Bipolar II disorder and suicidal behavior

Suicidality in Pediatric Bipolar Disorder

This article describes what is known about the epidemiology of suicidal ideation and behavior in pediatric bipolar disorder. Risk factors associated with suicidality in this population are reviewed in detail. Clinical recommendations for assessment, management and treatment are provided based on the literature to date.

Assessment and treatment of suicide risk in bipolar disorders

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.

Prevalence and correlates of bipolar II disorder in major depressive patients at a psychiatric outpatient clinic in Hong Kong

BACKGROUND

Western studies indicate a high prevalence of bipolar II disorder defined by a Research Diagnostic Criteria 2-day hypomania duration criterion (30 to 61%) amongst clinically depressive patients. The situation in Chinese patients with depression is unknown.

METHODS

64 (52.5% response rate) patients first presenting to a Hong Kong public psychiatric outpatient clinic in 2005 with a diagnosis of major depression were recruited. The SCID and Family History Screen were administered.

RESULTS

DSM-IV bipolar II was found in 20.5% of depressive outpatients; 35.9% had bipolar II disorder defined by RDC 2-day duration criterion for hypomania. Family bipolarity, age of onset, and depressive recurrence distinguished bipolar II subjects from unipolar depressives irrespective of duration criteria chosen for hypomania.

LIMITATIONS

Sample size was limited.

CONCLUSIONS

Bipolar II disorder is common amongst Chinese depressive outpatients. The evaluation method and 2-day duration criterion for hypomania were supported by bipolar validators. Replication using larger samples is needed to arrive at a more representative prevalence estimate and to enable more refined nosological evaluation.

The clinical-familial correlates and naturalistic outcome of panic-disorder-agoraphobia with and without lifetime bipolar II comorbidity

BACKGROUND

Much of the literature on panic disorder (PD)-bipolar disorder (BP) comorbidity concerns BP-I. This literature emphasizes the difficulties encountered in pharmacologic treatment and outcome when such comorbidity is present. The present report explores these issues with respect to BP-II.

METHODS

The sample comprised 326 outpatients (aged 34.5 +/- 11.5 years old; 222 females) with Diagnostic and Statistical Manual of Mental Disorders 3rd edn, revised (DSM-III-R) PD-agoraphobia; among them 52 subjects (16%) were affected by lifetime comorbidity with BP-II. Patients were evaluated by means of the Structured Clinical Interview for DSM-IV (SCID), the Panic-Agoraphobia Interview, and the Longitudinal Interview Follow-up Examination (Life-Up) and treated according to routine clinical practice at the University of Pisa, Italy, for a period of 3 years. Clinical and course features were compared between subjects with and without BP-II. All patients received the clinicians' choice of antidepressants and, in the case of the subsample with BP-II, mood stabilizers (for example, valproate, lithium) were among the mainstays of treatment.

RESULTS

In comparison to patients without bipolar comorbidity, those with BP-II showed a significantly greater frequency of social phobia, obsessive-compulsive disorder, alcohol-related disorders, and separation anxiety during childhood and adolescence. Regarding family history, a significantly greater frequency of PD and mood disorders was present among the BP-II. No significant differences were observed in the long-term course of PD or agoraphobic symptoms under pharmacological treatment or the likelihood of spontaneous pharmacological treatment interruptions.

CONCLUSION

Although the severity and outcome of panic-agoraphobic symptomatology appear to be similar in patients with and without lifetime bipolar comorbidity, the higher number of concomitant disorders in our PD patients with BP-II does indicate a greater complexity of the clinical picture in this naturalistic study. That such complexity does not seem to translate into poorer response and outcome in those with comorbid soft bipolarity probably reflects the fact that we had brought BP-II under control with mood stabilizers. We discuss the implications of our findings as further evidence for the existence of a distinct anxious-bipolar diathesis.

Bipolarity in depressive patients without histories of diagnosis of bipolar disorder and the use of the Mood Disorder Questionnaire for detecting bipolarity

OBJECTIVES

The present study was performed to evaluate the frequency of bipolar disorders among patients (a) presenting with depressive episodes but (b) who have never been diagnosed with bipolar disorder (c) in routine clinical practice in Korean subjects and to identify which clinical features were helpful in discriminating bipolar patients from unipolar patients. In addition, authors assessed the practical use of the Mood Disorder Questionnaire (MDQ) to distinguish bipolar from unipolar disorder in these subjects and tested whether modifications of the MDQ scoring could improve its performance.

METHODS

We evaluated consecutive patients who satisfied the inclusion criteria of a current depressive episode, plus at least one previous depressive episode. Subjects were interviewed for diagnosis using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV after completing the MDQ. To improve assessment of hypomania history, the interviewer made strenuous efforts to explore a possible history of hypomania, and patient-derived data were supplemented by information from family members or close relatives.

RESULTS

Fifty-nine patients (53.2%) were classified as having bipolar disorder, leaving a group of 52 (46.8%) with unipolar depression. Among bipolar disorders, 1.8% (n = 2) had bipolar I disorder; 29.7% (n = 33), bipolar II disorder; 6.3% (n = 7), bipolar III disorder (history of antidepressant-induced hypomania without spontaneous hypomanic episode); and 15.3% (n = 17), bipolar disorder not otherwise specified (1-3 days brief hypomania). Postpartum depression (relative risk [RR] [95% confidence interval {CI}], 2.00 [1.23-3.24]), early age of onset (RR [95% CI], 1.85 [1.30-2.64]), mood lability (RR [95% CI], 1.85 [1.30-2.64]), brief depressive episode (RR [95% CI], 1.66 (1.16-2.37]), bipolar family history (RR [95% CI], 1.62 [1.08-2.43]), history of suicide attempt (RR [95% CI], 1.47 (1.05-2.04]), and alcohol problem (RR [95% CI], 1.45 (1.04-2.02]) were found to have higher risks for bipolar disorder among depressive subjects. We found that a modified scoring of the MDQ (ignoring question on functional impairment and co-occurrence of symptoms) yielded a sensitivity of 0.68 and a specificity of 0.63 for bipolar diagnosis, whereas the figures were 0.29 and 0.77, respectively, with the standard MDQ scoring.

CONCLUSIONS

The results of this study clearly indicate that a high frequency of bipolar disorders in depressive patients who have never been diagnosed with bipolar disorders and clinical features indicating bipolarity could help to differentiate bipolar subjects from unipolar subjects. Adapting the standard scoring, the MDQ showed limited use for detecting bipolar disorder; however, if the scoring modification is adapted, the MDQ can offer tolerable sensitivity.

Missed bipolarity and psychiatric comorbidity in women with postpartum depression

OBJECTIVE

To investigate the diagnostic profile of women referred for postpartum depression.

METHODS

Fifty-six women seen consecutively with the referral diagnosis of postpartum depression were administered structured instruments to gather information about their DSM-IV Axis I diagnoses.

RESULTS

In terms of frequency of occurrence, the primary diagnoses in this sample were: major depressive disorder (46%), bipolar disorder not otherwise specified (29%), bipolar II disorder (23%), and bipolar I disorder (2%). A current comorbid disorder, with no lifetime comorbidity, occurred among 32% of the sample; by contrast, lifetime comorbidity alone (i.e., with no currently comorbid disorder) was found among 27%. Both a lifetime and a current comorbidity were found among 18% of the women, and 23% had no comorbid disorder. The most frequently occurring current comorbid disorder was an anxiety disorder (46%), with obsessive-compulsive disorder (62%) being the most common type of anxiety disorder. For lifetime comorbidity, substance use (20%) and anxiety disorders (12%) were the two most common. Over 80% of patients who scored positive on either the Highs Scale or the Mood Disorder Questionnaire met the diagnostic criteria for a bipolar disorder.

