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Parrish EM, Harvey PD, Ackerman RA, Moore RC, Depp CA, Gagnier M, Pinkham AE. The Tripartite Model of Depression in Schizophrenia and Bipolar Disorder: A Secondary Analysis. J Nerv Ment Dis 2023; 211:841-847. [PMID: 37734155 PMCID: PMC10615707 DOI: 10.1097/nmd.0000000000001714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
ABSTRACT Models of affect, like the tripartite model, suggest that positive affect (PA) and negative affect (NA) are independent between subjects and negatively correlated within. Correlations may differ in bipolar disorder (BD) and schizophrenia. Using ecological momentary assessment (EMA) and clinical ratings, this secondary analysis evaluated the tripartite model by examining PA and NA. Two hundred eighty-one participants with BD or a psychotic disorder completed 30 days of EMA of PA and NA, and clinical raters assessed depression. PA and NA were more related between subjects and less related within subjects among participants with schizophrenia. In BD, lower momentary PA was positively associated with clinical ratings of depression, although greater momentary NA was not significantly associated with clinical ratings. In schizophrenia, the inverse was found. These results suggest that the tripartite model was not confirmed in people with schizophrenia or BD. However, PA and NA manifested associations in BD that were more congruent with population studies than in schizophrenia. These findings may have implications for clinical interventions targeting depression, PA, and NA in these populations.
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Affiliation(s)
- Emma M. Parrish
- San Diego State University / University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California
| | - Philip D. Harvey
- University of Miami Miller School of Medicine, Miami, Florida, Research Service Miami VA Medical Center, Miami, FL
| | | | - Raeanne C. Moore
- University of California San Diego Department of Psychiatry, San Diego, California
| | - Colin A. Depp
- University of California San Diego Department of Psychiatry, San Diego, California
- Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Marc Gagnier
- University of Miami Miller School of Medicine, Miami, Florida, Research Service Miami VA Medical Center, Miami, FL
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2
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Zhu W, Chen X, Wu J, Li Z, Im H, Chen S, Deng K, Zhang B, Wei C, Feng J, Zhang M, Yang S, Wang H, Wang Q. Neuroanatomical and functional substrates of the hypomanic personality trait and its prediction on aggression. Int J Clin Health Psychol 2023; 23:100397. [PMID: 37560478 PMCID: PMC10407439 DOI: 10.1016/j.ijchp.2023.100397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/10/2023] [Indexed: 08/11/2023] Open
Abstract
Hypomanic personality manifests a close link with several psychiatric disorders and its abnormality is a risk indicator for developing bipolar disorders. We systematically investigated the potential neuroanatomical and functional substrates underlying hypomanic personality trait (HPT) and its sub-dimensions (i.e., Social Vitality, Mood Volatility, and Excitement) combined with structural and functional imaging data as well as their corresponding brain networks in a large non-clinical sample across two studies (n = 464). Behaviorally, HPT, specifically Mood Volatility and Excitement, was positively associated with aggressive behaviors in both studies. Structurally, sex-specific morphological characteristics were further observed in the motor and top-down control networks especially for Mood Volatility, although HPT was generally positively associated with grey matter volumes (GMVs) in the prefrontal, temporal, visual, and limbic systems. Functionally, brain activations related to immediate or delayed losses were found to predict individual variability in HPT, specifically Social Vitality and Excitement, on the motor and prefrontal-parietal cortices. Topologically, connectome-based prediction model analysis further revealed the predictive role of individual-level morphological and resting-state functional connectivity on HPT and its sub-dimensions, although it did not reveal any links with general brain topological properties. GMVs in the temporal, limbic (e.g., amygdala), and visual cortices mediated the effects of HPT on behavioral aggression. These findings suggest that the imbalance between motor and control circuits may be critical for HPT and provide novel insights into the neuroanatomical, functional, and topological mechanisms underlying the specific temperament and its impacts on aggression.
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Affiliation(s)
- Wenwei Zhu
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
| | - Xiongying Chen
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing 100088, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100069, China
| | - Jie Wu
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
- Key Research Base of Humanities and Social Sciences of the Ministry of Education, Academy of Psychology and Behavior, Tianjin Normal University, Tianjin 300387, China
- Tianjin Social Science Laboratory of Students’ Mental Development and Learning, Tianjin 300387, China
| | - Zixi Li
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
| | - Hohjin Im
- Department of Psychological Science, University of California, Irvine, CA 92697-7085, USA
| | - Shuning Chen
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
| | - Kun Deng
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
| | - Bin Zhang
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
| | - Chuqiao Wei
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
| | - Junjiao Feng
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
- Key Research Base of Humanities and Social Sciences of the Ministry of Education, Academy of Psychology and Behavior, Tianjin Normal University, Tianjin 300387, China
- Tianjin Social Science Laboratory of Students’ Mental Development and Learning, Tianjin 300387, China
| | - Manman Zhang
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
- Key Research Base of Humanities and Social Sciences of the Ministry of Education, Academy of Psychology and Behavior, Tianjin Normal University, Tianjin 300387, China
- Tianjin Social Science Laboratory of Students’ Mental Development and Learning, Tianjin 300387, China
| | - Shaofeng Yang
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
- Key Research Base of Humanities and Social Sciences of the Ministry of Education, Academy of Psychology and Behavior, Tianjin Normal University, Tianjin 300387, China
- Tianjin Social Science Laboratory of Students’ Mental Development and Learning, Tianjin 300387, China
| | - He Wang
- Institute of Biomedical Engineering, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin 300192, China
| | - Qiang Wang
- Faculty of Psychology, Tianjin Normal University, Tianjin 300387, China
- Key Research Base of Humanities and Social Sciences of the Ministry of Education, Academy of Psychology and Behavior, Tianjin Normal University, Tianjin 300387, China
- Tianjin Social Science Laboratory of Students’ Mental Development and Learning, Tianjin 300387, China
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3
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Wang Z, Zhang D, Du Y, Wang Y, Huang T, Ng CH, Huang H, Pan Y, Lai J, Hu S. Efficacy of Quetiapine Monotherapy and Combination Therapy for Patients with Bipolar Depression with Mixed Features: A Randomized Controlled Pilot Study. Pharmaceuticals (Basel) 2023; 16:287. [PMID: 37259431 PMCID: PMC9966274 DOI: 10.3390/ph16020287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/06/2023] [Accepted: 01/08/2023] [Indexed: 07/26/2023] Open
Abstract
Effective pharmacotherapy of bipolar depression with mixed features defined by DSM-5 remains unclear in clinical treatment guidelines. Quetiapine (QTP) and valproate have potential treatment utility but are often inadequate as monotherapy. Meanwhile, the efficacy of combination therapies of QTP plus valproate or lithium have yet to be verified. Hence, we conducted a randomized controlled pilot study to evaluate the efficacy of QTP monotherapy in patients with bipolar depression with mixed features defined by DSM-5 and compared the combination therapy of QTP plus valproate (QTP + V) versus QTP plus lithium (QTP + L) for those patients who responded insufficiently to QTP monotherapy. Data was analyzed according to the intent-to-treat population. Generalized linear mixed model was performed by using "nlme" package in R software. A total 56 patients were enrolled, among which, 35 patients responded to QTP alone, and 11 and 10 patients were randomly assigned to QTP + V and QTP + L group, respectively. Nearly 60% enrolled patients responded to QTP monotherapy at the first two weeks treatment. No statistically significant difference in efficacy between QTP + V and QTP + L was observed. In conclusion, QTP monotherapy appeared to be efficacious in patients with bipolar depression with mixed features, and for those who responded insufficiently to QTP, combining with either valproate or lithium appeared to have positive effects.
