The evolving bipolar spectrum. Prototypes I, II, III, and IV

Distinguishing bipolar disorder from other psychiatric disorders in children

Pediatric onset bipolar disorder (BD) is a challenging diagnosis with potentially debilitating outcomes. This review aims to critically evaluate recently published literature relevant to the diagnosis of BD in youth, emphasizing interesting and important new findings characterizing pediatric BD and reporting updates in the diagnostic and statistical manual relevant to this disorder in youth. Challenges regarding the diagnosis of BD will be discussed, in addition to important distinctions with other childhood disorders, including other bipolar spectrum disorders; major depressive disorder; dysthymia; disruptive mood dysregulation disorder (DMDD); attention-deficit/hyperactivity disorder (ADHD) and other disruptive behavioral disorders; anxiety disorders, including post-traumatic stress disorder (PTSD); psychotic disorders; autism spectrum disorders; substance use disorders; and borderline personality disorder. The review concludes with a comment on past research limitations and future directions in the field.

Depression means different things: A qualitative study of psychiatrists' conceptualization of depression in the palliative care setting

OBJECTIVE

Medical practitioners conceptualize depression in different ways, which adds to the challenges of its diagnosis and treatment, as well as research in the palliative care setting. Psychiatric assessment is often considered the "gold standard" for diagnosis, therefore how psychiatrists conceptualize depression in this setting is pertinent. Our study aimed to investigate this issue.

METHOD

Psychiatrists working in palliative care in Australia were individually interviewed using a semistructured approach. Nine participants were interviewed to reach data saturation. Interview transcripts were analyzed for themes.

RESULTS

Three overarching themes were identified: (1) depression means different things; (2) depression is conceptualized using different models; and (3) depression is the same concept within and outside of the palliative care setting. Participants explicitly articulated the heterogeneous nature of depression and described a different breadths of concepts, ranging from a narrow construct of a depressive illness to a broader one that encompassed depressive symptoms and emotions. However, depressive illness was a consistent concept, and participants considered this in terms of phenotypic subtypes. Participants used three models (spectral, dichotomous, and mixed) to relate various depressive presentations.

SIGNIFICANCE OF RESULTS

Psychiatrists did not subscribe to a unitary model of depression but understood it as a heterogeneous concept comprised of depressive illness and other less clearly defined depressive presentations. Given the influence of psychiatric opinion in the area of depression, these findings may serve as a platform for further discussions to refine the concepts of depression in the palliative care setting, which in turn may improve diagnostic and treatment outcomes.

Lifetime mood spectrum symptoms among bipolar patients and healthy controls: a cross sectional study with the Mood Spectrum Self-Report questionnaire

BACKGROUND

The "spectrum" model has advantages for the conceptualization of mental disorders, representing a complementary approach to the currently available categorical systems. We carried out a study in order to assess lifetime mood symptoms among patients with bipolar disorder (BD) and healthy controls from a dimensional perspective.

METHODS

The Mood Spectrum Self-Report instrument (MOODS-SR) was administered to 101 bipolar patients (52 BD I, 32 BD II, and 17 BD NOS, 36 males/65 females, mean age+SD=36.10±13.34 years) and 38 healthy controls (16 males/22females, mean age+SD=35.18±13.70 years). The scores of the different MOOD-SR scales and subscales among patients and controls were compared using non-parametric tests (Mann-Whitney and Kruskal-Wallis).

RESULTS

Bipolar patients scored significantly higher than healthy controls on the total MOOD-SR scores (BD: mean±SD=98.65±22.17; HC: mean±SD=12.92±10.72; p<0.01) and all subdomains. Multiple comparisons revealed lower scores among controls when compared to each one of the subtypes of BD, also regarding the total scores and all subdomains (p<0.01). Comparisons across the different subtypes of BD revealed statistically significant higher scores among BD I patients when compared to BD II and BD NOS patients, only in regard to the total MOOD-SR scores (BD I: mean±SD=102.94±22.79; BD II: mean±SD=93.53±21.97; BD NOS: mean±SD= 94.88±18.68; p=0.03) and two subdomains: mood mania and energy mania.

CONCLUSIONS

These results, although preliminary, suggest that even though the MOODS-SR seems effective in distinguishing BD patients from HC, it is not as good in discriminating different subtypes of BD, especially in respect to lifetime depressive symptoms.

LIMITATIONS

Our sample size was small, and comprised by outpatients. The MOOD-SR measures only lifetime symptoms and does not take into account the progression of mood symptoms or the current mood state of patients.

Koukopoulos׳ diagnostic criteria for mixed depression: a validation study

BACKGROUND

Mixed depression (MxD) is one subtype of depressive experiences within the depressive spectrum. MxD definition is debated among experts. Koukopoulos׳ proposed diagnostic criteria focused primarily on psychic agitation, marked irritability, and intense mood lability as markers of a mixed depressive episode. The present study validates Koukopoulos׳ criteria as diagnostic for MxD.

METHODS

A sample of 435 patients from the International Mood Network (IMN), multi-center, international network of sites, and the Centro LucioBini of Rome was analyzed. Koukopoulos׳ criteria were assessed in all patients.

RESULTS

The most prevalent MxD criteria were "absence of psychomotor retardation" (84%), "mood lability or marked reactivity" (78%), and "psychic agitation or inner tension" (75%). Multivariable predictors of a MxD (+) diagnosis were: higher current CGI (OR=1.23, 95% CI 1.23, 2.84), lower rates of previous bipolar type I diagnosis (OR=0.54, 95% CI -3.28, -0.13), mixed symptoms on the index episode (OR=10.02, 95% CI 2.32, 24.12), rapid cycling course (OR=2.6 95% CI 1.45, 3.56), past substance abuse (OR=3.02, 95% CI 2.01, 5.67) and lower education status (OR=0.44, 95% CI -3.23, -0.98). This model showed a sensitivity of 76.4%, specificity of 86.3%, negative predictive value of 75%, and positive predictive value of 86%.

LIMITATIONS

An external validation of these criteria in an independent sample is warranted.

CONCLUSION

A broad definition of mixed depression was internally validated with multiple diagnostic validators and was sensitively and specifically predicted. Contrary to DSM-5, Koukopoulos׳ broad criteria include agitation, irritability and mood lability as core features.

A three-year longitudinal study of affective temperaments and risk for psychopathology

BACKGROUND

Affective temperaments are presumed to underlie bipolar psychopathology. The TEMPS-A has been widely used to assess affective temperaments in clinical and non-clinical samples. Cross-sectional research supports the association of affective temperaments and mood psychopathology; however, longitudinal research examining risk for the development of bipolar disorders is lacking. The present study examined the predictive validity of affective temperaments, using the TEMPS-A, at a three-year follow-up assessment.

METHODS

The study interviewed 112 participants (77% of the original sample) at a three-year follow-up of 145 non-clinically ascertained young adults psychometrically at-risk for bipolar disorders, who previously took part in a cross-sectional examination of affective temperaments and mood psychopathology.

RESULTS

At the reassessment, 29 participants (26%) met criteria for bipolar spectrum disorders, including 13 participants who transitioned into disorders during the follow-up period (14% of the originally undiagnosed sample). Cyclothymic/irritable and hyperthymic temperaments predicted both total cases and new cases of bipolar spectrum disorders at the follow-up. Cyclothymic/irritable temperament was associated with more severe outcomes, including DSM-IV-TR bipolar disorders, bipolar spectrum psychopathology, major depressive episodes, and substance use disorders. Hyperthymic temperament was associated with bipolar spectrum psychopathology and hypomania, whereas dysthymic temperament was generally unassociated with psychopathology and impairment.

LIMITATIONS

The present sample of young adults is still young relative to the age of onset of mood psychopathology.

CONCLUSIONS

These results provide the first evidence of the predictive validity of affective temperaments regarding risk for the development of bipolar psychopathology. Affective temperaments provide a useful construct for understanding bipolar psychopathology.

Lifetime experiences of hypomanic symptoms are associated with delayed and irregular sleep-wake cycle and seasonality in non-clinical adult samples

OBJECTIVES

Disturbances of the sleep-wake cycle and seasonality have been reported in patients with bipolar disorder (BD). Considering that BD seems to be a spectrum condition in terms of clinical and biological characteristics, circadian and seasonal rhythm related to BD could be detected in non-clinical individuals with subthreshold bipolarity. The aim of this study was to screen past hypomanic symptoms in non-clinical samples and investigate their association with deviated sleep-wake cycle and seasonality.