CONCLUSION

The results suggest that postpartum depression is a heterogeneous entity and that misdiagnosis of bipolar disorder in the postpartum period may be quite common. The findings have important clinical implications, which include the need for early detection of bipolarity through the use of reliable and valid assessment instruments, and implementation of appropriate prevention and treatment strategies.

Differences in incidence of suicide attempts during phases of bipolar I and II disorders

BACKGROUND

Differences in the incidence of suicide attempts during various phases of bipolar disorder (BD), or the relative importance of static versus time-varying risk factors for overall risk for suicide attempts, are unknown.

METHODS

We investigated the incidence of suicide attempts in different phases of BD as a part of the Jorvi Bipolar Study (JoBS), a naturalistic, prospective, 18-month study representing psychiatric in- and outpatients with DSM-IV BD in three Finnish cities. Life charts were used to classify time spent in follow-up in the different phases of illness among the 81 BD I and 95 BD II patients.

RESULTS

Compared to the other phases of the illness, the incidence of suicide attempts was 37-fold higher [95% confidence interval (CI) for relative risk (RR): 11.8-120.3] during combined mixed and depressive mixed states, and 18-fold higher (95% CI: 6.5-50.8) during major depressive phases. In Cox's proportional hazards regression models, combined mixed (mixed or depressive mixed) or major depressive phases and prior suicide attempts independently predicted suicide attempts. No other factor significantly modified the risks related to these time-varying risk factors; their population-attributable fraction was 86%.

CONCLUSIONS

The incidence of suicide attempts varies remarkably between illness phases, with mixed and depressive phases involving the highest risk by time. Time spent in high-risk illness phases is likely the major determinant of overall risk for suicide attempts among BD patients. Studies of suicidal behavior should investigate the role of both static and time-varying risk factors in overall risk; clinically, management of mixed and depressive phases may be crucial in reducing risk.

Comparison of short-term venlafaxine versus lithium monotherapy for bipolar II major depressive episode: a randomized open-label study

OBJECTIVE

Practice guidelines for the initial treatment of bipolar II (BP II) major depressive episode (MDE) recommend mood stabilizer (MS) monotherapy or combined MS plus antidepressant drug (AD) therapy. We hypothesized that initial AD monotherapy would be superior to MS monotherapy for BP II MDE with a low hypomanic switch rate.

METHODS

Bipolar II MDE patients were randomized to a 12-week open-label treatment with either venlafaxine monotherapy (n = 43) or lithium carbonate monotherapy (n = 40). The primary outcome measure was the 28-item Hamilton Depression Rating Scale (HAM-D 28). The secondary outcome measures included the Young Mania Rating Scale (YMRS), clinical global impressions severity and change ratings, and the proportion of patients classified as responder (with > or = 50% reduction in baseline HAM-D score) or as remitter (final HAM-D score, < or = 8).

RESULTS

Thirty-four venlafaxine-treated patients (79.1%) and 15 lithium-treated patients (37.5%) completed the trial (P < 0.0005). Venlafaxine monotherapy produced a greater reduction in HAM-D 28 scores, with a difference in change of -6.57 points (95% confidence interval, -11.97 to -1.18) (P = 0.017) between treatment conditions. There was a greater proportion of venlafaxine-treated (vs lithium-treated) patients classified either as treatment responder (58.1% vs 20.0%; P < 0.0005) or as treatment remitter (44.2% vs 7.5%; P < 0.0005) for the HAM-D 28 scores. There was no significant increase in mean YMRS scores over time in the venlafaxine (vs lithium) treatment condition, and no significant increase in mean YMRS scores at any study visit compared with baseline for either treatment.

CONCLUSIONS

Results from this study suggest that AD monotherapy with venlafaxine may be an effective initial therapy for BP II MDE with a low hypomanic switch rate.

Validation of the Chinese version of the hypomania checklist (HCL-32) as an instrument for detecting hypo(mania) in patients with mood disorders

BACKGROUND

Bipolar disorder (BP) has been consistently under-recognized and erroneously diagnosed as major depression. The resulting inappropriate or delayed treatment is associated with elevated risk of (hypo)mania or cycling. The recognition of (hypo)manic episodes is essential for the correct diagnosis of BP. The Hypomania CheckList (HCL-32) is developed to increase the detection of suspected or manifest but mistreated BP cases. We aimed to determine the accuracy and validity of the Chinese version of the HCL-32 in an adult psychiatric setting. We also compared the results with prior studies carried out in a comparable sample.

METHODS

Patients suffering from mood disorders completed the HCL-32 before being interviewed with the Schedule for Affective Disorder and Schizophrenia-Lifetime (SADS-L) to make DSM-IV diagnosis. The 4-day duration criterion for hypomania was replaced by a 2-day cut-off for BPII. The internal consistency and discriminatory capacity of the HCL-32 were analyzed.

RESULTS

Results indicated high internal consistency of the Chinese version of the HCL-32. The dual factor structure was confirmed. A score of 14 or more on the HCL-32 total scale distinguished between BP and MDD yielding a sensitivity of 82% and a specificity of 67%. This scale also distinguished between BPI and BPII with a sensitivity of 64% and a specificity of 73% for the cut-off score of 21.

LIMITATIONS

The sample size of MDD patients needs to be increased.

CONCLUSIONS

The Chinese HCL-32 is a useful screening tool for BP in a psychiatric setting. Its performance is also comparable to that reported in previous studies.

Bipolar II disorder: arguments for and against a distinct diagnostic entity

OBJECTIVE

As a commitment to the International Society for Bipolar Disorders (ISBD), a Task Force was developed to investigate the diagnostic value of bipolar II disorder.

METHODS

Task Force members worked jointly reviewing all relevant literature (original articles, reviews, letters, book chapters and congress presentations) that included 'bipolar II disorder' and/or 'hypomania' as key words.

RESULTS

Bipolar II disorder appears to be a reasonably valid and reliable diagnostic category yet often underdiagnosed or misdiagnosed as unipolar disorder or personality disorder. Moreover, it is officially recognized as a mental disorder in DSM-IV-TR but not in ICD-10, and many clinicians still regard it as a milder form of manic-depressive illness, despite data supporting high morbidity and mortality rates. In fact, bipolar II may be the most prevalent bipolar phenotype, although current diagnostic boundaries are seen as quite restrictive concerning the required duration for hypomania (4 days), the exclusion of hypomanic episodes potentially triggered by antidepressants and other substances, and the negligence of hypomanic mixed states. The course of bipolar II disorder is characterized by depressive predominant polarity, and its treatment is still controversial and poorly evidence-based.

CONCLUSIONS

Bipolar II disorder is supported as a distinct category within mood disorders, but the definition and boundaries deserve a greater clarification in the DSM-V and ICD-11.

Bipolar spectrum disorder: differential diagnosis and treatment

Bipolar disorder commonly presents as a recurrent mood disorder characterized by frequent depressive episodes. Although manic or hypomanic phases are required for the diagnosis to be made based on current diagnostic criteria, a wider expression of mood instability and other historical features or family history may suggest the presence of a bipolar spectrum illness. This article covers the diagnostic issues related to bipolar disorder and the spectrum concept of the illness. A new definition of bipolar spectrum disorder is suggested, and treatment principles and options are discussed. Primary care providers often encounter patients who have depression and mood problems, placing them in a key position for the diagnosis and treatment of this psychiatric illness.

Suicidal risks among 2826 Sardinian major affective disorder patients

OBJECTIVE

We estimated risks of suicidal behaviors in 2826 mood-disorder patients evaluated and followed in a Sardinian mood disorders research center over the past 30 years.

METHOD

We determined rates of suicidal ideation, attempts, and suicides, with associated risk factors, in men and women with DSM-IV bipolar I (BP-I; n = 529), BP-II; (n = 314), or major depressive disorders (MDD; n = 1983), at risk for an average of 11 years of illness.

