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

Gene expression biomarkers of response to citalopram treatment in major depressive disorder

There is significant variability in antidepressant treatment outcome, with ∼30-40% of patients with major depressive disorder (MDD) not presenting with adequate response even following several trials. To identify potential biomarkers of response, we investigated peripheral gene expression patterns of response to antidepressant treatment in MDD. We did this using Affymetrix HG-U133 Plus2 microarrays in blood samples, from untreated individuals with MDD (N=63) ascertained at a community outpatient clinic, pre and post 8-week treatment with citalopram, and used a regression model to assess the impact of gene expression differences on antidepressant response. We carried out technical validation of significant probesets by quantitative reverse transcriptase PCR and conducted central nervous system follow-up of the most significant result in post-mortem brain samples from 15 subjects who died during a current MDD episode and 11 sudden-death controls. A total of 32 probesets were differentially expressed according to response to citalopram treatment following false discovery rate correction. Interferon regulatory factor 7 (IRF7) was the most significant differentially expressed gene and its expression was upregulated by citalopram treatment in individuals who responded to treatment. We found these results to be concordant with our observation of decreased expression of IRF7 in the prefrontal cortex of MDDs with negative toxicological evidence for antidepressant treatment at the time of death. These findings point to IRF7 as a gene of interest in studies investigating genomic factors associated with antidepressant response.

Longitudinal research on bipolar disorders

Longitudinal assessment of the course of major psychiatric disorders has been advanced by studies from onset, but only rarely have large numbers of patients with a range of psychotic and major affective disorders been studied simultaneously and systematically from illness-onset. The decade-long McLean-Harvard First Episode Project & International Consortium for Bipolar Disorder Research has systematically followed-up large numbers of patients with DSM-IV bipolar or psychotic disorders from first hospitalization. Major findings among patients with bipolar I disorder include: [a] full functional recovery from initial episodes was uncommon, and full symptomatic recovery, much slower than early syndromal recovery; [b] risks of relapse, recurrence, and switching were very high in the first two years; [c] most early morbidity was depressive-dysphoric, as reported in mid-course; [d] initial depression or mixed-states predicted more later depressive and overall morbidity, whereas initial mania or psychosis predicted later mania and a better prognosis; [e] based on within-subject modeling, most patients did not show progressive cycling over time, and illness-course was rather chaotic within and among patients; [f] treatment-latency or episode-counts were unassociated with responsiveness to long-term mood-stabilizing treatment; [g] very high rates of suicidal behavior and accidents occurred early; [h] early substance-use comorbidity associated with anxiety; [i] factor-analysis of prodromal symptoms predicted bipolar disorder much better than non-affective psychotic disorders. Project findings indicate that the course of bipolar I disorder is much less favorable than had been believed formerly, despite clinical treatment with modern mood-stabilizing and other treatments.

Patterns of Axis I comorbidity in relation to age in patients with Bipolar Disorder: a cross-sectional analysis

BACKGROUND

Several data indicate that the clinical course and treatment response of Bipolar Disorder (BD) is influenced by comorbidity. However, whether differences in comorbidity patterns exist in relation to classes of age remains debated. The present study was aimed to evaluate differences in terms of cross-sectional Axis I comorbidity among young (≤30 years), adult (>30 and ≤45 years) and older adult patients with BD (>45 years).

METHODS

Study sample included 508 patients with BD, subdivided into 3 groups of age: ≤30 years (n=52), >30 and ≤45 years (n=186) and >45 years (n=270). Demographic and clinical variables, with specific emphasis on Axis I comorbidity, were compared across the different groups using chi-square tests. Furthermore, a binary logistic regression was performed.

RESULTS

Two-hundred eleven patients (41.5%) showed at least another concomitant Axis I disorder. The 3 groups were homogenous in terms of type of diagnosis (type 1 or 2 BD) and gender. However, they were different in terms of cross-sectional Axis I comorbidity (p=0.001) with a higher frequency of substance abuse (p=0.04) and Anorexia (p=0.014) in young patients, and of Obsessive Compulsive Disorder in adult patients (p=0.001). In addition, young patients showed more frequently the presence of a second comorbid Axis I condition compared to the other sub-groups (p=0.05). With regard to the type of abuse, young subjects were more frequently cannabis (p<0.001) and cocaine abusers (p<0.001) compared to the other subgroups.

LIMITATIONS

Lifetime Axis I and Axis II and cross-sectional Axis II comorbidity patterns were not analyzed.

CONCLUSIONS

Preliminary results from the present exploratory study seem to suggest different profiles of cross-sectional Axis I comorbidity and abuse in bipolar patients in relation to age. This aspect should be taken into account for the choice of pharmacological treatments and global management in clinical practice.

Does psychomotor retardation define a clinically relevant phenotype of unipolar depression?

BACKGROUND

The recognition and assessment of psychomotor retardation may have implications for better definition of the clinical phenotypes of depression. The aim of this study was to assess the clinical correlates of psychomotor retardation endorsed at any time during the patients' lifetime (LPR).

METHODS

The study sample included 291 patients with non-psychotic major depressive disorder (MDD) participating in the clinical trial, "Depression: The Search for Treatment-Relevant Phenotypes." Psychomotor retardation was measured using a factor derived from the Mood Spectrum Self-Report (MOODS-SR) assessment. Using a pre-defined cut-off score on the lifetime psychomotor retardation (LPR) factor of the MOODS-SR, participants were classified into high and low scorers. Logistic regression analysis was used to evaluate the relationship between LPR and subthreshold bipolarity.

RESULTS

Compared to low scorers, participants with high scores on the LPR factor had greater severity of depression and more bipolarity indicators.

CONCLUSIONS

The MOODS-SR appears to be helpful to identify clinical phenotypes of unipolar depression and to highlight the usefulness of a lifetime approach to the assessment of psychopathology in the characterisation of patients with unipolar depression.

Reliability and validity of the Chinese Version of the Mood Disorder Questionnaire

The purpose of this study was to examine the reliability, validity, sensitivity, and specificity of the Chinese Version of the Mood Disorder Questionnaire (MDQ-C). A total of 170 patients were administered the Mini International Neuropsychological Interview and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision as criterion standard by on-site psychiatrists. The Cronbach's alpha, test-retest reliability, and the content validity index of the MDQ-C were .83, .76, and .80, respectively. Factor analysis revealed that two factors, elevated mood overactivity and irritable behavior, explained 40.89% of the variance. On the basis of the sensitivity and specificity results, the optimal cutoff point was 6. The MDQ-C is an effective short and comprehensive tool with robust psychometric properties for diagnosis of bipolar disorders, specifically for patients with bipolar I.

