Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants

Association of VAMP-2 and Syntaxin 1A Genes with Adult Attention Deficit Hyperactivity Disorder

OBJECTIVE

The etiology of attention deficit hyperactivity disorder (ADHD) has not been entirely clarified yet. Structural and metabolic differences at the prefrontal striatal cerebellary system and the interaction of gene and environment are the main factors that thought to play roles in the etiology. Genetic investigations are performed especially about the dopamine pathways and receptors. In this study; it was aimed to investigate the association of the synaptobrevin-2 (VAMP-2) gene Ins/Del polymorphism and syntaxin 1A gene intron 7 polymorphism, which take place in encoding presynaptic protein, with adult ADHD.

METHODS

One hundred thirty-nine patients, having ADHD aging between 18 and 60 years and 106 healthy people as controls were included into the study. DNA samples were extracted from whole blood and genetic analysis were performed.

RESULTS

A significant difference was determined between ADHD and VAMP-2 Ins/Del polymorphism and syntaxin 1A intron 7 polymorphism according to the control group. These polymorphisms were found not to be associated with subtypes of ADHD.

CONCLUSION

It is supposed that synaptic protein genes together with dopaminergic genes might have roles in the etiology of ADHD.

Trouble déficit d’attention avec ou sans hyperactivité chez des adultes souffrant d’un trouble de l’humeur : le rôle des dimensions de la personnalité

Introduction

Dans les cas des troubles bipolaires, les taux de comorbidité avec un TDAH peut varier entre 9,5 % et 27 % [1]. Ces patients présentent un début de trouble plus précoce, avec plus d’épisodes dépressifs et des épisodes mixtes. Il existe peu d’étude sur le lien entre ces deux pathologies et les différentes dimensions de personnalité selon le modèle de Big Five.

Methods

Notre étude comporte 106 patients souffrant de dépression, 102 patients bipolaires et 120 témoins, tous homogènes vis-à-vis de leurs caractéristiques démographiques. Le diagnostic de TDAH se basait sur les critères DSM-IV-TR. Les traits de TDAH étaient autoévalués avec la Wender Utah Rating Scale (WURS), la Adult ADHD Self-rating Scale (ASRS) et la Brown Attention Déficit Disorder Scale (ADD). L’Inventaire de Personnalité-Révisé, le NEO PI-R, servait également à évaluer les dimensions de la personnalité au sein des groupes cliniques.

Résultats

15,7 % des adultes souffrant d’un trouble bipolaire et 7,5 % souffrant d’une dépression sévère manifestaient une comorbidité d’un TDAH en comparaison avec seulement 3,3 % des témoins. Il existe des corrélations significatives entre des traits de personnalité et la présence d’un TDAH. Une analyse de régression logistique de l’ensemble des 208 sujets cliniques a montré que ceux avec des faibles niveaux de névrosisme manifestaient un taux moins important de comorbidité avec un TDAH.

Discussion

Notre étude souligne le lien entre des troubles de l’humeur, notamment les troubles bipolaires, et la présence d’un TDAH chez des adultes. Nos résultats soutiennent la nécessité d’évaluer les sujets souffrant des troubles d’humeur sur une éventuelle comorbidité de TDAH en milieu clinique. Il faudra étudier d’une façon plus approfondie ces traits de personnalité et les liens entre des troubles de l’humeur et un TDAH afin de pouvoir adapter la prise en charge.

The effect of lisdexamfetamine dimesylate on body weight, metabolic parameters, and attention deficit hyperactivity disorder symptomatology in adults with bipolar I/II disorder

OBJECTIVES

We primarily sought to determine the effect of adjunctive lisdexamfetamine dimesylate (LDX) on anthropometric and metabolic parameters. Our secondary aim was to evaluate the effect of LDX on attention deficit hyperactivity disorder (ADHD) symptom severity in adults with bipolar I/II disorder.

METHODS

Forty-five stable adults (i.e., non-rapid cycling, absence of clinically significant hypo/manic symptoms) with bipolar I/II disorder and comorbid ADHD were enrolled in a phase IV, 4-week, flexible dose, open-label study of adjunctive LDX. All subjects were initiated at 30 mg/day of adjunctive LDX for the first week with flexible dosing (i.e., 30-70 mg/day) between weeks 2 and 4.

RESULTS

Of the 45 subjects enrolled, 40 received adjunctive LDX (mean dose = 60 ± 10 mg/day). A statistically significant decrease from baseline to endpoint was evident in weight (p < 0.001), body mass index (p < 0.001), fasting total cholesterol (p = 0.011), low density lipoprotein cholesterol (p = 0.044), high density lipoprotein cholesterol (p = 0.015) but not triglycerides, or blood glucose. Significant reductions were also observed in leptin (p = 0.047), but not in ghrelin, adiponectin, or resistin levels. Diastolic blood pressure and pulse increased significantly over time but on average remained within the normal range (p < 0.001). There was a significant reduction from baseline to endpoint in the total score of the ADHD Self-Report Scale. Significant improvement from baseline to endpoint was also observed in the Montgomery-Åsberg Depression Rating Scale total score as well as the Clinical Global Impression Severity and Improvement score.

CONCLUSIONS

Short-term adjunctive LDX treatment was well tolerated by this sample of adults with stable bipolar I/II disorder. Lisdexamfetamine dimesylate offered beneficial effects on body weight, body mass index and several metabolic parameters. In addition to demonstrating short-term (i.e., 4 weeks) safety and tolerability, beneficial effects of LDX were also observed in mitigating depressive and ADHD symptom severity.

Higher risk of developing mood disorders among adolescents with comorbidity of attention deficit hyperactivity disorder and disruptive behavior disorder: a nationwide prospective study

Attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD) are frequently comorbid. Previous studies suggested that the comorbidity of CD and ODD in ADHD may increase the risk of a further development of mood disorder, but most studies had a small sample size. Using a population-based prospective study design, a large sample composed of 1277 adolescents with ADHD-alone, 46 with ADHD + ODD, 87 with ADHD + CD, and 5640 age/gender-matched controls were enrolled in 2003. These cases were followed to 2010 to identify the cases developing unipolar depressive disorder and bipolar disorder. ADHD + CD groups exhibited a higher prevalence of unipolar depressive disorder (23.0% vs. 13.0% vs. 8.7% vs. 0.7%, p < 0.001) and bipolar disorder (3.4% vs. 2.2% vs. 1.3% vs. 0.2%, p < 0.001) than ADHD + ODD group, ADHD-alone group, and control group. Adolescents with ADHD + CD, those with ADHD + ODD, and those with ADHD-alone had a higher likelihood of developing unipolar depressive disorder (hazard ratio [HR]: 44.34, 95% confidence interval [CI]: 23.95-71.36; HR: 18.76, 95%CI: 7.87-44.71; HR: 13.01, 95%CI: 8.99-18.82) and bipolar disorder (HR: 14.39, 95%CI: 4.00-51.80; HR: 8.32, 95%CI: 1.06-65.32; HR: 5.24, 95%CI: 2.44-11.24) than the controls. Adolescents with ADHD had elevated risks of unipolar depression and bipolar disorder in their later life, and especially, those with ADHD and comorbidity of CD or ODD exhibited the highest risk. Further study would be required to evaluate whether prompt intervention for ADHD and disruptive behavior problems would decrease the risk of developing mood disorder.

Attention deficit/hyperactivity disorder symptoms in Italian bipolar adult patients: a preliminary report

BACKGROUND

It has been recently suggested that bipolar disorder (BD) with comorbid ADHD represents a distinct clinical phenotype of BD. With the aim to assess the impact of ADHD symptoms, we investigated the prevalence, epidemiological and clinical features associated with such a comorbidity in a sample of adult BD patients.