METHODS

Lifetime history of hypomanic symptoms was assessed with the Hypomania Checklist-32 (HCL-32). Circadian preference, variability of sleep-wake time and seasonal changes in mood and behavior were evaluated on a lifetime-basis in non-clinical adult samples (n=313), using the Composite Scale of Morningness (CSM), the Sleep Timing Questionnaire (STQ), and the Seasonal Pattern Assessment Questionnaire (SPAQ).

RESULTS

Two subdomains of hypomanic symptoms were identified through factor analysis of HCL-32, i.e., "active/elated" factor and "irritable/risk-taking" factor. The HCL-32 total score (p<0.001) and the "active/elated" factor score (p=0.028) were weakly correlated only with seasonality, whereas the "irritable/risk-taking" factor score was associated not only with seasonality (p<0.001), but also with evening preference (p<0.001) and irregularity of sleep-wake times (p=0.001~0.011).

CONCLUSION

Circadian and seasonal characteristics related to BD are also associated with a past history of hypomanic symptoms in non-clinical samples, especially "irritable/risk-taking" symptoms, suggesting the existence of subclinical presentation of BD and their biological traits.

A neurobiological hypothesis of treatment-resistant depression - mechanisms for selective serotonin reuptake inhibitor non-efficacy

First-line treatment of major depression includes administration of a selective serotonin reuptake inhibitor (SSRI), yet studies suggest that remission rates following two trials of an SSRI are <50%. The authors examine the putative biological substrates underlying "treatment resistant depression (TRD)" with the goal of elucidating novel rationales to treat TRD. We look at relevant articles from the preclinical and clinical literature combined with clinical exposure to TRD patients. A major focus was to outline pathophysiological mechanisms whereby the serotonin system becomes impervious to the desired enhancement of serotonin neurotransmission by SSRIs. A complementary focus was to dissect neurotransmitter systems, which serve to inhibit the dorsal raphe. We propose, based on a body of translational studies, TRD may not represent a simple serotonin deficit state but rather an excess of midbrain peri-raphe serotonin and subsequent deficit at key fronto-limbic projection sites, with ultimate compromise in serotonin-mediated neuroplasticity. Glutamate, serotonin, noradrenaline, and histamine are activated by stress and exert an inhibitory effect on serotonin outflow, in part by "flooding" 5-HT1A autoreceptors by serotonin itself. Certain factors putatively exacerbate this scenario - presence of the short arm of the serotonin transporter gene, early-life adversity and comorbid bipolar disorder - each of which has been associated with SSRI-treatment resistance. By utilizing an incremental approach, we provide a system for treating the TRD patient based on a strategy of rescuing serotonin neurotransmission from a state of SSRI-induced dorsal raphe stasis. This calls for "stacked" interventions, with an SSRI base, targeting, if necessary, the glutamatergic, serotonergic, noradrenergic, and histaminergic systems, thereby successively eliminating the inhibitory effects each are capable of exerting on serotonin neurons. Future studies are recommended to test this biologically based approach for treatment of TRD.

The bipolar spectrum: conceptions and misconceptions

OBJECTIVE

This review aims to address concerns about the potential overinclusiveness and vagueness of bipolar spectrum concepts, and also, concerns about the overlap between bipolar illness and borderline personality.

METHOD

Narrative review based on historical and empirical studies.

RESULTS

Bipolar disorder (BD) and major depressive disorder (MDD) came to be separate entities with the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III), in contrast to the Kraepelinian manic-depressive insanity (MDI) concept, which included both. The bipolar spectrum concept is a return to this earlier Kraepelinian perspective. Further, very different features differentiate the disease of bipolar illness (family history of bipolar illness, severe recurrent mood episodes with psychomotor activation) from the clinical picture of borderline personality (dissociative symptoms, sexual trauma, parasuicidal self-harm). The term 'disorder' obfuscates an ontological difference between diseases, such as manic-depressive illness, and clinical pictures, such as hysteria/post-traumatic stress disorder/dissociation/borderline personality.

CONCLUSIONS

Bipolar spectrum concepts are historically rooted in Kraepelin's manic-depressive illness concept, are scientifically testable, and can be clearly formulated. Further, they differ in kind from traumatic/dissociative conditions in ways that can be both historically and scientifically established.

Genotype variant associated with add-on memantine in bipolar II disorder

Memantine is a non-competitive N-methyl-d-asparate (NMDA) receptor antagonist with a mood-stabilizing effect. We investigated whether using valproic acid (VPA) plus add-on memantine to treat bipolar II disorder (BP-II) is more effective than using VPA alone (VPA + Pbo). We also evaluated, in BP-II patients, the association between the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism with treatment response to VPA + add-on memantine and to VPA + Pbo. In this randomized, double-blind, controlled 12 wk study, BP-II patients undergoing regular VPA treatments were randomly assigned to a group: VPA + Memantine (5 mg/day) (n = 115) or VPA + Pbo (n = 117). The Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) were used to evaluate clinical response during week 0, 1, 2, 4, 8 and 12. The genotypes of the BDNF Val66Met polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis. To adjust within-subject dependence over repeated assessments, multiple linear regression with generalized estimating equation methods was used to analyze the effects of the BDNF Val66Met polymorphism on the clinical performance of memantine. Both groups showed significantly decreased YMRS and HDRS scores after 12 wk of treatment; the differences between groups were non-significant. When stratified by the BDNF Val66Met genotypes, significantly greater decreases in HDRS scores were found in the VPA + memantine group in patients with the Val Met genotype (p = 0.004). We conclude that the BDNF Val66Met polymorphism influenced responses to add-on memantine by decreasing depressive symptoms in patients with BP-II.

Association between affective temperaments and regional gray matter volume in healthy subjects

BACKGROUND

Affective temperaments such as cyclothymic and hyperthymic temperaments have been regarded as potential antecedents of bipolar disorder but the neural substrates underlying these temperaments have not been identified. The aim of this study is to determine whether these temperaments are associated with specific neural substrates in regional brain morphology in healthy subjects.

METHODS

We conducted a cross-sectional neuroimaging study of 60 healthy subjects (30 males and 30 females) with affective temperaments. All participants underwent the Mini-International Neuropsychiatric Interview (MINI) to screen for the past and present psychiatric disorder. The scores of cyclothymic and hyperthymic temperaments were measured by the Temperament Scale of Memphis, Pisa, Paris and San Diego-Autoquestionnaire. We analyzed the association between voxel-based morphometry of the brain and these affective temperaments.

RESULTS

Subjects classified as having high cyclothymic scores had a significantly larger gray matter volume of the left medial frontal gyrus (MFG) than low cyclothymic subjects. High hyperthymic males also had significantly larger gray matter volume of the left MFG than low hyperthymic males, but there was no difference in females. Subjects with both high cyclothymic and high hyperthymic temperaments demonstrated significantly larger gray matter volume of the left MFG than their counterparts. Region of interest analysis revealed that peaks of these clusters showed a significant positive correlation of the regional volume with temperament scores.

LIMITATIONS

The subjects were relatively young and the number was relatively small. Due to the nature of a cross-sectional research design, we could not determine the causal relationship between temperament and the volume changes.

CONCLUSIONS

These findings suggest that cyclothymic and hyperthymic temperaments in healthy subjects may have their morphological basis in the left MFG.

Cognitive compromise in bipolar disorder with chronic cannabis use: cause or consequence?

This article briefly reviews the neuropsychological deficits associated with bipolar disorder and examines how substance abuse, in particular chronic cannabis use, may contribute to these. The focus of the article is cannabis, owing to its popularity in patients with bipolar disorder, although many studies focus on its use in conjunction with other substances. The findings are contextualized within bipolar disorder, examining functional outcome.

The prevalence of bipolar spectrum disorder in elderly patients with recurrent depression

PURPOSE

Despite a growing body of knowledge on bipolar spectrum disorder (BSD), relatively little is known about the clinical characteristics of BSD in elderly people. We investigated the prevalence of BSD in elderly patients with recurrent depression.

