Retrospective analysis of psychomotor agitation, hypomanic symptoms, and suicidal ideation in unipolar depression

Identifying the DSM-5 mixed features specifier in depressed patients: A comparison of measures

BACKGROUND

A commonly used measure to assess mixed features in depressed patients is the Young Mania Rating Scale (YMRS), which only partially aligns with the DSM-5 criteria. Different algorithms on the YMRS have been used to approximate the DSM-5 mixed features criteria. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the agreement and validity of different approaches towards assessing the mixed features specifier.

METHODS

Three hundred nine depressed psychiatric patients were interviewed with the Structured Clinical Interview for DSM-IV, the DSM-5 Mixed Features Specifier Interview (DMSI) and the YMRS. Seven definitions of mixed features were examined, two based on the DMSI and five from the YMRS.

RESULTS

The prevalence of mixed features varied 8-fold amongst the 7 definitions. The level of agreement between the YMRS definitions and the DMSI was poor. For each definition, mixed features were significantly more common in patients with bipolar disorder than major depressive disorder. A family history of bipolar disorder was significantly associated with the DMSI assessment of mixed features but none of the YMRS approaches.

LIMITATIONS

The ratings on the measures were not independent of each other. The sample size was too small to compare the patients with bipolar I and bipolar II disorder.

CONCLUSIONS

While there was evidence of validity for both the DSM-5 and YMRS approaches towards identifying mixed features, the 2 approaches are not interchangeable. The algorithm on the YMRS used to classify patients has a significant impact on prevalence.

Antidepressant emergent mood switch in major depressive disorder: onset, clinical correlates and impact on suicidality

Antidepressant (AD)- emergent mood switch (AEMS) is a common complication of bipolar depression. This study aimed to investigate the prevalence and clinical correlates of subthreshold AEMS (i.e. not fulfilling DSM criteria for hypomanic episodes) in major depressive disorder (MDD) and, prognostically, its impact on AD treatment outcome and suicidality. The study involved 425 outpatients with MDD followed during the acute phase (12 weeks) and continuation (weeks 13-28) AD treatment. AEMS was assessed through the Altman Self-Rating Mania scale (ASRM ≥ 6). Several clinical features differentiated individuals with or without subthreshold AEMS (n = 204 vs. 221): negative self-perception [odds ratio (OR) 1.017-1.565]; panic disorder (OR 1.000-1.091); subthreshold hypomanic episodes (OR 1.466-13.352); childhood emotional abuse (OR 1.053-2.447); lifetime suicidal behaviour (OR 1.027-1.236); AD-related remission (χ 2  = 22.903 P  < 0.0001) and suicide ideation (χ 2  = 16.701 P  < 0.0001). In AEMS earlier onset showed a strong correlation with bipolar spectrum disorder (overall score: P  = 0.0053; mixed depression: P  = 0.0154; subthreshold hypomania: P  = 0.0150) whereas late-onset was associated with more severe suicidal behaviour ( P  < 0.001). In conclusion, our results demonstrate that subthreshold mood switches occur frequently in unipolar depression during acute AD treatment as well as in continuation phase. Time of switch onset seems to have the greatest diagnostic and prognostic value.

Clinical correlates and prognostic implications of severe suicidal ideation in major depressive disorder

Suicidal ideation (SI) is a risk factor for suicidal behaviour. To ascertain the clinical correlates and prognostic impact of severe SI, we analysed 249 outpatients with major depressive disorder (MDD) and suicidal thoughts included in the COmbining Medications to Enhance Depression outcome (CO-MED) trial. Patients with severe SI (36%) were younger at disease onset (P = 0.0033), more severely depressed (P = 0.0029), had more lifetime suicidal behaviour (P < 0.0001) and psychiatric comorbidities (panic disorder: P = 0.0025; post-traumatic stress disorder: P = 0.0216), and a history of childhood maltreatment (neglect: P = 0.0054; emotional abuse: P = 0.0230; physical abuse: P = 0.0076; sexual abuse: P = 0.0016) than those experiencing low-moderate SI. After controlling for depression score, severe SI was positively correlated with lifetime suicidal behaviour (OR [95% CI]: 1.26 [1.12-1.41]), panic disorder (1.05 [1.00-1.12]), and childhood maltreatment (neglect: 1.93 [1.13-3.30]; physical abuse: 2.00 [1.11-3.69]; sexual abuse: 2.13 [1.17-3.88]), and inversely correlated with age of onset (0.97 [0.95-0.99]) and sleep-onset insomnia (0.76 [0.61-0.96]). Finally, the occurrence of serious lifetime suicidal behaviour was predicted by SI severity (2.18 [1.11-4.27]), bipolar score (1.36 [1.02-1.81]), and childhood sexual abuse (2.35 [1.09-5.05]). These results emphasise the importance of assessing childhood maltreatment and bipolar liability in MDD to estimate suicidal behaviour risk.

Persistence of suicidal ideation within acute phase treatment of major depressive disorder: analysis of clinical predictors

Suicidal ideation (SI) is common in major depressive disorder (MDD), and it is a risk factor for suicidal behaviour. Antidepressants are effective in reducing SI, but in some subjects, SI may persist for weeks. This study aimed to disentangle the contribution of baseline clinical characteristics in SI nonremission at week 6. Research involved 198 outpatients with MDD and SI collected within the Combining Medications to Enhance Depression Outcomes trial and treated with different antidepressant combinations. Although SI decreased from baseline to week 6 ( P < 0.0001), 78 patients (39%) failed to achieve SI remission. Insomnia [OR, 0.72; 95% confidence interval (CI), 0.52-0.99], reduced need for sleep (OR, 0.75; 95% CI, 0.58-0.99), self-confidence (OR, 0.52; 95% CI, 0.32-0.82), cheerfulness (OR, 0.57; 95% CI, 0.33-0.98), and comorbid panic disorder (OR, 0.93; 95% CI, 0.87-0.99) at baseline were associated with lack of SI remission after controlling for baseline depression and SI scores. The combination of baseline SI and insomnia was moderately effective in predicting the lack of SI remission, with a specificity of 80% (95% CI, 72-87%) and an NPV of 68% (95% CI, 63-72%). In individuals with MDD and SI, the presence of insomnia and bipolar features should prompt a search for more effective treatment solutions in order to favour SI remission and prevent suicidal behaviour.