Are atypical depression, borderline personality disorder and bipolar II disorder overlapping manifestations of a common cyclothymic diathesis?

The constructs of atypical depression, bipolar II disorder and borderline personality disorder (BPD) overlap. We explored the relationships between these constructs and their temperamental underpinnings. We examined 107 consecutive patients who met DSM-IV criteria for major depressive episode with atypical features. Those who also met the DSM-IV criteria for BPD (BPD+), compared with those who did not (BPD-), had a significantly higher lifetime comorbidity for body dysmorphic disorder, bulimia nervosa, narcissistic, dependent and avoidant personality disorders, and cyclothymia. BPD+ also scored higher on the Atypical Depression Diagnostic Scale items of mood reactivity, interpersonal sensitivity, functional impairment, avoidance of relationships, other rejection avoidance, and on the Hopkins Symptoms Check List obsessive-compulsive, interpersonal sensitivity, anxiety, anger-hostility, paranoid ideation and psychoticism factors. Logistic regression revealed that cyclothymic temperament accounted for much of the relationship between atypical depression and BPD, predicting 6 of 9 of the defining DSM-IV attributes of the latter. Trait mood lability (among BPD patients) and interpersonal sensitivity (among atypical depressive patients) appear to be related as part of an underlying cyclothymic temperamental matrix.

Neuropsychological functions in Han Chinese patients in Taiwan with bipolar II disorder comorbid and not comorbid with alcohol abuse/alcohol dependence disorder

OBJECTIVE

Studies exploring neuropsychological functions of bipolar disorder (BP) specifically include patients comorbid with alcohol abuse (AB), alcohol dependence (AD), or both (AB/AD). Contradictory assessments of neuropsychological impairment may be caused by not excluding the confounding effects of comorbid AB/AD. Most of the literature discusses BP without subtyping, which overlooks that BP-II may be a valid diagnosis different from BP-I. Because neuropsychological functions are involved in overall BP-II outcomes, we hypothesized that the neuropsychological functions of patients with BP-II comorbid with AD (BP(+AD)) are significantly different from and more impaired than those of patients with BP-II not comorbid with AD (BP(-AD)).

METHODS

Using DSM-IV criteria, the study included 69 patients with BP-II (19 with BP(+AD); 28 with BP(-AD)) and 22 healthy controls compared using a battery of neuropsychological tests that assessed memory, psychomotor speed, and certain aspects of frontal executive function. All BP-II patients were in an inter-episode period (a period of remission between states of mania, hypomania, and depression).

RESULTS

BP(+AD) patients had lower scores than did BP(-AD) patients and controls in verbal memory, visual memory, attention, psychomotor speed, and executive function. Working memory was poorer for BP(+AD) than BP(-AD) patients and for both BP groups than for controls.

CONCLUSIONS

BP(+AD) patients manifested wide neuropsychological dysfunctions, and BP(-AD) patients showed a reduction in working memory, which suggested that working memory might be related to a history of BP-II. Neuropsychological dysfunctions seemed more strongly associated with AB/AD than with BP-II in inter-episode periods.

Comparison of second-generation antipsychotic treatment on psychiatric hospitalization in Medicaid beneficiaries with bipolar disorder

OBJECTIVE

To compare second-generation antipsychotics on time to and cost of psychiatric hospitalization in Medicaid beneficiaries with bipolar disorder.

METHODS

Retrospective study using healthcare claims from 10 US state Medicaid programs. Included beneficiaries were aged 18-64, initiated a single second-generation antipsychotic (aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone) between 1/1/2003-6/30/2008 (initiation date=index), and had a medical claim with an ICD-9-CM diagnosis code for bipolar disorder. A 360-day post-index period was used to measure time to and costs of psychiatric hospitalization (inpatient claims with a diagnosis code for a mental disorder [ICD-9-CM 290.xx-319.xx] in any position). Cox proportional hazards models and Generalized Linear Models compared time to and costs of psychiatric hospitalization, respectively, in beneficiaries initiating aripiprazole vs each other second-generation antipsychotic, adjusting for beneficiaries' baseline characteristics.

RESULTS

Included beneficiary characteristics: mean age 36 years, 77% female, 80% Caucasian, aripiprazole (n=2553), mean time to psychiatric hospitalization or censoring=85 days; olanzapine (n=4702), 81 days; quetiapine (n=9327), 97 days; risperidone (n=4377), 85 days; ziprasidone (n=1520), 82 days. After adjusting for baseline characteristics, time to psychiatric hospitalization in beneficiaries initiating aripiprazole was longer compared to olanzapine (hazard ratio [HR]=1.52, p<0.001), quetiapine (HR=1.40, p<0.001), ziprasidone (HR=1.33, p=0.032), and risperidone, although the latter difference did not reach significance (HR=1.18, p=0.13). The adjusted costs of psychiatric hospitalization in beneficiaries initiating aripiprazole were significantly lower compared to those initiating quetiapine (incremental per-patient per-month difference=$42, 95% CI=$16-66, p<0.05), but not significantly lower for the other comparisons.

LIMITATIONS

This study was based on a non-probability convenience sample of the Medicaid population. Analyses of administrative claims data are subject to coding and classification error.

CONCLUSIONS

Medicaid beneficiaries with bipolar disorder initiating aripiprazole had significantly longer time to psychiatric hospitalization than those initiating olanzapine, quetiapine, or ziprasidone, and significantly lower adjusted costs for psychiatric hospitalization than those initiating quetiapine.

Association between affective temperaments and bipolar spectrum disorders: preliminary perspectives from a controlled family study

BACKGROUND

The study aimed at determining the temperamental underpinnings of bipolar spectrum disorders (BSD) in the first-degree relatives (FDR) of patients with bipolar I disorder in comparison with control subjects.

SAMPLING AND METHODS

The sample consisted of 198 subjects: 33 bipolar I probands and their 33 FDR in the experimental group, 33 schizophrenia probands and their 33 FDR in the patient control group, and 33 normal healthy controls and their 33 FDR. The affective temperament and the BSD were assessed using the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire and the criteria of Ghaemi et al. [Can J Psychiatry 2002;47:125-134], respectively.