METHODS

A total of 96 outpatients (aged 18-65 years) with BD were included. All patients were screened using the Adult ADHD Self-report Scale (ASRS) and the Diagnostic, Clinical and Therapeutic Checklist (DCTC), a semi-structured interview developed for systematic collection of familial, demographic, anamnestic and clinical informations and exploration of DSM-IV-TR diagnostic criteria for mood, anxiety, eating, impulse control and alcohol and substance use disorders. The DCTC also includes the Clinical Global Impression Bipolar scale (CGI-BP), the Global Assessment of Functioning scale (GAF) and the Sheehan Disability Scale (SDS).

RESULTS

In our sample, 19 (19.8%) out of 96 BD patients fulfilled ASRS criteria for current and lifetime (onset before 7 years of age) ADHD symptoms (ADHD+). Compared to BD probands without ADHD symptoms (ADHD-), ADHD+ patients showed higher rates of current mixed episode, and lower rates of mania. ADHD+ resulted in more severe mean scores on the CGI-BP mixed, depressive and global subscales. None of the ADHD+ patients were in remission of BD at the time of the evaluation, versus 24 (31.2%) of the ADHD- group. ADHD+ patients also reported higher rate of lifetime comorbidity with Substance Use Disorder (SUD) and Alcohol Abuse in comparison to ADHD- patients. In particular the different rate in substance abuse was related to cocaine and poly-drug abuse. The two groups did not report significant differences in functioning and social adjustment with the exception of familial adjustment that was more compromised in ADHD+ than in ADHD- patients.

LIMITATIONS

Retrospective design and limited sample size.

CONCLUSIONS

In ADHD+ patients, BD is associated with higher rate of mixed states, more severe psychopathology and more impaired familial functioning as well as higher rates of comorbid substance, alcohol and poly-drug abuse compared to BD patients without adult ADHD. Our findings suggest that ADHD symptoms in adults may influence clinical presentation, course and prognosis of BD. Further prospective research is needed to confirm our findings and to explore treatment implications for the management of BD.

The comorbidity of adult attention-deficit/hyperactivity disorder in bipolar disorder patients

OBJECTIVE

High comorbidity ratio of bipolar mood disorder (BMD) with Axis I and Axis II diagnoses is reported in the literature. The possible relationship between BMD and attention-deficit/hyperactivity disorder (ADHD) in all age groups has been attracting more attention of researchers due to highly overlapping symptoms such as excessive talking, attention deficit, and increased motor activity. In this study, we aimed to investigate the prevalence of ADHD comorbidity in BMD patients and the clinical features of these patients.

METHODS

Of 142 patients, who presented to the Bipolar Disorder Unit of Zonguldak Karaelmas University Research and Application Hospital between the dates of August 1, 2008 and June 31, 2009 and diagnosed with BMD according to DSM-IV criteria consecutively, 118 patients signed informed consent and 90 of them completed the study. They all were in euthymic phase during the study evaluations. A sociodemographical data form, Wender-Utah Rating Scale (WURS), ADD/ADHD Diagnostic and Evaluation Inventory for Adults, and Structural Clinical Interview for DSM-IV Axis I Disorders, Clinical Version (SCID-I) were applied to all participating patients.

RESULTS

A total of 23.3% of all patients met the criteria for A-ADHD diagnosis along BMD. No difference was detected regarding sociodemographical features between the BMD+A-ADHD and the BMD without A-ADHD groups. The BMD+A-ADHD group had at least one extra educational year repetition than the other group and the difference was statistically significant. The BMD starting age in the BMD+A-ADHD group was significantly earlier (p=0.044) and the number of manic episodes was more frequent in the BMD+A-ADHD group (p=0.026) than the BMD without ADHD group. Panic disorder in the BMD+A-ADHD group (p=0.019) and obsessive-compulsive disorder in the BMD+C-ADHD group (p=0.001) were most frequent comorbidities.

CONCLUSIONS

A-ADHD is a frequent comorbidity in BMD. It is associated with early starting age of BMD, higher number of manic episodes during the course of BMD, and more comorbid Axis I diagnoses.

Risk factors for secondary substance use disorders in people with childhood and adolescent-onset bipolar disorder: opportunities for prevention

BACKGROUND

Compared to other mental illnesses, bipolar disorder is associated with a disproportionately high rate of substance use disorders (SUDs), and the co-occurrence is associated with significant morbidity and mortality. Early diagnosis of primary bipolar disorder may provide opportunities for SUD prevention, but little is known about the risk factors for secondary SUD among individuals with bipolar disorder. The purposes of this study were to describe the population of people with childhood and adolescent-onset primary bipolar disorder, and to identify risk factors for secondary SUD in this population.

METHODS

Using data collected from the National Comorbidity Survey Replication study, we identified 158 individuals with childhood-onset (<13 years) or adolescent-onset (13-18 years) primary bipolar disorder (I, II or subthreshold). Survival analysis was used to identify risk factors for SUD.

RESULTS

Compared to adolescent-onset, people with childhood-onset bipolar disorder had increased likelihoods of attention deficit hyperactivity disorder (ADHD) (adjusted odds ratio=2.81) and suicide attempt (aOR=3.61). Males were more likely than females to develop SUD, and did so at a faster rate. Hazard ratios of risk factors for SUD were: lifetime oppositional defiant disorder (2.048), any lifetime anxiety disorder (3.077), adolescent-onset bipolar disorder (1.653), and suicide attempt (15.424). SUD was not predicted by bipolar disorder type, family history of bipolar disorder, hospitalization for a mood episode, ADHD or conduct disorder.

CONCLUSIONS

As clinicians struggle to help individuals with bipolar disorder, this study provides information that might be useful in identifying individuals at higher risk for SUD. Future research can examine whether targeting these risk factors may help prevent secondary SUD.

Temperamental characteristics in adults with attention-deficit hyperactivity disorder: a comparison with bipolar disorder and healthy control groups

OBJECTIVE

To date, the affective temperamental characteristics of adults with attention-deficit hyperactivity disorder (ADHD) have not been studied. The aim of this study is to explore those temperamental characteristics for adults diagnosed with ADHD as measured by the TEMPS-A and then to compare those results with results for individuals diagnosed with bipolar disorder (BD) and with healthy controls.

METHODS

Forty adults with ADHD, 40 patients with BD, and 40 healthy controls were enrolled in this study. The groups were matched by age and gender. All patients were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I), the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Young Mania Rating Scale and the Wender Utah Rating Scale. Subjects' temperamental characteristics were examined using the Turkish version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto questionnaire (TEMPS-A).

RESULTS

Ten subjects (25%) in the ADHD group and 15 subjects (30%) in the bipolar group had at least one dominant temperament. There was no identifiable dominant temperament in the control group. Compared to the control group, the ADHD group scored higher than other groups on all domains of the TEMPS-A: depressive cyclothymic, irritable and anxious. However, the hyperthymic domain was not higher for this group. Adults with ADHD scored higher on the irritable temperament scale as compared to the BD group. The ADHD and BD groups had similar mean scores for each of the other four temperaments.

CONCLUSION

The adults diagnosed with ADHD in this study had different temperamental characteristics from the control group, and these temperamental characteristics were similar to those of the bipolar patients. Recognizing the role of temperamental characteristics in adults with ADHD may increase our understanding of ADHD.