Kynurenine monooxygenase inhibition and associated reduced quinolinic acid reverses depression-like behaviour by upregulating Nrf2/ARE pathway in mouse model of depression: In-vivo and In-silico studies

Kynurenine pathway, a neuroimmunological pathway plays a substantial role in depression. Consistently, increased levels of neurotoxic metabolite of kynurenine pathway; quinolinic acid (QA) found in the suicidal patients and remitted major depressive patients. QA, an endogenous modulator of N-methyl-d-aspartate receptor is produced by microglial cells, may serve as a potential candidate for a link between antioxidant defence system and immune changes in depression. Further, nuclear factor (erythroid-derived 2) like 2 (Nrf2), an endogenous antioxidant transcription factor plays a significant role in maintaining antioxidant homeostasis during basal and stress conditions. The present study was designed to explore the effects of KMO-inhibition (Kynurenine monooxygenase) and association of reduced QA on Keap1/Nrf2/ARE pathway activity in olfactory bulbectomized mice (OBX-mice). KMO catalysis the neurotoxic branch of kynurenine pathway directing the synthesis of QA. KMO inhibitionshowed significant reversal of depressive-like behaviour, restored Keap-1 and Nrf2 mRNA expression, and associated antioxidant levels in cortex and hippocampus of OBX-mice. KMO inhibition also increased PI3K/AKT mRNA expression in OBX-mice. KMO inhibition and associated reduced QA significantly decreased inflammatory markers, kynurenine and increased the 5-HT, 5-HIAA and tryptophan levels in OBX-mice. Furthermore, molecular docking studies has shown good binding affinity of QA towards ubiquitin proteasome complex and PI3K protein involved in Keap-1 dependent and independent proteasome degradation of Nrf2 respectively supporting our in-vivo findings. Hence, QA might act as pro-oxidant through downregulating Nrf2/ARE pathway along with modulating other pathways and KMO inhibition could be a potential therapeutic target for depression treatment.

Daily impulsivity: Associations with suicidal ideation in unipolar depressive psychiatric inpatients

Recent studies suggest that impulsivity fluctuates over time. It is unclear if state-impulsivity serves as a risk factor of suicidal ideation (SI) at a state level. A sample of 74 psychiatric inpatients with depression (M = 37.6 years, 72% female) and SI completed baseline measurements and an ecological momentary assessment over a 6-day period. Despite considerable within-person variance, state impulsivity was not significantly associated with clinical characteristics (depression, baseline SI, past suicide attempts). Daily variability of passive SI showed a significant prospective association with state impulsivity. Limiting factors are the small sample size and the short observation period.

Irritable Mood and Subthreshold Hypomanic Episodes Correlate with More Severe Major Depression

INTRODUCTION

Irritable mood (IM) and subthreshold hypomanic symptoms are reported in half and two-fifths of major depressed subjects respectively, but their clinical and prognostic meanings remain unclear. The aim of this study was to test the clinical usefulness of 2 specifiers in DSM-IV major depressive disorder (MDD): IM occurring during an index episode (IM+) and lifetime episodes of elated mood or IM with at least 2 concurrent hypomanic symptoms (subthreshold hypomanic episodes [SHEs]).

METHOD

We included 482 outpatients with MDD participating in the Combining Medications to Enhance Depression Outcome study (mean age 43.14 ± 12.46 years, 144 males - 30%). The main aim of the original study was to test whether 2 different medications when given in combination as the first treatment step, compared to 1 medication, would improve antidepressant response.

RESULTS

IM + subjects (N = 349; 70%) were younger and more often females, with a more severe depression, a more marked social impairment, and more psychiatric comorbidities. The IM + group was also characterized by higher levels of suicidal ideation and more cases of emotional abuse. The combination of IM+ and SHEs was associated with an even more severe clinical picture. Limitations include the post hoc method, incomplete assessment of bipolar validators (e.g., family history of bipolar illness), personality disorders and suicide attempts.

CONCLUSIONS

The presence of IM and SHEs in MDD correlate with an overall more severe clinical condition.

Network analysis of anxiety and depressive symptoms among quarantined individuals: cross-sectional study

BACKGROUND

The mental health burden of COVID-19 has been examined in different settings. Existing research has relied on the latent variable model in assessing COVID-19-related distress. Network theory provides an alternative framework wherein symptoms are conceptualised as causal, interconnected constituents rather than outcomes of mental disorders.

AIMS

To assess networks of self-reported anxiety and depressive symptoms among quarantined individuals.

METHOD

Consenting individuals in different quarantine centres in Qatar completed the Patient Health Questionnaire Anxiety and Depression Scale. We used partial correlation network methods to illustrate interactions of self-reported psychopathology.

RESULTS

Participants with COVID-19 were significantly older and had a significantly higher proportion of males. The most central node was COVID-19, followed by thoughts of self-harm. COVID-19 status was strongly positively connected to thoughts of self-harm, which was positively connected to psychomotor changes, which were connected to decreased concentration. COVID-19 status was also positively connected to feeling anxious, which was strongly connected to inability to concentrate, which was connected to feeling afraid.

CONCLUSIONS

COVID-19 was the most influential factor, with the highest number and strength of connections to psychopathology in a network of anxiety and depressive symptoms in a quarantine setting. Beyond the resolution of the infection, therapeutic interventions targeting psychomotor changes might prove beneficial in reducing suicidality among quarantined individuals with COVID-19. Follow-up with mental health services after COVID-19 infection is needed to restore psychological well-being. Further research is needed to understand the short- and long-term psychological effects of COVID-19, and the outcomes of different therapeutic interventions.