RESULTS

Observed rates (% of patients/year) of suicide ranked: BP-II (0.16) > or = BP-I (0.14) > MDD (0.05); attempts: BP-I (1.52) > BP-II (0.82) > MDD (0.48); ideation: BP-II (42.7) > MDD (33.8) > BP-I (22.7). The ratio of attempts/suicides (lethality index) ranked: BP-II (5.12) < MDD (9.60) < or = BP-I (10.8). Male/female risk-ratios were greater for suicide than attempts or ideation. One-third of all reported acts occurred within the first year of illness, and earliest among MDD patients. Factors associated independently with suicidal acts included BP diagnosis, hospitalizations/person, and early illness-onset; factors associated with suicidal ideation were having an affective temperament, BP-II diagnosis, and higher suicidality-corrected depression score at intake.

CONCLUSION

Suicidal behaviors were more prevalent among BPD than MDD out-patients.

Bipolar disorder: how far are we from a rigorous definition and effective management?

Bipolar disorder is a pathological disturbance of mood, characterized by waxing and waning manic, depressive and, sometimes distinctly mixed states. A diagnosis of bipolar disorder can only be made with certainty when the manic syndrome declares itself. Most individuals who are diagnosed with this disorder will experience both poles of the illness recurrently, but depressive episodes are the commonest cause of morbidity and, indeed, of death by suicide. Twin, adoption and epidemiological studies suggest a strongly genetic aetiology. It is a genetically and phenotypically complex disorder. Thus, the genes contributing are likely to be numerous and of small effect. Individuals with bipolar disorder also display deficits on a range of neuropsychological tasks in both the acute and euthymic phases of illness and correlations between number of affective episodes experienced and task performance are commonly reported. Current self-report and observer-rated scales are optimized for unipolar depression and hence limited in their ability to accurately assess bipolar depression. The development of a specific depression rating scale will improve the assessment of bipolar depression in both research and clinical settings. It will improve the development of better treatments and interventions. Guidelines support the use of antidepressants for bipolar depression. With regard to the adverse effects of antidepressants for bipolar depression, double-blind, placebo-controlled data suggest that antidepressant monotherapy or the addition of a tricyclic antidepressant may worsen the course of bipolar disorder. Importantly, adjunctive psychotherapies add significantly (both statistically and clinically) to the efficacy of pharmacological treatment regimens. The successful management of bipolar disorder clearly demands improved recognition of bipolar disorder and effective long-term treatment for bipolar depression as well as mania.

Bipolar II and anxious reactive "comorbidity": toward better phenotypic characterization suitable for genotyping

OBJECTIVE

In DSM-IV, bipolar II (BP-II) disorder is defined by depression and hypomania. There is little appreciation of affective instability, often associated with anxiety-particularly panic disorder and agoraphobia (PDA)-comorbidity. This association has genetic-familial implications, which we believe must be incorporated in refining the BP-II phenotype suitable for genotyping purposes.

METHOD

We examined in a semi-structured format 107 consecutive patients who met DSM-IV criteria for major depressive episode with atypical features and separated them into two subgroups according to the co-occurring criteria for PDA. They were further evaluated on the basis of the Atypical Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list (HSCL 90), and the Hamilton Rating Scale for Depression (HRSD), coupled with its modified form for reverse vegetative features, as well as Axis I and II comorbidity and temperamental dispositions, particularly cyclothymic instability.

RESULTS

Fifty (46.7%) of our patients met the DSM-IV criteria for PDA. In terms of significant results, PDA+ was more frequently female, had higher number of hypomanic episodes, and stressors; they were also more often BP-II, and cyclothymic. Ratings of reactivity, somatization, OCD and phobic anxiety too were significantly higher among the PDA+. In related analyses, most AD (75.7%) met criteria for BP-II; the BP-II subgroup was characterized by PDA, as well as borderline personality features and cyclothymic and hyperthymic temperaments.

LIMITATIONS

Correlational clinical study in which clinicians could not be kept entirely blind to the variables under investigation.

CONCLUSIONS

In line with the description by the French psychiatrist Pierre Kahn a century earlier, cyclothymic reactivity and neurotic features (i.e., atypicality and panic attacks) appear relevant to the definition of what today we consider BP-II disorder. These data, which are in line with current familial-genetic models of this disorder, suggest that the DSM-IV characterization of BP-II must be enriched by greater emphasis on temperamentally based mood and anxious reactivity. Such phenotypic characterization is likely to assist in better genotyping. Previous work by us further suggests the relevance of bulimic and addictive tendencies, as well as "borderline personality" diagnosis in the proband and/or the family. We submit that these conditions, rather than being "comorbid," constitute, along with BP-II, a spectrum of overlapping underlying genetic diatheses.

Challenging DSM-IV criteria for hypomania: diagnosing based on number of no-priority symptoms

BACKGROUND

DSM-IV definition of hypomania of bipolar-II disorder (BP-II), which includes elevated/irritable mood change as core feature (i.e., it must always be present), is not based on sound evidence.

STUDY AIM

Following classic descriptions of hypomania, was to test if hypomania could be diagnosed on the basis of its number (9) of DSM-IV symptoms, setting no-priority symptom.

METHODS

Consecutive 422 depression-remitted outpatients were re-interviewed by a mood specialist psychiatrist using the Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version [a semi-structured interview modified by Benazzi and Akiskal (J Affect Disord, 2003; J Clin Psychiatry, 2005) to improve the probing for BP-II] in a private practice. History of episodes of subthreshold (i.e., 2 or more symptoms) and threshold (i.e., meeting DSM-IV criteria of elevated mood plus at least 3 symptoms, or irritable mood plus at least 4) hypomania, lasting at least 2 days, and which were the most common symptoms during the episodes, were systematically assessed.

RESULTS

Bipolar-II disorder (BP-II) patients (according to DSM-IV criteria, apart from hypomania duration) were 260, and major depressive disorder (MDD) patients were 162. Mood change was present in all BP-II by definition. The most common symptoms were overactivity, which was present in almost all BP-II, followed by elevated mood and racing thoughts. ROC analysis of the number of hypomanic symptoms predicting BP-II found that a cut point of 5 or more symptoms over 9 had the best combination of sensitivity (90%) and specificity (84%), and the highest figure of correctly classified (87%) BP-II. History of episodes of 5 or more hypomanic symptoms was met by almost all BP-II.

LIMITATIONS

Single interviewer.

CONCLUSIONS

Following classic descriptions of hypomania, not setting any priority among the three basic domains of hypomania (mood, thinking, behavior), results suggest that a cutoff number of 5 symptoms over 9 (of those listed by DSM-IV) could be used to diagnose hypomania of BP-II. Diagnosing hypomania by counting a checklist of symptoms should make it easier to diagnose BP-II, and should reduce the current high misdiagnosis of BP-II as MDD, significantly impacting the treatment of depression.

Antidepressants and suicidal behavior in bipolar disorder

Patients with bipolar disorder are at very high risk for suicidal ideation, non-fatal suicidal behaviors and suicide and are frequently treated with antidepressants. However, no prospective, randomized, controlled study specifically evaluating an antidepressant on suicidality in bipolar disorder has yet been completed. Indeed, antidepressants have not yet been shown to reduce suicide attempts or suicide in depressive disorders and may increase suicidal behavior in pediatric, and possibly adult, major depressive disorder. Available data on the effects of antidepressants on suicidality in bipolar disorder are mixed. Considerable research indicates that mixed states are associated with suicidality and that antidepressants, especially when administered as monotherapy, are associated with both suicidality and manic conversion. In contrast, growing research suggests that antidepressants administered in combination with mood stabilizers may reduce depressive symptoms in patients with bipolar depression. Further, the only prospective, long-term study evaluating antidepressant treatment and mortality in bipolar disorder, although open-label, found antidepressants and/or antipsychotics in combination with lithium, but not lithium alone, reduced suicide in bipolar and unipolar patients (Angst F, et al. J Affect Disord 2002: 68: 167-181). We conclude that antidepressants may induce suicidality in a subset of persons with depressive (and probably anxious) presentations; that this induction may represent a form of manic conversion, and hence a bipolar phenotype, and that lithium's therapeutic properties may include the ability to prevent antidepressant-induced suicidality.