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Affiliation(s)
- Zheng Wang
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Danhua Zhang
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Yanli Du
- Department of Psychiatry, Dongyang People’s Hospital, Jinhua 322103, China
| | - Yin Wang
- Clinical Trial Unit, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai 310005, China
| | - Tingting Huang
- Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Chee H. Ng
- Department of Psychiatry, The Melbourne Clinic and St Vincent’s Hospital, University of Melbourne, Richmond, VIC 3121, Australia
| | - Huimin Huang
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Yanmeng Pan
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jianbo Lai
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Shaohua Hu
- Department of Psychiatry, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
- Brain Research Institute, Zhejiang University, Hangzhou 310003, China
- Zhejiang Engineering Center for Mathematical Mental Health, Hangzhou 310003, China
- Department of Neurobiology, NHC and CAMS Key Laboratory of Medical Neurobiology, School of Brain Science and Brian Medicine, and MOE Frontier Science Center for Brain Science and Brain-Machine Integration, Zhejiang University School of Medicine, Hangzhou 310003, China
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4
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Chakrabarti S. Bipolar disorder in the International Classification of Diseases-Eleventh version: A review of the changes, their basis, and usefulness. World J Psychiatry 2022; 12:1335-1355. [PMID: 36579354 PMCID: PMC9791613 DOI: 10.5498/wjp.v12.i12.1335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/07/2022] [Accepted: 11/22/2022] [Indexed: 12/16/2022] Open
Abstract
The World Health Organization’s 11th revision of the International Classification of Diseases (ICD-11) including the chapter on mental disorders has come into effect this year. This review focuses on the “Bipolar or Related Disorders” section of the ICD-11 draft. It describes the benchmarks for the new version, particularly the foremost principle of clinical utility. The alterations made to the diagnosis of bipolar disorder (BD) are evaluated on their scientific basis and clinical utility. The change in the diagnostic requirements for manic and hypomanic episodes has been much debated. Whether the current criteria have achieved an optimum balance between sensitivity and specificity is still not clear. The ICD-11 definition of depressive episodes is substantially different, but the lack of empirical support for the changes has meant that the reliability and utility of bipolar depression are relatively low. Unlike the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the ICD-11 has retained the category of mixed episodes. Although the concept of mixed episodes in the ICD-11 is not perfect, it appears to be more inclusive than the DSM-5 approach. Additionally, there are some uncertainties about the guidelines for the subtypes of BD and cyclothymic disorder. The initial results on the reliability and clinical utility of BD are promising, but the newly created diagnostic categories also appear to have some limitations. Although further improvement and research are needed, the focus should now be on facing the challenges of implementation, dissemination, and education and training in the use of these guidelines.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, UT, India
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5
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McIntyre RS, Alda M, Baldessarini RJ, Bauer M, Berk M, Correll CU, Fagiolini A, Fountoulakis K, Frye MA, Grunze H, Kessing LV, Miklowitz DJ, Parker G, Post RM, Swann AC, Suppes T, Vieta E, Young A, Maj M. The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management. World Psychiatry 2022; 21:364-387. [PMID: 36073706 PMCID: PMC9453915 DOI: 10.1002/wps.20997] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Bipolar disorder is heterogeneous in phenomenology, illness trajectory, and response to treatment. Despite evidence for the efficacy of multimodal-ity interventions, the majority of persons affected by this disorder do not achieve and sustain full syndromal recovery. It is eagerly anticipated that combining datasets across various information sources (e.g., hierarchical "multi-omic" measures, electronic health records), analyzed using advanced computational methods (e.g., machine learning), will inform future diagnosis and treatment selection. In the interim, identifying clinically meaningful subgroups of persons with the disorder having differential response to specific treatments at point-of-care is an empirical priority. This paper endeavours to synthesize salient domains in the clinical characterization of the adult patient with bipolar disorder, with the overarching aim to improve health outcomes by informing patient management and treatment considerations. Extant data indicate that characterizing select domains in bipolar disorder provides actionable information and guides shared decision making. For example, it is robustly established that the presence of mixed features - especially during depressive episodes - and of physical and psychiatric comorbidities informs illness trajectory, response to treatment, and suicide risk. In addition, early environmental exposures (e.g., sexual and physical abuse, emotional neglect) are highly associated with more complicated illness presentations, inviting the need for developmentally-oriented and integrated treatment approaches. There have been significant advances in validating subtypes of bipolar disorder (e.g., bipolar I vs. II disorder), particularly in regard to pharmacological interventions. As with other severe mental disorders, social functioning, interpersonal/family relationships and internalized stigma are domains highly relevant to relapse risk, health outcomes, and quality of life. The elevated standardized mortality ratio for completed suicide and suicidal behaviour in bipolar disorder invites the need for characterization of this domain in all patients. The framework of this paper is to describe all the above salient domains, providing a synthesis of extant literature and recommendations for decision support tools and clinical metrics that can be implemented at point-of-care.