Reliability and validity of the Chinese version of the CUDOS-M in patients with mood disorders: A multicenter study across China

BACKGROUND

A useful scale for identification of mixed features in major depressive episodes (MDE) patients is urgent in China. This study aimed to evaluate the reliability and validity of the Chinese version of the Clinically Useful Depression Outcome Scale supplemented with questions for the DSM-5 mixed features specifier (Chinese-CUDOS-M) in MDE patients.

METHODS

A total of 152 MDE patients were recruited and assessed using Chinese-CUDOS-M, Patient Health Questionnaire-9 (PHQ-9) and 32-item Hypomania Checklist (HCL-32). Principal component analysis (PCA) and exploratory factor analysis (EFA) were conducted. The predictive validity was calculated by the area under the receiver operating characteristic curve (AUROC).

RESULTS

The Cronbach's alpha of Chinese-CUDOS-M was 0.85. PCA showed three common factors with eigenvalue greater than 1; the eigenvalue of factor I was 4.96, with 38.1% of variance explanation. Chinese-CUDOS-M depression subscale was associated with PHQ-9 (r = 0.83, p<0.01), and manic subscale was associated with HCL-32 (r = 0.73, p< 0.01). AUROC of the Chinese-CUDOS-M for patients with mixed depression was 0.90 (95%CI: 0.85-0.95), with a cut-off value of 7, sensitivity of 0.95, and specificity of 0.73. Furthermore, AUROC was 0.88 in patients with major depressive disorder (MDD), with a cut-off value of 7, sensitivity of 0.96, and specificity of 0.71. AUROC was 0.92 in bipolar disorder (BD) depression patients, with a cut-off value of 9, sensitivity of 0.89, and specificity of 0.87.

CONCLUSION

Our study shows that the Chinese-CUDOS-M can identify mixed features in both MDD and BD depression with satisfactory reliability and validity.

Effect of adjunctive pimavanserin on suicidal ideation in patients with major depression: Analysis of the CLARITY study

BACKGROUND

Up to 15% of patients with major depressive disorder (MDD) attempt suicide and up to 2% complete suicide. This was a post-hoc analysis aimed to evaluate the risk of suicide ideation and behavior associated with adjunctive pimavanserin treatment in adults with MDD.

METHODS

CLARITY was a randomized, double-blind, placebo-controlled study in patients with MDD and an inadequate response to a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI). For this post-hoc analysis, the primary endpoint was mean change from baseline for HAMD item 3 (suicide). The incidence of suicidal ideation or behavior was also assessed from the Columbia-Suicide Severity Rating Scale (C-SSRS) and reports of adverse events.

RESULTS

During Stage 1, LS mean change for HAMD Item 3 was reduced from baseline at each week with pimavanserin with a significant difference between pimavanserin and placebo at Week 3 (p=0.012, effect size: 0.431). At any post-baseline assessment, suicidal ideation on the C-SSRS was reported in 28 (18.1%) of patients with placebo and 9 (17.3%) with pimavanserin during Stage 1 and in 7 (20.7%) with placebo and 4 (13.8%) with pimavanserin during Stage 2. No events of suicidal behavior were observed with either placebo or pimavanserin.

LIMITATIONS

The post hoc nature, exclusion of patients with any history of suicide from the primary study, and the small number of patients who demonstrated evidence of suicidal ideation.

CONCLUSIONS

Adjunctive pimavanserin was not associated with an increase in suicidal ideation in patients with MDD. Further study is needed to verify these results.

Perceived burdensomeness uniquely accounts for suicidal ideation severity in social anxiety disorder

BACKGROUND

High rates of suicidal ideation in those with social anxiety disorder (SAD) have been attributed to feelings of thwarted belongingness and perceived burdensomeness, but most work has been in non-clinical samples. We assessed the contributions of thwarted belongingness and perceived burdensomeness to suicidal ideation severity, over clinical covariates, in individuals diagnosed with SAD.

METHODS

Participants were 58 adult outpatients (mean age 25.62 years, 69% female) with SAD. Hierarchical linear regression assessed contributions of thwarted belongingness and perceived burdensomeness to suicidal ideation, before and after covarying other potential explanatory variables (depression, agitation, brooding rumination).

RESULTS

Perceived burdensomeness was significantly positively related to suicidal ideation severity (p < .001) above thwarted belongingness, which was not incremental (p = .791). The same pattern was found after inclusion of additional covariates (perceived burdensomeness p = .006; thwarted belongingness p = .757). Greater agitation also uniquely accounted for more severe suicidal ideation (p = .001).

LIMITATIONS

This study was cross-sectional, did not assess all potential confounding variables, and utilized a treatment-seeking sample.

CONCLUSIONS

Results suggest perceived burdensomeness is independently related to suicidal ideation severity in SAD, over thwarted belongingness and other clinical features. Future work should seek to replicate these findings and evaluate causal, longitudinal relationships among perceived burdensomeness, agitation, and severity of suicidal ideation in those with SAD in order to determine whether these may be clinically-relevant mechanisms.

Agitated depression in bipolar disorder

OBJECTIVES

It has been suggested that agitated depression (AD) is a common, severe feature in bipolar disorder. We aimed to estimate the prevalence of AD and investigate whether presence of AD was associated with episodic and lifetime clinical features in a large well-characterized bipolar disorder sample.

METHOD

The prevalence of agitation, based on semi-structured interview and medical case-notes, in the most severe depressive episode was estimated in 2925 individuals with DSM-IV bipolar disorder recruited into the UK Bipolar Disorder Research Network. Predictors of agitation were ascertained using symptoms within the same episode and lifetime clinical features using multivariate models.

