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Rizvi SJ, Grima E, Tan M, Rotzinger S, Lin P, Mcintyre RS, Kennedy SH. Treatment-resistant depression in primary care across Canada. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:349-57. [PMID: 25007419 PMCID: PMC4086317 DOI: 10.1177/070674371405900702] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 01/01/2014] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Treatment-resistant depression (TRD) represents a considerable global health concern. The goal of the InSight study was to investigate the prevalence of TRD and to evaluate its clinical characterization and management, compared with nonresistant depression, in primary care centres. METHODS Physicians completed a case report on a consecutive series of patients with major depressive disorder (n = 1212), which captured patient demographics and comorbidity, as well as current and past medication. RESULTS Using failure to respond to at least 2 antidepressants (ADs) from different classes as the definition of TRD, the overall prevalence was 21.7%. There were no differences in prevalence between men and women or among ethnicities. Patients with TRD had longer episode duration, were more likely to receive polypharmacy (for example, psychotropic, lipid-lowering, and antiinflammatory agents), and reported more AD related side effects. Higher rates of disability and comorbidity (axes I to III) were associated with treatment resistance. Obesity and being overweight were also associated with treatment resistance. While the selection and sequencing of pharmacotherapy by family physicians in this sample was in line with recommendations from evidence-based treatment guidelines, the wait time to make a change in treatment was 6 to 8 weeks in both groups, which exceeds guideline recommendations. CONCLUSIONS These real-world data demonstrate the high prevalence of TRD in primary care settings, and underscore the substantial burden of illness associated with TRD.
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Affiliation(s)
- Sakina J Rizvi
- Student, Departments of Pharmaceutical Sciences and Neuroscience, University of Toronto, Toronto, Ontario; Clinical Research Coordinator, Department of Psychiatry, University Health Network, Toronto, Ontario
| | - Etienne Grima
- Chief Operating Officer and Chief Financial Officer, Canadian Heart Research Centre, Toronto, Ontario
| | - Mary Tan
- Statistician, Canadian Heart Research Centre, Toronto, Ontario
| | - Susan Rotzinger
- Project Manager, Department of Psychiatry, University Health Network, Toronto, Ontario
| | - Peter Lin
- Director of Primary Care Initiatives, Canadian Heart Research Centre, Toronto, Ontario
| | - Roger S Mcintyre
- Psychiatrist, Department of Psychiatry, University Health Network, Toronto, Ontario; Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Professsor, Department of Pharmacology, University of Toronto, Toronto, Ontario
| | - Sidney H Kennedy
- Psychiatrist, Department of Psychiatry, University Health Network, Toronto, Ontario; Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Professor, Institute of Medical Sciences, University of Toronto, toronto, Ontario
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Anger with murderous impulse induced by lamotrigine. Gen Hosp Psychiatry 2014; 36:451.e1-2. [PMID: 24736088 DOI: 10.1016/j.genhosppsych.2014.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 03/07/2014] [Accepted: 03/11/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report two cases of major depressive disorder in which lamotrigine (LTG) induced anger with murderous impulse. PATIENTS Case 1 was a 22-year-old man with symptoms of obsessive-compulsive disorder who developed major depressive disorder with antidepressant-induced hypomanic episodes. Case 2 was a 23-year-old woman experiencing an antidepressant-refractory depressive episode for whom remission was achieved by switching to a mood stabilizer and antipsychotics. In both cases LTG was started to treat the depressive episode. RESULTS Case 1 manifested with anger and murderous impulse when taking 125 mg/day of LTG. A reduction to 75 mg/day calmed this anger. Case 2 manifested with the same symptom when taking 25 mg/day of LTG, and the symptom immediately disappeared upon stopping LTG. CONCLUSIONS Use of LTG for epilepsy in intellectually disabled patients was reported to be associated with onset or exacerbation of aggressive or violent behavior. The two cases would suggest that LTG may cause anger so severe as to be accompanied with murderous impulse when administered to patients with mood disorders. Physicians should be cognizant of this possible, albeit infrequent, adverse effect even in use of LTG for mood disorders.
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Pope CJ, Sharma V, Mazmanian D. Bipolar Disorder in the Postpartum Period: Management Strategies and Future Directions. WOMENS HEALTH 2014; 10:359-71. [DOI: 10.2217/whe.14.33] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Bipolar I and II disorder are chronic and severe psychiatric illnesses that affect many women. Furthermore, women are at increased risk for mood episodes during the postpartum period compared with non-postpartum periods. Unfortunately, identification of clinically significant depressive or (hypo)manic episodes can be challenging. Delays in detection, as well as misdiagnosis, put women at risk of many negative consequences, such as symptom exacerbation and treatment refractoriness. Early and accurate detection of bipolar I or II disorder in the postpartum period is critical to improve prognosis. At this time, limited recommendations can be made due to a paucity of research. Further research on postpartum bipolar I or II disorder focusing on its identification, consequences and treatment is urgently needed to allow for empirically informed clinical decision-making.
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Affiliation(s)
- Carley J Pope
- Lakehead University, Department of Psychology, 955 Oliver Road, Thunder Bay, ON, P7B 5E1, Canada
| | - Verinder Sharma
- University of Western Ontario, 1151 Richmond St, London, ON, N6A 3K7, Canada
- Perinatal Clinic, St Joseph's Health Care, 850 Highbury Avenue, London, ON, N6A 4H1, Canada
| | - Dwight Mazmanian
- Lakehead University, Department of Psychology, 955 Oliver Road, Thunder Bay, ON, P7B 5E1, Canada
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Inglis AJ, Hippman CL, Carrion PB, Honer WG, Austin JC. Mania and depression in the perinatal period among women with a history of major depressive disorders. Arch Womens Ment Health 2014; 17:137-43. [PMID: 24402681 PMCID: PMC3961475 DOI: 10.1007/s00737-013-0408-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 12/26/2013] [Indexed: 10/25/2022]
Abstract
Women with a history of major depressive disorder (MDD) have increased risks for postpartum depression, but less is known about postpartum mania in this population. The objectives of this study were to prospectively determine the frequency with which mania occurs in the postpartum among women who have a history of MDD and to explore temporal relationships between onset of mania/hypomania and depression. We administered the Structured Clinical Interview for DSM IV disorders (SCID) to pregnant women with a self-reported history of MDD to confirm diagnosis and exclude women with any history of mania/hypomania. Participants completed the Edinburgh Postnatal Depression Scale and Altman Self-Rating Mania Scale (ASRM) once during the pregnancy (∼26 weeks) and 1 week, 1 month, and 3 months postpartum. Among women (n = 107) with a SCID-confirmed diagnosis of MDD, 34.6 % (n = 37) experienced mania/hypomania (defined by an ASRM score of ≥6) at ≥1 time point during the postpartum, and for just over half (20/37, 54 %), onset was during the postpartum. The highest frequency of mania/hypomania (26.4 %, n = 26) was at 1 week postpartum. Women who experienced mania/hypomania at 1 week postpartum had significantly more symptoms of mania/hypomania later in the postpartum. A substantive proportion of women with a history of MDD may experience first onset of mania/hypomania symptoms in the early postpartum, others may experience first onset during pregnancy. Taken with other recent data, these findings suggest a possible rationale for screening women with a history of MDD for mania/hypomania during the early postpartum period, but issues with screening instruments are discussed.
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Affiliation(s)
- Angela J Inglis
- Department of Medical Genetics, University of British Columbia, Vancouver
| | - Catriona L Hippman
- Department of Psychiatry, University of British Columbia, Vancouver,Women’s Health Research Institute, BC Women’s Hospital & Health Centre, Vancouver
| | | | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver
| | - Jehannine C Austin
- Department of Medical Genetics, University of British Columbia, Vancouver,Department of Psychiatry, University of British Columbia, Vancouver
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Kelly E, Sharma V. Diagnosis and treatment of postpartum bipolar depression. Expert Rev Neurother 2014; 10:1045-51. [DOI: 10.1586/ern.10.81] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Tansey KE, Guipponi M, Domenici E, Lewis G, Malafosse A, O'Donovan M, Wendland JR, Lewis CM, McGuffin P, Uher R. Genetic susceptibility for bipolar disorder and response to antidepressants in major depressive disorder. Am J Med Genet B Neuropsychiatr Genet 2014; 165B:77-83. [PMID: 24339138 DOI: 10.1002/ajmg.b.32210] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 10/15/2013] [Indexed: 11/07/2022]
Abstract
The high heterogeneity of response to antidepressant treatment in major depressive disorder (MDD) makes individual treatment outcomes currently unpredictable. It has been suggested that resistance to antidepressant treatment might be due to undiagnosed bipolar disorder or bipolar spectrum features. Here, we investigate the relationship between genetic susceptibility for bipolar disorder and response to treatment with antidepressants in MDD. Polygenic scores indexing risk for bipolar disorder were derived from the Psychiatric Genomics Consortium Bipolar Disorder whole genome association study. Linear regressions tested the effect of polygenic risk scores for bipolar disorder on proportional reduction in depression severity in two large samples of individuals with MDD, treated with antidepressants, NEWMEDS (n=1,791) and STAR*D (n=1,107). There was no significant association between polygenic scores for bipolar disorder and response to treatment with antidepressants. Our data indicate that molecular measure of genetic susceptibility to bipolar disorder does not aid in understanding non-response to antidepressants.