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Affiliation(s)
- Roger S. McIntyre
- Mood Disorders Psychopharmacology UnitUniversity Health NetworkTorontoONCanada,Department of PsychiatryUniversity of TorontoTorontoONCanada,Department of PharmacologyUniversity of TorontoTorontoONCanada
| | - Martin Alda
- Department of PsychiatryDalhousie UniversityHalifaxNSCanada,National Institute of Mental HealthKlecanyCzech Republic
| | - Ross J. Baldessarini
- Harvard Medical SchoolBostonMAUSA,International Consortium for Bipolar & Psychotic Disorders ResearchMcLean HospitalBelmontMAUSA,Mailman Research CenterMcLean HospitalBelmontMAUSA
| | - Michael Bauer
- University Hospital Carl Gustav CarusTechnische Universität DresdenDresdenGermany
| | - Michael Berk
- IMPACT Strategic Research Centre, School of MedicineDeakin UniversityGeelongVICAustralia,Orygen, National Centre of Excellence in Youth Mental HealthCentre for Youth Mental Health, University of MelbourneMelbourneVICAustralia
| | - Christoph U. Correll
- Department of PsychiatryZucker Hillside Hospital, Northwell HealthGlen OaksNYUSA,Department of Psychiatry and Molecular MedicineZucker School of Medicine at Hofstra/NorthwellHempsteadNYUSA,Department of Child and Adolescent PsychiatryCharité Universitätsmedizin BerlinBerlinGermany
| | | | - Kostas Fountoulakis
- 3rd Department of Psychiatry, Division of Neurosciences, School of MedicineAristotle University of ThessalonikiThessalonikiGreece
| | - Mark A. Frye
- Department of Psychiatry & PsychologyMayo ClinicRochesterMNUSA
| | - Heinz Grunze
- Allgemeinpsychiatrie OstKlinikum am WeissenhofWeinsbergGermany,Paracelsus Medical Private University NurembergNurembergGermany
| | - Lars V. Kessing
- Copenhagen Affective Disorder Research CenterPsychiatric Center CopenhagenCopenhagenDenmark,Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - David J. Miklowitz
- Department of Psychiatry and Biobehavioral SciencesUniversity of California Los Angeles (UCLA) Semel InstituteLos AngelesCAUSA
| | - Gordon Parker
- School of PsychiatryUniversity of New South WalesSydneyNSWAustralia
| | - Robert M. Post
- School of Medicine & Health SciencesGeorge Washington UniversityWashingtonDCUSA,Bipolar Collaborative NetworkBethesdaMDUSA
| | - Alan C. Swann
- Department of PsychiatryBaylor College of MedicineHoustonTXUSA
| | - Trisha Suppes
- Department of Psychiatry and Behavioural SciencesStanford School of Medicine and VA Palo Alto Health Care SystemPalo AltoCAUSA
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital ClinicUniversity of Barcelona, IDIBAPS, CIBERSAMBarcelonaCataloniaSpain
| | - Allan Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and NeuroscienceKing's College LondonLondonUK,South London and Maudsley NHS Foundation TrustBethlem Royal HospitalBeckenhamUK
| | - Mario Maj
- Department of PsychiatryUniversity of Campania “L. Vanvitelli”NaplesItaly
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Tavares DF, Suen P, Moreno DH, Vieta E, Moreno RA, Brunoni AR. Distractibility, anxiety, irritability, and agitation symptoms are associated with the severity of depressive and manic symptoms in mixed depression. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2022; 44:576-583. [PMID: 36580584 PMCID: PMC9851764 DOI: 10.47626/1516-4446-2022-2606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/30/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To explore whether there is an association between distractibility, anxiety, irritability, and agitation (DAIA) symptoms and the severity of depressive and manic symptoms. METHODS Patients with unipolar and bipolar disorder (I and II) and mixed depression were evaluated. DAIA symptoms were assessed using previously described definitions. RESULTS The full analysis set comprised 100 patients. The severity of depressive symptoms in mixed depression, assessed by Montgomery-Åsberg Depression Rating Scale (MADRS), was significantly associated with the presence of two or more DAIA symptoms in the bipolar sample, influenced mainly by anxiety. The severity of manic symptoms in mixed depression, assessed by Young Mania Rating Scale (YMRS), was significantly associated with the presence of two or more DAIA symptoms in the bipolar sample and three or four DAIA symptoms in the unipolar sample. CONCLUSION DAIA symptoms were associated with greater severity of manic symptoms in mixed depression. DAIA symptoms must be evaluated in all patients with mixed features and are associated with the severity of depressive and manic symptoms in mixed depression.
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Affiliation(s)
- Diego Freitas Tavares
- Serviço Interdisciplinar de Neuromodulação, Departamento de Psiquiatria, Instituto de Psiquiatria, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil,Programa de Transtornos Afetivos, Departamento de Psiquiatria, Instituto de Psiquiatria, Faculdade de Medicina, USP, São Paulo, SP, Brazil
| | - Paulo Suen
- Serviço Interdisciplinar de Neuromodulação, Departamento de Psiquiatria, Instituto de Psiquiatria, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Doris Hupfeld Moreno
- Programa de Transtornos Afetivos, Departamento de Psiquiatria, Instituto de Psiquiatria, Faculdade de Medicina, USP, São Paulo, SP, Brazil
| | - Eduard Vieta
- Hospital Clínic, Instituto de Neurociencias, Universidad de Barcelona, L’Institut d’Investigacions Biomèdiques August Pi i Sunyer, Investigación Biomédica en Red en el Área de Salud Mental, Barcelona, Catalonia, Spain
| | - Ricardo Alberto Moreno
- Programa de Transtornos Afetivos, Departamento de Psiquiatria, Instituto de Psiquiatria, Faculdade de Medicina, USP, São Paulo, SP, Brazil
| | - André R. Brunoni
- Serviço Interdisciplinar de Neuromodulação, Departamento de Psiquiatria, Instituto de Psiquiatria, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil,Laboratório de Neurociências, Departamento de Psiquiatria, Instituto de Psiquiatria, Faculdade de Medicina, USP, São Paulo, SP, Brazil
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7
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Chakrabarti S, Singh N. Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review. World J Psychiatry 2022; 12:1204-1232. [PMID: 36186500 PMCID: PMC9521535 DOI: 10.5498/wjp.v12.i9.1204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/02/2022] [Accepted: 08/26/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.
AIM To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.
METHODS The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.
RESULTS This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.
CONCLUSION Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, UT, India
| | - Navdeep Singh
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, UT, India
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8
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Natale A, Mineo L, Fusar-Poli L, Aguglia A, Rodolico A, Tusconi M, Amerio A, Serafini G, Amore M, Aguglia E. Mixed Depression: A Mini-Review to Guide Clinical Practice and Future Research Developments. Brain Sci 2022; 12:92. [PMID: 35053835 PMCID: PMC8773514 DOI: 10.3390/brainsci12010092] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 12/28/2022] Open
Abstract
The debate on mixed states (MS) has been intense for decades. However, several points remain controversial from a nosographic, diagnostic, and therapeutic point of view. The different perspectives that have emerged over the years have turned into a large, but heterogeneous, literature body. The present review aims to summarize the evidence on MS, with a particular focus on mixed depression (MxD), in order to provide a guide for clinicians and encourage the development of future research on the topic. First, we review the history of MS, focusing on their different interpretations and categorizations over the centuries. In this section, we also report alternative models to traditional nosography. Second, we describe the main clinical features of MxD and list the most reliable assessment tools. Finally, we summarize the recommendations provided by the main international guidelines for the treatment of MxD. Our review highlights that the different conceptualizations of MS and MxD, the variability of clinical pictures, and the heterogeneous response to pharmacological treatment make MxD a real challenge for clinicians. Further studies are needed to better characterize the phenotypes of patients with MxD to help clinicians in the management of this delicate condition.
