Headache Society criteria for migraine. The group of patients reported on in the present study encompass 47 subjects with UP (n = 24) or BP 11 (n = 23) disorders. Fifteen of the bipolar II patients fulfilled DSM-IV criteria while eight were diagnosed according to the broader criteria of Akiskal.

RESULTS

Sixteen of the 38 patients with migraine headaches had bilateral pain or pain equally often on the left or right side while 22 had pain predominantly located on one side. Among the UP patients the pain was most often on the right side (8/10) while among the BP II patients the pain was most often on the left (9/12, p = 0.01). Apart from the presence of hypomanic symptoms in the BP II group there were no clinical or demographic characteristics that distinguished these two sub-groups of affective disorders.

CONCLUSIONS

These results indicate that there may be a differential affection of the cerebral hemispheres in patients with migraine and comorbid unipolar depressive disorder versus patients with migraine and comorbid bipolar II disorder.

The boundary between mixed and manic episodes in the ICD-10 classification

OBJECTIVE

To investigate the boundary between ICD-10 mixed and manic episodes, which has apparently remained understudied.

METHOD

In-patients with ICD-10 mixed (n=36) and manic episodes (n=145) were compared in terms of demographic, clinical, therapeutical and outcome variables.

RESULTS

Of in-patients with manic episode, 26 (18%) had several depressive symptoms at admission. These patients (dysphoric manic patients) were very similar to patients with ICD-10 mixed episode in terms of current symptomatic presentations and several clinical and therapeutic variables, which were significantly different from those in patients with pure mania.

CONCLUSION

The ICD-10 boundary between mixed and manic episodes is unlikely to be effective although experienced clinicians made the diagnoses. The system may have a high probability of diagnosing dysphoric manic patients as having manic episode, despite their great similarities to patients with mixed episode in terms of current psychopathological presentations as well as clinically important variables.

Mood Disorders in Family Practice: Beyond Unipolarity to Bipolarity

Primary care physicians increasingly have treated depressive disorders over the last decade. Unrecognized bipolar disorder, sometimes misdiagnosed as unipolar depression, may lead to treatment resistance or nonresponse. We describe differences between unipolar and bipolar disorders, focusing on recognition, diagnosis, and treatment of bipolar spectrum disorders such as bipolar I, bipolar II, antidepressant-induced mania, and cyclothymia. Broadening the understanding of these different disorders and their presentation in primary care settings can enable earlier and more targeted treatment. Though 3 mood stabilizers are U.S. Food and Drug Administration-approved for treatment of acute mania, no medications are currently approved for treating bipolar depression.

Highly recurrent unipolar may be related to bipolar II

Unipolar and bipolar disorders may be subgroups of a single mood disorder, of which the key feature is not polarity, but the episodic, recurrent course. The aim of this study was to determine whether highly recurrent unipolar was related to bipolar II, by comparing clinical and family history features. Eighty-nine consecutive unipolar and 151 consecutive bipolar II outpatients, presenting for major depressive episode (MDE) treatment, were interviewed using the Structured Clinical Interview for DSM-IV (SCID) and the Family History Screen. Unipolar patients were divided into highly recurrent (>4 MDEs) (HRUP) and low recurrent (</=4 MDEs) (LRUP). HRUP had significantly fewer atypical features and less bipolar II family history than bipolar II, while age at onset, axis I comorbidity, and depression chronicity were not significantly different. HRUP had statistically significant lower age at onset, more axis I comorbidity, more depression chronicity, and clinically significant more atypical features and more bipolar II family history than LRUP. Results suggest that HRUP could be midway between bipolar II and LRUP. Pages and Dunner (1997) view that recurrent unipolar and bipolar II could be part of a single mood disorder, and Goodwin and Jamison (1990) view that recurrence is the key feature of mood disorders are partly supported by the findings.

Identify bipolar spectrum disorders

Patients with bipolar spectrum disorders commonly present with depressive symptoms to primary care clinicians. This article details bipolar spectrum disorder assessment, treatment, and treatment response. By intervening early in the course of depressive and hypomanic episodes, you can help decrease the morbidity and suffering associated with bipolar spectrum disorders.