Suicide in bipolar disorder: Risks and management

Bipolar disorders are prevalent, often severe, and disabling illnesses with elevated lethality largely due to suicide. Suicide rates average approximately 1% annually, or perhaps 60 times higher than the international population rate of 0.015% annually. Suicidal acts typically occur early in bipolar disorders and in association with severe depressive or mixed states. The high lethality of suicidal acts in bipolar disorders is suggested by a much lower ratio of attempts:suicide (approximately 3:1) than in the general population (approximately 30:1). Risk factors can help to identify patients at increased suicidal risk, but ongoing clinical assessment is essential to limit risk. Empirical short-term interventions to manage acute suicidal risk include close clinical supervision, rapid hospitalization, and electroconvulsive therapy. Remarkably, however, evidence of the long-term effectiveness of most treatments against suicidal behavior is rare. A notable exception is lithium prophylaxis, which is associated with consistent evidence of major (approximately 80%), sustained relative reductions of risk of suicides and attempts, and lower lethality (increased attempts:suicide ratio). Such benefits are unproved for other treatments commonly used to treat bipolar disorder patients, including anticonvulsants, antipsychotics, antidepressants, and psychosocial interventions. Applying available knowledge systematically, with close and sustained clinical supervision, can enhance management of suicidal risk in bipolar disorders patients.

Pramipexole: augmentation in the treatment of depressive symptoms

We describe a retrospective case series of three patients, two with bipolar depression and one with unipolar depression. Pramipexole is a Food and Drug Administration-approved antiparkinsonian agent, which, when used to augment antidepressants, would be considered an off-label use and should be discussed with the patient. These patients had robust responses to pramipexole augmentation of their treatment regimen. All three patients had been taking an atypical antipsychotic. The depressive symptoms were evaluated using the Hamilton Rating Scale for Depression.

Gender differences in bipolar-II disorder

Gender differences in bipolar-II disorder (BP-II) are understudied.

STUDY AIM

was to test if there were gender differences in the clinical and family history features of BP-II.

METHODS

Consecutive 374 BP-II private practice outpatients were interviewed by a senior psychiatrist using the Structured Clinical Interview for DSM-IV, modified to improve the detection of BP-II (by Benazzi and Akiskal 2003, J Affect Disord 73:33-38), the Montgomery Asberg Depression Rating Scale (MADRS), the Hypomania Interview Guide, and the Family History Screen. Logistic regression was used to study associations and control for confounding. Alpha level was set at 0.05; P was two-tailed.

RESULTS

Females represented 67.3% of the group. The female to male ratio was independent of age. Females were more common in younger onset BP-II. Females, versus males, had significantly lower age at onset, more axis I comorbidity, atypical depressions, intra-depression hypomanic symptoms (i. e., mixed depression), and family history of suicidal behavior. On the MADRS, females had more sadness, loss of energy, loss of interest, and suicidal ideas. The symptom structure of hypomanic episodes was similar between females and males.

LIMITATIONS

Single interviewer, outpatient sample, private practice study setting.

DISCUSSION

Clinical differences were found between BP-II females and males. Differences were found only on the depressive pole of the disorder. However, the magnitude of the differences had not a strong clinical significance, suggesting that at present, on the basis of the variables and the population studied, there is little ground to support a female BP-II depression.

Borderline personality-bipolar spectrum relationship

BACKGROUND

The relationship between borderline personality disorder (BPD) and bipolar disorders, especially bipolar-II disorder (BP-II), is unclear. Several reviews on the topic have come to opposite conclusions, i.e., that BPD is a bipolar spectrum disorder or instead that it is unrelated to bipolar disorders. Study aim was to find which items of BPD were related to BP-II, and which instead had no relationship with BP-II.

STUDY SETTING

An outpatient psychiatry private practice, more representative of mood disorders usually seen in clinical practice in Italy. INTERVIEWER: A senior clinical and mood disorder research psychiatrist.

PATIENT POPULATION

A consecutive sample of 138 BP-II and 71 major depressive disorder (MDD) remitted outpatients. ASSESSMENT INSTRUMENTS: The Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version (SCID-CV) was used for diagnosing, the SCID-II Personality Questionnaire was used by patients to self-assess borderline personality traits. Interview methods: Patients were interviewed with the SCID-CV to diagnose BP-II and MDD. The questions of the Personality Questionnaire relative to borderline personality were self-assessed by patients. As clinically significant distress or impairment of functioning was not assessed by the questionnaire, a diagnosis of borderline personality disorder could not be made, but borderline personality traits (BPT) could be assessed (i.e., all DSM-IV BPD items but not the impairment criterion).

RESULTS

BPT items were significantly more common in BP-II versus MDD. The best combination of sensitivity and specificity for predicting BP-II was found by using a cutoff number of BPT items > or =5: specificity was 71.4%, sensitivity was 45.9%. BPT (defined by > or =5 items) was present in 29.5% of MDD and in 46.3% of BP-II (p=0.019). Logistic regression of BP-II versus BPT items number found a significant association. Principal component factor analysis of BPT items found two orthogonal factors: "affective instability" including unstable mood, unstable interpersonal relationships, unstable self-image, chronic emptiness, and anger, and "impulsivity" including impulsivity, suicidal behavior, avoidance of abandonment, and paranoid ideation. "Affective instability" was associated with BP-II (p=0.010), but "impulsivity" was not associated with BP-II (p=0.193). Interitem correlation was low. There was no significant correlation between the two factors.

DISCUSSION

Study findings suggest that DSM-IV BPD may mix two sets of unrelated items: an affective instability dimension related to BP-II, and an impulsivity dimension not related to BP-II, which may explain the opposite conclusions of several reviews. A subtyping of BPD according to these dimensions is supported by the study findings.

Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies

Since the previous publication of Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines in 1997, there has been a substantial increase in evidence-based treatment options for bipolar disorder. The present guidelines review the new evidence and use criteria to rate strength of evidence and incorporate effectiveness, safety, and tolerability data to determine global clinical recommendations for treatment of various phases of bipolar disorder. The guidelines suggest that although pharmacotherapy forms the cornerstone of management, utilization of adjunctive psychosocial treatments and incorporation of chronic disease management model involving a healthcare team are required in providing optimal management for patients with bipolar disorder. Lithium, valproate and several atypical antipsychotics are first-line treatments for acute mania. Bipolar depression and mixed states are frequently associated with suicidal acts; therefore assessment for suicide should always be an integral part of managing any bipolar patient. Lithium, lamotrigine or various combinations of antidepressant and mood-stabilizing agents are first-line treatments for bipolar depression. First-line options in the maintenance treatment of bipolar disorder are lithium, lamotrigine, valproate and olanzapine. Historical and symptom profiles help with treatment selection. With the growing recognition of bipolar II disorders, it is anticipated that a larger body of evidence will become available to guide treatment of this common and disabling condition. These guidelines also discuss issues related to bipolar disorder in women and those with comorbidity and include a section on safety and monitoring.

History of suicide attempts in pediatric bipolar disorder: factors associated with increased risk

BACKGROUND

Despite evidence indicating high morbidity associated with pediatric bipolar disorder (BP), little is known about the prevalence and clinical correlates of suicidal behavior among this population.

OBJECTIVE

To investigate the prevalence of suicidal behavior among children and adolescents with BP, and to compare subjects with a history of suicide attempt to those without on demographic, clinical, and familial risk factors.