RESULTS

32.3% (n = 946) experienced agitation during the worst depressive episode. Within the same episode, significant predictors of presence of agitation were: insomnia (OR 2.119, P < 0.001), poor concentration (OR 1.966, P = 0.027), decreased libido (OR 1.960, P < 0.001), suicidal ideation (OR 1.861, P < 0.001), slowed activity (OR 1.504, P = 0.001), and poor appetite (OR 1.297, P = 0.029). Over the lifetime illness course, co-morbid panic disorder (OR 2.000, P < 0.001), suicide attempt (OR 1.399, P = 0.007), and dysphoric mania (OR 1.354, P = 0.017) were significantly associated with AD.

CONCLUSIONS

Agitation accompanied bipolar depression in at least one-third of cases in our sample and was associated with concurrent somatic depressive symptoms, which are also common features of mixed manic states. Furthermore, AD in our sample was associated with lifetime experience of mixed mania, in addition to severe lifetime illness course including comorbid panic disorder and suicidal behavior. Our results have implications for the diagnosis and treatment of agitated features in bipolar depression.

Psychomotor agitation in subjects hospitalized for an acute exacerbation of Schizophrenia

The aims of this study were to establish the prevalence of moderate and severe psychomotor agitation in patients hospitalized for an active phase of schizophrenia, the associations between psychomotor agitation and patients' demographic and clinical variables, the intra-individual stability of the agitated/non-agitated dichotomy in independent psychotic breakdowns. The study was performed on a database relative to 630 inpatients hospitalized with a diagnosis of schizophrenia. Psychomotor agitation was measured with the Positive and Negative Syndrome Scale - Excited Component (PANSS-EC). Prevalence of moderate and severe psychomotor agitation was 40.5% and 23.7%, respectively. Non-agitated patients were older, with longer illness history and duration of untreated psychosis, were more frequently on antipsychotic medication, had lower incidence of recent use of substances, and functioned better before the index hospitalization than moderately and/or severely agitated patients. Non-agitated patients had lower scores for total PANSS and Emsley's positive and anxiety dimensions. Compared with the severely agitated group, non-agitated and moderately agitated patients scored more in Emsley's depression dimension. Poor functioning before index hospital admission, higher scores for negative subscale and Emsley's positive dimension and use of substances exerted an effect on risk of psychomotor agitation.

Prevalence, risk factors and clinical characteristics of suicidal ideation in Chinese patients with depression

BACKGROUND

Suicide risk is greatly increased in depression. Detection of those at risk is clinically important. Hence, this study aimed to evaluate the prevalence and identify independent risk factors associated with suicidal ideation (SI) in a widespread symptomatology within and outside DSM framework.

METHODS

This study was part of the National Survey on Symptomatology of Depression (NSSD) which was designed to investigate the magnitude of symptoms of current major depressive episode in China. Stepwise multivariable logistic regression was performed to examine the independent risk factors for SI, including variables that are statistically significant in univariate analysis. Receiver operating characteristic (ROC) was used to evaluate the performance of the regression model.

RESULTS

A total of 3275 patients (1293 males and 1982 females) were included in our analysis. Of these, 1750 patients (53.4%) had SI. Independent risk predictors included crying (P = 0.000; odds ratio = 1.827), helplessness (P = 0.000; odds ratio = 1.514), worthlessness (P = 0.001; odds ratio = 1.359), hopelessness (P = 0.000; odds ratio = 1.805), unusually restless (P = 0.005; odds ratio = 1.276), self-harm (P = 0.000; odds ratio = 3.385), mood-incongruent psychosis (P = 0.000; odds ratio = 2.782), feeling losing control of oneself (P = 0.009; odds ratio = 1.352), hypersomnia (P = 0.000; odds ratio = 1.805), sensory system complaints (P = 0.000; odds ratio = 1.546), derealization (P = 0.006; odds ratio = 1.580), guilt (P = 0.002; odds ratio = 1.332), suicidal attempts (P = 0.000; odds ratio = 2.841), male gender (P = 0.001; odds ratio = 0.756), the total course of depression (P = 0.010; odds ratio = 1.003) in the regression model. In addition, the areas under the curve of the ROC and the accuracy for the regression model were 0.80 and 0.76, respectively.

CONCLUSIONS

This study provided an effective risk model for SI in MDD and indicated that all these factors in our model allow better the employment of preventative measures.

Measures of the DSM-5 mixed-features specifier of major depressive disorder

During the past two decades, a number of studies have found that depressed patients frequently have manic symptoms intermixed with depressive symptoms. While the frequency of mixed syndromes are more common in bipolar than in unipolar depressives, mixed states are also common in patients with major depressive disorder. The admixture of symptoms may be evident when depressed patients present for treatment, or they may emerge during ongoing treatment. In some patients, treatment with antidepressant medication might precipitate the emergence of mixed states. It would therefore be useful to systematically inquire into the presence of manic/hypomanic symptoms in depressed patients. We can anticipate that increased attention will likely be given to mixed depression because of changes in the DSM-5. In the present article, I review instruments that have been utilized to assess the presence and severity of manic symptoms and therefore could be potentially used to identify the DSM-5 mixed-features specifier in depressed patients and to evaluate the course and outcome of treatment. In choosing which measure to use, clinicians and researchers should consider whether the measure assesses both depression and mania/hypomania, assesses all or only some of the DSM-5 criteria for the mixed-features specifier, or assesses manic/hypomanic symptoms that are not part of the DSM-5 definition. Feasibility, more so than reliability and validity, will likely determine whether these measures are incorporated into routine clinical practice.