Managing bipolar disorder during pregnancy: weighing the risks and benefits

BACKGROUND

Challenges for the clinical management of bipolar disorder (BD) during pregnancy are multiple and complex and include competing risks to mother and offspring.

METHOD

We reviewed recent research findings on the course of BD during pregnancy and postpartum, as well as reproductive safety data on the major mood stabilizers.

RESULTS

Pregnancy, and especially the postpartum period, are associated with a high risk for recurrence of BD. This risk appears to be limited by mood-stabilizing treatments and markedly increased by the abrupt discontinuation of such treatments. However, drugs used to treat or protect against recurrences of BD vary markedly in teratogenic potential: there are low risks with typical neuroleptics, moderate risks with lithium, higher risks with older anticonvulsants such as valproic acid and carbamazepine, and virtually unknown risks with other newer-generation anticonvulsants and atypical antipsychotics (ATPs).

CONCLUSIONS

Clinical management of BD through pregnancy and postpartum calls for balanced assessments of maternal and fetal risks and benefits.

Pharmacogenetics of lithium prophylaxis in mood disorders: analysis of COMT, MAO-A, and Gbeta3 variants

We studied the possible association between the prophylactic efficacy of lithium in mood disorders and the following gene variants: catechol-O-methyltransferase (COMT) G158A, monoamine oxydase A (MAO-A) 30-bp repeat, G-protein beta 3-subunit (Gbeta3) C825T. A total of 201 subjects affected by bipolar (n = 160) and major depressive (n = 41) disorder were followed prospectively for an average of 59.8 months and were typed for their gene variants using PCR techniques. COMT, MAO-A, and Gbeta3 variants were not associated with lithium outcome, even when possible stratification effects such as sex, polarity, age at onset, duration of lithium treatment, and previous episodes were included in the model. The pathways influenced by those variants are not therefore involved with long-term lithium outcome in our sample.

Mortality of patients with mood disorders: follow-up over 34-38 years

BACKGROUND

All follow-up studies of causes of death in affective disordered patients have found they have markedly elevated suicide rates and a less reproducible increased mortality from other causes. The reported rates by gender, disorder type and treatment are more variable.

METHODS

Hospitalised affective disordered patients (n=406) were followed prospectively for 22 years or more. Later, mortality was assessed for 99% of them at which time 76% had died.

RESULTS

Standardised Mortality Rates (observed deaths/expected deaths) for patients were elevated especially for suicide and circulatory disorders in both men and women. Women actually had higher suicide rates but that did not take into account the twofold increase in general population rates for men. Unipolar patients had significantly higher rates of suicide than bipolar Is or IIs. In all groups long term medication treatment with antidepressants alone or with a neuroleptic, or with lithium in combination with antidepressants and/or neuroleptics significantly lowered suicide rates even though the treated were more severely ill. Although at the age of onset the suicide rates were most elevated, from ages 30 to 70 the rates were remarkably constant despite the different courses of illness.

LIMITATIONS

The patients were identified as inpatients and followed prospectively. The treatments were uncontrolled and are not quantifiable but were documented during the follow-up.

CONCLUSIONS

Men and women hospitalised for affective disorders have elevated mortality rates from suicide and circulatory disorders. Unipolars have higher suicide rates than bipolar Is or IIs. Long term medication treatment lowers the suicide rates, despite the fact that it was the more severely ill who were treated.

"Cade's disease" and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder

The diagnosis and treatment of bipolar disorder (BD) has been inconsistent and frequently misunderstood in recent years. To identify the causes of this problem and suggest possible solutions, we undertook a critical review of studies concerning the nosology of BD and the effects of antidepressant agents. Both the underdiagnosis of BD and its frequent misdiagnosis as unipolar major depressive disorder (MDD) appear to be problems in patients with BD. Underdiagnosis results from clinicians' inadequate understanding of manic symptoms, from patients' impaired insight into mania, and especially from failure to involve family members or third parties in the diagnostic process. Some, but by no means all, of the underdiagnosis problem may also result from lack of agreement about the breadth of the bipolar spectrum, beyond classic type I manic-depressive illness (what Ketter has termed "Cade's Disease"). To alleviate confusion about the less classic varieties of bipolar illness, we propose a heuristic definition, "bipolar spectrum disorder." This diagnosis would give greater weight to family history and antidepressant-induced manic symptoms and would apply to non-type I or II bipolar illness, in which depressive symptom, course, and treatment response characteristics are more typical of bipolar than unipolar illness. The role of antidepressants is also controversial. Our review of the evidence leads us to conclude that there should be less emphasis on using antidepressants to treat persons with this illness.