PATIENTS AND METHODS

A total of 65 elderly outpatients (≥60 years of age) who met the Diagnostic and Statistical Manual of Mental Disorders IV criteria for recurrent major depressive disorder participated in the study. BSD was diagnosed according to the criteria developed by Ghaemi et al and the Mood Disorder Questionnaire (MDQ) was used to assess bipolarity.

RESULTS

Of 65 subjects, eleven (16.9%) and 54 (83.1%) were diagnosed with BSD and unipolar depression, respectively. A total of 32.3% (n=22) had a positive screen for bipolar disorder, and we found a significant association between the BSD criteria and the criteria for a positive MDQ (P<0.001). Patients with BSD had a longer duration of illness (P=0.040) and more prior depressive episodes (P<0.001) than did those with unipolar depression. The BSD criteria of first-degree relative with bipolar disorder (P=0.030), antidepressant-induced hypomania (P=0.034), hyperthymic personality (P=0.001), and atypical depression (P=0.030) were highly associated with MDQ-positive patients.

CONCLUSION

Our results indicate that many depressed elderly patients have bipolar-related illness; moreover, some features of the depression are associated with bipolarity.

Affective temperaments and self-harm in adolescents: a cross-sectional study from a community sample

BACKGROUND

Adolescent self-harm (SH) is a major health problem potentially associated with poor outcomes including reduced life expectancy and risk of completed suicide in adulthood. Several studies point to the role of possible constitutional vulnerabilities that could predispose to this behavior. This study sets out to assess the relationship between SH and affective temperaments (AT) in adolescents.

METHODS

A cross-sectional sample of public school students (n=1713), with age limits between 12 and 20, was examined using anonymously completed self-report instruments including 'The Lifestyle & Coping Questionnaire' and the 'Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto-questionnaire' (TEMPS-A). SH was defined according to strict criteria through a two-stage procedure. Statistical significance of associations with SH for categorical variables was assessed in bivariate analysis. AT predictors of lifetime SH were examined in multivariate logistic regression analyses.

RESULTS

Lifetime SH was reported by 7.3%, being about three times more frequent in females. SH was associated, in both genders, with a significant deviation on depressive, cyclothymic and irritable dimensions of TEMPS-A. After multivariate logistic regression adjusted to family typology, smoking status, alcohol and drug consumption, only depressive temperament remained significantly associated as a predictor of SH in both genders.

LIMITATIONS

The use of self-rating instruments and the cross-sectional nature of the study limit our results.

CONCLUSIONS

Cyclothymic, irritable and especially depressive temperament might represent an important marker of vulnerability to SH in both male and female adolescents.

Add-on memantine to valproate treatment increased HDL-C in bipolar II disorder

Memantine is a noncompetitive NMDA receptor antagonist. As an augmenting agent, it has an antidepressant-like and mood-stabilizing effect. Memantine also reduces binge eating episodes and weight. We investigated whether memantine added on to valproate (VPA) is more effective than VPA alone for treating BP-II depression and improving the patient's metabolic profile. This was a randomized, double-blind, controlled study. BP-II patients undergoing regular VPA treatments were randomly assigned to one of two groups: VPA plus either add-on [1] memantine (5 mg/day) (n = 62) or [2] placebo (n = 73) for 12 weeks. The Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale (HDRS) were used to evaluate clinical response. Height, weight, fasting serum glucose, fasting total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides were followed regularly. Multiple linear regressions with generalized estimating equation methods were used to analyze the effects of memantine on clinical performance. There were no significant differences in pre- and post-treatment YMRS and HDRS scores between the VPA + memantine and VPA + placebo groups. Although there were no significant differences in the pre- and post-treatment values of most metabolic indices between the two groups, there was a significant increase of HDL-C (p = 0.009) in the VPA + memantine group compared with the VPA + placebo group. This increase remained significant even after controlling for body mass index (BMI) (p = 0.020). We conclude that add-on memantine plus VPA treatment of BP-II depression increases the blood level of HDL-C even in the absence of change in affective symptoms.

TRIAL REGISTRATION

NCT01188148 (https://register.clinicaltrials.gov/), Trial date was from 1st August, 2008 to 31st July, 2012 in National Cheng Kung University and Tri-Service General Hospital.

Association between the so-called "activation syndrome" and bipolar II disorder, a related disorder, and bipolar suggestive features in outpatients with depression

BACKGROUND

Activation syndrome (AS) is a cluster of symptoms listed by the US Food and Drug Administration as possible suicidality precursors during antidepressant treatment. We aimed to clarify whether AS is associated with bipolar II disorder (BP-II) and its related disorder, i.e., bipolar disorder not otherwise specified (BP-NOS), which are often mistreated as major depressive disorder (MDD), as well as bipolar suggestive features in outpatients with depression.

METHODS

The frequency of AS, bipolar suggestive features, and background variables in consecutive outpatients with a major depressive episode (MDE) due to BP-II/BP-NOS or MDD, who were naturalistically treated with antidepressants, were investigated and analyzed retrospectively.

RESULTS

Of 157 evaluable patients (46 BP-II/BP-NOS, 111 MDD), 39 (24.8%) experienced AS. Patients with BP-II/BP-NOS experienced AS significantly more frequently than patients with MDD (52.2% of BP-II/BP-NOS vs. 13.5% of MDD, p<0.01). Univariate analysis revealed that BP-II/BP-NOS diagnosis, cyclothymic temperament, early age at onset of first MDE, psychiatric comorbidities, and depressive mixed state (DMX) were significantly associated with AS development in the entire sample. Multivariate analysis revealed that BP-II/BP-NOS diagnosis and DMX were independent risk factors for AS.

LIMITATIONS

This is a retrospective and naturalistic study; therefore, patient selection bias could have occurred.

CONCLUSIONS

Cautious monitoring of AS is needed during antidepressant trials in patients with BP-II/BP-NOS. Clinicians should re-evaluate underlying bipolarity when they confront AS. Antidepressants should be avoided for treating a current DMX beyond the unipolar-bipolar dichotomy. Prospective studies are needed to confirm these results.

Hyperthymic temperament and brightness judgment in healthy subjects: involvement of left inferior orbitofrontal cortex

BACKGROUND

Hyperthymic temperament has been generally accepted as one of premorbid temperament of bipolar disorders. Since recent several studies indicate an association between illuminance and hyperthymic temperament, it can be hypothesized that more hyperthymic temperament subjects have a different threshold of brightness or darkness perception in comparison with less hyperthymic temperament subjects.

METHODS

We compared the threshold of brightness and darkness judgment between more and less hyperthymic subjects, and by simultaneously using fMRI we compared activations of whole brain between these subjects by two sample t-test. Furthermore, the association between the activations and hyperthymic temperament scores was analyzed.

RESULTS

Although there was no significant difference in the threshold of brightness or darkness judgment between more and less hyperthymic subjects, there was a significant difference in activations of the regions including left superior temporal gyrus, left inferior orbitofrontal cortex, left triangular inferior frontal gyrus and left insula between these subjects. Moreover, there was a significantly positive association between a cluster containing left inferior orbitofrontal cortex and hyperthymic temperament scores. The common activated region of these two analyses (categorical and continuous ones) was determined as left inferior orbitofrontal cortex.

LIMITATIONS

Limitation of the present study is a lack of brightness and darkness preference experiment between more and less hyperthymic subjects.

CONCLUSIONS

The present findings suggest that the threshold of brightness and darkness judgment is not different between more and less hyperthymic subjects, and that hyperthymic temperament may be associated with left inferior orbitofrontal cortex, which has been reported to be associated with bipolar disorder.

Affective temperaments and psychotropic adherence

BACKGROUND

It is generally accepted that a range of factors affect adherence to psychotropic medications. In the present study, we focused on the influence of affective temperaments (i.e., depressive, hyperthymic, cyclothymic, irritable, and anxious temperaments) on treatment adherence.

METHODS

Thirty-eight psychiatric consecutive inpatients were instructed to perform Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire version (TEMPS-A) for affective temperaments, Drug attitude inventory-10 (DAI-10) for concordance and persistence, and Visual Analogue Scale (VAS) for compliance.

RESULTS

VAS scores for dose compliance were significantly and negatively associated with irritable temperament scores whereas DAI-10 scores were significantly and positively associated with male gender, depressive temperament scores and hyperthymic temperament scores.

LIMITATIONS

The main limitations of the study were the relatively small number of subjects and the lack of objective method of adherence.