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Affiliation(s)
- Antimo Natale
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy; (L.M.); (L.F.-P.); (A.R.); (E.A.)
| | - Ludovico Mineo
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy; (L.M.); (L.F.-P.); (A.R.); (E.A.)
| | - Laura Fusar-Poli
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy; (L.M.); (L.F.-P.); (A.R.); (E.A.)
| | - Andrea Aguglia
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy; (A.A.); (A.A.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Alessandro Rodolico
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy; (L.M.); (L.F.-P.); (A.R.); (E.A.)
| | - Massimo Tusconi
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, 09042 Cagliari, Italy;
| | - Andrea Amerio
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy; (A.A.); (A.A.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Gianluca Serafini
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy; (A.A.); (A.A.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy; (A.A.); (A.A.); (G.S.); (M.A.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Eugenio Aguglia
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy; (L.M.); (L.F.-P.); (A.R.); (E.A.)
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9
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Ramakrishnan N, Lijffijt M, Green CE, Balderston NL, Murphy N, Grillon C, Iqbal T, Vo-Le B, O’Brien B, Murrough JW, Swann AC, Mathew SJ. Neurophysiological and clinical effects of the NMDA receptor antagonist lanicemine (BHV-5500) in PTSD: A randomized, double-blind, placebo-controlled trial. Depress Anxiety 2021; 38:1108-1119. [PMID: 34254405 PMCID: PMC8560553 DOI: 10.1002/da.23194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is associated with hyperarousal and stress reactivity, features consistent with behavioral sensitization. In this Phase 1b, parallel-arm, randomized, double-blind, placebo-controlled trial, we tested whether the selective low-trapping N-methyl-D-aspartate receptor (NMDAR) antagonist [Lanicemine (BHV-5500)] blocks expression of behavioral sensitization. METHODS Twenty-four participants with elevated anxiety potentiated startle (APS) and moderate-to-severe PTSD symptoms received three infusions of lanicemine 1.0 mg/ml (100 mg) or matching placebo (0.9% saline) (1:1 ratio), over a 5-day period. The primary outcome was change in APS from baseline to end of third infusion. We also examined changes in EEG gamma-band oscillatory activity as measures of NMDAR target engagement and explored Clinician-Administered PTSD Scale (CAPS-5) hyperarousal scores. RESULTS Lanicemine was safe and well-tolerated with no serious adverse events. Using Bayesian statistical inference, the posterior probability that lanicemine outperformed placebo on APS T-score after three infusions was 38%. However, after the first infusion, there was a 90% chance that lanicemine outperformed placebo in attenuating APS T-score by a standardized effect size more than 0.4. CONCLUSION We demonstrated successful occupancy of lanicemine on NMDAR using gamma-band EEG and effects on hyperarousal symptoms (Cohen's d = 0.75). While lanicemine strongly attenuated APS following a single infusion, differential changes from placebo after three infusions was likely obscured by habituation effects. To our knowledge, this is the first use of APS in the context of an experimental medicine trial of a NMDAR antagonist in PTSD. These findings support selective NMDAR antagonism as a viable pharmacological strategy for salient aspects of PTSD.
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Affiliation(s)
- Nithya Ramakrishnan
- Mood and Anxiety Disorders Program, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA,Corresponding Authors: Nithya Ramakrishnan, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Houston, TX 77030, USA. , (713)798-7768; Sanjay J. Mathew, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Houston, TX 77030, USA. (713) 798-5877
| | - Marijn Lijffijt
- Mood and Anxiety Disorders Program, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
| | | | | | - Nicholas Murphy
- Mood and Anxiety Disorders Program, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA,The Menninger Clinic, Houston, TX, USA
| | | | - Tabish Iqbal
- Mood and Anxiety Disorders Program, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - Brittany Vo-Le
- Mood and Anxiety Disorders Program, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - Brittany O’Brien
- Mood and Anxiety Disorders Program, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - James W. Murrough
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry, Icahn School of Medicine at Mount Sinai; Department of Neuroscience, Icahn School of Medicine at Mount Sinai
| | - Alan C. Swann
- Mood and Anxiety Disorders Program, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - Sanjay J. Mathew
- Mood and Anxiety Disorders Program, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA,The Menninger Clinic, Houston, TX, USA,Corresponding Authors: Nithya Ramakrishnan, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Houston, TX 77030, USA. , (713)798-7768; Sanjay J. Mathew, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Houston, TX 77030, USA. (713) 798-5877
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10
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Swann AC, Graham DP, Wilkinson AV, Kosten TR. Nicotine Inhalation and Suicide: Clinical Correlates and Behavioral Mechanisms. Am J Addict 2021; 30:316-329. [PMID: 34109688 DOI: 10.1111/ajad.13171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 02/26/2021] [Accepted: 03/06/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Extensive evidence links smoking and suicide independently of psychiatric diagnoses, but there are questions about the pathophysiology and specificity of this relationship. We examined characteristics of this linkage to identify potential transdiagnostic mechanisms in suicide and its prevention. METHODS We reviewed literature that associated suicide with smoking and e-cigarettes, including the temporal sequence of smoking and suicide risk and their shared behavioral risk factors of sensitization and impulsivity. RESULTS Smoking is associated with increased suicide across psychiatric diagnoses and in the general population, proportionately to the number of cigarettes smoked per day. Rapid nicotine uptake into the brain through inhalation of conventional cigarettes, electronic cigarettes (e-cigarette), or even second-hand smoke can facilitate long-term sensitization and short-term impulsivity. Both impair action regulation and predispose to negative affect, continued smoking, and suicidal behavior. Intermittent hypoxia, induced by cigarettes or e-cigarettes, synergistically promotes impulsivity and sensitization, exacerbating suicidality. Two other shared behavioral risks also develop negative urgency (combined impulsivity and negative affect) and cross-sensitization to stressors or to other addictive stimuli. Finally, early smoking onset, promoted by e-cigarettes in never-smokers, increases subsequent suicide risk. CONCLUSION AND SCIENTIFIC SIGNIFICANCE Prevention or cessation of nicotine inhalation can strategically prevent suicidality and other potentially lethal behavior regardless of psychiatric diagnoses. Medications for reducing smoking and suicidality, especially in younger smokers, should consider the neurobehavioral mechanisms for acute impulsivity and longer-term sensitization, potentially modulated more effectively through glutamate antagonism rather than nicotine substitution. (Am J Addict 2021;30:316-329).