Principal components of the Beck Depression Inventory and regional cerebral metabolism in unipolar and bipolar depression

BACKGROUND

We determined clustering of depressive symptoms in a combined group of unipolar and patients with bipolar disorder using Principle Components Analysis of the Beck Depression Inventory. Then, comparing unipolars and bipolars, these symptom clusters were examined for interrelationships, and for relationships to regional cerebral metabolism for glucose measured by positron emission tomography.

METHODS

[18F]-fluoro-deoxyglucose positron emission tomography scans and Beck Depression Inventory administered to 31 unipolars and 27 bipolars, all medication-free, mildly-to-severely depressed. BDI component and total scores were correlated with global cerebral metabolism for glucose, and voxel-by-voxel with cerebral metabolism for glucose corrected for multiple comparisons.

RESULTS

In both unipolars and bipolars, the psychomotor-anhedonia symptom cluster correlated with lower absolute metabolism in right insula, claustrum, anteroventral caudate/putamen, and temporal cortex, and with higher normalized metabolism in anterior cingulate. In unipolars, the negative cognitions cluster correlated with lower absolute metabolism bilaterally in frontal poles, and in right dorsolateral frontal cortex and supracallosal cingulate.

CONCLUSIONS

Psychomotor-anhedonia symptoms in unipolar and bipolar depression appear to have common, largely right-sided neural substrates, and these may be fundamental to the depressive syndrome in bipolars. In unipolars, but not bipolars, negative cognitions are associated with decreased frontal metabolism. Thus, different depressive symptom clusters may have different neural substrates in unipolars, but clusters and their substrates are convergent in bipolars.

Rapid cycling bipolar disease: new concepts and treatments

Having been recognized by Kraeplin at the beginning of the 20th century, rapid cycling was first described as a specific entity by Dunner et al. in 1974. The prevalence of rapid cycling ranges from 12% to 20% in patients with bipolar disorder who are not selected for a high rate of cycling.

Depressive mixed state: testing different definitions

The aim of this study was to test different definitions of depressive mixed state (DMX) (major depressive episode (MDE) with some concurrent hypomanic symptoms), to find which one could better define DMX. Unipolar and bipolar II MDE outpatients (n = 168) were interviewed with the DSM-IV Structured Clinical Interview. Depressive mixed state was defined as a MDE with two or more (DMX2), and as a MDE with three or more (DMX3) concurrent hypomanic symptoms. DMX2 was present in 71.8% bipolar II patients, and in 41.5% unipolar (P < 0.01). DMX3 was present in 46.6% of bipolar II, and in 7.6% unipolar patients (P < 0.01). DMX2 and DMX3 had almost the same significant and non-significant associations with study variables (diagnosis, gender, age, age at onset, illness duration, MDE recurrences, axis I comorbidity, MDE severity, depression chronicity, hypomanic, MDE, psychotic, melancholic, and atypical symptoms and features). DMX3 was more strongly associated with bipolar II than DMX2 (odds ratio 10.4 vs 3.5). Findings suggest that DMX3 may be a better definition of DMX due to its stronger association with bipolar II disorder. Findings have important clinical and treatment implications because antidepressants may worsen DMX, and the presence of DMX may induce clinicians to assess systematically and carefully the history of past hypomania.

Role of risperidone in bipolar II: an open 6-month study

BACKGROUND

Since treatment approaches thought to be useful for mania are presumably suitable for hypomania as well, little systematic research has been done on the treatment of hypomanic episodes and their long-term outcome. As systematic trials have shown that the atypical antipsychotic risperidone may be effective and safe in the treatment of acute mania, we decided to conduct an open-label study of its effectiveness and tolerability in hypomania associated with bipolar II.