CONCLUSIONS

These findings suggest that patients with irritable temperament may be poor in their compliance with treatment, and that more education may be required for patients with irritable temperament in order to maintain good compliance. In contrast, men and patients with depressive or hyperthymic temperament have a relatively positive attitude towards medication.

Affective temperaments and hopelessness as predictors of health and social functioning in mood disorder patients: a prospective follow-up study

BACKGROUND

Affective disorders are highly disabling illnesses constituting a significant burden for the patients, their family and the society. Therefore, it would be very useful to find tools which carefully subtype these conditions and have a strong and reliable predictive power concerning the course of illness and health and social functioning. To date, the role of hopelessness and affective temperaments in the prediction of health and social functioning and the course of affective disorders has not been studied. Thus, the aim of the present study was to assess whether affective temperaments and hopelessness, measured during hospitalization, can be useful in the prediction of global functioning (the severity of the illness and the presence and severity of psychosocial problems) at follow-up in inpatients with major depressive disorder and bipolar disorder (BD).

METHODS

The patients were 96 consecutive patients admitted to the inpatient psychiatric clinic of Sant'Andrea Hospital between January 2009 and December 2010. All patients completed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A) and the Beck Hopelessness Scale on admission. They were contacted on average 14 months after discharge and were asked to complete a telephone interview based on the Health of the Nation Outcome Scales (HoNOS).

RESULTS

Two patients committed suicide before the follow-up assessment. Around 77% of the patients who completed the follow-up assessment were diagnosed as BD, and around 47% reported severe hopelessness. In the multivariate analyses, a factor derived from hopelessness and hyperthymia scores and unemployment, independently predicted severity of the illness and psychosocial functioning at the follow-up.

CONCLUSIONS

Screening for the affective temperament profile and for hopelessness has importance for designing the treatment and rehabilitation plans of affective disorder patients, as these variables are involved in the course and outcome of affective disorder patients and influence their health and social functioning.

Bipolar spectrum: a review of the concept and a vision for the future

This paper reviews the bipolar spectrum concept historically and empirically. It describes how the concept derives from Kraepelin, but was lost with DSM-III, which divided the broad manic-depressive illness concept, based on recurrent mood episodes of either polarity, to the bipolar versus unipolar dichotomy, based on allowing non-recurrent mood episodes of only one polarity. This approach followed the views of Karl Leonhard and other critics of Kraepelin. Thus post DSM-III American psychiatry is not neo-Kraepelinian, as many claim, but neo-Leonhardian. The bipolar spectrum approach, as advocated by Akiskal and Koukopoulos first, harkens back to the original broad Kraepelinian view of manic-depressive illness. The evidence for and against this approach is discussed, and common misconceptions, including mistaken claims that borderline personality is similar, are revealed and critiqued.

High-risk behaviour in hypomanic states

BACKGROUND

Risk-taking behaviours during hypomanic states are recognised, however the high-risk nature of some behaviours-including the potential for harm to both the individual and others-has not been detailed in the research literature. The current study examines risk-taking behaviours and their consequences (including their potential for impairment) in those with a bipolar II condition.

METHOD

Participants were recruited from the Sydney-based Black Dog Institute Depression Clinic. Diagnostic assignment of bipolar II disorder was based on clinician judgement and formal DSM-IV criteria. Participants completed a series of detailed questions assessing previous risk-taking behaviours during hypomanic states.

RESULTS

The sample comprised a total of 93 participants. Risk-taking behaviours during hypomania included spending significant amounts of money, excessive alcohol or drug use, dangerous driving and endangering sexual activities. Key consequences included interpersonal conflict, substantial financial burden and feelings of guilt, shame and remorse. Despite recognition of the risks and consequences associated with hypomanic behaviours, less than one-fifth of participants agreed that hypomania should be treated because of the associated risks.

LIMITATIONS

Study limitations included a cross-sectional design, reliance on self-report information, lack of controlling for current mood state, and comprised a tertiary referral sample that may be weighted to more severe cases. Findings may therefore not be generalisable and require replication.

CONCLUSIONS

Risk-taking behaviours during hypomania are common, and often linked with serious consequences. Whilst hypomania is often enjoyed and romanticised by patients-leading to ambivalence around treatment of such states-careful consideration of the impact of risk-taking behaviour is necessary, while the study raises the question as to what is 'impairment' in hypomania. Findings should advance clinical management by identifying those high-risk behaviours that would benefit from pre-emptive weighting in developing individual's wellbeing plans for managing the condition.

Inflammation's Association with Metabolic Profiles before and after a Twelve-Week Clinical Trial in Drug-Naïve Patients with Bipolar II Disorder

Inflammation is thought to be involved in the pathophysiology of bipolar disorder (BP) and metabolic syndrome. Prior studies evaluated the association between metabolic profiles and cytokines only during certain mood states instead of their changes during treatment. We enrolled drug-naïve patients with BP-II and investigated the correlation between changes in mood symptoms and metabolic indices with changes in plasma cytokine levels after 12 weeks of pharmacological treatment. Drug-naïve patients (n = 117) diagnosed with BP-II according to DSM-IV criteria were recruited. Metabolic profiles (cholesterol, triglyceride, HbA1C, fasting serum glucose, body mass index (BMI) and plasma cytokines (TNF-α, CRP, IL-6, and TGF-β) were measured at baseline and 2, 8, and 12 weeks post-treatment. To adjust within-subject dependence over repeated assessments, multiple linear regressions with generalized estimating equation methods were used. Seventy-six (65.0%) patients completed the intervention. Changes in plasma CRP were significantly associated with changes in BMI (P = 1.7E-7) and triglyceride (P = 0.005) levels. Changes in plasma TGF-β1 were significantly associated with changes in BMI (P = 8.2E-6), cholesterol (P = 0.004), and triglyceride (P = 0.006) levels. However, changes in plasma TNF-α and IL-6 were not associated with changes in any of the metabolic indices. Changes in Hamilton Depression Rating Scale scores were significantly associated with changes in IL-6 (P = 0.003) levels; changes in Young Mania Rating Scale scores were significantly associated with changes in CRP (P = 0.006) and TNF-α (P = 0.039) levels. Plasma CRP and TGF-β1 levels were positively correlated with several metabolic indices in BP-II after 12 weeks of pharmacological intervention. We also hypothesize that clinical symptoms are correlated with certain cytokines. These new findings might be important evidence that inflammation is the pathophysiology of clinical symptoms and metabolic disturbance in BP-II.

Trial Registration

ClinicalTrials.gov NCT01188148.

Affective temperaments: familiality and clinical use in mood disorders

BACKGROUND

The affective temperament profiles among patients with mood disorders may be an important parameter in the clinical evaluation of these patients. It has been proposed that temperament traits have familiality and may represent vulnerability markers to identify the risk to developing specific clinical type of mood disorders. To test these theories, measures of temperament were examined in bipolar patients (BP), unipolar major depressive patients (UP), healthy relatives of these patients (HRP) and normal controls (NC).

METHODS

We compared affective temperament scores, using the brief Brazilian version of TEMPS-A--TEMPS-Rio de Janeiro, between 90 BP, 88 UP, 132 HRP and 136 NC. A MANCOVA model was constructed. Dependent variables were the six subscales of the TEMPS-RJ (depressive, cyclothymic, irritable, hyperthymic, anxious and worrying temperaments). The effects of age and gender were adjusted as covariates. Furthermore, we performed a comparison between a subgroup of 68 HRP, relatives of bipolar patients (HRBP), and the remainders 64 HRP, relatives of unipolar patients (HRUP) and controls.

RESULTS

The clinical group (BP, UP) showed higher temperament scores than NC, except for hyperthymic scores. BP showed higher cyclothymic (p<0.001), hyperthymic (p<0.001) and lower anxious (p<0.01) temperament scores than UP. HRP showed lower scores than clinical groups. HRBP scored higher cyclothymic subscale than HRUP and NC groups.

LIMITATIONS

Bipolar I and II subjects were placed in the same group.

CONCLUSIONS

The cyclothymic and hyperthymic traits were associated with bipolarity in patients and cyclothymic temperament could be a characteristic trait of the healthy relatives of bipolar patients. Our data support that affective temperament might become a useful tool for clinical evaluation and research purposes in mood disorders.

A comprehensive analysis of features that suggest bipolarity in patients with a major depressive episode: which is the best combination to predict soft bipolarity diagnosis?