METHODS

Subjects were 405 children and adolescents aged 7-17 years, who fulfilled DSM-IV criteria for BPI (n = 236) or BPII (n = 29), or operationalized criteria for BP not otherwise specified (BP NOS; n = 140) via the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. As part of a multi-site longitudinal study of pediatric BP (Course and Outcome of Bipolar Youth), demographic, clinical, and family history variables were measured at intake via clinical interview with the subject and a parent/guardian.

RESULTS

Nearly one-third of BP patients had a lifetime history of suicide attempt. Attempters, compared with non-attempters, were older, and more likely to have a lifetime history of mixed episodes, psychotic features, and BPI. Attempters were more likely to have a lifetime history of comorbid substance use disorder, panic disorder, non-suicidal self-injurious behavior, family history of suicide attempt, history of hospitalization, and history of physical and/or sexual abuse. Multivariate analysis found that the following were the most robust set of predictors for suicide attempt: mixed episodes, psychosis, hospitalization, self-injurious behavior, panic disorder, and substance use disorder.

CONCLUSIONS

These findings indicate that children and adolescents with BP exhibit high rates of suicidal behavior, with more severe features of BP illness and comorbidity increasing the risk for suicide attempt. Multiple clinical factors emerged distinguishing suicide attempters from non-attempters. These clinical factors should be considered in both assessment and treatment of pediatric BP.

The phenotypes of bipolar disorder: relevance for genetic investigations

The search for susceptibility genes for bipolar disorder (BD) depends on appropriate definitions of the phenotype. In this paper, we review data on diagnosis and clinical features of BD that could be used in genetic studies to better characterize patients or to define homogeneous subgroups. Clinical symptoms, long-term course, comorbid conditions, and response to prophylactic treatment may define groups associated with more or less specific loci. One such group is characterized by symptoms of psychosis and linkage to 13q and 22q. A second group includes mainly bipolar II patients with comorbid panic disorder, rapid mood switching, and evidence of chromosome 18 linkage. A third group comprises typical BD with an episodic course and favourable response to lithium prophylaxis. Reproducibility of cognitive deficits across studies raises the possibility of using cognitive profiles as endophenotypes of BD, with deficits in verbal explicit memory and executive function commonly reported. Brain imaging provides a more ambiguous data set consistent with heterogeneity of the illness.

Psychopathologic correlates of suicidal ideation in major depressive outpatients: is it all due to unrecognized (bipolar) depressive mixed states?

BACKGROUND

Recent transatlantic concern about suicidality in patients receiving antidepressants prompted us to examine the psychopathologic correlates of suicidal ideation occurring in clinically depressed patients.

METHODS

The study sample, which consisted of 644 consecutive major depressive outpatients, of which 58.0% had bipolar II disorder (BP-II), was systematically interviewed with the SCID, in order to delineate the diagnostic and psychopathologic correlates of suicidal ideation.

RESULTS

Such ideation, which was present in 49.5% [and favoring BP-II vs. major depressive disorder (MDD)] at an odds ratio (OR) of 1.3 (95% confidence interval = 0.98-1.8), was clinically significantly associated with depressive mixed state (racing/crowded thoughts and psychomotor agitation/activation during index depression), mood lability, decreased self-esteem, anorexia, as well as melancholic and psychotic features. Multiple logistic regression of suicidal ideation versus depressive symptoms and intradepressive excitatory symptoms revealed that decreased self-esteem (OR = 3.3), racing/crowded thoughts (OR = 1.5), and psychomotor agitation/activation (OR = 1.4) were independent and clinically significant correlates of suicidal ideation, irrespective of depression severity.

DISCUSSION

From a psychopathologic standpoint, suicidality might be conferred by a combination of both the excited (mixed) depressive and agitated (melancholic) clusters. Trait mood lability appears to favor the genesis of these affective clusters. Within the framework of Kraepelinian psychiatry, both clusters represent depressive mixed states. Given that such states are more prevalent in BP-II, our data provide a possible explanation for the greater suicidality in BP-II patients reported in the literature. In light of the higher odds of suicidal ideation in BP-II versus MDD patients, we hypothesize that the higher prevalence of mental and psychomotor activation in BP-II might be one factor among others that favors the greater likelihood of the transition from suicidal ideation to suicidal action in BP-II. Our analyses delineate a mixed depressive substrate at risk for suicidality. To what extent, if any, antidepressant monotherapy might contribute to the genesis of such states and/or suicidality cannot be answered with the methodology of the present study.

Symptom components of standard depression scales and past suicidal behavior

BACKGROUND

Global severity on depression scales may obscure associations between specific symptoms and suicidal behavior.

METHODS

We studied 298 persons with major depressive disorder. Factor analysis of the 24-item Hamilton Depression Rating Scale (HDRS) and the Beck Depression Inventory (BDI) was used to compare symptom clusters between past suicide attempters and non-attempters.

RESULTS

Factor analyses extracted five HDRS and three BDI factors. Suicide attempters had significantly lower scores on an HDRS anxiety factor and higher scores on a BDI self-blame factor. The factor scores correlated with total number of suicide attempts and with known risk factors for suicidal behavior.

LIMITATIONS

The differences in factor scores between suicide attempters and non-attempters were significant but modest and may be most relevant in suggesting areas for further clinical studies. Structured diagnostic interviews in this study may have limited the detection of Bipolar II or milder bipolar spectrum disorders.

CONCLUSIONS

Depressed suicide attempters exhibit comparably severe mood and neuro-vegetative symptoms, but less anxiety and more intense self-blame than non-attempters. This clinical profile may help guide studies of biological correlates and of treatments to reduce suicide risk.

Factors associated with parent-reported suicide threats by children and adolescents with community-diagnosed bipolar disorder

BACKGROUND

It has recently been suggested that indicators of suicidality in youth may differ for different diagnostic groups []. Aggression, impulsivity and risk-taking behaviors may be strong indicators of suicidality in children and adolescents with symptoms of bipolar disorder.

METHODS

Parents completed the Child Bipolar Questionnaire (CBQ) via a secure, Internet-based data acquisition system. In multivariate modeling analyses, with age and sex as covariates, CBQ items that were most closely correlated with parent-reported suicide threat were identified. The strength of this multifactor association was then examined among subjects reported to have a community diagnosis of bipolar disorder compared to those who did not.

RESULTS

In order of strength of association, the CBQ items most closely correlated with parent-reported suicide threat were: hallucinations, cursing/foul language, low energy/withdrawal, imagery-gore/violence, destroys property, poor self-esteem, excessive risk-taking, and excessive anxiety/worry. Of these 8 CBQ items, 3 (low energy, poor self-esteem, and anxiety/worry) have a dysphoric orientation, but the items with the strongest associations are related to psychosis, aggression and impulsivity. The association of the 8 CBQ items with suicidal threats was found to be much stronger in subjects with a reported prior or current bipolar diagnosis, compared with all other subjects.

LIMITATIONS

Child report data is not available. Parent report data has not yet been validated by research diagnostic interview.

CONCLUSIONS

The presence of aggression and impulsivity are importantly related to suicidal threats independently of the risk associated with dysphoria in children and adolescents who have been assigned a diagnosis of bipolar disorder or exhibit some symptoms of the disorder. This may have implications for treatment with antidepressant medication when the diagnosis of bipolar disorder may be present.