METHODS

Forty-four DSM-IV bipolar II patients with Young Mania Rating Scale (YMRS) scores above 7 were included and followed-up for 6 months. Efficacy was measured by means of the YMRS and the Clinical Global Impression for Bipolar Disorder (CGI-BD). Treatment-emergent depression was measured by the Hamilton Depression Rating Scale (HDRS-17), and the Udvalg for Kliniske Undersøgelser (UKU) subscale was used for neurological/extrapyramidal side-effects.

RESULTS

Thirty-four patients completed the trial. The mean dose of risperidone at endpoint was 2.8 mg/day. Last observation-carried-forward analysis showed significant reduction of YMRS scores from the first week of treatment, which continued until the endpoint (P<0.0001). At 6-month follow-up, 60% of patients were assymptomatic according to the CGI. The 32% who received risperidone in monotherapy seemed to respond equally well. Risperidone, as used in this study, appeared to be most protective against hypomanic than depressive recurrences. Nine patients (12%) had a depressive relapse during 6-month follow-up, one patient (2%) had an hypomanic relapse and another (2%) had both. No patients developed tardive dyskinesia during the duration of the study. Although most patients received risperidone in combination with standard mood-stabilizers, only three patients discontinued risperidone because of other side-effects.

LIMITATIONS

In the absence of a placebo arm, it is uncertain to what extent the foregoing results could be ascribed to spontaneous remission of bipolar II disorder.

CONCLUSIONS

Risperidone, either in combination with mood-stabilizers or alone was well-tolerated in bipolar II patients, who presented in a hypomanic state, and appeared efficacious. Further controlled research on the role of atypical antipsychotics in the treatment of less-than-manic forms of bipolar illness is warranted.

Delineating bipolar II mixed states in the Ravenna-San Diego collaborative study: the relative prevalence and diagnostic significance of hypomanic features during major depressive episodes

BACKGROUND

Depressive mixed state (DMX), defined by hypomanic features during a major depressive episode (MDE) is under-researched. Accordingly, study aims were to find DMX prevalence in unipolar major depressive disorder (MDD) and bipolar II depressive phase, to delineate the most common hypomanic signs and symptoms during DMX, and to assess their sensitivity and specificity for the diagnosis of DMX and bipolar II.

METHODS

161 unipolar and bipolar II MDE psychotropic drug- and substance-free consecutive outpatients were interviewed during an MDE with the Structured Clinical Interview for DSM-IV. DMX was defined at two threshold levels as an MDE with two or more (DMX2), and with three or more (DMX3) simultaneous intra-episode hypomanic signs and symptoms.

RESULTS

DMX2 was present in 73.1% of bipolar II, and in 42.1% of unipolar MDD (P<0.000); DMX3 was present in 46.3% of bipolar II, and in 7.8% of unipolar MDD (P<0.000). The most common hypomanic manifestations during MDE were irritability, distractibility, and racing thoughts. Irritability had the best combination of sensitivity and specificity for the diagnosis of DMX2 and DMX3. Various combinations of irritability, distractibility, and racing thoughts correctly classified the highest number of DMX2 and DMX3, and had the strongest predictive power. DMX2 had high sensitivity and low specificity for bipolar II, whereas DMX3 had low sensitivity (46.3%) and high specificity (92.1%).

LIMITATIONS

Single interviewer, cross-sectional assessment, and interviewing clinician not blind to patients' unipolar vs. bipolar status.

CONCLUSIONS

When conservatively defined (>or = 3 intra-episode hypomanic signs and symptoms during MDE), DMX is prevalent in the natural history of bipolar II but uncommon in unipolar MDD. These findings have treatment implications, because of growing concerns that antidepressants may worsen DMX, which in turn may respond better to mood stabilizers. These data also have methodological implications for diagnostic practice: rather than solely depending on the vagaries of the patient's memory for past hypomanic episodes, the search for hypomanic features--ostensibly elation would not be one of those--during an index depressive episode could enhance the detection of bipolar II in otherwise pseudo-unipolar patients. Strict adherence to current clinical diagnostic interview instruments (e.g. the SCID) would make such detection difficult, if not impossible.