Frontostriatal neuroimaging findings differ in patients with bipolar disorder who have or do not have ADHD comorbidity

BACKGROUND

The inferior frontal cortical (IFC)-striatal network plays an integral role in response inhibition and is compromised in patients with Bipolar Disorder (BP) or Attention-Deficit/Hyperactivity Disorder (ADHD). Prior BP functional neuroimaging studies have not accounted for ADHD comorbidity despite its high prevalence.

METHODS

The authors conducted an fMRI study using a response inhibition task (Go-NoGo) in 32 euthymic adults with BP, half with comorbid ADHD (BP/ADHD); 16 adults with ADHD alone; and 30 healthy controls. Within- and between-group whole-brain analyses were performed to assess for significant neural function differences.

RESULTS

All groups activated frontal and striatal regions involved in response inhibition. ANOVA results demonstrated significant interaction effects of BP and ADHD in the anterior and posterior cingulate, left superior and middle frontal gyri and left inferior parietal lobule. Follow-up comparisons showed significant differences between BP subjects with and without ADHD. Other regions demonstrated main effects of BP (left inferior frontal gyrus, left middle frontal gyrus, right superior frontal gyrus and left insula) and ADHD (left inferior frontal gyrus, left precentral gyrus and right anterior cingulate).

LIMITATIONS

This study, as the first of its kind, requires replication using large sample sizes and controlling for potential effects of medication.

CONCLUSIONS

Euthymic bipolar adults with comorbid ADHD have significantly different neural activation patterns from BP patients without this comorbidity. If understanding of the neurobiology of bipolar disorder is to be achieved, it is critical to control for this potential confound, something not done by most prior fMRI studies of adults with BP.

Methylphenidate in mania project (MEMAP): study protocol of an international randomised double-blind placebo-controlled study on the initial treatment of acute mania with methylphenidate

BACKGROUND

Treatment of patients with acute mania remains a considerable medical challenge since onset of action of antimanic medication is delayed for several days. Psychostimulants could have an earlier onset of action. This assumption is based on the 'vigilance regulation model of mania' which postulates that vigilance is unstable in manic patients. Accordingly, vigilance-stabilising psychostimulants could be more useful than conventional treatment in acute mania. We present here the study protocol of a trial intended to study the efficacy and safety of methylphenidate in the initial treatment of acute mania.

METHODS/DESIGN

A multi-centre, randomised, double-blind, placebo-controlled clinical trial will be conducted in 88 bipolar inpatients with acute mania. Male and female patients older than 18 years will be randomised to treatment with either methylphenidate (20 to 40 mg/day) or placebo for 2.5 days, given once or twice daily. The main outcome measure is the reduction in the Young Mania Rating Scale (YMRS) after 2.5 days of treatment. Other outcome measures include the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) the Clinical Global Impression-Bipolar Scale (CGI-BP), the Screen for Cognitive Impairment in Psychiatry (SCIP), actigraphy and the EEG-'Vigilance Algorithm Leipzig' (VIGALL).

DISCUSSION

A positive study outcome of the proposed study could substantially impact our understanding of the etiopathogenesis of mania and open new treatment perspectives.

Methylphenidate treatment leads to abnormalities on krebs cycle enzymes in the brain of young and adult rats

Studies have shown a relationship between energy metabolism and methylphenidate (MPH); however, there are no studies evaluating the effects of MPH in Krebs cycle. So, we investigated if MPH treatment could alter the activity of citrate synthase (CS), malate dehydrogenase (MD), and isocitrate dehydrogenase (ID) in the brain of young and adult Wistar rats. Our results showed that MPH (2 and 10 mg/kg) reduced CS in the striatum and prefrontal cortex (PF), with MPH at all doses in the cerebellum and hippocampus after chronic treatment in young rats. In adult rats the CS was reduced in the cerebellum after acute treatment with MPH at all doses, and after chronic treatment in the PF and cerebellum with MPH (10 mg/kg), and in the hippocampus with MPH (2 and 10 mg/kg). The ID decreased in the hippocampus and striatum with MPH (2 and 10 mg/kg), and in the cortex (10 mg/kg) after acute treatment in young rats. In adult rats acute treatment with MPH (2 and 10 mg/kg) reduced ID in the cerebellum, and with MPH (10 mg/kg) in the cortex; chronic treatment with MPH (10 mg/kg) decreased ID in the PF; with MPH (2 and 10 mg/kg) in the cerebellum, and with MPH at all doses in the hippocampus. The MD did not alter. In conclusion, our results suggest that MPH can alter enzymes of Krebs cycle in brain areas involved with circuits related with attention deficit hyperactivity disorder; however, such effects depend on age of animal and treatment regime.

Occupational issues of adults with ADHD

BACKGROUND

ADHD is a common neurodevelopmental disorder that persists into adulthood. Its symptoms cause impairments in a number of social domains, one of which is employment. We wish to produce a consensus statement on how ADHD affects employment.

METHODS

This consensus development conference statement was developed as a result of a joint international meeting held in July 2010. The consensus committee was international in scope (United Kingdom, mainland Europe, United Arab Emirates) and consisted of individuals from a broad range of backgrounds (Psychiatry, Occupational Medicine, Health Economists, Disability Advisors). The objectives of the conference were to discuss some of the occupational impairments adults with ADHD may face and how to address these problems from an inclusive perspective. Furthermore the conference looked at influencing policy and decision making at a political level to address impaired occupational functioning in adults with ADHD and fears around employing people with disabilities in general.

RESULTS

The consensus was that there were clear weaknesses in the current arrangements in the UK and internationally to address occupational difficulties. More so, Occupational Health was not wholly integrated and used as a means of making positive changes to the workplace, but rather as a superfluous last resort that employers tried to avoid. Furthermore the lack of cross professional collaboration on occupational functioning in adults with ADHD was a significant problem.

CONCLUSIONS

Future research needs to concentrate on further investigating occupational functioning in adults with ADHD and pilot exploratory initiatives and tools, leading to a better and more informed understanding of possible barriers to employment and potential schemes to put in place to address these problems.

Investigation of the ZNF804A gene polymorphism with genetic risk for bipolar disorder in attention deficit hyperactivity disorder

BACKGROUND

Genome-wide association studies (GWAS) have been conducted on many psychiatric disorders. Evidence from large GWAS indicates that the single nucleotide polymorphism (SNP) rs1344706 in the zinc-finger protein 804A gene (ZNF804A) is associated with psychotic disorders including bipolar disorder and schizophrenia. One study also found significant association between rs1344706 and the executive control network of attention. In this study we examine the role of the rs1344706 polymorphism that previously showed association with BD and is known to alter expression of the gene in two clinical family-based ADHD samples from the UK and Taiwan.

FINDINGS

To investigate the association between rs1344706 and ADHD, two family samples of ADHD probands from the United Kingdom (n = 180) and Taiwan (n = 212) were genotyped using TaqMan SNP genotyping assays and analysed using within-family transmission disequilibrium test. No significant associations were found between rs1344706 polymorphism and ADHD in either of the samples from Taiwan (P = 0.91) and UK (P = 0.41). Even combining the two datasets together the A allele of rs1344706 SNP was still not significantly over-transmitted to affected probands (P = 0.50). Furthermore, there was no evidence of association with the specific symptoms subgroups of inattention or hyperactivity-impulsivity.

CONCLUSIONS

In this study we used family-based ADHD data in the UK and Taiwanese population to test for an association between rs1344706 SNP in the ZNF804A gene and ADHD. Results showed no significant association of rs1344706 with ADHD in UK and Taiwanese samples.