Suicidal attempt and psychiatric disorders in Iran

This study is part of broader research aimed to determine the lifetime prevalence and pattern of comorbidity on self-reported suicidal attempts in the general population of Iran. Overall, 25,180 subjects were interviewed, face-to-face, at home; the lifetime prevalence was 1.4% (0.9% males and 2% females). The majority of attempters were 26-55 years of age, married, more highly educated, female, retired, and lived in urban areas. Many of the attempters (45.3%) reported at least one psychiatric disorder during their lifetime; major depressive disorder (22%), panic disorder (6.3%), and obsessive compulsive disorder (6%) was the most common. Because less than half of suicidal attempters reported a psychiatric disorder, the existence of other pathways to suicide may be important foci for prevention. Many of the demographic correlates of suicidal behavior in Iran are very similar to those seen in Western cutlures; however, the sociodemographic factors such as few working women and very low levels of divorce is quite different to that of Western populations.

More tryptophan hydroxylase in the brainstem dorsal raphe nucleus in depressed suicides

Deficient serotonin neurotransmission in suicide is indicated by reduced brainstem serotonin (5-HT) and 5-hydroxyindoleacetic acid (5-HIAA), fewer 5-HT(1A) autoreceptors and reduced cortical serotonin transporter binding in suicide victims. Tryptophan hydroxylase (TPH) is the rate-limiting enzyme in the synthesis of 5-HT, and alterations in TPH could explain some of these findings. We sought to determine the amount of TPH immunoreactivity (TPH-IR) in the dorsal (DRN) and median (MRN) raphe nuclei in suicides and controls. Brainstems of suicide victims and controls (n = 11 pairs) were collected at autopsy, matched for age, sex and postmortem interval, frozen and sectioned (20 microm). Immunoautoradiography, using an antibody to label TPH, was performed, slides exposed to film and autoradiograms quantified by a computer-based image analysis system. We examined sections every 1000 microm throughout the whole length of the nucleus, performing statistical analysis only on those subjects for whom the raphe was complete (n = 8 pairs). TPH-IR (microCi/g) was higher in suicides than controls (S: 300.8 +/- 70.8 vs. C: 259.6 +/- 40.7, t = 2.57, df = 7, P = 0.04) in the dorsal raphe nucleus (DRN), and not different between suicides and controls (S: 251.3 +/- 44.2 vs. C: 235.9 +/- 27.4, t = 1.49, df = 7, P = 0.18) in the MRN. DRN TPH-IR was higher in male suicide victims (MS) compared to male controls (MC; MS: 318.4 +/- 54.4 vs. MC: 271.9 +/- 22.5, t = 2.66, df = 6, P = 0.03). The analysis of TPH-IR area and density at each DRN rostrocaudal levels showed higher area and density in suicides compared to controls in the rostral DRN and lower area and density in the caudal DRN. TPH-IR, an index of the amount of TPH enzyme, in the DRN is higher in depressed suicides. More TPH may be an upregulatory homeostatic response to impaired serotonin release or less autoreceptor activation. Alternatively, the serotonin impairment in suicide may be due to hypofunctional serotonin-synthesizing enzyme.

The dark side of bipolarity: detecting bipolar depression in its pleomorphic expressions

The depressive expressions of bipolar disorders have long been neglected. Current data, from both clinical and epidemiologic studies, indicate that such expressions far exceed the manic forms in both cross-section and during follow-up course. Thus, mania occurs in 1% of the population at large; bipolar depression afflicts at least 5 times more people. Much of the new literature on this subject has emphasized its high prevalence, morbidity, and mortality. There has been relatively less attention paid to the phenomenology of bipolar depression as it presents clinically. This special issue (volume 84/2-3, 2005) is devoted to a systematic data-based in-depth examination of the different clinical expressions of bipolar depression including, among others, retarded depression, agitated and/or activated depression, mood-labile depression, irritable-hostile depression, atypical depression, anxious depression, depressive mixed state, and resistant depression. Both bipolar I (BP-I), and the more prevalent yet relatively understudied bipolar II (BP-II), are covered. We trust that this extensive coverage of the "darker" side of bipolarity will set the stage for a much needed renaissance in its complex phenotypic expressions-and its delimitation from unipolar depression (UP). The phenomenology of BP-I depression ranges from depressive stupor to agitated psychosis, whereas UP depression expresses itself in psychic anxiety, and insomnia, as well as retardation. BP-II compared with UP is more likely to have atypical features, mood lability, hostility, activation, biographical instability, multiple anxiety comorbidities, suicidal tendencies, and to be rated as less "objectively" depressed. These findings are complex and do not fully agree with the conventional characterization of BP as retarded and UP as anxious and agitated. The inconsistency between the conventional and the phenomenology described herein is largely due to depressive mixed states, which tend to destabilize BP-II, and may account for the "contradictory" relationships of affect, sleep, drive, and psychomotor activity in mood disorders.

The Psychology and Neurobiology of Suicidal Behavior

Suicide is a leading cause of death, but it is not well understood or well researched. Our purpose in this review is to summarize extant knowledge on neurobiological and psychological factors involved in suicide, with specific goals of identifying areas particularly in need of future research and of articulating an initial agenda that may guide future research. We conclude that from both neurobiological and psychological perspectives, extant research findings converge on the view that two general categories of risk for suicide can be identified: (a) dysregulated impulse control; and (b) propensity to intense psychological pain (e.g., social isolation, hopelessness), often in the context of mental disorders, especially mood disorders. Each of these categories of risk is underlain at least to some degree by specific genetic and neurobiological factors; these factors in general are not well characterized, though there is emerging consensus that most if not all reside in or affect the serotonergic system. We encourage future theorizing that is conceptually precise, as well as epistemically broad, about the specific preconditions of serious suicidal behavior, explaining the daunting array of suicide-related facts from the molecular to the cultural level.

Bipolar II disorder: a review

OBJECTIVES

To review the current knowledge of bipolar II disorder.

METHODS

Literature was reviewed after conducting a Medline search and a hand search of relevant literature.

RESULTS

Bipolar II disorder is a common disorder, with a prevalence of approximately 3-5%. Distinct clinical features of bipolar II disorder have been described. The key to diagnosis is the recognition of past hypomania, while depression is the typical presenting feature of the illness. This is responsible for a significant rate of missed diagnosis, and consequent management according to unipolar guidelines. It is unclear if bipolar II disorder is over-represented amongst resistant depression populations and if abrupt offset of antidepressant action is a phenomenon over represented in bipolar II disorder, reflecting induction of predominantly depressive cycling. A few mood-stabilizer studies available provide provisional suggestion of utility. A supportive role for psychosocial therapies is suggested, however, there is a sparsity of published studies specific to bipolar II disorder cohorts. A small number of short-term antidepressant trials have suggested efficacy, however, compelling long-term maintenance data is absent.

CONCLUSIONS

An emerging literature on the specific clinical signature and management of the disorder exists, however, this is disproportionately small relative to the epidemiology and clinical significance of the disorder.

Profiles of "manic" symptoms in bipolar I, bipolar II and major depressive disorders

BACKGROUND

Classical authors such as Kraepelin, as well as the emerging literature during the past decade, indicate that manic-like signs and symptoms are present to a variable degree in all mood disorders. Current nosography does not differentiate between them and only the number of symptoms or severity is used for classification. This is particularly true for mania and hypomania. This paper will analyze the patterns of manic symptoms in bipolar I (BP-I), bipolar II (BP-II) and major depressive disorders (MDD), to test the hypothesis that mania and hypomania have different profiles, and ascertain which excitatory manic phenomena do occur in unipolar MDD.

METHODS

Six hundred and fifty-two inpatients (158 BP-I, 122 BP-II and 372 MDD) were assessed using the operational criteria for psychotic illness checklist (OPCRIT) [Arch. Gen. Psychiatry 48 (1991) 764] with a lifetime perspective. Manic or hypomanic symptoms were investigated and compared between BP-I, BP-II and MDD.

RESULTS

When compared with BP-II, BP-I disorder had a higher prevalence of reckless activity, distractibility, psychomotor agitation, irritable mood and increased self-esteem. These five symptoms correctly classified 82.8% of BP-I and 80.1% of BP-II patients. One or two manic symptoms were observed in more than 30% of major depressive patients; psychomotor agitation was the most frequent manifestations present in 18% of the MDD group.