Guidelines for the recognition and management of mixed depression

A significant minority of people presenting with a major depressive episode (MDE) experience co-occurring subsyndromal hypo/manic symptoms. As this presentation may have important prognostic and treatment implications, the DSM-5 codified a new nosological entity, the "mixed features specifier," referring to individuals meeting threshold criteria for an MDE and subthreshold symptoms of (hypo)mania or to individuals with syndromal mania and subthreshold depressive symptoms. The mixed features specifier adds to a growing list of monikers that have been put forward to describe phenotypes characterized by the admixture of depressive and hypomanic symptoms (e.g., mixed depression, depression with mixed features, or depressive mixed states [DMX]). Current treatment guidelines, regulatory approvals, as well the current evidentiary base provide insufficient decision support to practitioners who provide care to individuals presenting with an MDE with mixed features. In addition, all existing psychotropic agents evaluated in mixed patients have largely been confined to patient populations meeting the DSM-IV definition of "mixed states" wherein the co-occurrence of threshold-level mania and threshold-level MDE was required. Toward the aim of assisting clinicians providing care to adults with MDE and mixed features, we have assembled a panel of experts on mood disorders to develop these guidelines on the recognition and treatment of mixed depression, based on the few studies that have focused specifically on DMX as well as decades of cumulated clinical experience.

SPECIFIC MOOD SYMPTOMS CONFER RISK FOR SUBSEQUENT SUICIDAL IDEATION IN BIPOLAR DISORDER WITH AND WITHOUT SUICIDE ATTEMPT HISTORY: MULTI-WAVE DATA FROM STEP-BD

BACKGROUND

Little is known about specific mood symptoms that may confer risk for suicidal ideation (SI) among patients with bipolar disorder (BD). We evaluated prospectively whether particular symptoms of depression and mania precede the onset or worsening of SI, among adults with or without a history of a suicide attempt.

METHODS

We examined prospective data from a large (N = 2,741) cohort of patients participating in the Systematic Treatment Enhancement Program for BD (STEP-BD). We evaluated history of suicide attempts at baseline, and symptoms of depression and mania at baseline and follow-up visits. Hierarchical linear modeling tested whether specific mood symptoms predicted subsequent levels of SI, and whether the strength of the associations differed based on suicide attempt history, after accounting for the influence of other mood symptoms and current SI.

RESULTS

Beyond overall current depression and mania symptom severity, baseline SI, and illness characteristics, several mood symptoms, including guilt, reduced self-esteem, psychomotor retardation and agitation, increases in appetite, and distractibility predicted more severe levels of subsequent SI. Problems with concentration, distraction, sleep loss and decreased need for sleep predicted subsequent SI more strongly among individuals with a suicide attempt history.

CONCLUSIONS

Several specific mood symptoms may confer risk for the onset or worsening of SI among treatment-seeking patients with BD. Individuals with a previous suicide attempt may be at greater risk in part due to greater reactivity to certain mood symptoms in the form of SI. However, overall, effect sizes were small, suggesting the need to identify additional proximal predictors of SI.

Should major depressive disorder with mixed features be classified as a bipolar disorder?

SUMMARY

The new diagnostic category in the Depressive Disorders chapter of DSM-5 entitled 'Major Depressive Disorder With Mixed Features' is applied to individuals who meet criteria for Major Depressive Disorder and have concurrent subsyndromal hypomanic or manic symptoms. But the operational definition of this new specifier is much closer to that of hypomania and mania than to the definition of atypical depression or the older 'mixed depression.' Moreover, multiple studies have shown that the characteristics of individuals with this condition and the clinical trajectory of their illness is much closer to that of bipolar patients than to that of depressed individuals without comorbid hypomanic or manic symptoms. Thus we believe that this condition would be more appropriately placed in the Bipolar Disorders chapter of DSM-5. We also believe that this blurring of the depressive disorder- bipolar disorder boundary is one cause for the low inter-rater reliability in the diagnosis of Major Depressive Disorder.

A clinically useful self-report measure of the DSM-5 mixed features specifier of major depressive disorder

BACKGROUND

To acknowledge the clinical significance of manic features in depressed patients, DSM-5 included criteria for a mixed features specifier for major depressive disorder (MDD). In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we modified our previously published depression scale to include a subscale assessing the DSM-5 mixed features specifier.

METHODS

More than 1100 psychiatric outpatients with MDD or bipolar disorder completed the Clinically Useful Depression Outcome Scale (CUDOS) supplemented with questions for the DSM-5 mixed features specifier (CUDOS-M). To examine discriminant and convergent validity the patients were rated on clinician severity indices of depression, anxiety, agitation, and irritability. Discriminant and convergent validity was further examined in a subset of patients who completed other self-report symptom severity scales. Test-retest reliability was examined in a subset who completed the CUDOS-M twice. We compared CUDOS-M scores in patients with MDD, bipolar depression, and hypomania.

RESULTS

The CUDOS-M subscale had high internal consistency and test-retest reliability, was more highly correlated with another self-report measure of mania than with measures of depression, anxiety, substance use problems, eating disorders, and anger, and was more highly correlated with clinician severity ratings of agitation and irritability than anxiety and depression. CUDOS-M scores were significantly higher in hypomanic patients than depressed patients, and patients with bipolar depression than patients with MDD.

LIMITATIONS

The study was cross-sectional, thus we did not examine whether the CUDOS-M detects emerging mixed symptoms when depressed patients are followed over time. Also, while we examined the correlation between the CUDOS-M and clinician ratings of agitation and irritability, we did not examine the association with a clinician measure of manic symptomatology such as the Young Mania Rating Scale

CONCLUSIONS

In the present study of a large sample of psychiatric outpatients, the CUDOS-M was a reliable and valid measure of the DSM-5 mixed features specifier for MDD.

DSM-5 criteria for depression with mixed features: a farewell to mixed depression

OBJECTIVE

To review the DSM-5 proposed criteria for mixed depression in light of robust and consistent historical and scientific evidence.

METHOD

An extensive historical search, a systematic review of the papers used by DSM-5 as reference papers, and a PubMed search were performed.