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Affiliation(s)
- Alan C Swann
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
| | - David P Graham
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
| | | | - Thomas R Kosten
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
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11
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Clinical correlates of DSM-5 mixed features in bipolar disorder: A meta-analysis. J Affect Disord 2020; 276:234-240. [PMID: 32697704 DOI: 10.1016/j.jad.2020.07.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/13/2020] [Accepted: 07/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Systematic data on clinical correlates of mixed features in bipolar disorder are not available, so far. We conducted a systematic review and meta-analysis estimating the association between DSM-5 mixed features and candidate characteristics in depressive and manic/hypomanic episodes. METHODS We included observational studies indexed in the main electronic databases. The association between DSM-5 mixed features and relevant correlates was estimated using odds ratio (OR) and standardized mean difference (SMD) with 95% confidence intervals (CIs), for categorical and continuous variables, respectively. Analyses were based on random effects models. RESULTS Eight studies were included, involving 3070 individuals (1495 with a major depressive episode and 1575 with hypo/manic episode). No clinical characteristics were associated with mixed features in subjects with a depressive episode. Among subjects with a manic/hypomanic episode, those with mixed features were more likely to have a history of suicide attempts (OR: 2.37; 95%CI: 1.42 to 3.94; I2=39.7%), co-occurring anxiety disorders (OR: 2.67; 95%CI: 1.28 to 5.57; I2=0%), and a rapid cycling course (OR=4.23; 95%CI: 1.29 to 13.81; I2=0%), with less severe manic symptoms (SMD=-0.40; 95%CI: -0.65 to -0.16; I2=0%). LIMITATIONS (1) the heterogeneity of methods across studies and the inconsistency of findings; (2) the limited amount of data on correlates of DSM-5 mixed features; (3) the possible influence of publication bias. CONCLUSIONS Findings of this meta-analysis show that mixed features among individuals with a manic/hypomanic episode may identify a special clinical population, characterized not only by depressive symptoms, but also by anxiety, rapid cycling, and suicidality.
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12
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Filgueiras A, Nunes A, Silveira L, de Assis da Silva R, da Silva R, Landeira-Fernandez J, Cheniaux E. Latent structure of the symptomatology of hospitalized patients with bipolar mania. Eur Psychiatry 2020; 29:431-6. [DOI: 10.1016/j.eurpsy.2014.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/30/2014] [Accepted: 02/09/2014] [Indexed: 10/25/2022] Open
Abstract
AbstractSeveral studies have attempted to understand the dimensions of psychiatric symptoms in manic episodes, but only a few have been able to model the latent structure of mania in bipolar disorder patients using confirmatory factor analysis. The objective of the present study was to search for the best model of the symptomatology of hospitalized manic patients. To achieve this goal, 117 manic inpatients during a manic crisis participated in this research. Exploratory factor analysis was conducted followed by confirmatory factor analysis using an exploratory factor analysis solution and three other theory-based models. The exploratory factor analysis results revealed a six-factor structure: depression, suicide, insomnia, mania, psychosis, and anxiety. This solution also presented the best fit to the data when tested with confirmatory factor analysis. A five-factor solution, without suicide as a separate dimension, appeared to be more theoretically suitable. Another important finding was that anxiety was an independent dimension in mania. Some hypotheses are discussed in light of contemporary theories, and future studies should investigate this aspect further.
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13
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Forte A, Montalbani B, Mastrangelo M, Anibaldi G, De Luca GP, Imbastaro B, Pompili M. Suicide Risk in Mixed States: Clinical and Preventive Perspectives. Psychiatr Ann 2020. [DOI: 10.3928/00485713-20200312-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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14
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Swann AC, Lijffijt M, Simonetti A. Temporal Structure of Mixed States: Does Sensitization Link Life Course to Episodes? Psychiatr Clin North Am 2020; 43:153-165. [PMID: 32008682 DOI: 10.1016/j.psc.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Susceptibility to combined depressive and manic syndromes correlates strongly with arousal-related symptoms including impulsivity, anxiety and agitation. This relationship to a driven, "mixed" activation-depression state, generated by a life-long process, was described in classical times. Course of illness in mixed states includes increased episode frequency, duration, earlier onset, and association with addiction- and trauma/stress-related disorders. Mixed episodes have catecholamine and hypothalamic-pituitary-adrenocortical activity increased beyond nonmixed states of similar symptom severity. These properties resemble behavioral sensitization, where salient, survival-related stimuli (traumatic or rewarding) can generate persistently exaggerated responses with disrupted arousal and reward, with potential for suicide and other severe consequences.
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Affiliation(s)
- Alan C Swann
- Department of Psychiatry, Baylor College of Medicine, 1977 Butler Boulevard, Suite E4.400, Houston, TX 77030, USA; Mental Health Care Line, Michael E. DeBakey VAMC, 2002 East Holcombe Boulevard, Houston, TX 77030, USA.
| | - Marijn Lijffijt
- Department of Psychiatry, Baylor College of Medicine, 1977 Butler Boulevard, Suite E4.400, Houston, TX 77030, USA
| | - Alessio Simonetti
- Department of Psychiatry, Baylor College of Medicine, 1977 Butler Boulevard, Suite E4.400, Houston, TX 77030, USA; Department of Psychiatry and Neurology, Sapienza University of Rome, Rome, Italy
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15
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Abstract
Mixed states are frequent clinical pictures in psychiatric practice but are not well described in nosologic systems. Debate exists as to defining mixed states. We review factor and cluster analytical studies and prominent clinical/conceptual models of mixed states. While mania involves standard manic symptoms and depression involves standard depressive symptoms, core additional features of the mixed state are, primarily, psychomotor activation and, secondarily, dysphoria. Those features are more pronounced in mixed mania than in mixed depression but are present in both.
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Affiliation(s)
- Sergio A Barroilhet
- Clínica Psiquiátrica Universitaria, Facultad Medicina Universidad de Chile, Santiago, Chile; Department of Psychiatry, Tufts University, School of Medicine, Tufts Medical Center, Pratt Building, 3rd Floor, 800 Washington Street, Box 1007, Boston, MA 02111, USA.
| | - S Nassir Ghaemi
- Department of Psychiatry, Tufts University, School of Medicine, Tufts Medical Center, Pratt Building, 3rd Floor, 800 Washington Street, Box 1007, Boston, MA 02111, USA; Department of Psychiatry, Harvard Medical School, Harvard University, Boston, MA, USA
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16
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O'Brien B, Lee D, Swann AC, Mathew SJ, Lijffijt M. Psychotherapy for Mixed Depression and Mixed Mania. Psychiatr Clin North Am 2020; 43:199-211. [PMID: 32008685 DOI: 10.1016/j.psc.2019.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Treatment guidelines for mixed states of depression or (hypo)mania focus almost exclusively on psychopharmacologic intervention without tapping into the benefits of psychotherapy. The authors highlight the complex clinical picture and illness course of mixed states, and discuss the benefit of taking a patient-centered approach to treatment incorporating techniques from a variety of evidence-based psychotherapies. A careful assessment of suicide risk as well as interventions designed specifically for anxiety are also recommended.
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Affiliation(s)
- Brittany O'Brien
- Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA
| | - Delphine Lee
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA
| | - Alan C Swann
- Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA
| | - Sanjay J Mathew
- Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA
| | - Marijn Lijffijt
- Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA.