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Wigman JTW, van Os J, Abidi L, Huibers MJH, Roelofs J, Arntz A, Kelleher I, Peeters FPML. Subclinical psychotic experiences and bipolar spectrum features in depression: association with outcome of psychotherapy. Psychol Med 2014; 44:325-336. [PMID: 23651602 DOI: 10.1017/s0033291713000871] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Subthreshold psychotic and bipolar experiences are common in major depressive disorder (MDD). However, it is unknown if effectiveness of psychotherapy is altered in depressed patients who display such features compared with those without. The current paper aimed to investigate the impact of the co-presence of subclinical psychotic experiences and subclinical bipolar symptoms on the effectiveness of psychological treatment, alone or in combination with pharmacotherapy. METHOD In a naturalistic study, patients with MDD (n = 116) received psychological treatment (cognitive behavioural therapy or interpersonal psychotherapy) alone or in combination with pharmacotherapy. Depression and functioning were assessed six times over 2 years. Lifetime psychotic experiences and bipolar symptoms were assessed at the second time point. RESULTS Subclinical psychotic experiences predicted more depression over time (β = 0.20, p < 0.002), non-remission [odds ratio (OR) 7.51, p < 0.016] and relapse (OR 3.85, p < 0.034). Subthreshold bipolar symptoms predicted relapse (OR 1.16, p < 0.037). CONCLUSIONS In general, subclinical psychotic experiences have a negative impact on the course and outcome of psychotherapy in MDD. Effects of subclinical bipolar experiences were less prominent.
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Affiliation(s)
- J T W Wigman
- Department of Psychiatry and Psychology, School of Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J van Os
- Department of Psychiatry and Psychology, School of Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - L Abidi
- Department of Psychiatry and Psychology, School of Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M J H Huibers
- Department of Clinical Psychological Science, Research Institute of Experimental Psychopathology, Faculty of Psychology and Neuroscience, Maastricht University, The Netherlands
| | - J Roelofs
- Department of Clinical Psychological Science, Research Institute of Experimental Psychopathology, Faculty of Psychology and Neuroscience, Maastricht University, The Netherlands
| | - A Arntz
- Department of Clinical Psychological Science, Research Institute of Experimental Psychopathology, Faculty of Psychology and Neuroscience, Maastricht University, The Netherlands
| | - I Kelleher
- Department of Psychiatry, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin, Republic of Ireland
| | - F P M L Peeters
- Department of Psychiatry and Psychology, School of Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
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Kameyama R, Inoue T, Uchida M, Tanaka T, Kitaichi Y, Nakato Y, Hayashishita Y, Nakai Y, Nakagawa S, Kusumi I, Koyama T. Development and validation of a screening questionnaire for present or past (hypo)manic episodes based on DSM-IV-TR criteria. J Affect Disord 2013; 150:546-50. [PMID: 23474095 DOI: 10.1016/j.jad.2013.01.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 01/29/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND We developed a self-reported questionnaire, the Manic Episode Screening Questionnaire (MES), based on the eight diagnostic criteria items of DSM-IV-TR (hypo)manic episodes. This study was designed to determine the optimal screening methods to identify bipolar disorders among mood disorder patients of a psychiatric specialty clinic. METHODS In 95 mood disorder patients, we assessed the operational characteristics of the MES as a screening and diagnostic instrument using a DSM-IV-TR diagnosis by a trained psychiatrist as a reference standard. The reference criteria were bipolar disorders. MES was used with two methods: the diagnostic algorithm and the one-question method (question #1 only). The diagnostic algorithm was regarded as fulfilled if the answers to question #1 and three or more of questions #2 to #8 were "yes", corresponding to the DSM-IV-TR (hypo)manic episode criteria. In different subjects, the test-retest reliability of the MES was examined. RESULTS The two methods of the MES showed high specificity (0.93-0.94), high positive predictive value (0.81-0.83) and high negative predictive value (0.88-0.90), but the sensitivity scored lower (0.68-0.75). The test-retest reliability was moderate: 0.75 for the diagnostic algorithm and 0.68 for the one-question method. LIMITATIONS This study includes a small number of bipolar I patients. The findings might not be generalized to patients outside of this patient population. CONCLUSIONS The MES is useful for the screening and diagnosis of bipolar disorders among mood disorder patients in psychiatric specialty clinics. The one-question method of the MES is more convenient to use than prior questionnaires and is here recommended.
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Affiliation(s)
- Rie Kameyama
- Department of Psychiatry, Hokkaido University Graduate School of Medicine, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan
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Clinical differences between unipolar and bipolar depression: interest of BDRS (Bipolar Depression Rating Scale). Compr Psychiatry 2013; 54:605-10. [PMID: 23375261 DOI: 10.1016/j.comppsych.2012.12.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 12/17/2012] [Accepted: 12/31/2012] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES It is currently assumed that there are no important differences between the clinical presentations of unipolar and bipolar depression. Failure to distinguish bipolar from unipolar depression may lead to inappropriate treatment and poorer outcomes. We hereby compare unipolar and bipolar depressed subjects, in order to identify distinctive clinical specificities of bipolar depression. METHODS Two independent samples of depressed patients (unipolar and bipolar) were recruited, with 55 patients in one sample, and 49 in the other. In both samples, unipolar and bipolar patients were compared on a broad range of parameters, including sociodemographic characteristics, comorbidities, Montgomery and Asberg Depression Scale (MADRS; assessing depression severity), CORE (assessing psychomotor disturbance) and Bipolar Depression Rating Scale (assessing specific bipolar depression symptoms). RESULTS Results were similar in both samples. MADRS scores were similar in bipolar and unipolar subjects (median score 33 vs 34; p=0.74). On the CORE, there was a trend to higher scores among the bipolar subjects. BDRS scores were higher in bipolar than in unipolar subjects (median score 33 vs 27; p<0.001). The difference was particularly marked on the "mixed" subscale of the BDRS. We tested the ability of the mixed subscale of the BDRS to distinguish bipolar from unipolar depression, using different cut off points: a cut off point of 3 can predict bipolar depression, with a sensibility of 62% and a specificity of 82%. CONCLUSIONS Presence of mixed symptoms during a depressive episode is in favour of bipolar depression. The BDRS scale should be integrated in a probabilistic approach to distinguish bipolar from unipolar depression.
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Abstract
Bipolar depression remains a major unresolved challenge for psychiatric therapeutics. It is associated with significant disability and mortality and represents the major proportion of the approximately half of follow-up time spent in morbid states despite use of available treatments. Evidence regarding effectiveness of standard treatments, particularly with antidepressants, remains limited and inconsistent. We reviewed available clinical and research literature concerning treatment with antidepressants in bipolar depression and its comparison with unipolar depression. Research evidence concerning efficacy and safety of commonly used antidepressant treatments for acute bipolar depression is very limited. Nevertheless, an updated meta-analysis indicated that overall efficacy was significantly greater with antidepressants than with placebo-treatment and not less than was found in trials for unipolar major depression. Moreover, risks of non-spontaneous mood-switching specifically associated with antidepressant treatment are less than appears to be widely believed. The findings encourage additional efforts to test antidepressants adequately in bipolar depression, and to consider options for depression in types I vs. II bipolar disorder, depression with subsyndromal hypomania and optimal treatment of mixed agitated-dysphoric states--both short- and long-term. Many therapeutic trials considered were small, varied in design, often involved co-treatments, or lacked adequate controls.
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Sharma V, Mazmanian D. Bipolar disorders: a shift to overdiagnosis or to accurate diagnosis? CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:371-2. [PMID: 23888522 DOI: 10.1177/070674371305800611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Dudek D, Siwek M, Zielińska D, Jaeschke R, Rybakowski J. Diagnostic conversions from major depressive disorder into bipolar disorder in an outpatient setting: results of a retrospective chart review. J Affect Disord 2013; 144:112-5. [PMID: 22871536 DOI: 10.1016/j.jad.2012.06.014] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 06/12/2012] [Accepted: 06/13/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of the study was to check the stability of a diagnosis of major depressive disorder (MDD) in an outpatient setting, as well as to assess the scope of diagnostic conversions into bipolar disorder (BD). METHODS Retrospective chart review of 122 patients with a primary diagnosis of MDD. RESULTS Diagnostic conversion from MDD into BD was noticed in 40 subjects (32.8%), 25 patients (20.5%) were treatment-resistant. Mean time to the conversion was 9.27±8.64 years. A negative correlation between the age of illness onset and time to diagnostic conversion was observed (-0.41; p<0.05). Earlier onset of MDD was associated with higher risk of diagnostic conversion (<30vs≥30 years of age at onset: 69% vs 28%, p=0.0001; <35vs≥35 years of age: 50% vs 25%, p=0.0065). Treatment-resistance was more prevalent in the BD conversion group (40% vs 11%; p=0.0002). Diagnostic conversion into BD was also related longer duration of treatment received, higher number of illness episodes, and higher number of hospitalizations. LIMITATIONS Retrospective design of the study. CONCLUSIONS The problem of diagnosis evolution from MDD to BD was observed in about 1/3 of patients, and was associated with treatment-resistance of depression, earlier onset of depression, longer time of treatment, higher number of depressive episodes and hospitalizations. The variables above may be a useful predictor of bipolar diathesis.
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Affiliation(s)
- Dominika Dudek
- Adult Psychiatry Department, University Hospital, Cracow, Poland; Department of Psychiatry, Jagiellonian University, Collegium Medicum, Cracow, Poland.
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Calkin C, Alda M. Beyond the guidelines for bipolar disorder: practical issues in long-term treatment with lithium. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2012; 57:437-45. [PMID: 22762299 DOI: 10.1177/070674371205700707] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Several treatment guidelines are available for clinicians working with patients with bipolar disorder (BD), but some of the more nuanced aspects of lithium therapy go beyond the scope of such guidelines. Therefore, in this perspective, our objective was to focus on specific practical issues of lithium treatment, including the selection and initiation of long-term treatment, and management and discontinuation (if indicated) of lithium prophylaxis. METHOD We conducted a focused review of the relevant literature on the treatment of BD. RESULTS Consultation requests to a BD specialty service often relate to issues for which there is limited evidence, including when to initiate long-term treatment, whether choice of mood stabilizer is specific, how long to treat acute episodes, whether to switch or add on medication when treatment fails, how long to continue effective treatment, and what medication to use when a lithium-responsive patient must discontinue lithium. CONCLUSION Optimal long-term treatment of BD will require more research as well as better alignment of clinical and training programs.