BACKGROUND

The study aimed to identify specific predictors of soft bipolarity (bipolar II disorder or bipolar disorder not otherwise specified) in depressed patients and to evaluate the global predictive performance of combinations of these predictors.

METHODS

Subjects included 199 patients with a major depressive episode (MDE) due to soft bipolarity or major depressive disorder. Independent predictors of soft bipolar diagnosis were extracted from 12 previously proposed bipolar features using multiple logistic regression analyses, and the global performance of the combination of these predictors was evaluated using a receiver operating characteristic (ROC) curve.

RESULTS

Recurrent MDEs, family history of bipolar disorders in first-degree relatives, cyclothymic temperament, early age at onset of first MDE, and depressive mixed state were independent predictors of soft bipolarity diagnosis [odds ratio (95% confidence interval): 11.22 (2.19-57.63), 8.82 (1.31-59.15), 7.32 (2.22-24.19), 6.22 (1.58-24.57), and 5.57 (1.91-16.30), respectively]. The area under the ROC curve for the relationship between soft bipolarity diagnosis and the number of these five predictors in each patient was 0.911 (highly accurate). The presence of one or more predictors in each patient resulted in highest sensitivity (92.5%) and good specificity (73.1%), whereas that of two or more predictors resulted in good sensitivity (70.0%) and highest specificity (97.5%) for soft bipolarity diagnosis.

LIMITATIONS

Structured/semistructured interviews were not used. Tools for temperament assessments were different between institutions.

CONCLUSIONS

A combination of these predictors was quite helpful for a precise diagnosis of soft bipolarity in patients with depression.

The relationship between affective temperaments, defensive styles and depressive symptoms in a large sample

BACKGROUND

Affective temperaments may represent heritable subclinical manifestations of mood disorders. The concept of ego defense mechanisms also has provided a model for the comprehension of mood psychopathology. The relationships between affective temperaments, defense styles and depressive symptoms remain unknown.

METHODS

We obtained data from a subsample of the Brazilian Internet Study on Temperament and Psychopathology (BRAINSTEP). Socio-demographic information was collected and participants completed the Affective and Emotional Temperament Composite Scale (AFECTS), the defense style questionnaire (DSQ-40) and the Symptom Checklist-90-Revised (SCL-90-R).

RESULTS

Among 9937 participants (4472 male; 45%), individuals with hyperthymic or euthymic temperaments were more likely to present a mature defense style, whereas an immature defensive style was predominantly observed in individuals with cyclothymic, volatile, depressive, dysphoric, euphoric and disinhibited temperaments. Higher immature and lower mature defense style scores were independently associated with depressive symptoms. Participants with either euthymic or hyperthymic temperaments were less likely to endorse depressive symptoms. Euthymic and hyperthymic temperaments moderated the correlations of mature/immature defenses with depressive symptoms.

LIMITATIONS

The data was collected from a convenience web-based sample. The study was cross-sectional.

CONCLUSIONS

Affective temperaments are associated with distinct defense styles. These two personality theories provide distinct but interacting views for comprehension of depressive psychopathology.

Hypomania spectrum disorders from adolescence to adulthood: a 15-year follow-up of a community sample

BACKGROUND

There is a lack of scientific knowledge about the broader spectrum of hypomania in adolescence and the course over time. To investigate this, we used longitudinal data spanning from adolescence to age 31 years.

METHOD

A community sample of adolescents (N=2300) was screened for depressive symptoms. Adolescents (16-17 years) with a positive screening and matched controls were interviewed with a structured diagnostic interview. A blinded follow-up assessment was conducted 15 years later, with a structured diagnostic interview covering the age span 19-31 years. Questions about treatment and family history were included.

RESULTS

Ninety adolescents (16-17 years) with a lifetime hypomania spectrum episode (3.9% of the total sample) were identified: 40 with fullsyndromal, 18 with brief-episode (<4 day), and 32 with subsyndromal (1-2 main symptoms and 1-2 additional symptoms) hypomania. The hypomania symptoms reported by the fullsyndromal and the brief-episode groups were similar, whereas the subsyndromal group per definition reported fewer symptoms. Of the 90 adolescents with a hypomania spectrum episode, 64 (71%) participated in the follow-up interview. Mania in adulthood was reported by 2 (3%), hypomania by an additional 4 (6%), and major depression by 38 (59%). Incidence of mood episodes in adulthood did not differ between the subgroups of hypomania spectrum.

LIMITATIONS

29% of the participants with hypomania spectrum were lost to follow-up.

CONCLUSION

The results indicate that only a small proportion of adolescents with hypomania spectrum episodes continue to have (hypo)mania in adulthood. Thus, maintenance or prophylactic treatment does not seem warranted for this group.

A new look at borderline personality disorder and related disorders: hyper-reactivity in the limbic system and lower centers

Borderline Personality Disorder (BPD) has been often described recently as a condition characterized by emotional dysregulation. Several other conditions share this attribute; namely, Bipolar Disorder (BD), Attention-Deficit/Hyperactivity Disorder (ADHD), Intermittent Explosive Disorder (IED), and Major Depressive Disorder (MDD). The dysregulation is not always in the same direction: BPD, BD, ADHD, and IED, for example, show over-reactivity or "hyperactivity" of emotional responses, whereas patients with MDD show emotional sluggishness and underactivity. At the clinical/descriptive level the "over-reactive" conditions appear separate and distinct. BPD constitutes a large domain within the psychopathological arena, appearing to contain within it a variety of etiologically diverse subtypes. Among the latter is a type of BPD linked closely with Bipolar Disorder; family studies of either condition show an overrepresentation of both: BPD patients with bipolar relatives; Bipolar patients with BPD relatives. A significant percentage of children with ADHD go on to develop either BPD or BD as they approach adulthood. If one shifts the spotlight to neurophysiology, as captured by MRI studies, however, it emerges that an important subtype of BPD, and also BD, ADHD, and IED-share common features of abnormalities and peculiarities in the limbic system and in the cortex, especially the prefrontal cortex. Deeper subcortical regions such as the periaqueductal gray may also be implicated in strong emotional reactions. The diversity of clinical "over-reactive" conditions appear to harken back to a kind of unity at the brain-change level. There are therapeutic implications here, such as the advisability of mood stabilizers in many cases of BPD, not just for Bipolar Disorder.

Latitude effect on bipolar temperaments

BACKGROUND

Growing evidence points to an association of daily light exposure and both mood and mood disorders. In recent studies, we demonstrated that higher illuminance of daytime may be positively associated with hyperthymic temperament while lower illuminance of daytime may be positively associated with cyclothymic temperament. However, it is not possible to determine whether hyperthymic or cyclothymic temperament induces higher or lower illuminance via heliotropism or non-heliotropism or whether higher or lower illuminance induces hyperthymic or cyclothymic temperament via light effects.

METHODS

In order to elucidate these questions, we sought to compare bipolar temperaments between residents who live in regions with varying levels of sunshine. Japan has 4 large islands -Hokkaido, Honshu, Shikoku, and Kyushu. Sapporo in Hokkaido and Oita in Kyushu located at 43° and 33° of latitude differ significantly in mean yearly sunshine. We investigated the data of 189 subjects (94 from Sapporo and 95 from Oita) including their data of Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto questionnaire version (TEMPS-A).

RESULTS

Multiple regression analyses revealed that latitude (Sapporo or Oita) effect predicted significant variance of hyperthymic temperament, but not of the other temperaments.

LIMITATIONS

The limitation of the present study was that there was a small but significant difference in age between the subjects of Sapporo and those of Oita. Therefore, we included age in the multiple regression analysis. Second, there were several climate factors other than sunshine which were significantly different between Sapporo and Oita. We cannot exclude these effects completely. Finally, we did not consider other factors such as psychosocial factors which might have affected bipolar temperaments.

CONCLUSIONS

The present findings suggest that relatively lower latitude (potentially via more sunshine) may induce hyperthymic temperament.

Interaction of the DRD3 and BDNF gene variants in subtyped bipolar disorder

OBJECTIVES

Bipolar disorder is a severe mental disorder with prominent genetic etiologic factors. Dopaminergic dysfunction has been implicated in the pathogenesis of bipolar disorder, which suggests that the dopamine D3 receptor gene (DRD3) is a strong candidate gene. The brain-derived neurotrophic factor (BDNF) gene has been implicated in the etiology of bipolar disorder. We examined the association between the BDNF Val66Met and DRD3 Ser9Gly polymorphisms with two subtypes of bipolar disorder: bipolar-I and -II. Because BDNF regulates DRD3 expression (1), we also examined possible interactions between these genes.