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17
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Abstract
Mixed states have been discussed for more than 2 millennia. The theoretic conception of the coexistence of presumably opposite symptoms of mood or of different psychic domains is well established, although obscured by the presumed separation between bipolar and depressive disorders. Moreover, the lack of response to treatments and severe psychopathology raise important issues requiring urgent solution. The aim of this article was to review the development of the concept of mixed states from the classic literature to modern nosologic systems and to claim for the need of a new paradigm to address the still-open issues about mixed states.
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Affiliation(s)
- Gabriele Sani
- Institute of Psychiatry, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Psychiatry, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Roma, Italy.
| | - Alan C Swann
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Michael E. Debakey Veterans Affairs Medical Center, 1977 Butler Boulevard, 4th Floor, Houston, TX 77030, USA.
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18
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Lijffijt M, O'Brien B, Salas R, Mathew SJ, Swann AC. Interactions of immediate and long-term action regulation in the course and complications of bipolar disorder. Philos Trans R Soc Lond B Biol Sci 2020; 374:20180132. [PMID: 30966917 DOI: 10.1098/rstb.2018.0132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Immediate and long-term mechanisms interact in the regulation of action. We will examine neurobiology and practical clinical consequences of these interactions. Long-term regulation of immediate behavioural control is based on analogous responses to highly rewarding or stressful stimuli: (i) impulsivity is a failure of the balance between activation and inhibition in the immediate regulation of action. (ii) Sensitization is a persistently exaggerated behavioural or physiological response to highly salient stimuli, such as addictive stimuli or inescapable stress. Sensitization can generalize across classes of stimuli. (iii) Impulsivity, possibly related to poor modulation of catecholaminergic and glutamatergic functions, may facilitate development of long-term sensitized responses to stressful or addictive stimuli. In turn, impulsivity is prominent in sensitized behaviour. (iv) While impulsivity and sensitization are general components of behaviour, their interactions are prominent in the course of bipolar disorder, emphasizing roles of substance-use, recurrent course and stressors. (v) Suicide is a complex and severe behaviour that exemplifies the manner in which impulsivity facilitates behavioural sensitization and is, in turn, increased by it, leading to inherently unpredictable behaviour. (vi) Interactions between impulsivity and sensitization can provide targets for complementary preventive and treatment strategies for severe immediate and long-term behavioural disorders. Progress along these lines will be facilitated by predictors of susceptibility to behavioural sensitization. This article is part of the theme issue 'Risk taking and impulsive behaviour: fundamental discoveries, theoretical perspectives and clinical implications'.
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Affiliation(s)
- Marijn Lijffijt
- 1 Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX 77030-4101 , USA.,2 Michael E. DeBakey Veterans Affairs Medical Center , Houston, TX 77030-4211 , USA
| | - Brittany O'Brien
- 1 Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX 77030-4101 , USA
| | - Ramiro Salas
- 1 Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX 77030-4101 , USA.,2 Michael E. DeBakey Veterans Affairs Medical Center , Houston, TX 77030-4211 , USA
| | - Sanjay J Mathew
- 1 Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX 77030-4101 , USA.,2 Michael E. DeBakey Veterans Affairs Medical Center , Houston, TX 77030-4211 , USA
| | - Alan C Swann
- 1 Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX 77030-4101 , USA.,2 Michael E. DeBakey Veterans Affairs Medical Center , Houston, TX 77030-4211 , USA
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19
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Tavares DF, Dos Santos CGR, Valiengo LDCL, Klein I, Borrione L, Forte PM, Brunoni AR, Moreno RA. Efficacy, Safety, and Tolerability of Theta-Burst Stimulation in Mixed Depression: Design, Rationale, and Objectives of a Randomized, Double-Blinded, Sham-Controlled Trial. Front Psychiatry 2020; 11:435. [PMID: 32499730 PMCID: PMC7242745 DOI: 10.3389/fpsyt.2020.00435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 04/28/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Mixed-specifier mood disorders are probably a different subgroup in terms of response to treatment, socio-demographic parameters, course, and family history. Here we describe the rationale and design of a clinical trial aimed to test the efficacy, safety, and tolerability of a non-pharmacological treatment known as theta-burst stimulation (TBS) for treating the mixed depressive episodes of both bipolar (I or II), and unipolar depression. METHODS The study is designed as a randomized, sham-controlled, double-blinded clinical trial evaluating TBS for the treatment of moderate or severe major depressive episodes with mixed features of patients receiving at least one first or second-line pharmacological treatment for depressive episodes without adequate response. Ninety adult (18 to 65 years old) patients will be enrolled and submitted to 6-week (comprising 5 consecutive days a week sessions for the first 3 weeks and then 2 days a week for a further 3 week) of inhibitory followed by excitatory TBS in dorsolateral prefrontal cortex. Participants will be assessed using clinical and neuropsychological tests before and after the intervention. The primary outcome is change in Montgomery-Åsberg Depression Scale (MADRS) score over time and across groups. Cognitive parameters will also be assessed with neuropsychological tests. RESULTS The clinical results will provide evidence about TBS as an adjunctive treatment for mixed depression treatment and neuropsychological parameters will contribute toward an improved understanding the effects of TBS in cognition. CONCLUSION Our results could introduce a novel therapeutic technique for mixed depressive episodes of both bipolar and unipolar disorders. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov, identifier NCT04123301; date of registration: 10/10/2019; URL: https://clinicaltrials.gov/ct2/show/NCT04123301?term=NCT04123301&rank=1.
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Affiliation(s)
| | | | | | - Izio Klein
- Department of Psychiatry, University of São Paulo, São Paulo, Brazil
| | - Lucas Borrione
- Department of Psychiatry, University of São Paulo, São Paulo, Brazil
| | | | - Andre R Brunoni
- Department of Psychiatry, University of São Paulo, São Paulo, Brazil
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Swann AC, Lijffijt M, O'Brien B, Mathew SJ. Impulsivity and Suicidal Behavior. Curr Top Behav Neurosci 2020; 47:179-195. [PMID: 32472429 DOI: 10.1007/7854_2020_144] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Suicide is the leading cause of injury mortality in the United States and the second-leading cause of death in people aged 10-34 years. While many long-term risk factors are known, the short-term prediction of suicidal behavior remains elusive. Many characteristics of suicidal behavior cut across diagnoses, but suicide is increased in recurrent psychiatric disorders, addictive disorders, and trauma-related disorders. Suicide results from the interaction of short-term and long-term behavioral regulation. The shorter the time-course of the mechanism, the closer it is to actual suicidal behavior, and the harder it is to prevent. We will discuss the manner in which impulsivity, a major determinant of short-term suicide risk, interacts with longer-term risk factors, especially sensitization to addictive or traumatic stimuli. Impulsivity predisposes to sensitization; in turn, impulsivity is a prominent component of sensitized behavior. Impulsivity can be described as a general pattern of behavior ("trait" impulsivity), as responses that are not conformed to their context (action-impulsivity), or as inability to delay reward or to take future consequences into account (choice-impulsivity). Each of these contributes to suicidal behavior. The neural mechanisms of impulsivity and sensitization are analogous, and sensitization can produce rapidly fluctuating patterns of impulsive behavior, arousal, and anhedonia. In order to recognize and prevent suicidal behavior, it is necessary to identify factors associated with susceptibility to bouts of impulsive behavior in people at elevated long-term risk.