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Affiliation(s)
- Cynthia Calkin
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
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Maalouf FT, Porta G, Vitiello B, Emslie G, Mayes T, Clarke G, Wagner KD, Asarnow JR, Spirito A, Keller M, Birmaher B, Ryan N, Shamseddeen W, Iyengar S, Brent D. Do sub-syndromal manic symptoms influence outcome in treatment resistant depression in adolescents? A latent class analysis from the TORDIA study. J Affect Disord 2012; 138:86-95. [PMID: 22284022 PMCID: PMC3621087 DOI: 10.1016/j.jad.2011.12.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 12/01/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND To identify distinct depressive symptom trajectories in the TORDIA study and determine their correlates. METHODS Latent Class Growth Analysis (LCGA) using the Children's Depression Rating Scale-Revised (CDRS-R) through 72 weeks from intake. RESULTS 3 classes were identified: (1) little change in symptomatic status ("NO"), comprising 24.9% of participants, with a 72-week remission rate of 25.3%; (2) slow, steady improvement ("SLOW"), comprising 47.9% of participants, with a remission rate of 60.0%, and (3) rapid symptom response ("GO"), comprising 27.2% of participants, with a remission rate of 85.7%. Higher baseline CDRS-R (p<0.001) and poorer functioning (p=0.03) were the strongest discriminators between NO and GO. Higher baseline CDRS (p<0.001) and scores on the Mania Rating Scale (MRS) (p=0.01) were the strongest discriminators between SLOW and GO. Other variables differentiating GO from both NO and from SLOW, were better baseline functioning, lower hopelessness, and lower family conflict. Both NO and SLOW showed increases on the MRS over time compared to GO (ps ≤ 0.04), and increasing MRS was strongly associated with lack of remission by 72 weeks (p=0.02). LIMITATIONS High rate of open treatment by the end of the follow-up period creates difficulty in drawing clear inferences about the long-term impact of initial randomization. CONCLUSION Along with depressive severity, sub-syndromal manic symptoms, at baseline, and over time emerged as important predictors and correlates of poor outcome in this sample. Further research is needed on the treatment of severe depression, and on the assessment and management of sub-syndromal manic symptoms in treatment resistant depression.
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Bipolarity and inadequate response to antidepressant drugs: clinical and psychopharmacological perspective. J Affect Disord 2012; 136:e13-e19. [PMID: 21621266 DOI: 10.1016/j.jad.2011.05.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 04/28/2011] [Accepted: 05/08/2011] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The reason why depression may respond poorly to treatment with antidepressant drugs may be connected with the features of bipolarity. Evidence to this effect has accumulated in recent studies of various kinds of depression in mood disorders. Additional evidence for such a connection may be the efficacy of mood-stabilizing drugs in the augmentation of antidepressants in treatment-resistant depression. METHODS This review is based on clinical and psychopharmacological research performed over the past five years. The clinical investigation was based on the response to antidepressants of bipolar depression or to symptoms of hypomania, assessed mainly by the Mood Disorder Questionnaire (MDQ) and the Hypomania Checklist-32 (HCL-32). The psychopharmacological research tested the efficacy of augmentation of antidepressants in treatment-resistant depression by mood-stabilizing drugs of the 1st and 2nd generations. RESULTS A number of studies have pointed to an association between bipolar depression, or symptoms of hypomania and an inadequate response to antidepressants. Such a connection was also found in the Polish TRES-DEP study which included 1051 depressed patients. Pharmacological studies have demonstrated the efficacy of first generation mood-stabilizing drugs (lithium, carbamazepine) and second generation drugs (quetiapine, olanzapine, risperidone, ziprasidone, lamotrigine) for augmentation of antidepressants in treatment-resistant depression. Some evidence has been presented that mixed depressive episodes may also belong to this category. CONCLUSIONS The results of these clinical and psychopharmacological studies appear to confirm an association between bipolarity and a poor response of depression to treatment with antidepressant drugs.
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Li CT, Bai YM, Huang YL, Chen YS, Chen TJ, Cheng JY, Su TP. Association between antidepressant resistance in unipolar depression and subsequent bipolar disorder: cohort study. Br J Psychiatry 2012; 200:45-51. [PMID: 22016435 DOI: 10.1192/bjp.bp.110.086983] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND People with major depressive disorder who fail to respond to adequate trials of antidepressant treatment may harbour hidden bipolar disorder. AIMS We aimed to compare the rates of a change in diagnosis to bipolar disorder among people with major depressive disorder with stratified responses to antidepressants during an 8-year follow-up period. METHOD Information on individuals with major depressive disorder identified during 2000 (cohort 2000, n = 1485) and 2003 (cohort 2003, n = 2459) were collected from a nationally representative cohort of 1,000,000 health service users in Taiwan. Participants responding well to antidepressants were compared with those showing poor responses to adequate trials of antidepressants. RESULTS In 7.6-12.1% of those with a diagnosis of unipolar major depressive disorder this diagnosis was subsequently changed to bipolar disorder, with a mean time to change of 1.89-2.98 years. Difficult-to-treat participants presented higher rates of change to a bipolar diagnosis (25.6% in cohort 2000; 26.6% in cohort 2003) than easy-to-treat participants (8.8-8.9% in cohort 2000; 6.8-8.6% in cohort 2003; P<0.0001). Regression analysis showed that the variable most strongly associated with the change in diagnosis was antidepressant use history. The difficult-to-treat participants were associated most with diagnostic changing (cohort 2000: odds ratio (OR) = 1.88 (95% CI 1.12-3.16); cohort 2003: OR = 4.94 (95% CI 2.81-8.68)). CONCLUSIONS This is the first large-scale study to report an association between antidepressant response history and subsequent change in diagnosis from major depressive disorder to bipolar disorder. Our findings support the view that a history of poor response to antidepressants in unipolar depression could be a useful predictor for bipolar diathesis.
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Affiliation(s)
- Cheng-Ta Li
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
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Souery D, Zaninotto L, Calati R, Linotte S, Mendlewicz J, Sentissi O, Serretti A. Depression across mood disorders: review and analysis in a clinical sample. Compr Psychiatry 2012; 53:24-38. [PMID: 21414619 DOI: 10.1016/j.comppsych.2011.01.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 01/20/2011] [Accepted: 01/27/2011] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES In this article we aimed to: (1) review literature concerning the clinical and psychopathologic characteristics of Bipolar (BP) depression; (2) analyze an independent sample of depressed patients to identify any demographic and/or clinical feature that may help in differentiating mood disorder subtypes, with special attention to potential markers of bipolarity. METHODS A sample of 291 depressed subjects, including BP -I (n = 104), BP -II (n = 64), and unipolar (UP) subjects with (n = 53) and without (n = 70) BP family history (BPFH), was examined to evidence potential differences in clinical presentation and to validate literature-derived markers of bipolarity. Demographic and clinical variables and, also, single items from the Hamilton Depression Rating Scale (HDRS), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Young Mania Rating Scale (YMRS) were compared among groups. RESULTS UP subjects had an older age at onset of mood symptoms. A higher number of major depressive episodes and a higher incidence of lifetime psychotic features were found in BP subjects. Items expressing depressed mood, depressive anhedonia, pessimistic thoughts, and neurovegetative symptoms of depression scored higher in UP, whereas depersonalization and paranoid symptoms' scores were higher in BP. When compared with UP, BP I had a significantly higher incidence of intradepressive hypomanic symptoms. Bipolar family history was found to be the strongest predictor of bipolarity in depression. CONCLUSIONS Overall, our findings confirm most of the classical signs of bipolarity in depression and support the view that some features, such as BPFH, together with some specific symptoms may help in detecting depressed subjects at higher risk for BP disorder.
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Affiliation(s)
- Daniel Souery
- Laboratoire de Psychologie Medicale, Université Libre de Bruxelles and Psy Pluriel, Centre Europeén de Psychologie Medicale, Brussels, Belgium
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Mazza M, Mandelli L, Zaninotto L, Di Nicola M, Martinotti G, Harnic D, Bruschi A, Catalano V, Tedeschi D, Colombo R, Bria P, Serretti A, Janiri L. Factors associated with the course of symptoms in bipolar disorder during a 1-year follow-up: depression vs. sub-threshold mixed state. Nord J Psychiatry 2011; 65:419-26. [PMID: 21728783 DOI: 10.3109/08039488.2011.593101] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Mixed mood states, even in their sub-threshold forms, may significantly affect the course and outcome of bipolar disorder (BD). AIM To compare two samples of BD patients presenting a major depressive episode and a sub-threshold mixed state in terms of global functioning, clinical outcome, social adjustment and quality of life during a 1-year follow-up. METHODS The sample was composed by 90 subjects (Group 1, D) clinically diagnosed with a major depressive episode and 41 patients (Group 2, Mx) for a sub-threshold mixed state. All patients were administered with a pharmacological treatment and evaluated for depressive, anxious and manic symptoms by common rating scales. Further evaluations included a global assessment of severity and functioning, social adjustment and quality of life. All evaluations were performed at baseline and after 1, 3, 6 and 12 months of treatment. RESULTS The two groups were no different for baseline as well as improvement in global severity and functioning. Though clearly different for symptoms severity, the amount of change of depressive and anxiety symptoms was also no different. Manic symptoms showed instead a trend to persist over time in group 2, whereas a slight increase of manic symptoms was observed in group 1, especially after 6 months of treatment. Moreover, in group 1, some manic symptoms were also detected at the Young Mania Rating Scale (n = 24, 26.6%). Finally, improvement in quality of life and social adjustment was similar in the two groups, though a small trend toward a faster improvement in social adjustment in group 1. CONCLUSIONS Sub-threshold mixed states have a substantial impact on global functioning, social adjustment and subjective well-being, similarly to that of acute phases, or at least major depression. In particular, mixed features, even in their sub-threshold forms, tend to be persistent over time. Finally, manic symptoms may be still often underestimated in depressive episodes, even in patients for BD.