RESULTS

Among the FDR of bipolar I probands, 27.3% satisfied the diagnosis of BSD, which was significantly higher than in the other groups (relative risk = 6, 95% CI = 1.74-20.69). Bipolar probands were significantly more hyperthymic as compared to controls (relative risk = 2, 95% CI = 1.34-2.98), and both the FDR of the bipolar and the FDR of the patient control groups were significantly more hyperthymic as compared to the FDR of the normal controls (relative risk = 1.52, 95% CI = 0.93-2.51). FDR (of bipolar patients) with BSD had a significantly higher total irritable temperament score as compared to FDR (of bipolar patients) without BSD (mean difference = 2.07, 95% CI = 0.64-3.50).

CONCLUSIONS

Our findings support the fact that the whole spectrum of bipolarity is transmitted in susceptible families. The graded distribution of hyperthymia suggests it to be a milder expression of bipolarity in the FDR of bipolar patients. The irritable temperament appears to be a specific vulnerability marker for the development of BSD.

Association between bipolar spectrum features and treatment outcomes in outpatients with major depressive disorder

CONTEXT

It has been suggested that patients with major depressive disorder (MDD) who display pretreatment features suggestive of bipolar disorder or bipolar spectrum features might have poorer treatment outcomes.

OBJECTIVE

To assess the association between bipolar spectrum features and antidepressant treatment outcome in MDD.

DESIGN

Open treatment followed by sequential randomized controlled trials.

SETTING

Primary and specialty psychiatric outpatient centers in the United States.

PARTICIPANTS

Male and female outpatients aged 18 to 75 years with a DSM-IV diagnosis of nonpsychotic MDD who participated in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study.

INTERVENTIONS

Open treatment with citalopram followed by up to 3 sequential next-step treatments.

MAIN OUTCOME MEASURES

Number of treatment levels required to reach protocol-defined remission, as well as failure to return for the postbaseline visit, loss to follow-up, and psychiatric adverse events. For this secondary analysis, putative bipolar spectrum features, including items on the mania and psychosis subscales of the Psychiatric Diagnosis Screening Questionnaire, were examined for association with treatment outcomes.

RESULTS

Of the 4041 subjects who entered the study, 1198 (30.0%) endorsed at least 1 item on the psychosis scale and 1524 (38.1%) described at least 1 recent maniclike/hypomaniclike symptom. Irritability and psychoticlike symptoms at entry were significantly associated with poorer outcomes across up to 4 treatment levels, as were shorter episodes and some neurovegetative symptoms of depression. However, other indicators of bipolar diathesis including recent maniclike symptoms and family history of bipolar disorder as well as summary measures of bipolar spectrum features were not associated with treatment resistance.

CONCLUSION

Self-reported psychoticlike symptoms were common in a community sample of outpatients with MDD and strongly associated with poorer outcomes. Overall, the data do not support the hypothesis that unrecognized bipolar spectrum illness contributes substantially to antidepressant treatment resistance.

The relationship of bipolar disorder lifetime duration and vascular burden to cognition in older adults

OBJECTIVES

  We describe the cognitive function of older adults presenting with bipolar disorder (BD) and mania and examine whether longer lifetime duration of BD is associated with greater cognitive dysfunction. We also examine whether there are negative, synergistic effects between lifetime duration of BD and vascular disease burden on cognition.

METHODS

  A total of 87 nondemented individuals with bipolar I disorder, age 60 years and older, experiencing manic, hypomanic, or mixed episodes, were assessed with the Dementia Rating Scale (DRS) and the Framingham Stroke Risk Profile (FSRP) as a measure of vascular disease burden.

RESULTS

  Subjects had a mean (SD) age of 68.7 (7.1) years and 13.6 (3.1) years of education; 50.6% (n = 44) were females, 89.7% (n = 78) were white, and 10.3% (n = 9) were black. They presented with overall and domain-specific cognitive impairment in memory, visuospatial ability, and executive function compared to age-adjusted norms. Lifetime duration of BD was not related to DRS total score, any other subscale scores, or vascular disease burden. FSRP scores were related to the DRS memory subscale scores, but not total scores or any other domain scores. A negative interactive effect between lifetime duration of BD and FSRP was only observed with the DRS construction subscale.

CONCLUSIONS

  In this study, lifetime duration of BD had no significant relationship with overall cognitive function in older nondemented adults. Greater vascular disease burden was associated with worse memory function. There was no synergistic relationship between lifetime duration of BD and vascular disease burden on overall cognition function. Addressing vascular disease, especially early in the course of BD, may mitigate cognitive impairment in older age.

Is unrecognized bipolar disorder a frequent contributor to apparent treatment resistant depression?

BACKGROUND

There is widespread clinical belief that unrecognized bipolar disorder (BD) is a frequent contributor to apparent treatment resistant depression (TRD). This review attempts to assess the degree to which prevailing empirical data supports that view.

METHODS

All English-language articles published between January 1998 and January 2008 that focused on adults with major depressive disorder (MDD) and BD bearing on the question "Is unrecognized BD a frequent contributor to apparent TRD in patients initially diagnosed with MDD?" were reviewed.

RESULTS

196 articles were reviewed; the preponderance of the data suggested: 1) TRD populations demonstrate high rates of hidden bipolar disorder, 2) there is not sufficient evidence to unequivocally support or reject the hypothesis that patients who relapse despite continued antidepressant treatment are likely to have bipolar spectrum disorder, 3) patients initially diagnosed with MDD do not demonstrate high rates of switching to mania or hypomania when treated with antidepressants and 4) in patients diagnosed with BD, antidepressants are not robustly effective and are poorly tolerated.

LIMITATIONS

The main limitation of this review is that none of the individual studies were designed to test our primary hypothesis.

CONCLUSIONS

This review provides at least moderate support to the hypothesis that BD is a contributor to apparent TRD. Thus, clinicians treating MDD are urged to search for "soft" signs of bipolarity and to be prepared to alter diagnosis and treatment strategies accordingly.

Association between age of onset and mood in bipolar disorder: comparison of subgroups identified by cluster analysis and clinical observation

BACKGROUND

This study compared subgroups identified by cluster analysis and clinical observation by evaluating the association between the age of onset of bipolar disorder and self-reported daily mood ratings.

METHODS

Two hundred and seventy patients with bipolar disorder provided daily self-reported mood ratings for about 6 months returning 55,188 days of data. The age of onset subgroups were determined both using previously defined cutoff values based upon clinical observation (≤12 years, 13-19 years, 20-29 years, >29 years), and model-based cluster analysis. Demographic characteristics were compared in the age of onset subgroups. Univariate general linear models with age of onset subgroups and other demographic variables as fixed factors and covariates were used to analyze the percent of days depressed, euthymic and hypomanic/manic.