METHODS

We recruited 964 participants: 268 with bipolar-I, 436 with bipolar-II, and 260 healthy controls. The genotypes of the BDNF Val66Met and DRD3 Ser9Gly polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis.

RESULTS

Logistic regression analysis showed a significant main effect for the Val/Val genotype of the BDNF Val66Met polymorphism (P=0.020), which predicted bipolar-II patients. Significant interaction effects for the BDNF Val66Met Val/Val genotype and both DRD3 Ser9Gly Ser/Ser and Ser/Gly genotypes were found only in bipolar-II patients (P=0.027 and 0.006, respectively).

CONCLUSION

We provide initial evidence that the BDNF Val66Met and DRD3 Ser9Gly genotypes interact only in bipolar-II disorder and that bipolar-I and bipolar-II may be genetically distinct.

Comparative Study of Personality Traits in Patients with Bipolar I and II Disorder from the Five-Factor Model Perspective

OBJECTIVE

The distinguishing features of Bipolar I Disorder (BD I) from Bipolar II Disorder (BD II) may reflect a separation in enduring trait dimension between the two subtypes. We therefore assessed the similarities and differences in personality traits in patients with BD I and BD II from the perspective of the Five-Factor Model (FFM).

METHODS

The revised NEO Personality Inventory (NEO-PI-R) was administered to 85 BD I (47 females, 38 males) and 43 BD II (23 females, 20 males) patients. All included patients were in remission from their most recent episode and in a euthymic state for at least 8 weeks prior to study entry.

RESULTS

BDII patients scored higher than BD I patients on the Neuroticism dimension and its four corresponding facets (Anxiety, Depression, Self-consciousness, and Vulnerability). In contrast, BD II patients scored lower than BD I patients on the Extraversion dimension and its facet, Positive emotion. Competence and Achievement-striving facets within the Conscientiousness dimension were significantly lower for BD II than for BD I patients. There were no significant between-group differences in the Openness and Agreeableness dimensions.

CONCLUSION

Disparities in personality traits were observed between BD I and BD II patients from the FFM perspective. BD II patients had higher Neuroticism and lower Extraversion than BD I patients, which are differentiating natures between the two subtypes based on the FFM.

Collaborative role of the pediatrician in the diagnosis and management of bipolar disorder in adolescents

Despite the complexity of diagnosis and management, pediatricians have an important collaborative role in referring and partnering in the management of adolescents with bipolar disorder. This report presents the classification of bipolar disorder as well as interviewing and diagnostic guidelines. Treatment options are described, particularly focusing on medication management and rationale for the common practice of multiple, simultaneous medications. Medication adverse effects may be problematic and better managed with collaboration between mental health professionals and pediatricians. Case examples illustrate a number of common diagnostic and management issues.

Bipolar spectrum: Relevant psychological and biological factors

The bipolar spectrum is a concept which bridges bipolar I disorder and unipolar depression. As Kraepelin described, there may be continuity across mood disorders. If this is the case, why should we discriminate for drug choice For example, it is generally accepted that mood stabilizers should be used for the bipolar spectrum, whereas antidepressants are for unipolar depression. If these disorders are diagnostically continuous, it is possible that the same drug could be effective in treating both bipolar I disorder/spectrum and unipolar depression. To resolve this question, I would like to propose my hypothesis that there is an inflexion point which constitutes the boundary between the bipolar spectrum and unipolar depression. It is likely that this inflexion point consists of temperaments as, reportedly, there are many significant differences in the presence of various temperaments between the bipolar spectrum (bipolar II, II1/2 and IV) and unipolar depression. These findings suggest that temperaments could draw a boundary between the bipolar spectrum and unipolar depression. Moreover, it has been shown that certain temperaments may be associated with several biological factors and may be associated with drug response. As such, whilst the concept of the bipolar spectrum emphasizes continuity, it is the proposed inflexion point that discriminates drug responses between the bipolar spectrum and unipolar depression. At the moment, although hypothetical, I consider this idea worthy of further research.

COMT and BDNF interacted in bipolar II disorder not comorbid with anxiety disorder

Bipolar disorder (BP), especially bipolar II disorder (BP-II), is highly comorbid with anxiety disorder (AD). Monoaminergic dysfunction has been implicated in the pathogenesis of BP, it may be important to investigate genes such as the catechol-O-methyltransferase (COMT), involved in monoamine metabolism and brain-derived neurotrophic factor (BDNF) genes, modulating the monoamine system. We therefore examined the association of the COMT Val158Met and BDNF Val66Met polymorphisms with BP-II with and without comorbidity of AD, and possible interactions between these genes. Seven hundred and seventy-one participants were recruited: 314 with bipolar-II without AD, 117 with bipolar-II with AD, and 340 healthy controls. The genotypes of the COMT and BDNF polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis. Logistic regression analysis showed a significant effect of the COMT and the BDNF polymorphisms, and a significant interaction effect for the Val/Val genotypes of the BDNF Val66Met polymorphism and the COMsT Val158Met Val/Met and Met/Met genotypes (P=0.007, 0.048) discriminated between BP-II without AD patients and controls. Our findings provide initial evidence that the COMT and BDNF genes interact in bipolar-II without AD. Our findings suggest the involvement of dopaminergic pathway in the pathogenesis of bipolar-II.

Characteristics of bipolar disorder patients given antidepressants

Evidence concerning efficacy of antidepressants in bipolar disorder remains inconsistent and inconclusive. As the appropriate clinical use for such patients remains unclear, we characterized outpatients with bipolar disorders who were or were not treated with antidepressants. Clinical data were collected systematically from consecutive outpatients in 11 participating Argentine mood-disorder clinics in 2007-2008. Diagnoses met DSM-IV criteria, supported by structured interviews based on the MINI-500. Of 338 outpatients diagnosed with bipolar I (45.0%), II (29.3%), or not-otherwise-specified (NOS) (25.7%) disorder, 128 (37.9%) received antidepressants. Subjects given antidepressants or not did not differ significantly by presence or severity of current depression or being suicidal but were more likely to be women. Bipolar I disorder patients were three times less likely than types II or NOS to receive an antidepressant, with or without a mood-stabilizer or antimanic agent. Despite inconclusive evidence for efficacy and safety of antidepressants in various phases of bipolar disorders, 37.9% of such patients were receiving an antidepressant in 11 Argentine outpatient clinics. Antidepressant treatment was least likely with type I disorder and was independent of current depression and not associated with more use of mood-stabilizing or antimanic agents.

The Affective and Emotional Composite Temperament (AFECT) model and scale: a system-based integrative approach

Based on many temperament frameworks, here we propose an integration of emotional and affective temperaments (the AFECT model), forming a common substrate for mood, behavior, personality and part of cognition. Temperament is conceived as a self-regulated system with six emotional dimensions: volition, anger, inhibition, sensitivity, coping and control. The different combinations of these emotional dimensions result in 12 affective temperament types, namely depressive, anxious, apathetic, obsessive, cyclothymic, dysphoric, irritable, volatile, disinhibited, hyperthymic and euphoric. We also developed and validated a self-report scale to evaluate this construct, the Affective and Emotional Composite Temperament Scale (AFECTS).

METHODS

Exploratory and confirmatory psychometric analyses were performed with the internet version of the AFECTS in 2947 subjects (72% females, 35±11years old).

RESULTS

The factors interpreted as volition, anger, inhibition, sensitivity, coping and control showed very good Cronbach's alphas for 5 dimensions (0.87-0.90) and acceptable alpha for inhibition (0.75). Confirmatory factor analysis corroborated this 6-factor structure when considering inhibition as a second-order factor with fear and caution as first-order factors (SRMR=0.061; RMSEA=0.053). In the Affective section, all 12 categorical affective temperaments were selected in the categorical choice, with 99% of volunteers identifying at least one adequate description of their affective temperament.

LIMITATIONS

Only the internet version was used in a general population sample.