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Affiliation(s)
- Marianna Mazza
- Department of Neurosciences, Institute of Psychiatry and Psychology, Bipolar Disorders Unit, Catholic University of Sacred Heart, Rome, Italy.
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Lloyd LC, Giaroli G, Taylor D, Tracy DK. Bipolar depression: clinically missed, pharmacologically mismanaged. Ther Adv Psychopharmacol 2011; 1:153-62. [PMID: 23983940 PMCID: PMC3736904 DOI: 10.1177/2045125311420752] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Bipolar affective disorders are common and frequently debilitating mental illnesses. Diagnostic criteria mean they are defined by the presence of pathological mood elevation, but research shows greater disease burden is inflicted by depressive phases (bipolar depression) both in terms of duration and impact of symptoms. Despite this there is consistent evidence for the underdiagnosis of bipolar depression and its misdiagnosis as a unipolar disorder, with significant subsequent impact on medication management. There is currently less robust evidence for the appropriate pharmacological approach in such individuals than in unipolar depression, and fewer guidelines for clinicians. Despite this there is clear and growing evidence that 'treatment as usual' of depressive symptomatology is ineffective at best, harmful at worst, and that there is little role for the use of antidepressants. Both mood stabilizers and antipsychotics demonstrate efficacy, and whilst there are emerging data on intraclass differences, more research is needed, particularly concerning bipolar II disorder. Present treatment strategies are limited by insufficient large randomized control trials, an inadequate understanding of the neuropathology of bipolar illnesses and a lack of tailored medications. Better clinical training, understanding and recognition of this common condition are essential.
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Affiliation(s)
- Lisa C Lloyd
- CSI Lab, Psychological Medicine, The Institute of Psychiatry, King's College London, DeCrespigny Park, London, UK
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Cook CAL, Flick LH, Homan SM, Campbell C, McSweeney M, Gallagher ME. Psychiatric disorders and treatment in low-income pregnant women. J Womens Health (Larchmt) 2011; 19:1251-62. [PMID: 20524895 DOI: 10.1089/jwh.2009.1854] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
AIMS This study estimated the prevalence of twenty-two 12-month and lifetime psychiatric disorders in a sample of 744 low-income pregnant women and the frequency that women with psychiatric disorders received treatment. METHOD To identify psychiatric disorders, the Diagnostic Interview Schedule (DIS) was administered to Medicaid or Medicaid-eligible pregnant women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). The sample was stratified by the rural or urban location of the WIC sites in southeastern Missouri and the city of St. Louis. Eligible women were enrolled at each site until their numbers were proportional to the racial distribution of African American and Caucasian pregnant women served there. RESULTS The 12-month prevalence of one or more psychiatric disorders was 30.9%. Most common were affective disorders (13.6%), particularly major depressive disorder (8.2%) and bipolar I disorder (5.2%). Only 24.3% of those with a psychiatric disorder reported that they received treatment in the past year. Lifetime prevalence of at least one disorder was 45.6%, with affective disorders being the most frequent (23.5%). Caucasian women were more likely than African Americans to have at least one 12-month disorder, with the difference largely accounted for by nicotine dependence. Higher prevalence of lifetime disorders was also found in Caucasian women, particularly affective disorders and substance use disorders. There were no differences in the prevalence of 12-month or lifetime psychiatric disorders by the urban or rural residence of subjects. CONCLUSIONS With nearly one third of pregnant women meeting criteria for a 12-month psychiatric disorder and only one fourth receiving any type of mental health treatment, comprehensive psychiatric screening during pregnancy is needed along with appropriate treatment.
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Smith DJ, Griffiths E, Kelly M, Hood K, Craddock N, Simpson SA. Unrecognised bipolar disorder in primary care patients with depression. Br J Psychiatry 2011; 199:49-56. [PMID: 21292927 DOI: 10.1192/bjp.bp.110.083840] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Bipolar disorder is complex and can be difficult to diagnose. It is often misdiagnosed as recurrent major depressive disorder. AIMS We had three main aims. To estimate the proportion of primary care patients with a working diagnosis of unipolar depression who satisfy DSM-IV criteria for bipolar disorder. To test two screening instruments for bipolar disorder (the Hypomania Checklist (HCL-32) and Bipolar Spectrum Diagnostic Scale (BSDS)) within a primary care sample. To assess whether individuals with major depressive disorder with subthreshold manic symptoms differ from those individuals with major depressive disorder but with no or little history of manic symptoms in terms of clinical course, psychosocial functioning and quality of life. METHOD Two-phase screening study in primary care. RESULTS Three estimates of the prevalence of undiagnosed bipolar disorder were obtained: 21.6%, 9.6% and 3.3%. The HCL-32 and BSDS questionnaires had quite low positive predictive values (50.0 and 30.1% respectively). Participants with major depressive disorder and with a history of subthreshold manic symptoms differed from those participants with no or little history of manic symptoms on several clinical features and on measures of both psychosocial functioning and quality of life. CONCLUSIONS Between 3.3 and 21.6% of primary care patients with unipolar depression may have an undiagnosed bipolar disorder. The HCL-32 and BSDS screening questionnaires may be more useful for detecting broader definitions of bipolar disorder than DSM-IV-defined bipolar disorder. Subdiagnostic features of bipolar disorder are relatively common in primary care patients with unipolar depression and are associated with a more morbid course of illness. Future classifications of recurrent depression should include dimensional measures of bipolar symptoms.
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Affiliation(s)
- Daniel J Smith
- Department of Psychological Medicine and Neurology, Cardiff University School of Medicine, University Hospital of Wales, Cardiff, UK.
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Sharma V, Xie B. Screening for postpartum bipolar disorder: validation of the Mood Disorder Questionnaire. J Affect Disord 2011; 131:408-11. [PMID: 21185082 DOI: 10.1016/j.jad.2010.11.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 11/10/2010] [Accepted: 11/24/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Despite the prevalent nature of postpartum depression in women with bipolar disorder, there are currently no screening instruments designed specifically for bipolar disorder in the postpartum period. METHODS Women with histories of major depressive disorder or bipolar disorder (type I or II) attending an outpatient perinatal clinic were administered the Mood Disorder Questionnaire during the first month after delivery. An experienced research coordinator, blind to the Mood Disorder Questionnaire results, conducted a face to face diagnostic interview using the Structured Clinical Interview for DSM-IV. RESULTS A total of 57 women with bipolar disorder (30 with bipolar II disorder and 27 with bipolar I disorder) and 68 women with major depressive disorder completed the Mood Disorder Questionnaire between two to four weeks after delivery. The traditional scoring criteria yielded a sensitivity of 75.44% [95%CI: 62.24%-85.87%] and a specificity of 86.76% [95%CI: 76.36%-93.77%]. The optimal cut-off score was eight or more endorsed symptoms without the supplementary questions (a sensitivity of 87.72% [95% CI: 76.32%-94.92%] and a specificity of 85.29% [95%CI: 74.61%-92.72%]). CONCLUSIONS The Mood Disorder Questionnaire with alternate scoring is a useful screening instrument for bipolar disorder in the postpartum period.
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Wooderson SC, Juruena MF, Fekadu A, Commane C, Donaldson C, Cowan M, Tomlinson M, Poon L, Markopoulou K, Rane L, Donocik J, Tunnard C, Masterson B, Cleare AJ. Prospective evaluation of specialist inpatient treatment for refractory affective disorders. J Affect Disord 2011; 131:92-103. [PMID: 21144591 DOI: 10.1016/j.jad.2010.11.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 10/06/2010] [Accepted: 11/02/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Little data exist to inform the treatment of severe and resistant affective disorders. We report here the effectiveness of specialist multimodal inpatient treatment for refractory affective disorders. METHODS Prospective evaluation of 225 consecutive patients admitted to the National Affective Disorders Unit between 2001 and 2008. RESULTS Patients were highly treatment-resistant: most had already received ECT, lithium augmentation and over 10 prior treatment trials. Even so, sequential assessment with the Hamilton Depression Rating Scale found that 69% showed a clinical response (≥ 50% reduction in Hamilton score) to intensive therapy during admission; 50% continued to sustain a full response and 71% at least a partial response on discharge. Patients' self-ratings (57% very much or much improved, 24% slightly improved) and relative and referrer reports (75% and 68% respectively rated patients as improved) gave similar levels of improvement. LIMITATIONS This was an observational study, without any untreated control group. The generalisability of the findings is limited by the highly specialised nature of the unit. CONCLUSIONS Most patients with depression highly resistant to prior treatment respond to specialist and intensive multimodal inpatient therapy.
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Affiliation(s)
- Sarah C Wooderson
- King's College London, Institute of Psychiatry, Department of Psychological Medicine, Section of Neurobiology of Mood Disorders, London SE5 8AZ, UK
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Pacchiarotti I, Valentí M, Bonnin CM, Rosa AR, Murru A, Kotzalidis GD, Nivoli AMA, Sánchez-Moreno J, Vieta E, Colom F. Factors associated with initial treatment response with antidepressants in bipolar disorder. Eur Neuropsychopharmacol 2011; 21:362-9. [PMID: 21056928 DOI: 10.1016/j.euroneuro.2010.10.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 10/15/2010] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Controversy in antidepressant (AD) use in bipolar depression relies in its potential induction of mood switches and ineffectiveness. Responders to acute AD add-on treatment maintain response with continued treatment, whilst partial/non-responders fail to reach remission despite continuation treatment. We aimed to identify response predictors to acute AD addition in bipolar depression in order to optimize treatment choice in bipolar depression and avoid unnecessary AD exposure of people unlikely to respond. METHODS Two hundred and twenty-one DSM-IV-TR depressed bipolar - type I and II - patients were treated with AD on an observational study. AD response was defined as an at least 50% drop from baseline of their HDRS17 score after 8weeks of treatment. One hundred and thirty-eight patients (138, 62.4%) fulfilled response criteria (RI) whilst 83 patients (37.6%) did not (NRI). In all cases AD therapy was on top of previously prescribed stabilizers and/or atypical antipsychotics. RESULTS RI patients were more likely to have had previous response to ADs, whereas NRI had a higher number of previous mood switches with ADs during past depressive episodes. Psychotic symptoms were more frequent amongst RI, whilst lifetime history of atypical depression was more frequent amongst NRI. NRI had more total, depressive, and hypomanic, but not manic or mixed, episodes in the past than RI. Analyzed through a logistic regression, higher previous response to ADs and lower rate of past hypomanic episodes in RI were the variables explaining intergroups (RI vs. NRI) differences. DISCUSSION Taking into account the proper caution in the use of Ads in bipolar disorder, there is a subgroup of bipolar patients who might benefit from adjunctive Ads. Looking at specific clinical factors during the course of the illness could help physicians in deciding whether to use an antidepressant in a bipolar depressed patient already treated with mood stabilizers.