RESULTS

Using the predetermined subgroups, demographic differences were found between the four subgroups in the diagnosis of bipolar I/II, years of illness, age and use of lamotrigine. Post-hoc pairwise comparison found that patients with an age of onset less ≤ 12 years spent more days hypomanic/manic: 16.4 percent versus 8.0 for patients with an age of onset between 13 and 19 years (p=0.006) and 8.2 percent for patients with an age of onset between 20 and 29 years (p = 0.031). The majority of the additional days of hypomania/mania occurred outside of an episode. Model-based cluster analysis found a mixture of 2 distributions of onset with peaks at age 15.1 years (SD = 4.7) and 27.5 years (SD = 10.2). Analysis of these two subgroups detected no significant differences in demographic characteristics or mood ratings.

CONCLUSION

Age of onset subgroups arising from clinical observation may be more useful than those determined by cluster analysis.

Major depressive disorder with subthreshold bipolarity in the National Comorbidity Survey Replication

OBJECTIVE

There is growing clinical and epidemiologic evidence that major mood disorders form a spectrum from major depressive disorder to pure mania. The authors examined the prevalence and clinical correlates of major depressive disorder with subthreshold bipolarity compared with pure major depressive disorder in the National Comorbidity Survey Replication (NCS-R).

METHOD

The NCS-R is a nationally representative face-to-face household survey of the U.S. population conducted between February 2001, and April 2003. Lifetime history of mood disorders, symptoms, and clinical indicators of severity were collected using version 3.0 of the World Health Organization's Composite International Diagnostic Interview.

RESULTS

Nearly 40% of study participants with a history of major depressive disorder had a history of subthreshold hypo-mania. This subgroup had a younger age at onset, more episodes of depression, and higher rates of comorbidity than those without a history of hypomania and lower levels of clinical severity than those with bipolar II disorder.

CONCLUSIONS

These findings demonstrate heterogeneity in major depressive disorder and support the validity of inclusion of subthreshold mania in the diagnostic classification. The broadening of criteria for bipolar disorder would have important implications for research and clinical practice.

Prevalence of mixed mania using 3 definitions

OBJECTIVES

Mixed episodes are a combination of depressive and manic symptoms in bipolar disorder (BD). We want to identify the proportion of patients who have depressive symptoms during an acute episode and also the validity of current methods for its diagnosis.

MATERIAL AND METHOD

Cross-sectional multicentre study of patients with type I BD who are admitted to specialized units. 368 patients in 76 centres were included. The patients should have a well established diagnosis of BD and need hospitalisation. The severity of the disorder and clinical status were evaluated upon admission and discharge using CGI-BP-M clinical impression scales, the Hamilton depression scale (HAMD-17) and the Young mania rating scale (YMRS). Upon admission, the necessary criteria for diagnosing a mixed type episode were recorded according to DSM-IV-TR, ICD-10 and McElroy criteria. Clinical judgment of the current type of episode was also recorded.

RESULTS

Prevalence estimations for mixed episodes were: 12.9% according to DSM-IV-TR (n=45), 9% according to ICD-10 (n=31), 16.7% according to McElroy criteria (n=58), and 23.2% according to clinical judgment (n=81). Statistically significant differences were found between the estimated prevalence rates (Cochrane's Q-test, p<0.0001), with the maximum concordance level found between the McElroy and ICD-10 (Kappa=0.66, 95% CI, 0.54-0.77). The DSM-IV-TR criteria only present moderate concordance with ICD-10 (Kappa=0.65, 95% CI, 0.52 to 0.78) and McElroy criteria (Kappa=0.62, 95% CI, 0.50 to 0.74).

CONCLUSIONS

The definition of mixed episodes for BD must be revised to improve consensus and, consequently, therapeutic management. Current diagnostic systems, based on DSM-IV and IDC-10, only capture a limited proportion of patients suffering from mixed episodes, giving rise to important limitations concerning the therapeutic management of BP patients.

Assessment and treatment of bipolar II postpartum depression: a review

OBJECTIVE

This paper critically reviews the current literature on the detection, diagnosis, and treatment of bipolar II postpartum depression.

METHOD

A Pub-Med search (1998-2009), using the search terms 'postpartum depression', 'postpartum depression AND screening/detection/diagnosis/treatment', 'bipolar I AND postpartum depression', 'bipolar II AND postpartum depression', 'postpartum hypomania', and 'postpartum hypomania AND screening', was carried out. The reference lists of articles identified were also searched to select other relevant publications.

RESULTS

Brief hypomanic symptoms occur in the early puerperium in approximately 15% of women. Despite preliminary evidence that postpartum depression in some patients may be a manifestation of bipolar II disorder or bipolar disorder NOS, there are no screening instruments to differentiate unipolar from bipolar depression arising in pregnancy or the postpartum. Also lacking are evidence-based treatment options specifically targeted to treat bipolar II postpartum depression.

CONCLUSIONS

Research into postpartum mood disorders has focused primarily on major depressive disorder, bipolar I disorder, and puerperal psychosis, and has largely ignored the study of bipolarity beyond bipolar I disorder. The clinical and research implications of the misdiagnosis of bipolar II depression as major depressive disorder in the postpartum period are discussed.

Screening for bipolar disorders in Spanish-speaking populations: sensitivity and specificity of the Bipolar Spectrum Diagnostic Scale-Spanish Version

BACKGROUND

Bipolar disorder is commonly misdiagnosed, perhaps more so in Latin American and Spanish-speaking populations than in the United States. The Bipolar Spectrum Diagnostic Scale (BSDS) is a 19-item screening instrument designed to assist in screening for all types of bipolar disorder.

METHODS

The authors investigated the sensitivity of a Spanish-language version of the BSDS in a cohort of 65 outpatients with a diagnosis of bipolar disorder, based on a semi-structured interview and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. To determine specificity, we assessed a control group of 36 outpatients with diagnosis of unipolar major depressive disorder.

RESULTS

The overall sensitivity of the BSDS Spanish version with bipolar disorders types I, II, and NOS was 0.70, which was slightly lower than the sensitivity in the study using the English version of the BSDS (0.76). The specificity was 0.89. When the threshold was decreased from 13 to 12, the sensitivity of the Spanish BSDS increased to 0.76 and specificity dropped to 0.81.