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Affiliation(s)
- Alan C Swann
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. .,Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.
| | - Marijn Lijffijt
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Research Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Brittany O'Brien
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Sanjay J Mathew
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Zhang X, Li Y, Huang Z, Cui Y, Zhao Z, Yue X, Wang G, Liang R, Huang Y, Tan W, Wu C. Development and pharmacokinetics evaluation of quetiapine fumarate sustained-release tablets based on hydrophilic matrix. J Drug Deliv Sci Technol 2019. [DOI: 10.1016/j.jddst.2019.101322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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22
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McIntyre RS, Masand PS, Earley W, Patel M. Cariprazine for the treatment of bipolar mania with mixed features: A post hoc pooled analysis of 3 trials. J Affect Disord 2019; 257:600-606. [PMID: 31344528 DOI: 10.1016/j.jad.2019.07.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 05/29/2019] [Accepted: 07/04/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND When bipolar I disorder (BP-I) mania is accompanied by subsyndromal depressive symptoms, a more complicated illness presentation results. To qualify for the mixed features specifier during mania, the DSM-5 requires ≥3 "non-overlapping" depressive symptoms (DS); notwithstanding, concerns of this definition's ecological validity and implications for timely diagnosis remain. METHODS Herein, patients were pooled from three similarly-designed pivotal trials of cariprazine compared to placebo for BP-I mania (NCT00488618/NCT01058096/NCT01058668) in post hoc analyses of mixed features using three criteria: ≥3 DS (DSM-5), ≥2 DS, and Montgomery-Åsberg Depression Rating Scale (MADRS) total score ≥10. Efficacy of cariprazine compared to placebo was assessed (Week 3) by Young Mania Rating Scale (YMRS) and MADRS scores and rates of mania response and remission. RESULTS In pooled patients (N = 1037), cariprazine significantly improved mean YMRS scores compared to placebo for each criterion; LSMDs were ≥3 DS = -3.79 (P = .0248), ≥2 DS = -2.91 (P = .0207), and ≥10 MADRS = -5.49 (P < .0001). More cariprazine- than placebo-treated patients met YMRS response and remission criteria, reaching significance for response in ≥2 DS (34% versus 47%; number-needed-to-treat [NNT] = 8, P = .0483) and ≥10 MADRS (31% versus 57%, NNT = 4, P < .0001) and for remission in ≥2 DS (27% versus 39%, NNT = 9, P = .0462), ≥10 MADRS (23% versus 44%, NNT = 5, P < .0001). Depressive symptoms were improved compared to placebo, reaching statistical significance in the MADRS ≥10 subgroup (LSMD = -1.59, P = .0082). LIMITATIONS Post hoc analysis, MADRS < 18 entry criterion may have prevented assessment of MADRS changes. CONCLUSIONS Cariprazine significantly reduced manic and depressive symptoms in patients with mixed features with differential efficacy across the subgroups analyzed herein.
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Affiliation(s)
- Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON M5T 2S8, Canada; Brain Cognition Discovery Foundation, Toronto, Ontario, Canada.
| | - Prakash S Masand
- Centers of Psychiatric Excellence, New York, New York, United States
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Perugi G, Pacchiarotti I, Mainardi C, Verdolini N, Menculini G, Barbuti M, Angst J, Azorin JM, Bowden CL, Mosolov S, Young AH, Vieta E. Patterns of response to antidepressants in major depressive disorder: Drug resistance or worsening of depression are associated with a bipolar diathesis. Eur Neuropsychopharmacol 2019; 29:825-834. [PMID: 31227264 DOI: 10.1016/j.euroneuro.2019.06.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/27/2019] [Accepted: 06/03/2019] [Indexed: 01/01/2023]
Abstract
Resistance and worsening of depression in response to antidepressants (ADs) are major clinical challenges. In a large international sample of patients with major depressive disorder (MDD), we aim to explore the possible associations between different patterns of response to ADs and bipolarity. A total of 2811 individuals with a major depressive episode (MDE) were enrolled in the BRIDGE-II-MIX study. This post-hoc analysis included only 1329 (47%) patients suffering from MDD. Patients with (TRD-MDD, n = 404) and without (NTRD-MDD, n = 925) history of resistance to AD treatment and with (n = 184) and without (n = 1145) previous AD-induced irritability and mood lability (AIM) were compared using Chi-square, t-Student's test and logistic regression models. TRD-MDD patients resulted significantly associated with higher rates of AIM, psychotic features, history of suicide attempts, emotional lability and impulsivity, comorbid borderline personality disorder and polipharmacological treatment, compared to NTRD-MDD group. In comparison to NAIM-MDD patients, subjects in the AIM-MDD group showed significantly higher rates of first-degree family history for BD, previous TRD, atypical features, mixed features, psychiatric comorbidities, lifetime suicide attempts and lower age at first psychiatric symptoms. In addition, patients with AIM presented more often almost all the hypomanic symptoms evaluated in this study. Among these latter symptoms, logistic regressions showed that distractibility, impulsivity and hypersexuality were significantly associated with AIM-MDD. In conclusion, in MDD patients, a lifetime history of resistance and/or irritability/mood lability in response to ADs was associated with the presence of mixed features and a possible underlying bipolar diathesis.