Further evidence that pediatric-onset bipolar disorder comorbid with ADHD represents a distinct subtype: results from a large controlled family study

We used familial risk analysis to clarify the diagnostic comorbidity between pediatric BP-I disorder and ADHD, testing the hypothesis that pediatric-BP-I disorder comorbid with ADHD represents a distinct subtype. Structured diagnostic interviews were used to obtain DSM-IV psychiatric diagnoses on first-degree relatives (n = 726) of referred children and adolescents satisfying diagnostic criteria for BP-I disorder (n = 239). For comparison, diagnostic information on the first-degree relatives (N = 511) of non-bipolar ADHD children (N = 162) and the first degree relatives (N = 411) of control children (N = 136) with neither ADHD nor BP-I disorder were examined. BP-I disorder and ADHD in probands bred true irrespective of the comorbidity with the other disorder. We also found that the comorbid condition of BP-I disorder plus ADHD also bred true in families, and the two disorders co-segregated among relatives. This large familial risk analysis provides compelling evidence that pediatric BP-I disorder comorbid with ADHD represents a distinct familial subtype.

The impact of cyclothymic temperament in adult ADHD

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) is a prevalent neurodevelopmental disorder in children and adults. Many ADHD patients experience affective symptoms that resemble the cyclothymic temperament trait, which is suggested to be a part of the bipolar spectrum. However, the relationship between adult ADHD and cyclothymic temperament has never been systematically studied.

METHODS

A sample of 586 clinically diagnosed Norwegian adult ADHD patients and 721 population derived controls responded to the 21-item cyclothymic subscale of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego auto-questionnaire (TEMPS-A). Self-reported data on psychiatric symptoms, comorbidity, educational and occupational level, and known comorbidity in family members, including bipolar disorder, was also obtained.

RESULTS

The mean TEMPS-A scores were 13.0 for patients and 4.6 for controls (p<0.001), and 71% of the patients compared to 13% of the controls were classified as having a cyclothymic temperament (TEMPS score ≥11 points). Among ADHD patients, cyclothymic temperament was strongly associated with more childhood and adult ADHD symptoms, lower educational and occupational achievements and increased psychiatric comorbidity, including bipolar disorder (10%). In addition, 49% screened positive on the Mood Disorder Questionnaire.

LIMITATIONS

Although the cyclothymic TEMPS-A scale has been used in clinical settings in Norway for many years, it has not yet been officially validated.

CONCLUSIONS

Cyclothymic temperament is highly prevalent in adults with ADHD, and this characterises a subgroup of more psychiatrically impaired individuals, possibly reflecting an underlying affective instability with a pathophysiology closer to the bipolar spectrum disorders.

ADHD comorbidity can matter when assessing cortical thickness abnormalities in patients with bipolar disorder

OBJECTIVES

Attention-deficit hyperactivity disorder (ADHD) is prevalent in patients with bipolar disorder (BP), but very few studies consider this when interpreting magnetic resonance imaging findings. No studies, to our knowledge, have screened for or controlled for the presence of ADHD when examining cortical thickness in patients with BP. We used a 2 × 2 design to evaluate the joint effects of BP and ADHD on cortical thickness and uncover the importance of ADHD comorbidity in BP subjects.

METHODS

The study included 85 subjects: 31 healthy controls, 17 BP-only, 19 ADHD-only, and 18 BP/ADHD. All patients with BP were subtype I, euthymic, and not taking lithium. Groups did not differ significantly in age or gender distribution. We used cortical thickness measuring tools combined with cortical pattern matching methods to align sulcal/gyral anatomy across participants. Significance maps were used to check for both main effects of BP and ADHD and their interaction. Post-hoc comparisons assessed how the effects of BP on cortical thickness varied as a function of the presence or absence of ADHD.

RESULTS

Interactions of BP and ADHD diagnoses were found in the left subgenual cingulate and right orbitofrontal cortex, demonstrating that the effect of BP on cortical thickness depends on ADHD status.

CONCLUSIONS

Some brain abnormalities attributed to BP may result from the presence of ADHD. Diagnostic interactions were found in regions previously implicated in the pathophysiology of BP, making it vital to control for an ADHD comorbid diagnosis when attempting to isolate neural or genetic abnormalities specific to BP.

Attention-deficit/hyperactivity disorder in adults with bipolar disorder or major depressive disorder: results from the international mood disorders collaborative project

OBJECTIVE

Relatively few studies have evaluated the clinical implications of lifetime attention-deficit/hyperactivity disorder (ADHD) in adults with bipolar disorder or major depressive disorder (MDD). Herein, we sought to determine the prevalence as well as the demographic and clinical correlates of lifetime ADHD in persons with a mood disorder.

METHOD

The first 399 patients enrolled in the International Mood Disorders Collaborative Project (IMDCP) were evaluated for lifetime ADHD using the Mini-International Neuropsychiatric Interview-Plus (MINI-Plus) as the primary instrument to derive current and lifetime DSM-IV diagnoses. All analyses of variables of interest were conducted utilizing the MINI-Plus, the Adult ADHD Self-Report Scale-v1.1, and the Wender Utah Rating Scale-Short Form. The effect of ADHD on clinical presentation, course of illness variables, comorbidity, anamnesis, treatment, and outcome are reported. The IMDCP is a joint initiative of the Mood Disorders Psychopharmacology Unit at the University Health Network, University of Toronto, Toronto, Ontario, Canada, and the Cleveland Clinic Center for Mood Disorders Treatment and Research at Lutheran Hospital, Cleveland, Ohio. All data for this study were procured between January 2008 and January 2009.

RESULTS

The percentages of subjects with MDD or bipolar disorder meeting the DSM-IV criteria for lifetime adult ADHD were 5.4% and 17.6% (P < .001), respectively. Lifetime comorbid ADHD in both mood disorder populations was associated with earlier age at illness onset (MDD, P = .049; bipolar disorder, P = .005), a higher number of psychiatric comorbidities (eg, MDD and current panic disorder with agoraphobia [P = .002]; bipolar disorder and social phobia [P = .012]), and decreased quality of life (MDD, P = .018).

CONCLUSIONS

The overarching findings herein are that the adult ADHD phenotype is commonly reported by individuals with MDD or bipolar disorder and is associated with a greater illness burden and complexity.

Diacylglycerol kinase β knockout mice exhibit attention-deficit behavior and an abnormal response on methylphenidate-induced hyperactivity

Background

Diacylglycerol kinase (DGK) is an enzyme that phosphorylates diacylglycerol to produce phosphatidic acid. DGKβ is one of the subtypes of the DGK family and regulates many intracellular signaling pathways in the central nervous system. Previously, we demonstrated that DGKβ knockout (KO) mice showed various dysfunctions of higher brain function, such as cognitive impairment (with lower spine density), hyperactivity, reduced anxiety, and careless behavior. In the present study, we conducted further tests on DGKβ KO mice in order to investigate the function of DGKβ in the central nervous system, especially in the pathophysiology of attention deficit hyperactivity disorder (ADHD).

Methodology/Principal Findings

DGKβ KO mice showed attention-deficit behavior in the object-based attention test and it was ameliorated by methylphenidate (MPH, 30 mg/kg, i.p.). In the open field test, DGKβ KO mice displayed a decreased response to the locomotor stimulating effects of MPH (30 mg/kg, i.p.), but showed a similar response to an N-methyl-d-aspartate (NMDA) receptor antagonist, MK-801 (0.3 mg/kg, i.p.), when compared to WT mice. Examination of the phosphorylation of extracellular signal-regulated kinase (ERK), which is involved in regulation of locomotor activity, indicated that ERK1/2 activation induced by MPH treatment was defective in the striatum of DGKβ KO mice.