CONCLUSION

The Spanish version of the BSDS is promising as a screening instrument in Spanish-speaking populations.

"Folie circulaire" vs "Folie à double forme": contribution from a French national study

OBJECTIVE

To check whether the presence or not of free intervals between episodes could help differentiate subtypes of bipolar disorder, as suggested by the seminal controversy between Falret and Baillarger.

METHODS

From 1090 bipolar I patients included in a French national study, 981 could be classified as with or without free intervals and assessed for demographic and illness characteristics.

RESULTS

Compared with patients with free intervals (n=722), those without (n=259) had an earlier age at onset, more episodes, suicide attempts, cyclothymic and irritable temperaments. The following independent variables were associated with no free intervals: being single or divorced, delay to mood stabilizer treatment, multiple hospitalizations, incongruent psychotic features, panic and generalized anxiety disorder.

CONCLUSION

"Folie à double forme" (without free intervals) and "folie circulaire" (with free intervals) may actually refer to early and later onset bipolar subtypes, insofar as most differences we found between them were previously evidenced between the latter two. We cannot, however, exclude that they might simply be two separate subtypes, whose main characteristics could be accounted for by different explanatory factors.

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.

Screening for bipolar disorder during pregnancy and the postpartum period

Bipolar disorder is a significant mental health problem among perinatal women; however, little attention has been devoted to methods of screening for bipolar disorder during this phase of women's life cycle. There is a need for reliable and valid screening instruments for perinatal women. This paper presents a review of 11 self-report measures used to screen bipolar disorder in the general population and discusses their applicability to screening among perinatal women. Published psychometric data, including reliability, sensitivity, specificity, and positive predictive value of each self-report instrument, is presented and critiqued. We make recommendations for screening in clinical practice and highlights priorities for future research. The need for more research in this area is emphasized.

Late-life bipolar depression due to the soft form of bipolar disorder compared to unipolar depression: an inpatient chart review study

BACKGROUND

Several studies have been conducted regarding the clinical features of the manic state in elderly patients with bipolar disorder; however, little information is available about bipolar depression in these patients, especially depression related to bipolar II disorder (BP-II) and bipolar disorder not otherwise specified (BP-NOS).

METHODS

A chart review study of 87 patients (age > or = 60 years) hospitalized due to a major depressive episode (MDE) was conducted.

RESULTS

Thirty-two (36.8%) and 55 (63.2%) patients were diagnosed with bipolar disorder and major depressive disorder (MDD), respectively. BP-II/BP-NOS accounted for 81.3% of bipolar disorder and 29.9% of MDE. Of the 26 BP-II/BP-NOS patients, 73% had been initially diagnosed with MDD (61.0%) or others (12.0%). Compared to MDD patients, BP-II/BP-NOS patients showed a significantly younger age-at-onset of the first MDE (median, 52 vs. 66 years, p=0.000) and significantly more frequent MDEs (median, 3 vs. 1, p=0.000). The depressed mixed state (DMX) was observed in 61.5% of BP-II/BP-NOS patients in contrast to only 16.4% of MDD patients (p=0.000). The multiple logistic regression analysis revealed that younger age at onset of first MDE and DMX were independent markers of bipolarity.

LIMITATIONS

Certain features were retrospectively specified by a single reviewer.

CONCLUSION

Late-life depression due to BP-II/BP-NOS is generally misdiagnosed, but should never be neglected in elderly inpatients. Some features of the depression suggest bipolarity. In particular, DMX was found to be an independent marker of bipolarity, which supports the mixed nature of this disorder across generations.

One-year treatment outcomes of African-American and Hispanic patients with bipolar I or II disorder in STEP-BD

OBJECTIVE

Few studies have compared treatment outcomes of African-American, Hispanic, and non-Hispanic white patients with bipolar disorder. The U.S. Systematic Treatment Enhancement Program for Bipolar Disorder compared one-year outcomes for bipolar I or II disorder from each of these racial-ethnic groups.

METHODS

African Americans (N=155) were retrospectively compared with a matched group of non-Hispanic whites (N=729), and Hispanics (N=152) were compared with a separate matched group of non-Hispanic whites (N=822). Response and recovery outcomes were examined. Survival analysis was used to compare time to treatment response for depression (Montgomery-Asberg Depression Rating Scale) and mania (Young Mania Rating Scale) as well as global assessment of functioning (Global Assessment of Functioning).

RESULTS

For manic and depressive symptoms, time to response and proportion of responders were similar across groups. Over the study year the proportion of days well was similar across groups. A smaller proportion of African Americans met criteria for improved global functioning. Depression response among African Americans with psychotic symptoms was slower than the response among African Americans without psychotic symptoms and among non-Hispanic whites with or without psychotic symptoms. No differences between Hispanics and non-Hispanic whites in response times and recovery were observed.

CONCLUSIONS

Results are consistent with U.S. clinical trials for other psychiatric disorders, which have reported similar outcomes for ratings of primary symptoms. Baseline psychotic symptoms are likely a significant contributor when African Americans with bipolar disorder are slow to recover. These results may be less generalizable to uninsured patients.

Efficacy of ziprasidone in dysphoric mania: pooled analysis of two double-blind studies

BACKGROUND

Dysphoric mania is a common and often difficult to treat subset of bipolar mania that is associated with significant depressive symptoms.

OBJECTIVE

This post hoc analysis was designed to evaluate the efficacy of ziprasidone in the treatment of depressive and other symptoms in a cohort of patients with dysphoric mania.

METHODS

Pooled data were examined from two similarly designed, 3-week placebo-controlled trials in acute bipolar mania. Patients scoring >/=2 on at least two items of the extracted Hamilton Rating Scale for Depression (HAM-D) met criteria for dysphoric mania and were included in the post hoc analysis. Changes from baseline in symptom scores were evaluated by a mixed-model analysis of covariance.

RESULTS

179 patients with dysphoric mania were included in the post hoc analysis (ziprasidone, n=124; placebo, n=55). Beginning at day 4, HAM-D scores were significantly lower at all visits in patients treated with ziprasidone compared with those treated with placebo (p<0.05). Ziprasidone-treated patients also demonstrated significant improvements on the Mania Rating Scale and all secondary efficacy measures, and had significantly higher response and remission rates compared with placebo.

LIMITATIONS

The main limitations are the use of a post hoc analysis and the pooling of two studies with slightly different designs.