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Psychiatric diagnoses during institutionalization: an investigation of 1334 psychiatric patients hospitalized in an Italian asylum during the 20th century. Wien Klin Wochenschr 2011; 123:135-44. [PMID: 21365271 DOI: 10.1007/s00508-010-1499-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Accepted: 10/13/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Interest in the history of psychiatry continues to grow, with an increasing emphasis on topics of current interest such as the history of nosology and the interplay between psychiatry and society. AIMS The present study was designed to investigate diagnoses and sociodemographic characteristics of patients during the course of the last century in a sample of Italian psychiatric inpatients. The study also throws light on changes in the practice of explaining and classifying mental disorders. METHODS This was a chart analysis of clinical records of 1334 patients hospitalized at "Santa Maria della Pietà" in Rome from 1920 to 1980. We chose every tenth year and the month of May because, on average, there was a reasonable number of admissions compared with the peak of admissions in August and an almost lack of admissions in January. RESULTS There were relevant differences in diagnostic nomenclature and course of illnesses from 1920 to 1980 in Italy. Schizophrenia was first diagnosed in 1930 and 1940 and then rapidly declined; melancholia was first diagnosed in 1930 but rapidly decreased, whereas dysthymia appeared later in 1960. Dysthymia, manic, and depressive disorders rapidly appeared since 1980. In the "other disorders" group category, there were three peaks in frequency--one in 1930, another in 1940, and the most frequent in 1980. CONCLUSIONS The consistency in diagnosis and the organization of psychiatric services in the last century were quite poor. Improving psychiatric services and quality of care remain a relevant challenge for physicians.
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Affiliation(s)
- Verinder Sharma
- Department of Psychiatry, University of Western Ontario, Perinatal Clinic, St. Joseph's Health Care, London, Ont
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Cyclothymic and hyperthymic temperaments may predict bipolarity in major depressive disorder: a supportive evidence for bipolar II1/2 and IV. J Affect Disord 2011; 129:34-8. [PMID: 20699193 DOI: 10.1016/j.jad.2010.07.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Revised: 06/04/2010] [Accepted: 07/17/2010] [Indexed: 01/18/2023]
Abstract
BACKGROUND The concept of soft bipolar spectrum has not been fully confirmed. The aim of the present study is to investigate the validity of bipolar II1/2 and IV concept. METHODS The subjects were 46 consecutive outpatients. The individual temperament of each patient was recorded using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A). The operational definition of bipolar II1/2 was those who had depression with cyclothymic temperament and that of bipolar IV was those who had depression with hyperthymic temperament. Finally, drug responses were investigated. RESULTS DSM-IV-TR diagnoses were bipolar I (N=1), bipolar II (N=9), major depressive disorder (N=34) and depressive disorder not otherwise specified (N=2). Excluding one bipolar I patient, who had both cyclothymic and hyperthymic temperaments, patients with bipolar II1/2 (N=32) and IV (N=13) as well as bipolar II (N=9) were classified into the soft bipolar spectrum, although there was considerable overlap. The categorization of soft bipolar spectrum and unipolar depression significantly predicted depressive, cyclothymic, irritable, and anxious temperaments. Moreover, soft bipolar spectrum patients with lithium treatment were significantly more in remission than those without lithium treatment. In addition, more of those with selective serotonin reuptake inhibitors (SSRIs) had a significant tendency to lower remission than those without SSRIs. LIMITATIONS This is a cross-sectional study with a relatively small number of subjects. CONCLUSIONS The present findings suggest that cyclothymic and hyperthymic temperaments may predict bipolarity, and the validity of bipolar II1/2 and IV concept is supported.
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Inoue T, Abekawa T, Nakagawa S, Suzuki K, Tanaka T, Kitaichi Y, Boku S, Nakato Y, Toda H, Koyama T. Long-term naturalistic follow-up of lithium augmentation: relevance to bipolarity. J Affect Disord 2011; 129:64-7. [PMID: 20837361 DOI: 10.1016/j.jad.2010.08.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 06/05/2010] [Accepted: 08/26/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Whether bipolarity (unrecognized bipolar disorder) is related to the treatment response to lithium augmentation in antidepressant-refractory depression remains unclear. This study of responders and non-responders to lithium augmentation of 29 antidepressant-refractory patients with major depression, whom we had studied during 1995-1997, compared the bipolar diagnosis at the follow-up based on diagnostic confirmation after long-term follow-up. METHODS Before being classified as stage 2 treatment-resistant depression, these patients had been treated adequately with at least two tricyclic or heterocyclic antidepressants from different pharmacological classes (a minimum of the equivalent of 150 mg of imipramine for 4 weeks). During 1995-1997, 29 patients received lithium augmentation. Their treatment responses were recorded. Mean follow-up was 8.0 years (range, 1-13 years). Bipolar conversion and full remission were evaluated. RESULTS After the long-term follow-up, diagnoses were changed to bipolar depression in 3 of 4 lithium responders and 3 of 25 lithium non-responders; lithium augmentation was more effective for unrecognized bipolar patients. Only the family history of bipolar disorder predicted subsequent bipolar conversion. LIMITATIONS Treatment was not controlled in this naturalistic study, which had a small sample size. CONCLUSIONS Results of this long-term follow-up study suggest that bipolarity is related to a positive response to lithium augmentation in stage 2 treatment-resistant major depression. The family history of bipolar disorder suggests false unipolar depression, and therefore indicates lithium responders.
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Affiliation(s)
- Takeshi Inoue
- Department of Psychiatry, Hokkaido University Graduate School of Medicine, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan.
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Rybakowski J, Dudek D, Pawlowski T, Lojko D, Siwek M, Kiejna A. Use of the Hypomania Checklist-32 and the Mood Disorder Questionnaire for detecting bipolarity in 1,051 patients with major depressive disorder. Eur Psychiatry 2011; 27:577-81. [DOI: 10.1016/j.eurpsy.2010.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 12/03/2010] [Accepted: 12/05/2010] [Indexed: 10/18/2022] Open
Abstract
AbstractPurposeTo use the Hypomania Checklist (HCL-32) and the Mood Disorder Questionnaire (MDQ), for detecting bipolarity in depressed patients.PatientsOne thousand and fifty-one patients fulfilling ICD-10 criteria for unipolar major depressive episode, single or recurrent, were studied. Patients were assessed using a structured demographic and clinical data interview, and by the Polish versions of the HCL-32 and MDQ questionnaires.ResultsHypomanic symptoms exceeding cut-off criteria for bipolarity by HCL-32 were found in 37.5% of patients and, by MDQ, in 20% of patients. Patients with HCL-32 (+) or MDQ (+) differed significantly from patients with HCl-32 (−) and MDQ (−) respectively, by being less frequently married, having more family history of depression, bipolar disorder, alcoholism and suicide, earlier onset of illness, and more depressive episodes and psychiatric hospitalizations. The percentage of patients resistant to treatment with antidepressant drugs was significantly higher in HCL-32 (+) vs HCL-32 (−) and in MDQ (+) vs MDQ (−): 43.9% vs 30.0%, and 26.4% vs 12.4%, respectively.ConclusionsThe results confirm a substantial percentage of bipolarity in major depressive disorder. Such patients have a number of clinical characteristics pointing on a more severe form of the illness and their depression is more resistant to treatment with antidepressants.
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Bipolar spectrum disorders in primary care: optimising diagnosis and treatment. Br J Gen Pract 2010; 60:322-4. [PMID: 20423583 DOI: 10.3399/bjgp10x484165] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Perlis RH, Uher R, Ostacher M, Goldberg JF, Trivedi MH, Rush AJ, Fava M. Association between bipolar spectrum features and treatment outcomes in outpatients with major depressive disorder. ACTA ACUST UNITED AC 2010; 68:351-60. [PMID: 21135313 DOI: 10.1001/archgenpsychiatry.2010.179] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
CONTEXT It has been suggested that patients with major depressive disorder (MDD) who display pretreatment features suggestive of bipolar disorder or bipolar spectrum features might have poorer treatment outcomes. OBJECTIVE To assess the association between bipolar spectrum features and antidepressant treatment outcome in MDD. DESIGN Open treatment followed by sequential randomized controlled trials. SETTING Primary and specialty psychiatric outpatient centers in the United States. PARTICIPANTS Male and female outpatients aged 18 to 75 years with a DSM-IV diagnosis of nonpsychotic MDD who participated in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. INTERVENTIONS Open treatment with citalopram followed by up to 3 sequential next-step treatments. MAIN OUTCOME MEASURES Number of treatment levels required to reach protocol-defined remission, as well as failure to return for the postbaseline visit, loss to follow-up, and psychiatric adverse events. For this secondary analysis, putative bipolar spectrum features, including items on the mania and psychosis subscales of the Psychiatric Diagnosis Screening Questionnaire, were examined for association with treatment outcomes. RESULTS Of the 4041 subjects who entered the study, 1198 (30.0%) endorsed at least 1 item on the psychosis scale and 1524 (38.1%) described at least 1 recent maniclike/hypomaniclike symptom. Irritability and psychoticlike symptoms at entry were significantly associated with poorer outcomes across up to 4 treatment levels, as were shorter episodes and some neurovegetative symptoms of depression. However, other indicators of bipolar diathesis including recent maniclike symptoms and family history of bipolar disorder as well as summary measures of bipolar spectrum features were not associated with treatment resistance. CONCLUSION Self-reported psychoticlike symptoms were common in a community sample of outpatients with MDD and strongly associated with poorer outcomes. Overall, the data do not support the hypothesis that unrecognized bipolar spectrum illness contributes substantially to antidepressant treatment resistance.