Conclusions/Significance

These findings suggest that DGKβ KO mice showed attention-deficit and hyperactive phenotype, similar to ADHD. Furthermore, the hyporesponsiveness of DGKβ KO mice to MPH was due to dysregulation of ERK phosphorylation, and that DGKβ has a pivotal involvement in ERK regulation in the striatum.

Working memory network alterations and associated symptoms in adults with ADHD and Bipolar Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) and Bipolar Disorder (BPD) co-occur frequently and represent a particularly morbid clinical form of both disorders, however underlying neural circuitry contributing to the comorbidity remain understudied. Our aim was to investigate functional brain circuitry during working memory in a group of participants who meet criteria for both disorders (ADHD + BPD), and to explore the relationship of symptoms of each disorder to brain function. We used fMRI to image brain activity in 18 male adults with both ADHD and BPD, and 18 healthy control participants matched one-to-one on age, sex, and handedness, while they performed a sequential letter N-back task. We investigated differences in activation between these groups, and also correlations of brain activity during the task to symptoms of ADHD and BPD independently. We found significant hypoactivity in the subjects with ADHD + BPD vs. controls across frontal and parietal regions, and further, found that BPD and ADHD symptoms related to activity in anatomically distinct regions that were respectively characterized by activation and suppression during task. We conclude that comorbid ADHD + BPD is associated with alterations across anterior and posterior nodes of the working memory network, and symptoms of each disorder are related to anatomically and functionally distinct brain regions.

The lifetime impact of attention deficit hyperactivity disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

The aim of the study was to present nationally representative data on the lifetime independent association between attention deficit hyperactivity disorder (ADHD) and psychiatric co-morbidity, correlates, quality of life and treatment seeking in the USA.

METHOD

Data were derived from a large national sample of the US population. Face-to-face surveys of more than 34 000 adults aged 18 years and older residing in households were conducted during the 2004-2005 period. Diagnoses of ADHD, Axis I and II disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV version.

RESULTS

ADHD was associated independently of the effects of other psychiatric co-morbidity with increased risk of bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, specific phobia, and narcissistic, histrionic, borderline, antisocial and schizotypal personality disorders. A lifetime history of ADHD was also associated with increased risk of engaging in behaviors reflecting lack of planning and deficient inhibitory control, with high rates of adverse events, lower perceived health, social support and higher perceived stress. Fewer than half of individuals with ADHD had ever sought treatment, and about one-quarter had ever received medication. The average age of first treatment contact was 18.40 years.

CONCLUSIONS

ADHD is common and associated with a broad range of psychiatric disorders, impulsive behaviors, greater number of traumas, lower quality of life, perceived social support and social functioning, even after adjusting for additional co-morbidity. When treatment is sought, it is often in late adolescence or early adulthood, suggesting the need to improve diagnosis and treatment of ADHD.

Aims and results of the NIMH systematic treatment enhancement program for bipolar disorder (STEP-BD)

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) was funded as part of a National Institute of Mental Health initiative to develop effectiveness information about treatments, illness course, and assessment strategies for severe mental disorders. STEP-BD studies were planned to be generalizable both to the research knowledge base for bipolar disorder and to clinical care of bipolar patients. Several novel methodologies were developed to aid in illness characterization, and were combined with existing scales on function, quality of life, illness burden, adherence, adverse effects, and temperament to yield a comprehensive data set. The methods integrated naturalistic treatment and randomized clinical trials, which a portion of STEP-BD participants participated. All investigators and other researchers in this multisite program were trained in a collaborative care model with the objective of retaining a high percentage of enrollees for several years. Articles from STEP-BD have yielded evidence on risk factors impacting outcomes, suicidality, functional status, recovery, relapse, and caretaker burden. The findings from these studies brought into question the widely practiced use of antidepressants in bipolar depression as well as substantiated the poorly responsive course of bipolar depression despite use of combination strategies. In particular, large studies on the characteristics and course of bipolar depression (the more pervasive pole of the illness), and the outcomes of treatments concluded that adjunctive psychosocial treatments but not adjunctive antidepressants yielded outcomes superior to those achieved with mood stabilizers alone. The majority of patients with bipolar depression concurrently had clinically significant manic symptoms. Anxiety, smoking, and early age of bipolar onset were each associated with increased illness burden. STEP-BD has established procedures that are relevant to future collaborative research programs aimed at the systematic study of the complex, intrinsically important elements of bipolar disorders.

DIRAS2 is associated with adult ADHD, related traits, and co-morbid disorders

Several linkage analyses implicated the chromosome 9q22 region in attention deficit/hyperactivity disorder (ADHD), a neurodevelopmental disease with remarkable persistence into adulthood. This locus contains the brain-expressed GTP-binding RAS-like 2 gene (DIRAS2) thought to regulate neurogenesis. As DIRAS2 is a positional and functional ADHD candidate gene, we conducted an association study in 600 patients suffering from adult ADHD (aADHD) and 420 controls. Replication samples consisted of 1035 aADHD patients and 1381 controls, as well as 166 families with a child affected from childhood ADHD. Given the high degree of co-morbidity with ADHD, we also investigated patients suffering from bipolar disorder (BD) (n=336) or personality disorders (PDs) (n=622). Twelve single-nucleotide polymorphisms (SNPs) covering the structural gene and the transcriptional control region of DIRAS2 were analyzed. Four SNPs and two haplotype blocks showed evidence of association with ADHD, with nominal p-values ranging from p=0.006 to p=0.05. In the adult replication samples, we obtained a consistent effect of rs1412005 and of a risk haplotype containing the promoter region (p=0.026). Meta-analysis resulted in a significant common OR of 1.12 (p=0.04) for rs1412005 and confirmed association with the promoter risk haplotype (OR=1.45, p=0.0003). Subsequent analysis in nuclear families with childhood ADHD again showed an association of the promoter haplotype block (p=0.02). rs1412005 also increased risk toward BD (p=0.026) and cluster B PD (p=0.031). Additional SNPs showed association with personality scores (p=0.008-0.048). Converging lines of evidence implicate genetic variance in the promoter region of DIRAS2 in the etiology of ADHD and co-morbid impulsive disorders.

Symptoms and behaviors prior to the first major affective episode of bipolar II disorder. An exploratory study

BACKGROUND

Few studies have investigated the initial prodrome of bipolar disorders, and none has explicitly addressed bipolar II disorder (BD-II). We explored symptoms and behaviors preceding the first major affective episode (FMAE) of BD-II to generate hypotheses concerning possible clinical targets for early intervention.

METHODS

In-depth interviews of 15 BD-II patients and 22 family informants were carried out. Clinical diagnoses were reassessed. The textual data of transcribed interviews were analyzed utilizing qualitative methodology supplemented by quantitative analyses.

RESULTS

All patients experienced clinically significant symptoms and behaviors at an average of more than a decade before the FMAE. Anxiety and depression-type symptoms were the most common. Two distinct subgroups were identified based on prominent and enduring personal characteristics prior to the FMAE. The individuals in one of the subgroups were described as very well-functioning, whereas the individuals in the other subgroup were characterized by neurocognitive deficits, relatively low academic and social functioning, and pronounced irritability and aggressiveness. Furthermore, it is possible that these individuals experience earlier prodromal symptom onset, earlier FMAEs, and more symptoms than individuals without these characteristics.

LIMITATIONS

This is a retrospective and hypothesis-generating qualitative study. The hypotheses generated need to be tested in future studies.