CONCLUSION

The AFECT model provides an integrated framework of temperament as a self-regulated system, with implications for mental health, psychiatric disorders and their treatment. The AFECTS showed good psychometric properties to further study this model.

Type A behaviour: a reappraisal of its characteristics in cardiovascular disease

AIMS

  The role of type A behaviour in cardiovascular disease is controversial and most of the research is based on self-rating scales. The aim of this study was to assess the prevalence of type A behaviour in cardiology and in other medical settings using reliable interview methods that reflect its original description.

METHODS

A sample of 1398 consecutive medical patients (198 with heart transplantation, 153 with a myocardial infarction, 190 with functional gastrointestinal disorders, 104 with cancer, 545 with skin disorders and 208 referred for psychiatric consultation) was administered the Structured Clinical Interview for the DSM-IV and the Structured Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR) which identifies 12 clusters, including type A behaviour.

RESULTS

A cardiac condition was present in 366 patients. There was a significant difference in the prevalence of type A behaviour in cardiovascular disease (36.1%) compared with other medical disorders (10.8%). Type A behaviour frequently occurred together with psychiatric and psychosomatic disturbances, particularly irritable mood, even though in the majority of cases it was not associated with DSM-IV diagnoses. Among cardiac patients, those with type A behaviour were less depressed, demoralised and worried about their illness.

CONCLUSIONS

Type A behaviour was found to occur in about a third of cases of patients with cardiovascular disease. Only in a limited number of cases was it associated with depression. It has a lifestyle connotation that may have important clinical consequences as to stress vulnerability and illness behaviour.

Evaluation of mood disorder patients in a primary care practice: measures of affective temperament, mental health risk factors, and functional health in a retrospective, descriptive study of 35 patients

OBJECTIVE

THE PURPOSE OF THIS RETROSPECTIVE, DESCRIPTIVE STUDY WAS TO EVALUATE PRIMARY CARE PATIENTS DIAGNOSED WITH A MOOD DISORDER ON THE BASIS OF THE FOLLOWING: (1) comorbid medical illnesses, (2) risk factors for mood disorders and longitudinal presence of symptoms, (3) presence of affective temperament, and (4) functional status and quality of life.

METHOD

Patients (N = 35) were a convenience sample diagnosed in the Mood Disorder Clinic (MDC), a family practice site-based mental health treatment consultation service. All study patients were assessed using a semistructured interview and diagnosed according to DSM-IV-TR criteria. Data were collected using both chart review and secondary analysis of a computerized touch-screen mood disorders database that included the 36-item Short-Form Medical Outcomes Study Health Survey (SF-36) and an affective temperament survey. The study was conducted from January 2000 through August 2000.

RESULTS

A total of 62 comorbid medical illnesses were present in this group of patients; only 2 patients had no comorbid illnesses. Psychiatric diagnoses included 25 cases (78.1%) of bipolar depression, 5 cases (15.6%) of unipolar or dysthymic depression, and 2 cases (6.3%) of nonmood or anxiety disorders. All patients (100%) had a positive family history for mood disorders or substance abuse. Twenty-four patients (70.6%) had onset of their depressive symptoms prior to age 21, and 11 patients (35.5%) had a positive history of sexual abuse. Affective temperaments were positive in the 30 patients who completed this section. SF-36 scale scores were predominantly below national norms.

CONCLUSION

The medical comorbidities in our study were expected; the positive family and individual histories for risk along with low SF-36 scores reflect the severity and chronicity of mood disorders in this population.

The ALDH2 and 5-HT2A genes interacted in bipolar-I but not bipolar-II disorder

OBJECTIVE

Clarifying the similarities and differences between the two most common subtypes of bipolar disorder, bipolar-I and bipolar-II, is essential for improving our understanding of them. Because the serotonergic system has been implicated in the pathogenesis of bipolar disorder, it may be important to investigate genes such as the aldehyde dehydrogenase 2 (ALDH2) and serotonin 2A receptor genes, which are involved in metabolizing serotonin and encoding serotonin receptors. We examined the association of the ALDH2 and 5-HT2A-A1438G polymorphisms with bipolar I and II and possible interactions between these genes.

METHODS

One thousand forty-nine participants were recruited: 249 with bipolar-I, 456 with bipolar-II, and 344 healthy controls. The genotypes of the ALDH2 and 5HT2A-A1438G polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis.

RESULTS

Logistic regression analysis showed a significant effect of the ALDH2 and the 5-HT2A-A1438G polymorphisms, and a significant interaction effect for the A/G genotypes of the 5-HT2A-A1438G polymorphism and the ALDH2*1*1 genotypes (p=0.004) discriminated between bipolar-I patients and controls without bipolar disorder. These polymorphisms, however, were not associated with bipolar-II disorder.

LIMITATIONS

The significant differences of age and gender between patients and controls limit the comparison, although statistical adjustments were made for them.

CONCLUSION

Our findings provide initial evidence that the ALDH2 and 5-HT2A genes interact in bipolar-I but not in bipolar-II disorder. Our findings suggest a unique genetic distinction between bipolar-I and bipolar-II.

The interaction between BDNF and DRD2 in bipolar II disorder but not in bipolar I disorder

Bipolar I (BP-I) and bipolar II (BP-II) disorders are the two most common subtypes of bipolar disorder. However, most studies have not differentiated bipolar disorder into BP-I and BP-II groups, for which the underlying etiology differentiating these two subtypes remains unclear. The genetic association between both subtypes is essential for improving our understanding. The dopamine D2 receptor/ankyrin repeat and kinase domain containing 1 (DRD2/ANKK1), one of the dopaminergic pathways, as well as the brain-derived neurotrophic factor (BDNF) gene, were reported as candidate genes in the etiology of bipolar disorder. Therefore, we examined the contribution of the BDNF and DRD2/ANKK1 genes and their interaction to the differentiation of BP-I and BP-II. Seven hundred ninety-two participants were recruited: 208 with BP-I, 329 with BP-II, and 255 healthy controls. The genotypes of the BDNF and DRD2/ANKK1 Taq1A polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis. A significant main effect for the Val/Val genotype of the BDNF Val66Met polymorphism predicted BP-II patients. The significant interaction effect for the Val/Val genotype of the BDNF Val66Met polymorphism and A1/A2 genotype of DRD2/ANKK1 Taq1A polymorphism was found only in BP-II patients. We provide initial evidence that the BDNF Val66Me and DRD2/ANKK1 Taq1A polymorphisms interact only in BP-II disorder and that BP-I and BP-II are genetically distinct.

Efficacy of pharmacotherapy in bipolar disorder: a report by the WPA section on pharmacopsychiatry

The current statement is a systematic review of the available data concerning the efficacy of medication treatment of bipolar disorder (BP). A systematic MEDLINE search was made concerning the treatment of BP (RCTs) with the names of treatment options as keywords. The search was updated on 10 March 2012. The literature suggests that lithium, first and second generation antipsychotics and valproate and carbamazepine are efficacious in the treatment of acute mania. Quetiapine and the olanzapine-fluoxetine combination are also efficacious for treating bipolar depression. Antidepressants should only be used in combination with an antimanic agent, because they can induce switching to mania/hypomania/mixed states/rapid cycling when utilized as monotherapy. Lithium, olanzapine, quetiapine and aripiprazole are efficacious during the maintenance phase. Lamotrigine is efficacious in the prevention of depression, and it remains to be clarified whether it is also efficacious for mania. There is some evidence on the efficacy of psychosocial interventions as an adjunctive treatment to medication. Electroconvulsive therapy is an option for refractory patients. In acute manic patients who are partial responders to lithium/valproate/carbamazepine, adding an antipsychotic is a reasonable choice. The combination with best data in acute bipolar depression is lithium plus lamotrigine. Patients stabilized on combination treatment might do worse if shifted to monotherapy during maintenance, and patients could benefit with add-on treatment with olanzapine, valproate, an antidepressant, or lamotrigine, depending on the index acute phase. A variety of treatment options for BP are available today, but still unmet needs are huge. Combination therapy may improve the treatment outcome but it also carries more side-effect burden. Further research is necessary as well as the development of better guidelines and algorithms for the step-by-step rational treatment.