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Affiliation(s)
- Roy H Perlis
- Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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Inoue T, Kitaichi Y, Masui T, Nakagawa S, Boku S, Tanaka T, Suzuki K, Nakato Y, Usui R, Koyama T. Pramipexole for stage 2 treatment-resistant major depression: an open study. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:1446-9. [PMID: 20708060 DOI: 10.1016/j.pnpbp.2010.07.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 06/30/2010] [Accepted: 07/31/2010] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To examine the effectiveness and safety of adjunctive pramipexole in the treatment of stage 2 treatment-resistant major depressive disorder. METHODS This study included patients with moderate or non-psychotic severe major depressive disorder according to DSM-IV-TR criteria despite at least two adequate treatment trials with antidepressants from different pharmacological classes. Pramipexole 0.25 to 2 mg daily was added to antidepressant therapy. Previous treatments were continued unchanged, but no new treatments were allowed. We conducted assessments at baseline and at weeks 2, 4, 6, and 8. We defined response as a 50% or greater reduction on the Montgomery-Åsberg Depression Rating Scale (MADRS). RESULTS Ten patients (4 men, 6 women) aged 43.7±11.4 years received pramipexole at mean dose of 1.3±0.6 mg/d. Mean MADRS scores improved significantly from baseline to endpoint (mean differences=11.4, 95% CI [4.1, 18.7], P=0.0064). At the endpoint, six of 10 (60%) were responders on MADRS (≥50% reduction). Two patients (20%) terminated early due to mild somatic and psychiatric adverse effects. CONCLUSION These preliminary data suggest that the addition of pramipexole to antidepressant treatment may be effective and well tolerated in patients with stage 2 treatment-resistant major depressive disorder.
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Affiliation(s)
- Takeshi Inoue
- Department of Psychiatry, Hokkaido University Graduate School of Medicine, North 15, West 7, Kita-ku, Sapporo 060-8638, Japan.
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Correa R, Akiskal H, Gilmer W, Nierenberg AA, Trivedi M, Zisook S. Is unrecognized bipolar disorder a frequent contributor to apparent treatment resistant depression? J Affect Disord 2010; 127:10-8. [PMID: 20655113 DOI: 10.1016/j.jad.2010.06.036] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 06/28/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is widespread clinical belief that unrecognized bipolar disorder (BD) is a frequent contributor to apparent treatment resistant depression (TRD). This review attempts to assess the degree to which prevailing empirical data supports that view. METHODS All English-language articles published between January 1998 and January 2008 that focused on adults with major depressive disorder (MDD) and BD bearing on the question "Is unrecognized BD a frequent contributor to apparent TRD in patients initially diagnosed with MDD?" were reviewed. RESULTS 196 articles were reviewed; the preponderance of the data suggested: 1) TRD populations demonstrate high rates of hidden bipolar disorder, 2) there is not sufficient evidence to unequivocally support or reject the hypothesis that patients who relapse despite continued antidepressant treatment are likely to have bipolar spectrum disorder, 3) patients initially diagnosed with MDD do not demonstrate high rates of switching to mania or hypomania when treated with antidepressants and 4) in patients diagnosed with BD, antidepressants are not robustly effective and are poorly tolerated. LIMITATIONS The main limitation of this review is that none of the individual studies were designed to test our primary hypothesis. CONCLUSIONS This review provides at least moderate support to the hypothesis that BD is a contributor to apparent TRD. Thus, clinicians treating MDD are urged to search for "soft" signs of bipolarity and to be prepared to alter diagnosis and treatment strategies accordingly.
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Affiliation(s)
- R Correa
- Department of Psychiatry, University of California San Diego (UCSD), USA
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84
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Sharma V, Burt VK, Ritchie HL. Assessment and treatment of bipolar II postpartum depression: a review. J Affect Disord 2010; 125:18-26. [PMID: 19837461 DOI: 10.1016/j.jad.2009.09.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Revised: 09/23/2009] [Accepted: 09/23/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This paper critically reviews the current literature on the detection, diagnosis, and treatment of bipolar II postpartum depression. METHOD A Pub-Med search (1998-2009), using the search terms 'postpartum depression', 'postpartum depression AND screening/detection/diagnosis/treatment', 'bipolar I AND postpartum depression', 'bipolar II AND postpartum depression', 'postpartum hypomania', and 'postpartum hypomania AND screening', was carried out. The reference lists of articles identified were also searched to select other relevant publications. RESULTS Brief hypomanic symptoms occur in the early puerperium in approximately 15% of women. Despite preliminary evidence that postpartum depression in some patients may be a manifestation of bipolar II disorder or bipolar disorder NOS, there are no screening instruments to differentiate unipolar from bipolar depression arising in pregnancy or the postpartum. Also lacking are evidence-based treatment options specifically targeted to treat bipolar II postpartum depression. CONCLUSIONS Research into postpartum mood disorders has focused primarily on major depressive disorder, bipolar I disorder, and puerperal psychosis, and has largely ignored the study of bipolarity beyond bipolar I disorder. The clinical and research implications of the misdiagnosis of bipolar II depression as major depressive disorder in the postpartum period are discussed.
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Affiliation(s)
- Verinder Sharma
- Department of Psychiatry, University of Western Ontario, London, Ontario, Canada.
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85
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Forty L, Kelly M, Jones L, Jones I, Barnes E, Caesar S, Fraser C, Gordon-Smith K, Griffiths E, Craddock N, Smith DJ. Reducing the Hypomania Checklist (HCL-32) to a 16-item version. J Affect Disord 2010; 124:351-6. [PMID: 20129673 DOI: 10.1016/j.jad.2010.01.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Revised: 01/11/2010] [Accepted: 01/11/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND The under-recognition of hypomanic symptoms by both clinicians and patients is a major clinical problem which contributes to misdiagnosis and diagnostic delay in patients with bipolar disorder. The recent development of validated screening instruments for hypomania, such as the Hypomania Checklist (HCL-32), may help to improve the detection of bipolar disorder. In this study, we assess whether it is possible to reduce the number of items on the HCL-32 without any loss in the screening tool's ability to reliably differentiate between bipolar disorder (BD) and major depressive disorder (MDD). METHODS Using our large samples of patients with DSM-IV defined bipolar I disorder (BD-I) (n=230) and recurrent MDD (n=322), we performed item correlations in order to identify potentially redundant items in the HCL-32. We then tested the performance of a shortened 16-item HCL questionnaire within a separate sample of patients with BD (including BD-I, BD-II and BD-NOS) (n=59) and MDD (n=76). RESULTS The structure of the 16-item HCL demonstrated two main factors similar to those identified for the HCL-32 (an 'active-elated' factor and a 'risk-taking/irritable' factor). A score of 8 or more on a shortened 16-item version of the HCL had excellent ability to distinguish between BD and MDD. The sensitivity (83%) and specificity (71%) of the 16-item version were very similar to those for the full 32-item HCL. LIMITATIONS The HCL-16 was derived after subjects had completed the full HCL-32. It will be important to test the validity of a 'stand-alone' 16-item HCL questionnaire. CONCLUSIONS A shortened 16-item HCL (the HCL-16) is potentially a useful screening tool for hypomania within busy clinical settings.
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Affiliation(s)
- Liz Forty
- Department of Psychological Medicine, School of Medicine, Cardiff University, University Hospital of Wales, Cardiff, CF14 4XN, UK
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86
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Berk M, Ng F, Dodd S, Goldberg JF, Malhi GS. Do we need to flick the switch? The need for a broader conceptualization of iatrogenic course aggravation in clinical trials of bipolar disorder. Psychiatry Clin Neurosci 2010; 64:367-71. [PMID: 20492556 DOI: 10.1111/j.1440-1819.2010.02098.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The term 'switching' is often used in bipolar disorder when describing polarity changes in bipolar disorder, but this term is ambiguous and imprecise, and is sometimes used interchangeably with the term 'cycling'. Furthermore, polarity changes in bipolar disorder can be understood in different ways, because their clinical manifestations range from the emergence of subthreshold symptoms to a full episode of the opposite pole. Besides the need to tighten the meaning of the term 'switching', this paper also argues that switching does not adequately describe the complex phenomena that occur with course aggravation of bipolar disorder, such as alteration in episode frequency or amplitude. A more-fine grained approach to course aggravation in bipolar disorder is proposed, which incorporates trans-polar switching, index polarity aggravation, as well as alterations in episodic amplitude, episodic duration, and inter-episode length. This approach has the potential to capture a broader, more fine-grained and clinically relevant picture of the process of aggravation of the bipolar cycle.
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Affiliation(s)
- Michael Berk
- Department of Clinical and Biomedical Sciences, Barwon Health, University of Melbourne, Swanston Centre, Vic. 3220, Australia.