CONCLUSION

In this analysis, ziprasidone significantly improved both depressive and manic mood symptoms in patients with dysphoric mania, suggesting that it might be a useful treatment option in this patient population. Further prospective controlled trials are needed to confirm these findings.

Borderline personality disorder and the misdiagnosis of bipolar disorder

Recent reports suggest bipolar disorder is not only under-diagnosed but may at times be over-diagnosed. Little is known about factors that increase the odds of such mistakes. The present work explores whether symptoms of borderline personality disorder increase the odds of a bipolar misdiagnosis. Psychiatric outpatients (n=610) presenting for treatment were administered the Structured Clinical Interview for DSM-IV (SCID) and the Structured Interview for DSM-IV Personality for DSM-IV axis II disorders (SIDP-IV), as well as a questionnaire asking if they had ever been diagnosed with bipolar disorder by a mental health care professional. Eighty-two patients who reported having been previously diagnosed with bipolar disorder but who did not have it according to the SCID were compared to 528 patients who had never been diagnosed with bipolar disorder. Patients with borderline personality disorder had significantly greater odds of a previous bipolar misdiagnosis, but no specific borderline criterion was unique in predicting this outcome. Patients with borderline personality disorder, regardless of how they meet criteria, may be at increased risk of being misdiagnosed with bipolar disorder.

Relationship of residual mood and panic-agoraphobic spectrum phenomenology to quality of life and functional impairment in patients with major depression

The aim of this study was to analyze the relationship of residual mood and panic-agoraphobic spectrum phenomenology to functional impairment and quality of life in 226 adult outpatients who had remitted from a major depressive episode. Quality of life and functioning were assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire and the Work and Social Adjustment Scale. Residual symptoms were assessed using the Mood and Panic-Agoraphobic Spectrum Questionnaires. Linear and logistic regression models were used to analyze the relationship of mood and panic-agoraphobic spectrum factors with quality of life and functioning. Poor quality of life was associated with the Mood Spectrum Self-Report Questionnaire factors 'depressive mood' and 'psychotic features' and the Panic-Agoraphobic Spectrum Self-Report Questionnaire factors 'separation anxiety' and 'loss sensitivity'. Functional impairment was associated with the Mood Spectrum Self-Report Questionnaire factor 'psychomotor retardation' and the Panic-Agoraphobic Spectrum Self-Report Questionnaire factor 'fear of losing control'. These relationships were held after controlling for the severity of depression at the entry in the continuation treatment phase. In conclusion, the spectrum assessment is a useful tool for clinicians to identify areas of residual symptomatology that can be targeted with focused and effective long-term treatment strategies.

The early stages of bipolar disorder and recent developments in the understanding of its neurobiology

Bipolar disorder is a severe recurrent psychiatric illness that often manifests in adolescence, a time of marked neurobiological change. The current model is one of multiple susceptibility genes interacting with other risk factors leading to alterations in the normal maturational trajectory of the CNS. Longitudinal studies of children of affected parents has enabled mapping of the early natural history of bipolar disorder. Convergent evidence from longitudinal high-risk studies suggest that bipolar disorder evolves in a series of clinical stages from nonspecific childhood disorders to depressive disorders in early adolescence and bipolar spectrum disorders in later adolescence and adulthood. At present, genetic studies and research into specific biological markers in bipolar patients and their family members are underway. Advances in understanding the neurobiological underpinnings of bipolar disorder will require addressing etiological heterogeneity of bipolar disorder and refining the phenotypic definition. In the latter case, the staging model may be a helpful organizing framework.

Principal domains of behavioral psychopathology identified by the Bipolar Inventory of Signs and Symptoms Scale (BISS)

Current symptom rating scales and diagnostic categories for bipolar disorder (BD) do not provide dimensional profiles of the types of behavior disturbed in this complex disorder. To overcome these limitations we identified the principal domains of behavioral symptomatology in bipolar individuals, including all mood states, and used a more comprehensive rating scale for BD: the Bipolar Inventory of Signs and Symptoms Scale (BISS). A total of 246 patients with BD (196 with BD type I, and 50 with BD type II) were interviewed using the BISS. Exploratory factor analysis was performed on the BISS results using the maximum likelihood factor extraction method, followed by oblique rotation of the extracted factor loadings. We determined the strength of relationships between factor scores using the Pearson correlation coefficient. The following five factors were extracted: mania, depression, irritability, anxiety and psychosis. Anxiety was significantly correlated with depression and irritability. The mania factor score was only weakly associated with the other four factors. The domains of the BISS capture both the historical categories of depression and mania, plus irritability, psychosis, and an additional principal domain, anxiety. Despite the common occurrence of anxiety in BD, it has not been identified in most prior factor analyses, in part due to limited coverage of anxiety symptoms in the source scales.

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.

Is bipolar II depression phenotypically distinctive?

OBJECTIVE

We examine the depressive symptom profile of bipolar II disorder patients compared with a comparator (composite) group of those with unipolar depression, with stratification by melancholic and non-melancholic subtypes.

METHOD

Out-patients (n = 394) attending a specialist depression clinic comprised the sample. Data on severity and prototypic status of depressive symptoms were analysed.

RESULTS

Age-matched analyses revealed minimal differentiation between bipolar II and composite unipolar groups. Stratified analyses suggested that 'bipolar II depression' more closely approximated melancholic depression in terms of psychomotor and cognitive slowing. Severity-based analyses and prototypic symptom patterns yielded differing results, suggesting that definition of bipolar II depression is influenced by rating strategies, and age.

CONCLUSION

We found limited differentiation of bipolar II depression from unipolar, melancholic and non-melancholic depression. Differences suggested previously may reflect age, gender and severity differences, highlighting the need for appropriately matched groups in defining bipolar II depression.

Predominant polarity and temperament in bipolar and unipolar affective disorders

INTRODUCTION

Recently, the concept of predominant polarity (two-thirds of episodes belonging to a single pole of the illness) has been introduced to further characterise subtypes of bipolar disorders. This concept has been proven to have diagnostic and therapeutic implications, but little is known on the underlying psychopathology and temperaments. With this study, we aimed to further validate the concept and explore its relationships with temperament.

METHODS

This study enrolled 143 patients with bipolar or unipolar disorder. We analysed predominant polarity in the sample of bipolar I patients (N=124), focussing on those who showed a clear predominance for one or the other polarity, and distinguishing manic/hypomanic (MP) from depressive polarity (DP), and a unipolar major depression (UP) group (N=19),. We also assessed temperament by means of the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A).