The increasing frequency of mania and bipolar disorder: causes and potential negative impacts

The frequency of mania has not changed during the last century even with the development of new diagnostic criteria sets. More specifically, from the mid-1970s to 2000, the rate of mania (variably labeled major affective disorder-bipolar disorder and bipolar I disorder) was consistently identified in US and international studies as ranging from 0.4% to 1.6%. By the late 1990s to the 2000s, the prevalence reported by some researchers for bipolar disorders (I and II and others) was in the 5% to 7% and higher ranges. The purpose of this paper was to review explanations for this change and the potentially negative impacts on the field.

Kraepelin's concept of manic-depressive insanity: one hundred years later

Kraepelin's work is frequently cited and repeatedly interpreted as groundwork for the categorical classification of mental disorders. The scope of this paper is to present a fragment of Kraepelin's contribution to the nosology of manic-depressive illness from another point of view. Studying conscientiously the original text written by Emil Kraepelin more than one hundred years ago, the reader could conclude that the author's attitudes were more in line with numerous contemporaries who promote the dimensional approach to the classification in psychiatry and spectrum concept of mood disorders. This text is an attempt to inspire the reader to examine the original textbook.

The use of Mood Disorder Questionnaire, Hypomania Checklist-32 and clinical predictors for screening previously unrecognised bipolar disorder in a general psychiatric setting

Bipolar disorder is often unrecognised and misdiagnosed in the general psychiatric setting. This study compared the psychometric properties of the Mood Disorder Questionnaire (MDQ) and the Hypomania Checklist-32 (HCL-32), examined the clinical predictors of bipolar disorder and determined the best approach for screening previously unrecognised bipolar disorder in a general psychiatric clinic. A random sample of 340 non-psychotic outpatients with no previous diagnosis of bipolar disorder completed the MDQ and HCL-32 during their scheduled clinic visits. Mood and alcohol/substance use disorders were reassessed using a telephone-based Structured Clinical Interview for DSM-IV. We found that the HCL-32 had better psychometric performance and discriminatory capacity than the MDQ. The HCL-32's internal consistency and 4-week test-retest reliability were higher. The area under the curve was also greater than that of the MDQ at various clustering and impairment criteria. The optimal cut-off of the MDQ was co-occurrence of four symptoms with omission of the impairment criterion; for the HCL-32, it was 11 affirmative responses. Multivariable logistic regression found that bipolar family history was associated with an increased risk of bipolar disorder (odds ratio=4.93). The study showed that simultaneous use of the HCL-32 and bipolar family history was the best approach for detecting previously unrecognised bipolar disorder.

Bipolar temperaments and light

BACKGROUND

Converging lines of evidence have established a relationship between exposure to ambient light and both mood state and mood disorders. In view of the association between mood disorder and affective disposition, in this study, the relationship between temperament (depressive, cyclothymic, hyperthymic, irritable and anxious) and daily light exposure was closely examined.

METHODS

Fifty-six subjects completed the Japanese standardized version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto questionnaire version (TEMPS-A) and illuminance of daytime using actigraphy.

RESULTS

Cyclothymic temperament scores were significantly and negatively associated with illuminance of daytime whereas hyperthymic temperament scores were significantly and positively associated with illuminance of daytime.

LIMITATIONS

Sample size was relatively small and they were only healthy subjects and no patients.

CONCLUSIONS

The findings suggest that illuminance of daytime may be related to both cyclothymic and hyperthymic temperaments but that the associations lie in opposite directions. If this is the case, it seems important to consider individual patients' temperaments when light therapy is used to treat their depressive episode. Further studies are required to determine why and how these temperaments are associated with illuminance.

Low anxiety disorder comorbidity rate in bipolar disorders in Han Chinese in Taiwan

OBJECTIVES

Studies report high comorbidity of lifetime anxiety disorders with bipolar disorders in Western patients, but it is unclear in Taiwan. The authors explored the comorbidity of anxiety disorders in different bipolar disorder subtypes in Han Chinese in Taiwan.

METHODS

Three hundred twenty-five patients with bipolar disorder (bipolar I: 120; bipolar II: 205) disorder were recruited from two general medical outpatient services. They were evaluated and their diagnoses confirmed by a psychiatrist using the Chinese version of the Modified Schedule of Affective Disorder and Schizophrenia-Lifetime. The exclusion criteria were: any DSM-IV-TR Axis I diagnosis, other than bipolar disorder, being outside the 18-65-year-old age range, any other major and minor mental illnesses except anxiety disorder, any neurological disorders or organic mental disorders.

RESULTS

Thirty-two (26.7%) of patients were comorbid with lifetime anxiety disorder and bipolar I, 80 (39.0%) with lifetime anxiety disorder and bipolar II, 7 (5.8%) were comorbid with two or more anxiety disorders and bipolar I, and 27 (13.2%) with two or more anxiety disorders and bipolar II.

CONCLUSION

That more than twice as many bipolar II than bipolar I patients reported two or more anxiety disorders implies that the complication is more prevalent in bipolar II patients.

The influence of affective temperaments and psychopathological traits on the definition of bipolar disorder subtypes: a study on bipolar I Italian national sample

Affective temperament and psychopathological traits such as separation anxiety (SA) and interpersonal sensitivity (IPS) are supposed to impact on the clinical manifestation and on the course of Bipolar Disorder (BD); in the present study we investigated their influence on the definition of BD subtypes.

METHOD

: Among 106 BD-I patients with DSM-IV depressive, manic or mixed episode included in a multi-centric Italian study and treated according to the routine clinical practice, 89 (84.0%) were in remission after a follow-up period ranging from 3 to 6 months (Clinical Global Impression-BP [CGI-BP] <2). Remitting patients underwent a comprehensive evaluation including self-report questionnaires such as the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A) scale, Separation Anxiety Symptom Inventory (SASI), Interpersonal Sensitivity Measure (IPSM) and the Semi-structured interview for Mood Disorder (SIMD-R) administered by experienced clinicians. Correlation and factorial analyses were conducted on temperamental and psychopathological measures. Comparative analyses were conducted on different temperamental subtypes based on the TEMPS-A, SASI and IPSM profile.

RESULTS

: Depressive, cyclothymic and irritable TEMPS-A score and SASI and IPSM total scores were positively and statistically correlated with each other. On the contrary, hyperthymic temperament score was negatively correlated with depressive temperament and not significantly correlated with the other temperamental and psychopathological dimensions. The factorial analysis of the TEMPS-A subscales and SASI and IPSM total scores allowed the extraction of 2 factors: the cyclothymic-sensitive (explaining 46% of the variance) that included, as positive components, depressive, cyclothymic, irritable temperaments and SASI and IPSM scores; the hyperthymic (explaining the 19% of the variance) included hyperthymic temperament as the only positive component and depressive temperament and IPSM, as negative components. Dominant cyclothymic-sensitive patients (n=49) were more frequently females and reported higher number of depressive, hypomanic and suicide attempts when compared to the dominant hyperthymic patients (n=40). On the contrary, these latter showed a higher number of manic episodes and hospitalizations than cyclothymic-sensitive patients. The rates of first-degree family history for both mood and anxiety disorders were higher in cyclothymic-sensitive than in hyperthymic patients. Cyclothymic sensitive patients also reported more axis I lifetime co-morbidities with Panic Disorder/Agoraphobia and Social Anxiety Disorder in comparison with hyperthymics. As concerns axis II co-morbidity the cyclothymic-sensitive patients met more frequently DSM-IV criteria 1, 5 and 7 for borderline personality disorder than the hyperthymics. On the contrary, antisocial personality disorder was more represented among hyperthymic than cyclothymic patients, in particular for DSM-IV criteria 1 and 6.

LIMITATION

: No blind evaluation and uncertain validity of personality inventory.

CONCLUSION

: Our results support the view that affective temperaments influence the clinical features of BD in terms of both clinical and course characteristics, family history and axis I and II co-morbidities. Hypothetical temperamental subtypes as measured by TEMPS-A presented important interrelationships that permit to reliably isolate two fundamental temperamental disposition: the first characterized by rapid fluctuations of mood and emotional instability, and the second by hyperactivity, high level of energy and emotional intensity. Dominant cyclothymic and hyperthymic bipolar I patients reported important differences in terms of gender distribution, number and polarity of previous episodes, hospitalizations, suicidality, rates of co-morbid anxiety and personality traits and disorders. Our data are consistent with the hypothesis that affective temperaments, and in particular cyclothymia, could be utilized as quantitative, intermediate phenotypes in order to identify BD susceptibility genes.