CONCLUSIONS

Prodromal clinical phenomenology is too nonspecific to predict the occurrence of the FMAE of BD-II. However, identifiable subgroups may exist. We hypothesize that neurocognitive deficits together with pronounced irritability and aggressiveness may constitute a vulnerability marker for a subgroup of individuals who subsequently develop BD-II. This subgroup may be of potential interest for early identification.

Distinguishing symptoms of ADHD from other psychiatric disorders in the adult primary care setting

Attention-deficit/hyperactivity disorder (ADHD) is frequently misdiagnosed or undiagnosed in adults. Owing to the relatively recent recognition of adult ADHD as a valid mental disorder and its overlapping symptomatology with other conditions, primary care physicians often fail to screen for ADHD in patients who present with inattention, impulsivity, and hyperactivity. A substantial proportion of adults with ADHD also have psychiatric comorbidities. Physicians need to recognize the ways in which ADHD symptoms are expressed in adults and distinguish them from symptoms of other disorders, including mood, anxiety, and substance abuse disorders.

Neuropsychological functioning in adult bipolar disorder and ADHD patients: a comparative study

Bipolar disorder (BD) and adult attention deficit hyperactivity disorder (ADHD) usually manifest with shared clinical symptoms, proving quite challenging to thoroughly differentiate one from another. Previous research has characterized these two disorders independently, but no study compared both pathologies from a neuropsychological perspective. The aim of this study was to compare the neuropsychological profile of adult ADHD and BD with each other and against a control group, in order to understand the way in which comprehensive cognitive assessment can contribute to their discrimination as distinct clinical entities as well as their differential diagnosis. All groups were successfully matched for age, sex, years of education, and premorbid IQ. Participants were assessed with an extensive neuropsychological battery evaluating multiple domains. Compared to controls, BD patients had a poorer performance on immediate verbal memory tasks. Both clinical groups exhibited significantly lower scores than controls on the recognition phase of verbal and non-verbal memory tasks, as well as on a task of executive functioning with high working memory demand. Noticeably, however, ADHD had significantly better performance than BD on the recognition phase of both the Rey list memory task and the Rey Figure. The better performance of ADHD patients over BD may reflect the crucial role of the executive component on their memory deficits and gives empirical support to further differentiate the neuropsychological profile of BD and adult ADHD patients in clinical practice.

Beyond the serotonin hypothesis: mitochondria, inflammation and neurodegeneration in major depression and affective spectrum disorders

For many years, a deficiency of monoamines including serotonin has been the prevailing hypothesis on depression, yet research has failed to confirm consistent relations between brain serotonin and depression. High degrees of overlapping comorbidities and common drug efficacies suggest that depression is one of a family of related conditions sometimes referred to as the "affective spectrum disorders", and variably including migraine, irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia and generalized anxiety disorder, among many others. Herein, we present data from many different experimental modalities that strongly suggest components of mitochondrial dysfunction and inflammation in the pathogenesis of depression and other affective spectrum disorders. The three concepts of monoamines, energy metabolism and inflammatory pathways are inter-related in many complex manners. For example, the major categories of drugs used to treat depression have been demonstrated to exert effects on mitochondria and inflammation, as well as on monoamines. Furthermore, commonly-used mitochondrial-targeted treatments exert effects on mitochondria and inflammation, and are increasingly being shown to demonstrate efficacy in the affective spectrum disorders. We propose that interactions among monoamines, mitochondrial dysfunction and inflammation can inspire explanatory, rather than mere descriptive, models of these disorders.

Early-onset bipolar disorder: how about visual-spatial skills and executive functions?

Early-onset bipolar disorder is an impairing condition that is strongly associated with genetic inheritance. Neurocognitive deficits are core traits of this disorder which seem to be present in both young and adult forms. Deficits in verbal memory and attention are persistent within euthymic phases in bipolar adults, adolescents, and children. In younger samples, including type I or II and not otherwise specified patients, executive functions are not widely impaired and the existence of visual-spatial deficits remains unclear. The main aim of this study was to compare the neurocognitive performance in young stabilized type I or II bipolar patients and healthy controls. Fifteen medicated adolescents with bipolar disorder and 15 healthy adolescents, matched in age and gender, were compared on visual-spatial skills (reasoning, memory, visual-motor accuracy) and executive functioning (attention and working memory, set-shifting, inhibition) using t-tests and MANCOVA. Correcting for verbal competence, MANCOVA showed that patients performed significantly worse than controls in letters and numbers sequencing (P = 0.003), copy (P < 0.001) and immediate recall (P = 0.007) of the Rey Complex Figure Test, interference of the Stroop Color-Word Test (P = 0.007) and non-perseverative errors on the Wisconsin Card Sorting Test (P = 0.038). Impaired cognitive performance was found in young bipolar patients in working memory, visual-motor skills, and inhibitory control.

Prevalence and correlates of eating disorders in 875 patients with bipolar disorder

OBJECTIVE

Relatively little is known about the co-occurrence of bipolar and eating disorders. We therefore assessed the prevalence and clinical correlates of eating disorders in 875 patients with bipolar disorder.

METHOD

875 outpatients with DSM-IV bipolar I or II disorder were evaluated with structured diagnostic interviews and clinician- and self-administered questionnaires to determine bipolar and eating disorder diagnoses, other comorbid Axis I disorder diagnoses, and demographic and historical illness characteristics.

RESULTS

125 (14.3%) patients met DSM-IV criteria for at least one comorbid lifetime Axis I eating disorder, with binge eating disorder (N=77) being more common than bulimia nervosa (n=42) and anorexia nervosa (N=27). There were no significant eating disorder comorbidity differences between bipolar I and bipolar II patients. Presence of a lifetime comorbid eating disorder was associated with female gender, younger age, earlier age of onset of mood symptoms and of bipolar disorder, presentation in a mixed episode, greater number of prior mood episodes, history of rapid cycling and suicide attempts, greater mean BMI, obesity and severe obesity, and family history of depression, bipolar disorder, alcoholism, and drug abuse. When the three eating disorder groups were compared, lifetime anorexia nervosa was associated with normal weight and a lifetime anxiety disorder, lifetime bulimia nervosa was associated with overweight, and lifetime binge eating disorder was associated with obesity and severe obesity.

CONCLUSIONS

Patients with bipolar disorder, especially women, not infrequently have comorbid eating disorders, and this comorbidity is associated with an earlier age of onset and more severe course of bipolar illness.

Presence of co-morbid substance use disorder in bipolar patients worsens their social functioning to the level observed in patients with schizophrenia

Bipolar disorder has been considered to have a better prognosis than schizophrenia at the very beginning of its definition. However, psychosocial functioning may vary not only because of the characteristics of the disorder, but also of co-morbid conditions, especially regarding substance use disorder (SUD). The purpose of this study was to compare the social adjustment level of patients with bipolar disorder with that observed in patients with schizophrenia, taking into account substance use disorder (SUD). Forty subjects with schizophrenia and 40 subjects with bipolar disorder, in the stable phase of the disorder, were matched for age, gender and presence of SUD (DSM-IV criteria). The social adjustment scale was completed with socio-demographic and clinical characteristics of illness. The global adaptation score of bipolar patients with SUD was poorer than bipolar patients without SUD, but was not observed as being significantly different from that of patients with schizophrenia, with or without associated SUD. Suicide attempts, poor compliance, longer hospitalisation, shorter remissions and criminal activity were also more frequently observed in the group of patients with bipolar disorder and SUD. Presence of substance use disorder seems to have a greater weight than the main diagnostic (schizophrenia versus bipolar disorder) to predict worse social adjustment and poorer outcome.