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87
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Kiejna A, Pawłowski T, Dudek D, Lojko D, Siwek M, Roczeń R, Rybakowski JK. The utility of Mood Disorder Questionnaire for the detection of bipolar diathesis in treatment-resistant depression. J Affect Disord 2010; 124:270-4. [PMID: 20060173 DOI: 10.1016/j.jad.2009.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 11/30/2009] [Accepted: 12/01/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treatment-resistant depression is a heterogeneous entity. There are many variables associated with poor response to antidepressants, one of which is missed bipolarity. Therefore, the present study investigated the bipolar diathesis between patients with treatment-resistant (TR) depression and non-treatment-resistant (NTR) depression as assessed with the Mood Disorder Questionnaire (MDQ). METHOD The population studied included 1051 patients diagnosed with single or recurrent major depressive disorder. They were classified into a non-treatment-resistant group (481 patients) and a treatment-resistant group (570 patients). The psychiatrist, using information from the patient's medical history, psychiatric examination and available documentation, assessed each eligible patient. The symptoms of bipolarity were additionally assessed by the Mood Disorder Questionnaire. RESULTS A positive screen on the MDQ defined as endorsement of at least 6 of the 13 yes or no questions was an independent risk factor for treatment resistance.The total MDQ score was significantly higher in TR vs NTR (4.33 vs 2.66 points p<0.001) and the percentage of patients screened positive was significantly higher in TR than in NTR (13.7% vs 5.6% p<0.001). Factor analysis resulted in 2 factors with eigenvalues >1 explaining 91.5% of total variance. CONCLUSIONS Using the MDQ scale we confirmed the association between bipolarity and worse response to antidepressant drugs in patients with major depressive disorder.
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Affiliation(s)
- Andrzej Kiejna
- Department of Psychiatry, Medical University of Wroclaw, Wroclaw, Poland
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88
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Comments on "Delayed loss of efficacy and depressogenic action of antidepressants". J Clin Psychopharmacol 2010; 30:352-3; author reply 353. [PMID: 20473085 DOI: 10.1097/jcp.0b013e3181dc6c3a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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89
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Fornaro M, Giosuè P. Current nosology of treatment resistant depression: a controversy resistant to revision. Clin Pract Epidemiol Ment Health 2010; 6:20-4. [PMID: 20563286 PMCID: PMC2887642 DOI: 10.2174/1745017901006010020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Revised: 03/11/2010] [Accepted: 03/14/2010] [Indexed: 01/04/2023]
Abstract
Treatment-Resistant Depression (TRD) represents a source of ongoing clinical and nosological controversy and confusion. While no univocal consensus on its definition and specific correlation with major mood disorders has been reached to date, a progressively greater number of evidences tend to suggest a revision of current clinical nosology. Since a better assessment of TRD should be considered mandatory in order to achieve the most appropriate clinical management, this narrative review aims to briefly present current most accepted definitions of the phenomenon, speculating on its putative bipolar diathesis for some of the cases originally assessed as unipolar depression.
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Affiliation(s)
- Michele Fornaro
- Department of Neuroscience, Section of Psychiatry, University of Genova, Genoa, Italy
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90
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Abstract
OBJECTIVE No studies to date have assessed the pharmacological management of treatment-resistant postpartum depression. We reviewed the pharmacological treatment of postpartum depression in patients diagnosed with treatment-resistant 'unipolar' depression. METHODS We conducted a chart review of patients treated consecutively at a perinatal clinic. Treatment-resistant postpartum depression was defined as a failure to respond to at least one adequate antidepressant trial. Patients were diagnosed using the DSM-IV criteria, and the Clinical Global Impression-Improvement (CGI-I) rating scale was used to assess response to various pharmacological interventions. RESULTS The majority of patients (57%, 34/60) referred for postpartum depression actually suffered from bipolar disorder. All patients were on antidepressants at the time of referral, but by the end of the study 37% (22/60) continued on antidepressants alone or in combination with other medications. CGI-I ratings showed appreciable improvement in depression at the end of six months following the initial consultation. Very much improvement was noted in 65% (39/60) of patients, and 22% (13/60) were considered much improved. The most common change in medication was a switch to or addition of an atypical neuroleptic. LIMITATIONS Retrospective design, small sample size, and lack of a control group. CONCLUSIONS Management of treatment resistance in women with postpartum depression should be considered within the context of types of mood disorders. Atypical neuroleptics and mood stabilizers used alone or as adjuncts should be considered in the treatment of resistant postpartum depression in patients with a bipolar diathesis.
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Affiliation(s)
- Verinder Sharma
- Department of Psychiatry, University of Western Ontario, London, ON, Canada.
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91
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John H, Sharma V. Misdiagnosis of bipolar disorder as borderline personality disorder: clinical and economic consequences. World J Biol Psychiatry 2010; 10:612-5. [PMID: 19224409 DOI: 10.1080/15622970701816522] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We report the case of a 26-year-old patient with bipolar spectrum disorder who was misdiagnosed with borderline personality disorder. In spite of trials of various psychotropic drugs and frequent, prolonged hospitalizations, the patient had remained chronically symptomatic. Following a detailed examination of the longitudinal illness course and confirmation of the diagnosis of bipolar spectrum disorder, antidepressants were discontinued and the patient was treated with lamotrigine and quetiapine. This treatment resulted in sustained euthymia and cessation of deliberate self-harm in addition to a significant reduction in utilization of health resources.
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Affiliation(s)
- Hyacinth John
- Department of Psychiatry, University of Western Ontario, London, Ontario, Canada
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92
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Amsterdam JD, Wang G, Shults J. Venlafaxine monotherapy in bipolar type II depressed patients unresponsive to prior lithium monotherapy. Acta Psychiatr Scand 2010; 121:201-8. [PMID: 19694630 DOI: 10.1111/j.1600-0447.2009.01462.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We examine the safety and efficacy of venlafaxine monotherapy in bipolar type II (BP II) patients with major depressive episode (MDE) who were unresponsive to prior lithium monotherapy. We hypothesized that venlafaxine would be superior to lithium with a low hypomanic conversion rate. METHOD Seventeen patients who were unresponsive to prior lithium monotherapy were crossed to venlafaxine monotherapy for 12 weeks. The primary outcome was within-subject change in total Hamilton Depression Rating (HAM-D) score over time. Secondary outcomes included the change in Young Mania Rating (YMRS) and clinical global impressions severity (CGI/S) and change (CGI/C) scores. RESULTS Venlafaxine produced significantly greater reductions in HAM-D (P < 0.0005), CGI/S (P < 0.0005), and CGI/C (P < 0.0005) scores vs. prior lithium. There was no difference in mean YMRS scores between treatment conditions (P = 0.179). CONCLUSION Venlafaxine monotherapy may be a safe and effective monotherapy of BP II MDE with a low hypomanic conversion rate in lithium non-responders.
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Affiliation(s)
- J D Amsterdam
- Depression Research Unit, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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93
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Rybakowski JK, Angst J, Dudek D, Pawlowski T, Lojko D, Siwek M, Kiejna A. Polish version of the Hypomania Checklist (HCL-32) scale: the results in treatment-resistant depression. Eur Arch Psychiatry Clin Neurosci 2010; 260:139-44. [PMID: 19557301 DOI: 10.1007/s00406-009-0030-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Accepted: 06/15/2009] [Indexed: 02/07/2023]
Abstract
We performed the factor analysis of the Polish version of the Hypomania Check List (HCL-32) scale and assessed the utility of HCL-32 in discriminating patients with treatment-resistant and treatment non-resistant depression. The study included 1,051 patients with single or recurrent depressive episode among which 569 met the criteria for treatment-resistant depression. The Polish version of HCL-32 was employed to all patients. The Cronbach's alpha for entire scale was 0.93 which indicates high degree of consistency. The factor analysis of the scale yielded three factors with item loadings of 0.4 or more. Factor 1, comprising ten items connected with elevated mood and increased activity explained more than half of total variance, Factor 2 (two items) was connected with sexual activity, and factor 3 (three items) with irritability. The mean score of HCL-32 was significantly higher in treatment-resistant versus non-resistant depression (11.9 +/- 8.3 vs. 8.5 +/- 7.7, respectively, P < 0.001). Also, the percentage of patients having positive response to 14 or more items of the scale was significantly higher in treatment-resistant than in non-resistant depression (43.9 vs. 30.0%, respectively, P < 0.001). Therefore, using Polish version of HCL-32 we have confirmed the association between bipolarity and worse response to antidepressant drugs in patients with mood disorders.
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Affiliation(s)
- Janusz K Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences, ul.Szpitalna 27/33, Poznan, Poland.
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94
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Casamassima F, Huang J, Fava M, Sachs GS, Smoller JW, Cassano GB, Lattanzi L, Fagerness J, Stange JP, Perlis RH. Phenotypic effects of a bipolar liability gene among individuals with major depressive disorder. Am J Med Genet B Neuropsychiatr Genet 2010; 153B:303-9. [PMID: 19388002 DOI: 10.1002/ajmg.b.30962] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Variations in voltage-dependent calcium channel L-type, alpha 1C subunit (CACNA1C) gene have been associated with bipolar disorder in a recent meta-analysis of genome-wide association studies [Ferreira et al., 2008]. The impact of these variations on other psychiatric disorders has not been yet investigated. Caucasian non-Hispanic participants in the STAR*D study of treatment for depression for whom DNA was available (N = 1213) were genotyped at two single-nucleotide polymorphisms (SNPs) (rs10848635 and rs1006737) in the CACNA1C gene. We examined putative phenotypic indicators of bipolarity among patients with major depression and elements of longitudinal course suggestive of latent bipolarity. We also considered remission and depression severity following citalopram treatment. The rs10848635 risk allele was significantly associated with lower levels of baseline agitation (P = 0.03; beta = -0.09). The rs1006737 risk allele was significantly associated with lesser baseline depression severity (P = 0.04; beta = -0.4) and decreased likelihood of insomnia (P = 0.047; beta = -0.22). Both markers were associated with an increased risk of citalopram-emergent suicidality (rs10848635: OR = 1.29, P = 0.04; rs1006737: OR = 1.34, P = 0.02). In this exploratory analysis, treatment-emergent suicidality was associated with two risk alleles in a putative bipolar liability gene.