RESULTS

As Hippocrates, depressive mixed states have been described as conditions of intense psychic suffering, consisting of depressed mood, inner tension, restlessness, and aimless psychomotor agitation. In DSM-5, new criteria are proposed for a mixed features specifier, as part of depression either in major depressive disorder (MDD) or bipolar disorder. Those criteria require, as diagnostically specific, manic/hypomanic symptoms that are the least common kinds of symptoms that actually arise in depressive mixed states. The DSM-5 proposal is based, almost entirely, on a speculative wish to avoid 'overlapping' manic and depressive symptoms. Mixed states are, in fact, nothing but overlapping manic and depressive symptoms.

CONCLUSION

In this article, we review the psychopathology and research on mixed depressive states, and try to demonstrate that the DSM-5 proposal has weak scientific basis and does not identify a large number of mixed depressive states. This may be harmful because of the different treatment required by these conditions.

A case series on the use of lavendula oil capsules in patients suffering from major depressive disorder and symptoms of psychomotor agitation, insomnia and anxiety

OBJECTIVE

Symptoms of agitation, anxiety and insomnia are frequent among patients with major depressive disorder (MDD) during the first weeks of psychiatric care. But a substantial number of patients declines taking pharmaceutical medication to avoid side effects. Therefore, an alternative herbal medication is needed. Clinical studies demonstrated that lavender oil capsules, termed Lasea®, have an anxiolytic effect comparable to Lorazepam and significantly reduce insomnia and agitation in non-depressed patients. Therefore, the aim of this retrospective case series was to analyze the effectiveness of Lasea® for patients with MDD and symptoms of anxiety, insomnia and psychomotor agitation.

DESIGN

Eight cases were analyzed retrospectively regarding the dosage, length of treatment, possible side effects and effectiveness of Lasea®.

SETTING

All cases were treated at the Department of Psychiatry at Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin in a naturalistic setting.

MAIN OUTCOME MEASURE

Effectiveness was measured by a change in the Hamilton Rating Scale for Depression (HAMD-17) total score and subscores.

RESULTS

In 6 cases, the combination of Lasea® and an antidepressant resulted in a reduction of MDD. Lasea® also reduced agitation in 6 cases. Psychological anxiety was reduced in 5, somatic anxiety in 4 cases whereas sleep-onset and sleep-maintenance insomnia improved in 3 cases each.

CONCLUSIONS

The results demonstrate that Lasea® reduces some of the anxiety related symptoms and sleep disturbances in MDD patients. Furthermore Lasea® significantly reduces psychomotor agitation. Additionally, the results indicate a significant global improvement stemming from the combinational therapy of Lasea® and antidepressant medication.

Chronic clomipramine treatment reverses core symptom of depression in subordinate tree shrews

Chronic stress is the major cause of clinical depression. The behavioral signs of depression, including anhedonia, learning and memory deficits, and sleep disruption, result from the damaging effects of stress hormones on specific neural pathways. The Chinese tree shrew (Tupaia belangeri chinensis) is an aggressive non-human primate with a hierarchical social structure that has become a well-established model of the behavioral, endocrine, and neurobiological changes associated with stress-induced depression. The tricyclic antidepressant clomipramine treats many of the core symptoms of depression in humans. To further test the validity of the tree shrew model of depression, we examined the effects of clomipramine on depression-like behaviors and physiological stress responses induced by social defeat in subordinate tree shrews. Social defeat led to weight loss, anhedonia (as measured by sucrose preference), unstable fluctuations in locomotor activity, sustained urinary cortisol elevation, irregular cortisol rhythms, and deficient hippocampal long-term potentiation (LTP). Clomipramine ameliorated anhedonia and irregular locomotor activity, and partially rescued the irregular cortisol rhythm. In contrast, weight loss increased, cortisol levels were even higher, and in vitro LTP was still impaired in the clomipramine treatment group. These results demonstrate the unique advantage of the tree shrew social defeat model of depression.

Activated depression: mixed bipolar disorder or agitated unipolar depression?

The combination of depression and activation presents clinical and diagnostic challenges. It can occur, in either bipolar disorder or major depressive disorder, as increased agitation as a dimension of depression. What is called agitation can consist of expressions of painful inner tension or as disinhibited goal-directed behavior and thought. In bipolar disorder, elements of depression can be combined with those of mania. In this case, the agitation, in addition to increased motor activity and painful inner tension, must include symptoms of mania that are related to goal-directed behavior or manic cognition. These diagnostic considerations are important, as activated depression potentially carries increased behavioral risk, especially for suicidal behavior, and optimal treatments for depressive episodes differ between bipolar disorder and major depressive disorder.

Clinical responses to antidepressants among 1036 acutely depressed patients with bipolar or unipolar major affective disorders

OBJECTIVE

Whether responses to antidepressants differ in bipolar and unipolar depression remains unresolved.

METHOD

We analyzed patient characteristics and outcomes of antidepressant treatment of 1036 depressed patients with bipolar-I or bipolar-II disorder, or unipolar major depression, using bivariate and multivariate methods and survival analysis, testing the hypothesis that responses would be superior in unipolar depression.

RESULTS

Antidepressants were given to 84.8% (878/1036) of depressed patients: 58.9% of 93 bipolar-I, 80.1% of 117 bipolar-II, and 91.3% of 668 unipolar disorder cases. The 158 not given antidepressants had more manias/year, spent more months in mania and depression, and were far more likely to receive mood stabilizers or antipsychotics long term. Improvement of HDRS21 depression ratings ranked: bipolar-II (69.6%) > bipolar-I (62.9%) > unipolar (57.9%; P < 0.0001), independent of initial illness severity. Responder rates (≥50% improved without switching) ranked: bipolar-II (77.0%) > bipolar-I (71.6%) > unipolar (61.7%; P < 0.0001). Remission rates (final HDRS < 7) ranked: 54.0%, 50.6%, and 40.8% respectively (P = 0.02); 67.5% remitted within 12 weeks of treatment. Survival-computed median time to remission (15.0 weeks, overall) was shortest for bipolar-II patients (10.7 weeks). The 3-month risk of switching into mania-hypomania ranked: bipolar-II (15.8%) > bipolar-I (8.60%) > unipolar (0.56%). Multivariate modeling found bipolar diagnosis, shorter latency to remission, more recent trial year, and fewer weeks depressed before treatment to be associated with greater percent improvement of HDRS ratings.