Bipolar and ADHD Comorbidity: Both Artifact and Outgrowth of Shared Mechanisms

Published rates of comorbidity between pediatric bipolar disorder (PBD) and attention-deficit/hyperactivity disorder (ADHD) have been higher than would be expected if they were independent conditions, but also dramatically different across different studies. This review examines processes that could artificially create the appearance of comorbidity or substantially bias estimates of the ADHD-BPD comorbidity rate, including: categorization of dimensional constructs, overlap among diagnostic criteria, over-splitting, developmental sequencing, and referral or surveillance biases. Evidence also suggests some mechanisms for "true" BPD-ADHD comorbidity, including shared risk factors, distinct subtypes, and weak causal relationships. Keys to differential diagnosis include focusing on episodic presentation and non-overlapping symptoms unique to mania.

Risk factors predicting onset and persistence of subthreshold expression of bipolar psychopathology among youth from the community

OBJECTIVE

To examine factors increasing the risk for onset and persistence of subthreshold mania and depression.

METHOD

In a prospective cohort community study, the association between risk factors [a family history of mood disorders, trauma, substance use, attention-deficit/hyperactivity disorder (ADHD) and temperamental/personality traits] and onset of manic/depressive symptoms was determined in 705 adolescents. The interaction between baseline risk factors and baseline symptoms in predicting 8-year follow-up symptoms was used to model the impact of risk factors on persistence.

RESULTS

Onset of manic symptoms was associated with cannabis use and novelty seeking (NS), but NS predicted a transitory course. Onset of depressive symptoms was associated with a family history of depression. ADHD and harm avoidance (HA) were associated with persistence of depressive symptoms, while trauma and a family history of depression predicted a transitory course.

CONCLUSION

Different risk factors may operate during onset and persistence of subthreshold mania and depression. The differential associations found for mania and depression dimensions suggest partly different underlying mechanisms.

Attention deficit hyperactivity disorder in adults

OBJECTIVE

To examine available literature regarding attention deficit hyperactivity disorder (ADHD) in adults.

METHODS

An electronic literature search of peer-reviewed English language articles using MEDLINE (without time limits) was undertaken.

RESULTS

Symptoms of ADHD in adults exert a substantial negative impact on daily life, including work, social life and relationships. Co-morbidities are common, further impairing quality of life. Diagnosis of adult ADHD can be difficult, as current criteria require evidence of symptom onset before the age of 7 years and impact on activities typically undertaken by children. Drug therapy is the first-line treatment for adult ADHD, particularly stimulant medication. However, methylphenidate (MPH) immediate-release tablets require three or more times daily dosing, which can impact on compliance, while demonstrating a loss of symptomatic benefit later in the day. Extended-release preparations of MPH, mixed amphetamine salts and dexamphetamine can provide symptom control for 6-12 h and the non-stimulant atomoxetine has demonstrated benefit in reducing ADHD symptoms. These therapies are generally well tolerated, but may be associated with adverse effects on the cardiovascular system, which need to be further assessed in controlled clinical trials. Psychological therapy may be beneficial in adults who continue to experience clinically significant symptoms while receiving pharmacotherapy.

CONCLUSION

Further research in all areas of adult ADHD is urgently needed.

Adult ADHD and its comorbidities, with a focus on bipolar disorder

Attention deficit hyperactivity disorder (ADHD) is a syndrome that most often presents in childhood. However, the condition is also relatively common in adults, with prevalence rates reaching 5% in the general population, with more than half the children affected by ADHD retaining the condition during their adult years. While the disorder in children is most often described as a disorder involving hyperactivity and impulsiveness, ADHD presents with very different characteristics in adulthood, notably with less externalizing symptoms and with a higher rate of psychiatric comorbidities, including major depressive disorder, bipolar disorder (BD), anxiety disorders and substance abuse. This review will focus on the evidence relating to bipolar disorder BD and its potential link with ADHD, looking at epidemiological, familial and neuroimaging studies. The comorbid presentation of people suffering with ADHD and BD (ADHD/BD) is associated with a more severe disease course, more severe mood disorder symptoms, and lower functional scores. Importantly, the co-segregation of these two conditions makes ADHD diagnosis challenging because its symptoms are often mistakenly assumed to be part of BD. As a result, patients with comorbid ADHD/BD are under-diagnosed and under-treated. Optimal diagnosis, understanding and treatment of the comorbid condition are important, as ADHD/BD has been associated with significant functional impairment and suboptimal treatment responses when compared to ADHD or BD populations alone.

Attention deficit hyperactivity disorder in men and women newly committed to prison: clinical characteristics, psychiatric comorbidity, and quality of life

Attention deficit hyperactivity disorder (ADHD) is associated with comorbid psychiatric diagnoses and antisocial behaviors that contribute to criminality, yet studies of ADHD in offenders are few. The authors evaluate a random sample of 319 offenders using a version of the Mini International Neuropsychiatric Interview and Medical Outcome Survey Health Survey. ADHD was present in 68 subjects (21.3%). Offenders with ADHD were more likely to report problems with emotional and social functioning and to have higher suicide risk scores (p < .001). They also had higher rates of mood, anxiety, psychotic, and somatoform disorders. Antisocial and borderline personality disorders were also more common among offenders with ADHD. The authors conclude that ADHD is common in offenders and is associated with comorbid disorders, worse quality of life, and higher risk for suicidal behaviors. Its presence should alert prison staff that the offender is likely to require more intensive mental health services.

Bipolar disorder and comorbid attention deficit hyperactivity disorder. A distinct clinical phenotype? Clinical characteristics and temperamental traits

OBJECTIVES

It has been suggested that bipolar disorder (BD) with comorbid ADHD represents a distinct clinical phenotype of BD. There are no data regarding potential heterogeneity between BD subjects with a diagnosis of ADHD in childhood whose ADHD remitted in adulthood (cADHD-BD) vs. BD patients with persistent ADHD diagnosis in adulthood (aADHD-BD). This heterogeneity may constitute a confounder in investigations of the nature of the co-occurrence between BD and ADHD. The aim of this paper is to compare BD patients without ADHD, to those with aADHD-BD, and those with cADHD-BD on clinical and temperamental characteristics, hypothesizing that maladaptive temperament will be increased in BD subjects with a stable diagnosis of ADHD in adulthood compared to those whose ADHD remitted. We further hypothesize that maladaptive temperament will be associated with the severity of both illnesses.

METHODS

A total of 100 outpatients (aged 18-30 years) with BD in remission were included. The assessment of ADHD was made according to a procedure aimed to reduce potential recall biases. Subjects had to have a parent available and had never been treated with stimulants. Temperamental traits were assessed with the California Child Q-sort (CCQ) and the Early Adolescent Temperament Questionnaire (EATQ).

RESULTS

Rate of co-occurrence of ADHD-BD was 18% lifetime and 10% current diagnosis. Patients with ADHD-BD (aADHD-BD+cADHD-BD) reported a significantly earlier onset of mood disorder, higher number of previous mood episodes, and significantly higher impulsivity than BD patients without ADHD. aADHD-BD showed a significantly earlier BD onset, higher number of previous mood episodes, higher impulsivity, decreased Reactive Control and higher Negative Emotionality temperamental scores than cADHD patients.

CONCLUSION

Findings suggest that patients with aADHD-BD present a clinical phenotype distinct from that of patients with BD without ADHD or with a childhood ADHD diagnosis that remitted with the age. This appealing hypothesis of a BD-distinct phenotype that can be detected early due to its associated maladaptive temperamental traits requires further investigation in larger samples, supported by neuropsychological, genetic and imaging data.