LIMITATIONS

We did not control for severity of symptoms, nor for neuroleptic use that could produce akathisia.

CONCLUSIONS

This study suggests that mania and hypomania can be differentiated in their symptom profiles, and highlights the presence of few manic symptoms, particularly psychomotor agitation, in MDD. From the standpoint of number of manic signs and symptoms, controlling for psychomotor agitation did not substantially change the predictive power of the remaining manic symptoms. Given that excitatory manic signs and symptoms are present to a decreasing degree in BP-I, BP-II and MDD, these disorders can be proposed to lie along a dimensional model. Overall, these data are compatible with the concept of a bipolar spectrum, whereby each of the affective subtypes requires specific genetic factors.

Suicidal ideation and bipolar-II depression symptoms

OBJECTIVE

The FDA issued a warning about a possible risk of suicidal behaviour related to 'newer' antidepressants. Suicidal behaviour is common in bipolar-II (BP-II) depression, which is frequent in outpatients, and often mixed (i.e. it has concurrent hypomanic symptoms). The study aim was to find major depressive episode (MDE) and intra-MDE hypomanic symptoms associated with suicidal ideation.

METHODS

A total of 374 consecutive BP-II MDE outpatients were interviewed by the structured clinical interview for DSM-IV (SCID), the hypomania interview guide, and the family history screen.

RESULTS

Suicidal ideation was present in 52.6%. Suicidal ideation and lower GAF (meaning more severity), more persistent MDE symptoms, more melancholic depressions were significantly associated. Multiple logistic regression of suicidal ideation versus MDE symptoms and intra-MDE hypomanic symptoms found, as significant independent predictors, decreased self-esteem, racing/crowded thoughts, psychomotor agitation.

DISCUSSION

As expected, suicidal ideation and depression severity were associated. Racing/crowded thoughts and psychomotor agitation were independent predictors of suicidal ideation. While cross-sectional associations cannot show a causal association, some evidence from prospective studies supports the direction of the association. As BP-II depression is common and often mixed in outpatients, clinicians should assess intra-MDE racing/crowded thoughts and psychomotor agitation, as antidepressants alone may worsen these symptoms, and this may induce or increase suicidal behaviour. Mood stabilizing agents may be needed to control these excitement symptoms before using antidepressants.

Unmet needs in bipolar depression

Bipolar disorders, particularly bipolar spectrum disorders, frequently go unrecognized and undiagnosed by clinicians and thus remain untreated or inappropriately treated. Although the symptoms of bipolar I disorder are widely acknowledged and recognized among clinicians, epidemiology sampling studies over the past several years have found that bipolar II disorder and bipolar spectrum disorders are likely to be more prevalent and more challenging to diagnose, particularly as depressive presentations are far more common in these groups. Bipolar disorder is associated with increased morbidity and mortality, as well as higher healthcare costs, but it is unclear how much of the consequences of bipolar disorder are unrecognized in the face of poor recognition of bipolar II and bipolar spectrum disorders. This article addresses challenges in diagnosing and treating bipolar disorder in the face of a depressive episode, and offers guidelines for recognizing and appropriately managing these patients. Studies with the newer anticonvulsant mood stabilizer lamotrigine have shown antidepressant effects in bipolar disorder, and may fill an unmet need for treatment options in patients who present with depression in the context of bipolar disorder.

Bipolar II disorder: an overview of recent developments

OBJECTIVE

Recent research on the epidemiology, clinical course, diagnosis, and treatment of bipolar II disorder (BD II) stands to have a considerable impact on clinical practice. This paper reviews these developments.

METHOD

We conducted a Pubmed search, focusing on the period from January 1, 1994, to August 31, 2004. Articles deemed directly relevant to the epidemiology, course, diagnosis, and management of BD II were considered.

RESULTS

The prevalence of BD II is likely higher than previously suggested. Systematic probing for particular clinical features and use of screening tools allow for a more timely and accurate detection of the disorder. There is a paucity of good quality data to guide clinicians treating BD II.

CONCLUSION

Significant progress has been made in clarifying diagnostic and treatment issues in BD II. Neither strong nor broad treatment recommendations can be made; a cautious interpretation of available data suggests that lithium or lamotrigine are fairly reasonable first-line choices. More well-designed studies with larger samples are needed to improve the evidence base for managing this disorder.

Toward a validation of a new definition of agitated depression as a bipolar mixed state (mixed depression)

PURPOSE

As psychotic agitated depression is now a well-described form of mixed state during the course of bipolar I disorder, we sought to investigate the diagnostic validity of a new definition for agitated (mixed) depression in bipolar II (BP-II) and major depressive disorder (MDD).

MATERIALS AND METHODS

Three hundred and thirty six consecutive outpatients presenting with major depressive episodes (MDE) but without history of mania were evaluated with the Structured Clinical Interview for DSM-IV when presenting for the treatment of MDE. On the basis of history of hypomania they were assigned to BP-II (n = 206) vs. MDD (n = 130). All patients were also examined for hypomania during the current MDE. Mixed depression was operationally defined by the coexistence of a MDE and at least two of the following excitatory signs and symptoms as described by Koukopoulos and Koukopoulos (Koukopoulos A, Koukopoulos A. Agitated depression as a mixed state and the problem of melancholia. In: Akiskal HS, editor. Bipolarity: beyond classic mania. Psychiatr Clin North Am 1999;22:547-64): inner psychic tension (irritability), psychomotor agitation, and racing/crowded thoughts. The validity of mixed depression was investigated by documenting its association with BP-II disorder and with external variables distinguishing it from unipolar MDD (i.e., younger age at onset, greater recurrence, and family history of bipolar disorders). We analyzed the data with multivariate regression (STATA 7).

RESULTS

MDE plus psychic tension (irritability) and agitation accounted for 15.4%, and MDE plus agitation and crowded thoughts for 15.1%. The highest rate of mixed depression (38.6%) was achieved with a definition combining MDE with psychic tension (irritability) and crowded thoughts: 23.0% of these belonged to MDD and 76.9% to BP-II. Moreover, any of these permutations of signs and symptoms defining mixed depression was significantly and strongly associated with external validators for bipolarity. The mixed irritable-agitated syndrome depression with racing-crowded thoughts was further characterized by distractibility (74-82%) and increased talkativeness (25-42%); of expansive behaviors from the criteria B list for hypomania, only risk taking occurred with some frequency (15-17%).

CONCLUSIONS

These findings support the inclusion of outpatient-agitated depressions within the bipolar spectrum. Agitated depression is validated herein as a dysphorically excited form of melancholia, which should tip clinicians to think of such a patient belonging to or arising from a bipolar substrate. Our data support the Kraepelinian position on this matter, but regrettably this is contrary to current ICD-10 and DSM-IV conventions. Cross-sectional symptomatologic hints to bipolarity in this mixed/agitated depressive syndrome are virtually absent in that such patients do not appear to display the typical euphoric/expansive characteristics of hypomania-even though history of such behavior may be elicited by skillful interviewing for BP-II. We submit that the application of this diagnostic entity in outpatient practice would be of considerable clinical value, given the frequency with which these patients are encountered in such practice and the extent to which their misdiagnosis as unipolar MDD could lead to antidepressant monotherapy, thereby aggravating it in the absence of more appropriate treatment with mood stabilizers and/or atypical antipsychotics.

Pramipexole for bipolar II depression: a placebo-controlled proof of concept study

BACKGROUND

The original serotonergic and noradrenergic hypotheses do not fully account for the neurobiology of depression or mechanism of action of effective antidepressants. Research implicates a potential role of the dopaminergic system in the pathophysiology of bipolar disorder. The current study was undertaken as a proof of the concept that dopamine agonists will be effective in patients with bipolar II depression.