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95
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Smith S, Heron J, Haque S, Clarke P, Oyebode F, Jones I. Measuring hypomania in the postpartum: a comparison of the Highs Scale and the Altman Mania Rating Scale. Arch Womens Ment Health 2009; 12:323-7. [PMID: 19415453 DOI: 10.1007/s00737-009-0076-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 04/23/2009] [Indexed: 11/27/2022]
Abstract
We examine the prevalence of hypomania on day 3 postpartum using two self-report mania scales: The Highs Scale and Altman Mania Rating Scale (AMRS). 279 women were recruited from postnatal wards and completed the questionnaires on day 3 postpartum. The scales show good correlation, however, 11% of women meet the suggested threshold for caseness on the Highs Scale and 44% on the AMRS. Hypomanic symptoms are commonly experienced in the early postpartum. Although there is some evidence that the Highs Scale might be conservative, the AMRS likely overestimates hypomania in the postpartum. The definition of what constitutes 'a case' of postnatal hypomania requires further validation against clinical interview and ability to predict variables of clinical importance. Mania scales developed in bipolar disorder populations must be specifically validated for postpartum use.
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Affiliation(s)
- S Smith
- School of Medicine, University of Birmingham, Birmingham, UK
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96
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Datta V, Cleare AJ. Recent advances in bipolar disorder pharmacotherapy: focus on bipolar depression and rapid cycling. Expert Rev Clin Pharmacol 2009; 2:423-34. [PMID: 22112185 DOI: 10.1586/ecp.09.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This article reviews recent advances in the evidence base for effective pharmacotherapy in bipolar disorder. We focus first on bipolar depression, since this pole of the illness forms the bulk of the burden of illness for both bipolar I and bipolar II patients. Recent studies throw doubt on the benefits of antidepressants in bipolar depression and suggest that selected mood stabilizers or second-generation antipsychotics may be effective alternatives. A second focus is on rapid-cycling bipolar disorder, a more severe phase of the illness, in which four or more episodes occur in a year. Although this form of the illness responds poorly to monotherapy, evidence is accumulating concerning which treatments are best combined in order to manage rapid cycling most effectively. Additional nonpharmacological management strategies are a vital element of the effective management of bipolar disorder but are beyond the scope of this review. Finally, suggestions are made for future research.
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Affiliation(s)
- Vivek Datta
- King's College London, Institute of Psychiatry, Department of Psychological Medicine, Section of Neurobiology of Mood Disorders, 103 Denmark Hill, London SE5 8AZ, UK.
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97
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Amsterdam JD, Shults J. Does tachyphylaxis occur after repeated antidepressant exposure in patients with Bipolar II major depressive episode? J Affect Disord 2009; 115:234-40. [PMID: 18694599 DOI: 10.1016/j.jad.2008.07.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Revised: 07/02/2008] [Accepted: 07/07/2008] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Tachyphylaxis often refers to the loss of antidepressant efficacy during long-term treatment. However, it may also refer to the gradual loss of efficacy after repeated antidepressant exposures over time. The aim of this study was to examine the phenomenon of tachyphylaxis in patients with Bipolar II major depression treated with either venlafaxine or lithium. We hypothesized that a greater number of prior antidepressant exposures would result in a reduced response to venlafaxine, but not lithium, therapy. METHODS 83 patients were randomized to treatment with either venlafaxine (n=43) or lithium (n=40). The primary outcome was a >or= 50% reduction in baseline Hamilton Depression Rating score. A detailed history of prior drug therapy was obtained. Logistic regression was used to test the hypothesis that prior antidepressant exposure was associated with reduced response to venlafaxine therapy. RESULTS The mean number of prior antidepressant and mood stabilizer exposures was significantly higher in venlafaxine non-responders versus responders (p=0.02). There was no significant association between response to lithium and the number of prior antidepressant and mood stabilizer exposures (p=0.38). The odds of responding to venlafaxine or lithium therapy decreased with an increasing number of prior antidepressant exposures (p=0.04). Response was not significantly affected by the number of prior mood stabilizer exposures (p=0.30). Adjustment for clinical and demographic covariates sharpened the estimated impact of prior antidepressant exposure on treatment outcome. LIMITATIONS This study was a post hoc exploratory analysis. The study was not specifically powered to test the hypothesis of an association between number of prior antidepressant drug exposures and response to venlafaxine or lithium therapy. CONCLUSION These observations support earlier findings suggesting the presence of tachyphylaxis occurring after repeated antidepressant drug exposures. Possible mechanisms of tachyphylaxis may include genetic predisposition for non-response, physiological adaptation after repeated antidepressant exposures, and inherent illness and pharmacokinetic heterogeneity.
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Affiliation(s)
- Jay D Amsterdam
- Depression Research Unit, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-3309, United States.
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98
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Smith DJ, Forty L, Russell E, Caesar S, Walters J, Cooper C, Jones I, Jones L, Craddock N. Sub-threshold manic symptoms in recurrent major depressive disorder are a marker for poor outcome. Acta Psychiatr Scand 2009; 119:325-9. [PMID: 19120045 DOI: 10.1111/j.1600-0447.2008.01324.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE A small but significant proportion of patients with major depressive disorder (MDD) report mild manic symptoms which are below the diagnostic threshold for a hypomanic episode. METHOD We tested for an association between sub-threshold manic symptoms and clinical outcome in almost 600 patients with recurrent MDD who also had no known family history of bipolar disorder. RESULTS 9.6% of this large sample had a life-time history of sub-threshold manic symptoms. These patients were significantly more likely to have a history of poor response to antidepressants (OR 2.84; 95% CI 1.23-6.56; P < 0.02) and more likely to have experienced psychosis (OR 2.07; 95% CI 1.05-4.09; P < 0.04). They had also experienced more depressive episodes on average (P = 0.006) and were more likely to have been admitted to hospital (P < 0.03). CONCLUSION Sub-threshold manic symptoms in patients with recurrent MDD may be a useful clinical marker for poor response to antidepressants and a more morbid long-term clinical course.
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Affiliation(s)
- D J Smith
- Department of Psychological Medicine, School of Medicine, Cardiff University, University Hospital of Wales, Cardiff, UK.
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Pompili M, Rihmer Z, Innamorati M, Lester D, Girardi P, Tatarelli R. Assessment and treatment of suicide risk in bipolar disorders. Expert Rev Neurother 2009; 9:109-36. [PMID: 19102673 DOI: 10.1586/14737175.9.1.109] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Completed suicide and suicide attempts are major issues in the management of bipolar disorders. There is evidence that suicide rates among these patients are more than 20-fold higher than the general population and, furthermore, suicidal behavior is much more lethal in bipolar disorder than in the general population. Patients with mood disorders may sometimes exhibit highly perturbed mixed states, which usually increase the risk of suicide. Such states are particularly frequent in bipolar II patients, especially if patients are treated with antidepressant monotherapy (unprotected by mood stabilizers), when depression switches into mania (or vice versa), or when depression lifts and functioning approaches normality. Researchers worldwide agree that treatment involving lithium is the best way to protect patients from suicide risk. Psychosocial activities, including psychoeducation, can protect bipolar patients either directly or, more probably, indirectly by increasing adherence to treatment and helping in daily difficulties that otherwise may lead to demoralization or hopelessness. An extensive understanding of the psychosocial circumstances and the psychopathology of bipolar patients (including temperament) may help clinicians describe the clinical picture accurately and prevent suicidal behavior in these patients.
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100
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Cassano G, Mula M, Rucci P, Miniati M, Frank E, Kupfer D, Oppo A, Calugi S, Maggi L, Gibbons R, Fagiolini A. The structure of lifetime manic-hypomanic spectrum. J Affect Disord 2009; 112:59-70. [PMID: 18541309 PMCID: PMC3387675 DOI: 10.1016/j.jad.2008.04.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 04/23/2008] [Accepted: 04/23/2008] [Indexed: 12/17/2022]
Abstract
BACKGROUND The observation that bipolar disorders frequently go unrecognized has prompted the development of screening instruments designed to improve the identification of bipolarity in clinical and non-clinical samples. Starting from a lifetime approach, researchers of the Spectrum Project developed the Mood Spectrum Self-Report (MOODS-SR) that assesses threshold-level manifestations of unipolar and bipolar mood psychopathology, but also atypical symptoms, behavioral traits and temperamental features. The aim of the present study is to examine the structure of mania/hypomania using 68 items of the MOODS-SR that explore cognitive, mood and energy/activity features associated with mania/hypomania. METHODS A data pool of 617 patients with bipolar disorders, recruited at Pittsburgh and Pisa, Italy was used for this purpose. Classical exploratory factor analysis, based on a tetrachoric matrix, was carried out on the 68 items, followed by an Item Response Theory (IRT)-based factor analytic approach. RESULTS Nine factors were initially identified, that include Psychomotor Activation, Creativity, Mixed Instability, Sociability/Extraversion, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Inflated Self-esteem, Euphoria, Wastefulness/Recklessness, and account overall for 56.4% of the variance of items. In a subsequent IRT-based bi-factor analysis, only five of them (Psychomotor Activation, Mixed Instability, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Euphoria) were retained. CONCLUSIONS Our data confirm the central role of Psychomotor Activation in mania/hypomania and support the definitions of pure manic (Psychomotor Activation and Euphoria) and mixed manic (Mixed Instability and Mixed Irritability) components, bearing the opportunity to identify patients with specific profiles for a better clinical and neurobiological definition.
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Affiliation(s)
- G.B. Cassano
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy,Corresponding author. Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa, via Roma 67-56100 Pisa, Italy. Tel.: +39 050 835419; fax: +39 050 21581. (G.B. Cassano)
| | - M Mula
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy
| | - P Rucci
- Department of Psychiatry, University of Pittsburgh School of Medicine, United States
| | - M Miniati
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy
| | - E Frank
- Department of Psychiatry, University of Pittsburgh School of Medicine, United States
| | - D.J. Kupfer
- Department of Psychiatry, University of Pittsburgh School of Medicine, United States
| | - A Oppo
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy
| | - S Calugi
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy
| | - L Maggi
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy
| | - R Gibbons
- Center for Health Statistics, University of Illinois at Chicago, United States
| | - A Fagiolini
- Department of Psychiatry, University of Pittsburgh School of Medicine, United States
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