CONCLUSION

Selective use of antidepressants with or without mood stabilizers in non-agitated, depressed bipolar disorder patients for short periods was effective with moderate risk of potentially dangerous, manic mood elevation.

Medical, psychiatric and demographic factors associated with suicidal behavior in homeless veterans

This study assessed potential for suicidal behaviors associated with sociodemographic, predisposing physical and mental health factors and self-reported psychological problems among homeless veterans in a large northeastern region. Data were obtained from a demographic and clinical history interview conducted with 3595 homeless veterans. Odds-ratio (OR) statistics were used to assess potential for suicidal behavior. Statistically significant ratios were similar for ideation and attempts. The highest ratios were for self-report of depression and difficulty controlling violence, but statistically significant ratios were found for reporting sleeping in a treatment facility the night before the interview, receiving VA support for a psychiatric condition, and the diagnoses of Alcoholism, Mood Disorder and Post Traumatic Stress Disorder (PTSD). Low but statistically significant odds-ratios were obtained for most of the physical health items. A negative odds-ratio was obtained for African-American ethnicity. Logistic regression results indicated that for ideation and attempts items entered first involved subjective report of trouble controlling violent behavior and experiencing depression. High odds ratios for the interview items concerning experiencing serious depression and having difficulties controlling violence may have strong implications for treatment and management of homeless veterans. There may be up to 14-1 odds that an individual who reports being seriously depressed or having difficulty inhibiting aggression may have a serious potential for suicidal behaviors.

Healthy life behaviors and suicide probability in university students

This study aims to determine the sociodemographic factors and healthy life behaviors affecting suicide and suicide probability of university students. The research was designed as a complementary study and conducted with 334 students from several faculties and colleges at Ege University, Turkey. The study findings indicated that suicide probability could be affected by the students' age, their problems at school, their troubled relations with friends, and a psychiatric disorder history within the last year. Moreover, it was concluded that the students with healthy life behaviors had significantly lower scores on the Suicide Probability Scale and its subscales.

Is insomnia associated with suicidality in stroke?

OBJECTIVE

To evaluate the relationship between insomnia and suicidality (SI) in Chinese patients with first or recurrent stroke.

DESIGN

Cross-sectional survey.

SETTING

Acute stroke unit of a general hospital.

PARTICIPANTS

Patients (N=787) with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Suicidality (SI) was assessed with the Geriatric Mental State Examination at 3 months after subjects' index stroke. Insomnia symptoms were evaluated with a standard insomnia questionnaire. The association between insomnia symptoms and SI was examined and adjusted for potential confounders, including age, sex, marital status, previous stroke, depression, fatigue, Mini-Mental State Examination score, and neurologic deficits measured with the National Institutes of Health Stroke Scale.

RESULTS

Eighty-seven patients (11.1%) were found to have SI (SI group). Frequent awakening was significantly more common in the SI group than in the non-SI group and remained a significant predictor of SI in forward logistic regression analysis (odds ratio, 1.7) after adjusting for possible confounders.

CONCLUSIONS

These findings should alert clinicians to the potential danger of insomnia and the importance of its early identification and treatment in stroke patients.

Sleep disturbances and suicidality: a common association to look for in clinical practise and preventive care

Suicidality and suicide has been associated with many risk factors, while recent clinical and epidemiological studies increasingly point to a potential link between sleep loss or sleep disturbances and suicidality. This review on studies of sleep disturbances associated with suicidality, i.e., suicidal ideation, suicide attempt and completed suicide suggests a frequent association especially with insomnia and nightmares but also hypersomnia and sleep panic attacks. In suicidal insomniacs with comorbid psychiatric disorders, there is some evidence for an even independent predictive nature of sleep problems for suicidality. Considerations on the shared neurobiology, risk assessment and treatment options complement the overview. Thus, sleep disturbances may qualify as an individual treatable target of personalised medicine in the clinical routine as well as in suicide prevention programmes. A more detailed assessment of sleep problems and identification of specific risk domains in primary or secondary prevention of suicidality seem to be a future area of high importance.

Risk of suicide and mixed episode in men in the postpartum period

OBJECTIVES

To assess suicide risk in men with mood disorders at the postpartum period.

METHODS

We conduct a longitudinal study with 650 men whose child has born from April 2007 to May 2008 at maternity hospital. The first assessment was in the antenatal period and the second within 30 to 60days postpartum. Suicide risk, anxiety disorders, hypomanic, manic and mixed episodes were assessed by the Mini International Neuropsychiatric Interview (MINI).

RESULTS

The prevalence of suicide risk in fathers in postpartum was of 4.8%. Fathers with postpartum depression were 20.97 (CI: 5.74; 76.53) more likely to present suicide risk and those with mixed episodes showed a chance of 46.50 (CI: 10.52; 205.53) times higher than those who did not suffer from any mood disorder.

CONCLUSION

Mixed episodes are common in fathers at postpartum, posing a higher suicide risk than depressive and manic/hypomanic episodes. Therefore, in order to reduce the suicide risk, clinicians should address and treat adequately mixed affective states in this specific population.

Agitated depression in substance dependence

BACKGROUND

Depression with psychomotor agitation (PMA; "agitated depression") is a putative psychiatric phenotype that appears to associate with some forms of substance dependence. However, it is unclear whether such relationships extend across different substances and independent (I-MDE) versus substance-induced (SI-MDE) subtypes of major depressive episodes.