RESULTS

Over 55% of the bipolar I sample fulfilled predominant polarity criteria, with two-thirds of those meeting criteria for MP and one third for DP. MP and DP were similar in scoring higher than UP on the hyperthymic/cyclothymic scales of the TEMPS-A; the UP group scored higher on the anxious/depressive scales.

DISCUSSION

Our results show that both bipolar I MP and DP subgroups are temperamentally similar and different from UP. Depression in DP bipolar I patients should be viewed as the overlap of depression on a hyperthymic/cyclothymic temperament. These findings confirm the value of the predominant polarity concept as well as the importance of temperaments to separate bipolar from unipolar disorders.

Difficult to swallow: patient preferences for alternative valproate pharmaceutical formulations

OBJECTIVE

To determine the degree to which swallowing valproate (VP) tablets is an issue, the proportion of patients who would prefer an alternative formulation, and the predictors of preference.

METHODS

A quantitative telephone survey of eligible adults (n = 400, >/=18 years old) who currently take (n = 236) or previously took (n = 164) VP tablets within the past 6 months was conducted.

RESULTS

More than half of the patients indicated that VP tablets were 'uncomfortable to swallow' (68.5%, n = 274) and were 'very interested' (65.8%, n = 263) in medications that were easier to swallow. When choosing conceptually between taking VP tablet once/day or an equally safe and effective but significantly smaller soft gel capsule twice per day, the 82.8%, (n = 331) preferred the soft gel capsule. In the multivariate regression analysis, perceiving soft gel capsules to be easier to swallow (OR = 73.54; 95% CI = 15.01 to 360.40) and taking VP more frequently (OR = 2.02; 95% CI = 1.13 to 3.61) were significant predictors of soft gel capsule treatment preference.

CONCLUSION

VP users would prefer a formulation that is easier to swallow, even if it is needed to be taken twice per day. When choosing between medications with similar efficacy and safety, physicians can consider patient preferences to optimize conditions for medication adherence.

Altered risk-aversion and risk-seeking behavior in bipolar disorder

BACKGROUND

Bipolar disorder (BD) is associated with high-risk behaviors, such as gambling and impulsivity. However, little is known about the psychological factors that influence these behaviors or their significance for the development of the disorder. In this study, we investigated the effects of highlighting rewards versus highlighting punishments in the risky decision-making of euthymic individuals with bipolar disorder.

METHODS

Twenty euthymic, medication-free men and women with previously undiagnosed bipolar II or bipolar disorder not otherwise specified and 20 age- and IQ-matched healthy men and women completed a computerized risky decision-making task in which mathematically equivalent dilemmas were presented in terms of opportunities to gain rewards ("positively-framed") or to avoid suffering losses ("negatively-framed"). The dependent measures were the proportion of risk-seeking choices (and deliberation times) when making decisions in positively versus negatively framed dilemmas.

RESULTS

As expected, healthy control participants made more risky-seeking choices in response to the negatively framed dilemmas compared with the positively framed dilemmas. However, this effect was significantly attenuated in BD participants who also took significantly longer to make risk-averse responses to the positively framed dilemmas. The BD participants overestimated the number of bad outcomes arising out of positively framed dilemmas.

CONCLUSIONS

These data demonstrate that risky choice in BD is associated with reduced sensitivity to emotional contexts that highlight rewards or punishments, possibly reflecting altered valuations of prospective gains and losses associated with behavioral options.

Validity and reliability of the Hamilton depression rating scale (5 items) for manic and mixed bipolar disorders

Depressive symptoms during mania have prognostic value in bipolar disorder. For depressive symptoms, it has been proposed that shorter scales should be cost-effective and practical. To determine the usefulness of 5-item Hamilton Depression Rating Scale (HAMD-5) in manic and mixed bipolar disorder, we used a four-week follow-up prospective, observational study. Convergent and discriminant validity, internal consistency, and reliability were analyzed and compared with HAMD-21, HAMD-5, and HAMD-21 cut-off points were calculated versus CGI-BP. A total of 173 manic and mixed patients were evaluated. HAMD-5 showed appropriate convergent validity, discriminant validity, internal consistency, and test-retest reliability. Discriminant validity was higher for HAMD-5 than HAMD-21. Best cut-off point of remission was: HAMD-21 < or =5 and HAMD-5 < or =1. HAMD-5 presents appropriate validity and reliability estimates. It is comparable to HAMD-21 and focuses more specifically on depressive symptoms.

An initial report of a new biological marker for bipolar disorder: P85 evoked brain potential

OBJECTIVES

Progress toward understanding the neurobiological and genetic underpinnings of bipolar disorder has been limited by the scarcity of potential biological markers that predict its occurrence. A measure of the integrity of brain inhibitory function, sensory gating, measured using the amplitude of the evoked potential at 50 ms to the first of two paired clicks divided by the response to the second, has been characterized as a biological marker for schizophrenia. Currently, no such biological marker exists for bipolar disorder. The goal of this research was to determine how gating of an auditory brain potential at 85 ms (P85), not previously examined in sensory gating studies, differentiated control and patient groups.

METHODS

P50 and P85 auditory evoked potentials were collected from individuals diagnosed with schizoaffective disorder (n = 45), paranoid schizophrenia (n = 66), and bipolar I disorder (n = 42) using DSM-IV criteria and the Structured Clinical Interview for DSM-IV; and from 56 healthy controls.

RESULTS

The P85 gating ratio was significantly larger in the bipolar disorder group compared to each of the other groups (F(3,204) = 5.47, p = 0.001, and post-hoc tests). The P50 gating ratio was significantly larger for the schizoaffective group than for the control group (F(3,204) = 2.81, p = 0.040), but did not differ from the ratio for the schizophrenia, paranoid type (p = 0.08) and bipolar groups.

CONCLUSIONS

The previously unstudied P85 gating ratio may provide a new marker specific to bipolar disorder. The findings will promote further studies to investigate the unique contribution of this measure as an endophenotype.

Bipolar II disorder and major depressive disorder: Continuity or discontinuity?

AIM

To find if bipolar II disorder (BPII) and major depressive disorder (MDD) were distinct categories or overlapping syndromes.