METHODS

In a double-blind, placebo-controlled study, 21 patients with DSM-IV bipolar II disorder, depressive phase on therapeutic levels of lithium or valproate were randomly assigned to treatment with pramipexole (n = 10) or placebo (n = 11) for 6 weeks. Primary efficacy was assessed by the Montgomery-Asberg Depression Rating Scale.

RESULTS

All subjects except for one in each group completed the study. The analysis of variance for total Montgomery-Asberg Depression Rating Scale scores showed a significant treatment effect. A therapeutic response (>50% decrease in Montgomery-Asberg Depression Rating Scale from baseline) occurred in 60% of patients taking pramipexole and 9% taking placebo (p =.02). One subject on pramipexole and two on placebo developed hypomanic symptoms.

CONCLUSIONS

The dopamine agonist pramipexole was found to have significant antidepressant effects in patients with bipolar II depression.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders, part III: maintenance treatment

As with the two preceding guidelines of this series, these practice guidelines for the pharmacological maintenance treatment of bipolar disorder were developed by an international task force of the World Federation of Societies of Biological Psychiatry (WFSBP). Their purpose is to supply a systematic overview of all scientific evidence relating to maintenance treatment. The data used for these guidelines were extracted from a MEDLINE and EMBASE search, from recent proceedings from key conferences and various national and international treatment guidelines. The scientific justification of support for particular treatments was categorised into four levels of evidence (A-D). As these guidelines are intended for clinical use, the scientific evidence was not only graded, but also reviewed by the experts of the task force to ensure practicality.

Bipolar II disorder: personality and outcome in two clinical samples

OBJECTIVE

To compare the personality traits and disorders of patients with bipolar II disorder and major depression and to examine the impact on treatment outcome of a bipolar II diagnosis.

METHOD

Patients from two clinical trials, a depressive sample (n = 195, 10% bipolar II) and a bulimic sample (n = 135, 16% bipolar II), were assessed for personality traits using DSM-IV criteria. Patients were randomised to treatments (fluoxetine or nortriptyline for depressive sample; cognitive behaviour therapy for bulimic sample) and followed for 3 years (depressive sample) or 5 years (bulimic sample) to assess the impact on outcome of a bipolar II diagnosis.

RESULTS

Bipolar II patients were assessed as having more borderline, histrionic and schizotypal personality traits than patients with major depression. A baseline bipolar II diagnosis did not impact negatively on treatment outcome, and less than 5% of bipolar II patients developed bipolar I disorder during follow up.

CONCLUSIONS

The low rate of conversion of bipolar II to bipolar I disorder and the lack of adverse impact of the diagnosis on outcome, questions the need for antimanic or mood stabiliser medication in most bipolar II patients.

Affective disorders in the first-degree relatives of bipolar probands: results from the South Island Bipolar Study

The current study was performed to document observed rates of affective disorders in the first degree relatives of probands with bipolar I or II disorder; to determine whether bipolar II probands have an excess of bipolar II relatives; and to determine whether bipolar probands with a history of one or more suicide attempts have more relatives who have also made suicide attempts. Bipolar probands with positive family histories of affective disorder were recruited from a variety of sources for a study on the molecular genetics of bipolar disorder. Probands and relatives were interviewed with the Diagnostic Interview for Genetic Studies (DIGS) and blood was obtained for DNA extraction and genetic analyses. Among 423 first-degree adult relatives of 153 bipolar probands, 7% (29) had bipolar I disorder, 7% had bipolar II disorder, and 7% had bipolar not otherwise specified (NOS) disorder, making 21% of relatives with any bipolar disorder. A further 42% of relatives had a depressive disorder and only 38% had no affective disorder. A suicide attempt by a proband was not associated with any increase in suicide attempts by relatives. We conclude that while unipolar depressive disorders are the most common affective disorders in the first-degree relatives of bipolar probands, extension of the bipolar phenotype to include bipolar spectrum disorders results in 21% of relatives having any bipolar disorder.

Bipolar II disorder family history using the family history screen: findings and clinical implications

Psychiatric family history of bipolar II disorder is understudied. The aims of the current study were to find the psychiatric family history of bipolar II patients using a new structured interview, the Family History Screen by Weissman et al (2000), and to find bipolar disorders family history predicting power for the diagnosis of bipolar II. One hundred sixty-four consecutive unipolar major depressive disorder (MDD) and 241 consecutive bipolar II major depressive episode (MDE) outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID). The Family History Screen was used. Sensitivity and specificity of predictors of the diagnosis of bipolar II (bipolar [type I and II] family history, bipolar II family history, atypical depression, depressive mixed state, many MDE recurrences, early onset) were studied. Bipolar II subjects had significantly more bipolar I, more bipolar II (50.7%), more MDE, and more social phobia in first-degree relatives than did unipolar subjects. Bipolar II subjects had many more first-degree relatives with bipolar II than with bipolar I. Among the predictors of the diagnosis of bipolar II, bipolar II family history had the highest specificity (82.8%), while early onset had the highest sensitivity. Discriminant analysis of predictor variables found that bipolar II family history and early onset were highly significant predictors. In conclusion, bipolar II family history was common in bipolar II patients, and it had high specificity for predicting bipolar II. If detected, it could reduce bipolar II misdiagnosis by inducing careful probing for a history of hypomania.

Pharmacotherapy of bipolar II disorder: a critical review of current evidence

OBJECTIVES

There is much controversy surrounding the diagnosis and treatment of patients with bipolar II disorder (BP II). To address the growing need to find effective treatment strategies for patients with BP II, this article identifies and summarizes available published evidence specific to the pharmacotherapy of BP II.

METHODS

Using the keywords, 'bipolar disorder', 'type II' or 'type 2', 'bipolar II', 'hypomania', and 'bipolar spectrum', a search of the databases Medline (via PubMed), the Cochrane Central Register of Controlled Trials (via Ovid), and PsychInfo was conducted for the period January 1994 to January 2003. Articles deemed directly relevant to the treatment of BP II were selected. Studies that included both BP I and II patients were excluded if results for BP II patients were not analyzed and reported separately.

RESULTS

Fourteen articles were selected for the review period. There are no double blind, randomized controlled trials (RCT) involving only BP II patients. Most studies investigating the pharmacotherapy of BP II are methodologically limited, having observational or retrospective designs and small samples. For long-term treatment, lamotrigine has the strongest quality of evidence (double blind RCT), while lithium is the best studied. With regard to short-term treatment, there is some limited support for the use of risperidone in hypomania, and for divalproex, fluoxetine and venlafaxine in treating depression.

CONCLUSIONS

There is a paucity of sound evidence to help guide clinicians treating BP II patients. Decisions about pharmacotherapy should be made on a case-by-case basis; overall, broad recommendations that are based on available evidence cannot be adequately made. More quality research is needed to delineate effective treatment strategies.

Undiagnosed Bipolar Disorder: New Syndromes and New Treatments

Recent studies have indicated that bipolar disorder is more common than previously believed. The socioeconomic and personal burdens of this illness are significant, and the lifetime risk of suicide attempts by patients with bipolar II disorder is high. It is not uncommon for patients with bipolar disorder, especially those presenting with depression, to be seen first in a primary care setting; therefore, primary care physicians need to be ready to diagnose and manage patients with these mental illnesses. The diagnosis of bipolar disorder or bipolar spectrum disorder is easily missed, or these illnesses may be misdiagnosed. A systematic and detailed initial history from the patient and a reliable family member is essential to making the correct diagnosis. The Mood Disorder Questionnaire, a validated screening instrument for bipolar disorder, may help primary care physicians make an appropriate diagnosis. Long-term management of patients with bipolar disorder should involve close liaison with a psychiatrist.