METHOD

We examined whether lifetime depression with (vs. without) PMA was associated with lifetime substance dependence across individuals with lifetime: (1) I-MDE only (n=575); and (2) SI-MDE only (n=1683). Data were pooled from several family and genetic studies of substance dependence in which participants received identical structured interviews to diagnose DSM-IV mental disorders.

RESULTS

In I-MDE, PMA was significantly associated with alcohol, cocaine, opioid, other drug (hallucinogen, inhalant, speed-ball), and sedative dependence. After controlling for demographic and clinical co-factors, PMA's relationship to dependence on opioids, other drugs, and sedatives remained significant, but not its relationship to alcohol or cocaine. In SI-MDE, PMA was significantly associated with alcohol, cocaine, opioid, and other drug dependence. After adjusting for co-factors, associations remained significant for dependence on cocaine and opioids, but not alcohol or other drugs. Relationships between PMA and opioid dependence were stronger in I-MDE than SI-MDE. Depression subtype (I-MDE vs. SI-MDE) did not moderate relations between PMA and non-opioid forms of substance dependence.

CONCLUSIONS

Agitated depression associates with certain forms of substance dependence, particularly opioid dependence. MDE subtype did not alter most PMA-dependence associations, which suggests that the mechanisms underlying this comorbidity are complex and potentially bidirectional.

Suicide in a large population of former psychiatric inpatients

AIMS

The aim of this study was to identify predictors of completed suicide in a wide sample of psychiatric inpatients receiving retrospective and prospective DSM-IV diagnoses.

METHODS

We followed up 4441 severe psychiatric patients who were hospitalized for some time during a 35-year period in a private hospital setting. We collected sociodemographic, clinical and temperamental data.

RESULTS

Ninety-six patients from the sample committed suicide. There were no sex differences in suicide completion and no differences between major psychiatric disorders, but people who had been hospitalized for anxiety disorders did not commit suicide and people with bipolar disorders were more likely to commit suicide than people with unipolar major depression. Shorter-term treatment with lithium and anticonvulsants, longer-term treatment with antidepressants, history of suicide attempts, suicidal thinking, and single status positively predicted completed suicide. Suicide tended to occur after a mean period of about 14 years of duration of disease. Patients' symptoms during the period preceding suicide were assessed through interviewing patients' physicians or family members. Symptoms occurring in >10% of cases were, in decreasing order, inner tension, racing/crowded thoughts, aggressive behavior, guilt, psychomotor agitation, persecutory ideation, anxiety, and hallucinations. Surprisingly, cyclothymic temperament was less associated with completed suicide as compared to other temperaments.

CONCLUSIONS

Suicide is likely to occur in a milieu of agitation, mixed anxiety and depression, and psychosis. Longer-term mood stabilizer treatment may reduce the rate of completed suicide.

Characterizing major depression phenotypes by presence and type of psychomotor disturbance in adolescents and young adults

Major depressive disorder (MDD) is phenomenologically heterogeneous, which has prompted investigation of intermediate MDD phenotypes based on specific key symptoms. Presence and type of psychomotor disturbance may be an important psychopathologic feature that differentiates clinically distinct forms of juvenile MDD. This study examined the phenotypic status of three putative MDD phenotypes in a community sample of 941 youths: (1) agitated depression (MDD with psychomotor agitation), (2) retarded depression (MDD with psychomotor retardation), and (3) agitated-retarded depression (MDD with psychomotor agitation and retardation within an episode). Hasler et al.'s [2004: Neuropsychopharmacology 29:1765-1781] criteria of specificity (degree of association with relevant symptoms and conditions related to the disease of interest versus other psychiatric conditions), stability (degree of stability over time), and heritability (degree of familial aggregation with relevant conditions) were used to evaluate the phenotypic significance of these subtypes. Results were suggestive that agitated depression was a relatively specific phenotypic syndrome characterized by irritability, arousal, physical complaints, and vulnerability to anxiety disorders and alcohol dependence; low stability across depressive episodes; and low heritability. Agitated-retarded depression was relatively specific and characterized by increased severity, recurrence, vegetative symptoms, suicidal ideation, social impairment, endogeneity, and vulnerability to anxiety disorders and bulimia; low stability across episodes; and modest heritability. Although retarded depression was associated with some specific distinguishing characteristics, most associations were explained by the increased severity of this phenotype. Retarded depression evidenced little stability or heritability. These findings offer partial support of the phenotypic status of agitated and agitated-retarded depression in youths.

Adjunctive antidepressant treatment with quetiapine in agitated depression: positive effects on symptom reduction, psychopathology and remission rates

OBJECTIVES

To investigate the adjunctive effects of quetiapine on overall treatment response and on specific symptoms in agitated depression.

METHODS

Twenty-one patients suffering from an acute agitated major depressive episode were enrolled in the quetiapine/venlafaxine study group (QUET) in the context of a 6-week open-label, flexible dose, non-randomized case-control study. Eighteen matched depressed patients treated with antidepressants only served as controls (CON). Clinical assessment was carried out by the use of Hamilton Rating Scale for Depression (HAM-D) 21 scale.

RESULTS

Both groups had high HAM-D scores at baseline (27.6 vs. 27.5; p = 0.94). The QUET group displayed a significantly larger HAM-D decrease already after 1 week of treatment (p = 0.026, d = 0.77). This group difference increased slightly until week 6 (p = 0.005, d = 1.0). The remission rate in the QUET group (70%) was almost double that of the CON group (38.5%), p = 0.022. The overall effect originated from various HAM-D items indicating agitation, sleep problems and anxiety.

CONCLUSIONS

Adjunctive quetiapine treatment in agitated depression showed faster and greater response leading to higher remission rates compared with antidepressants alone. Overall clinical improvement was specifically related to single aspects of psychopathology indicating that quetiapine develops its positive effects through a variety of psychopharmacological properties.