METHODS

308 BPII and 236 MDD outpatients, presenting for major depressive episode (MDE) treatment, were interviewed with the Structured Clinical Interview for DSM-IV. History of mania and hypomania, and hypomanic symptoms present during MDE, were systematically investigated. Presence of zones of rarity between BPII and MDD depressive syndromes was assessed. Atypical and hypomanic symptoms were chosen because atypical features and depressive mixed state (ie, MDE plus more than 2 concurrent hypomanic symptoms, according to Akiskal and Benazzi 2003) were often reported to distinguish BPII from MDD depressive syndromes (more common in BPII). If BPII were a distinct category, distributions of these symptoms should show zones of rarity between BPII and MDD depressive syndromes. Histograms and Kernel density estimate were used to study distributions of these symptoms.

RESULTS

BPII had significantly more atypical features and depressive mixed state than MDD. Histograms and Kernel density estimate curves of distributions of atypical and hypomanic symptoms in the entire sample did not show zones of rarity.

CONCLUSIONS

Finding no zones of rarity supports a continuity between BPII and MDD (meaning partly overlapping disorders without clear boundaries).

"Mixed hypomania" in children and adolescents: is it a pediatric bipolar phenotype with extreme diurnal variation between depression and hypomania?

BACKGROUND

Although DSM-IV and the literature on pediatric bipolarity recognize mania and mixed phases neither recognizes states of "mixed hypomania." There has been preliminary presentation of the latter phenomenon in the adult bipolar literature. The authors herein describe this phenomenon in a consecutive clinical series of bipolar children and adolescents.

METHODS

This exploratory study involved 47 consecutive bipolar patients between the ages of 7 and 17 years presenting to an outpatient clinic. They were evaluated using a structured instrument designed to ascertain the presence of major depressive episodes (MDE), hypomania, mania, psychotic disorders, behavioral disorders such as oppositional defiant disorder and conduct disorder and substance use disorders. We defined mixed hypomania as MDE and hypomania coexisting over at least 2 weeks.

RESULTS

Of 47 patients, 9 girls (42.9%) and 9 boys (34.6%) were bipolar II mixed. This paper focuses on them. The mean ages of the bipolar II girls and boys were 14.3 (1.9) years and 12.0 (3.4) years, respectively (p<0.05, t=2.45, df=17). This mixed subgroup tended to experience rising mood in the evening, often with spikes of euphoria; a history of late afternoon to evening increased talkativeness or pressured speech was common. Some patients exhibited flight of ideas. Psychomotor acceleration, heightened level of energy, and increased goal directed activity between 1900 and 0300 were frequently reported. Retrospectively obtained circadian information revealed, in most cases an age inappropriate phase delay of sleep onset: After falling asleep in the early hours of the morning the patients awoke feeling depressed, lethargic and as if they could sleep throughout much of the day.

LIMITATION

Cross-sectional, exploratory study based on a relatively small sample size and in need of replication in other clinical settings.

CONCLUSION

Mixed hypomania was a common phenomenon in pediatric bipolar II patients. It is apt to go unrecognized in cross-sectional assessments done in the morning or in the early or mid-afternoon. Those with this proposed phenotype would appear "depressed" at these times. Alternatively, what we have proposed can also be described as severe diurnal variation between depression and hypomania in the evening. Further study is required combining 24-hour clinical observation and state of the art technologically derived data.

Social and Familial Factors in the Course of Bipolar Disorder: Basic Processes and Relevant Interventions

This article reviews the role of social factors, notably life events and family relationships, in the course of bipolar illness in adults and youth. We also discuss psychological variables that help explain the vulnerability of bipolar patients to social environments, including personality factors (e.g., neuroticism), reward sensitivity, and difficulty with the accurate perception of facial emotions. Bipolar patients are highly sensitive to reward, and excessive goal pursuit after goal-attainment events may be one pathway to mania. Negative life events predict depressive symptoms, as do levels of familial expressed emotion. Psychosocial interventions can speed recoveries from episodes and delay recurrences over 1-2 year intervals. Future research should examine the nature of vulnerability/stress interactions at different phases of development, and the role of psychosocial interventions in altering these processes.

A critical appraisal of lithium's efficacy and effectiveness: the last 60 years

The history that depicts the evaluation of lithium's efficacy presents an interesting contrast: on the one hand, conviction that, of all psychotropic drugs, lithium has the best demonstrated efficacy; on the other hand, repeated attempts to question it. Those contesting lithium's stabilizing abilities have argued from several angles, for example that the proof was methodologically incorrect or insufficient, that the number of responders is small, or that the response is poor in practice and does not last. But there is a good explanation for this paradox. While the early challenges to lithium's value in recurrent mood disorders reflected mainly that psychiatry had not yet developed a methodology suitable for testing long-term efficacy, more recent questioning has resulted mostly from retesting its efficacy and effectiveness in a substantially broadened bipolar spectrum, outside the classical diagnosis. Lithium, however, continues to stabilize very well the patients suffering from typical bipolar disorder--the condition for which its efficacy was originally demonstrated. More recently, lithium has also proven to dramatically reduce suicidal behavior and mortality and to augment markedly the efficacy of antidepressants in unresponsive patients.

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

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

[Interpersonal psychotherapy and social rhythm therapy for bipolar II disorder: treatment development and case examples]

Bipolar II (BP II) disorder is a common, recurrent, and disabling psychiatric illness. Individuals suffering from this disorder comprise a large segment of the outpatient mental health treatment population, and yet little is known about how best to manage it. Psychotherapy, although untested in this population, represents a potentially important treatment modality for individuals suffering from this disorder. Because BP II disorder is characterized by subsyndromal, non-psychotic, episodes of mania (hypomania), there are no clear contraindications to the use of psychotherapy as monotherapy in BP II disorder (in contrast to BP I disorder where the risk of mania makes medication the sine qua non of treatment). In addition, unlike medication, psychotherapy has the potential to help patients address the multiple psychosocial problems associated with this chronic illness. Thus, an effective psychotherapy for BP II disorder may provide an appealing alternative for patients, especially for those who prefer to avoid the risks and discomfort associated with current pharmacotherapeutic options. Interpersonal and social rhythm therapy (IPSRT), a treatment combining a behavioral approach to increasing the regularity of daily routines with interpersonal psychotherapy (IPT), has demonstrated efficacy BP I disorder when in combination with medication. The current report gives brief overviews of BP II disorder and IPSRT, describes the process of adapting IPSRT for the treatment of BP II disorder, and then presents a series of vignettes based on our experience using IPSRT as monotherapy for the acute treatment of BP II depression. We argue that IPSRT warrants further systematic study to formally assess its efficacy as a treatment for BP II disorder.