Advancing bipolar disorder: key lessons from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

OBJECTIVE

To review the overall clinical research findings from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), the world's largest study of BD.

METHODS

STEP-BD was conducted from 1998 to 2005, enrolling participants (n = 4361) across 22 clinical sites in the United States. Each individual was followed for up to 2 years in naturalistic practice with blinded research assessments, while subgroups participated in randomized controlled trials (RCTs) for bipolar depression. The naturalistic database was used to examine the course of BD, comorbidity with other psychiatric disorders, and suicidality. Relevant studies in English, published from January 1, 1994, to May 31, 2009, were identified using computerized searches of electronic databases (PubMed, PsycINFO, and Cochrane Register of Clinical Trials), inspection of bibliographies, and review of other major reports.

RESULTS

One large RCT involving the addition of either paroxetine or bupropion to mood stabilizers in acute depression found neither more effective than placebo in achieving sustained recovery (8 weeks of euthymia). A second large RCT found intensive psychosocial interventions superior to a brief psychosocial intervention as an adjunct to medication in acute depression. A third small RCT found minimal effects of lamotrigine, risperidone, or inositol in refractory depression. Recovery was difficult to achieve, with subsyndromal symptoms or full relapse very common. Anxiety disorders and smoking in particular were treatable conditions that adversely affected the course of BD.

CONCLUSIONS

STEP-BD yielded numerous clinical and systems observations that provide fresh direction for research and treatment of BD, including setting new benchmarks for outcome and demonstrating the viability of large BD networks.

Phenomenology of racing and crowded thoughts in mood disorders: a theoretical reappraisal

BACKGROUND

Racing thoughts is a frequent symptom in mood disorders, particularly mixed depressive states. This paper aims to summarize our current knowledge about its phenomenology and frequency in the spectrum of mood disorders, and to offer a new theoretical framework.

METHODS

We made a selective review of original and review papers in Medline and PsychInfo database using the keywords "racing thoughts", "crowded thoughts" and "depressive mixed state" in conjunction with "mood disorders".

RESULTS

In the context of a hypomanic state, "racing thoughts" may appear as a result from an excessive production of thoughts, moving quickly from one to the other, and generating a sense of fluidity and pleasantness. In the context of depression, "racing thoughts" are phenomenologically different and better described as "crowded thoughts": they are not only characterized by too many thoughts occurring at the same time in the field of consciousness, but perceived as unpleasant and induce the feeling that ideas are difficult to catch. DISCUSSION AND CLINICAL RELEVANCE: We suggest that crowded thoughts might result from the mixture of a hypomanic component, with an accelerated production of new thoughts (constituting the main source of this symptom in hypomania), and a depressive component, with a deficit of inhibition of previous thoughts (hence making thoughts crowded rather than truly racing). This distinction could help better identify crowded thoughts, and consequently depressive mixed states, which has important implications for therapeutic management. It might also help to further disentangle the psychobiological processes which contribute to the complexity of mood disorders.

Evidence that bipolar disorder is the poor outcome fraction of a common developmental phenotype: an 8-year cohort study in young people

BACKGROUND

Reported rates of bipolar syndromes are highly variable between studies because of age differences, differences in diagnostic criteria, or restriction of sampling to clinical contacts.

METHOD

In 1395 adolescents aged 14-17 years, DSM-IV (hypo)manic episodes (manic and hypomanic episodes combined), use of mental health care, and five ordinal subcategories representing the underlying continuous score of (hypo)manic symptoms ('mania symptom scale') were measured at baseline and approximately 1.5, 4 and 10 years later using the Munich-Composite International Diagnostic Interview (DIA-X/M-CIDI).

RESULTS

Incidence rates (IRs) of both (hypo)manic episodes and (hypo)manic symptoms (at least one DSM-IV core symptom) were far higher (714/105 person-years and 1720/10(5) person-years respectively) than traditional estimates. In addition, the risk of developing (hypo)manic episodes was very low after the age of 21 years [hazard ratio (HR) 0.031, 95% confidence interval (CI) 0.0050-0.19], independent of childhood disorders such as attention deficit hyperactivity disorder (ADHD). Most individuals with hypomanic and manic episodes were never in care (87% and 62% respectively) and not presenting co-morbid depressive episodes (69% and 60% respectively). The probability of mental health care increased linearly with the number of symptoms on the mania symptom scale. The incidence of the bipolar categories, in particular at the level of clinical morbidity, was strongly associated with previous childhood disorders and male sex.

CONCLUSIONS

This study showed, for the first time, that experiencing (hypo)manic symptoms is a common adolescent phenomenon that infrequently predicts mental health care use. The findings suggest that the onset of bipolar disorder can be elucidated by studying the pathway from non-pathological behavioural expression to dysfunction and need for care.

Issues in the management of patients with complex attention-deficit hyperactivity disorder symptoms

Patients with attention-deficit hyperactivity disorder (ADHD) exhibit a wide range of symptoms related to functional impairment. Psychiatric comorbidities are highly prevalent among these patients, often emerging at an early age and persisting (or reoccurring) into adulthood. Among the most common types of comorbidities in children and adults are disruptive behaviour disorders such as oppositional defiant disorder and conduct disorder, mood disorders, anxiety disorders, and substance use disorders. The heterogeneous clinical presentation of ADHD, which also changes with maturation into adulthood, may often obscure the presence of psychiatric comorbidity. Co-occurring disorders frequently go undetected and lead to negative effects on psychosocial and long-term functional outcomes. As with uncomplicated ADHD, medication therapy combined with psychosocial interventions may be necessary. With comorbid disorders, two or more medications may be considered to appropriately manage both ADHD and the comorbid disorder. However, there are few studies that discuss combination medication treatments and there are no current US FDA-approved combined treatments for ADHD and comorbid conditions. This raises significant challenges and risks for poor tolerability and drug-drug interactions. Nevertheless, identification and appropriate treatment must be given a high priority for these highly vulnerable patients to derive optimal benefits from treatment.

A history of childhood attention-deficit hyperactivity disorder (ADHD) impacts clinical outcome in adult bipolar patients regardless of current ADHD

OBJECTIVE

The occurrence of comorbid attention-deficit hyperactivity disorder (ADHD) might have an impact of the course of the bipolar disorder.

METHOD

Patients with bipolar disorder (n = 159) underwent a comprehensive evaluation with respect to affective symptoms. Independent psychiatrists assessed childhood and current ADHD, and an interview with a parent was undertaken.

RESULTS

The prevalence of adult ADHD was 16%. An additional 12% met the criteria for childhood ADHD without meeting criteria for adult ADHD. Both these groups had significantly earlier onset of their first affective episode, more frequent affective episodes (except manic episodes), and more interpersonal violence than the bipolar patients without a history of ADHD.

CONCLUSION

The fact that bipolar patients with a history of childhood ADHD have a different clinical outcome than the pure bipolar group, regardless of whether the ADHD symptoms remained in adulthood or not, suggests that it represent a distinct early-onset phenotype of bipolar disorder.

Bipolar disorder and ADHD: Clinical concerns

During the past decade, a similar composite has emerged for both bipolar disorder and adult attention-deficit/hyperactive disorder (ADHD). First, both conditions have a relatively high prevalence, a low case detection, a protracted illness course, a high rate of comorbidity, multifactorial ideology, substantial heritable liability, and tremendous burden of illness in economic cost as well as interpersonal and vocational maladjustments. What has also been interesting along with these reports is that there has been emerging scientific studies implicating common brain regions and neural circuits subserving essential features of both conditions.