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Affiliation(s)
- Giulio Perugi
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Italy
| | - Isabella Pacchiarotti
- Bipolar Disorders Unit, Hospital Clinic, Institute of Neurosciences, IDIBAPS CIBERSAM, Hospital Clínic de Barcelona, University of Barcelona, c/Villarroel, 170, 12-0, 08036, Barcelona, Catalonia, Spain; CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain
| | - Cecilia Mainardi
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Italy; Bipolar Disorders Unit, Hospital Clinic, Institute of Neurosciences, IDIBAPS CIBERSAM, Hospital Clínic de Barcelona, University of Barcelona, c/Villarroel, 170, 12-0, 08036, Barcelona, Catalonia, Spain
| | - Norma Verdolini
- Bipolar Disorders Unit, Hospital Clinic, Institute of Neurosciences, IDIBAPS CIBERSAM, Hospital Clínic de Barcelona, University of Barcelona, c/Villarroel, 170, 12-0, 08036, Barcelona, Catalonia, Spain; CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain; Division of Psychiatry, Clinical Psychology and Rehabilitation, Department of Medicine, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy; FIDMAG Germanes Hospitalàries Research Foundation, Sant Boi de Llobregat, Barcelona, Catalonia, Spain
| | - Giulia Menculini
- Bipolar Disorders Unit, Hospital Clinic, Institute of Neurosciences, IDIBAPS CIBERSAM, Hospital Clínic de Barcelona, University of Barcelona, c/Villarroel, 170, 12-0, 08036, Barcelona, Catalonia, Spain; Division of Psychiatry, Clinical Psychology and Rehabilitation, Department of Medicine, University of Perugia, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Margherita Barbuti
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Italy
| | - Jules Angst
- Psychiatric Hospital, University of Zurich, Switzerland
| | | | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Sergey Mosolov
- Department for Therapy of Mental Disorders, Moscow Research Institute of Psychiatry, Moscow, Russia
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London & South London and Maudsley NHS Foundation Trust, Denmark Hill, Camberwell, London SE5 8AZ, United Kingdom
| | - Eduard Vieta
- Bipolar Disorders Unit, Hospital Clinic, Institute of Neurosciences, IDIBAPS CIBERSAM, Hospital Clínic de Barcelona, University of Barcelona, c/Villarroel, 170, 12-0, 08036, Barcelona, Catalonia, Spain; CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain.
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Fiedorowicz JG, Persons JE, Assari S, Ostacher MJ, Zandi P, Wang PW, Thase ME, Frye MA, Coryell W. Depressive symptoms carry an increased risk for suicidal ideation and behavior in bipolar disorder without any additional contribution of mixed symptoms. J Affect Disord 2019; 246:775-782. [PMID: 30623823 PMCID: PMC6914253 DOI: 10.1016/j.jad.2018.12.057] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 06/28/2018] [Accepted: 12/19/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine whether the risk of suicidal ideation or behavior during mixed states exceeds that attributable to the depressive components of these states alone in bipolar disorder. METHODS We utilized real-world, longitudinal clinical data collected on 290 patients with bipolar disorders (bipolar I, bipolar II, and bipolar not otherwise specified (NOS)) from the National Network of Depression Centers (NNDC) Clinical Care Registry (CCR) seen for 891 visits over a mean of 27.5 weeks. Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9), manic symptoms with the Altman Self-Rating Mania (ASRM), and suicidal ideation and behavior with the Columbia-Suicide Severity Rating Scale (C-SSRS), obtained as part of the routine, measurement-based care provided across the NNDC. The relations between depressive symptoms, manic symptoms, and the interaction thereof (mixed symptoms) on coinciding suicidal ideation and behavior were modeled in generalized linear mixed models. RESULTS Depressive symptoms, as measured by the PHQ-9, were strongly associated with suicidal ideation and behavior (p < 0.0001), while there was no significant association with manic symptoms as measured by the ASRM or the interaction between depressive and manic symptoms. Similar results were observed when the outcome was restricted to suicidal behavior and when mood was modeled categorically. There was evidence of a gender by ASRM interaction (p = 0.011) and risk of suicidal ideation or behavior was significant for women, but not men with manic symptoms. LIMITATIONS Diagnoses were based on clinician assessment and not structured interview. Mood assessments were self-reported rather than clinician-administered. Suicidal ideation was more frequently observed than suicidal behavior (23/272 visits where outcome positive). CONCLUSIONS Depression represents the primary mood state accounting for suicide risk in bipolar disorder. Co-occurring symptoms of mania (mixed symptoms) do not appear to convey an elevated risk for suicidal ideation or behavior beyond that explained by the depressive symptoms alone.
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Affiliation(s)
- Jess G. Fiedorowicz
- Departments of Psychiatry and Internal Medicine, 4François M. Abboud Cardiovascular Research Center, Iowa Neuroscience Institute, Obesity Research and Education Initiative, The University of Iowa, Iowa City, IA,Department of Epidemiology, College of Public Health, 4François M. Abboud Cardiovascular Research Center, Iowa Neuroscience Institute, Obesity Research and Education Initiative, The University of Iowa, Iowa City, IA,Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Jane E. Persons
- Roy J. and Lucille A. Carver College of Medicine, 4François M. Abboud Cardiovascular Research Center, Iowa Neuroscience Institute, Obesity Research and Education Initiative, The University of Iowa, Iowa City, IA
| | - Shervin Assari
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States.
| | - Michael J. Ostacher
- Bipolar Disorder & Depression Research Program, VA Palo Alto Health System, Palo Alto, CA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University, Palo Alto, CA
| | - Peter Zandi
- Department of Mental Health and Epidemiology, Johns Hopkins Bloomberg School of Public Health, Department of Psychiatry, Johns Hopkins Medicine, Baltimore, MD, United States.
| | - Po W. Wang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University, Palo Alto, CA
| | - Michael E. Thase
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark A. Frye
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN
| | - William Coryell
- Departments of Psychiatry and Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States.
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McIntyre RS, Young AH, Haddad PM. Rethinking the spectrum of mood disorders: implications for diagnosis and management - Proceedings of a symposium presented at the 30th Annual European College of Neuropsychopharmacology Congress, 4 September 2017, Paris, France. Ther Adv Psychopharmacol 2018; 8:1-16. [PMID: 29977518 PMCID: PMC6022880 DOI: 10.1177/2045125318762911] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/09/2018] [Indexed: 12/17/2022] Open
Abstract
The simultaneous occurrence of manic and depressive features has been recognized since classical times, but the term 'mixed state' was first used by Kraepelin at the end of the 19th century. From the 1980s, until the advent of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), psychiatric disorders were classified using a categorical approach. However, it was recognized that such an approach was too rigid to encompass the range of symptomatology encountered in clinical practice. Therefore, a dimensional approach was adopted in DSM-5, in which affective states are considered to be distributed across a continuum ranging from pure mania to pure depression. In addition, the copresence of symptoms of the opposite pole are captured using a 'with mixed features' specifier, applied when three or more nonoverlapping subthreshold symptoms of the opposite pole are present. Mixed features are common in patients with mood episodes, complicating the course of illness, reducing treatment response and worsening outcomes. However, research in this area is scarce and treatment options are limited. Current evidence indicates that antidepressants should be avoided for the treatment of bipolar mixed states. Evidence for bipolar mixed states supports the use of several second-generation antipsychotics, valproate and electroconvulsive therapy. One randomized controlled trial has demonstrated the efficacy of lurasidone, compared with placebo, in patients with major depressive disorder with mixed features, and there is limited evidence supporting the use of ziprasidone in such patients. Further research is required to determine whether other antipsychotic agents, or additional therapeutic approaches, might also be effective in this setting.
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Affiliation(s)
- Roger S McIntyre
- UHN-Toronto Western Hospital, Mood Disorders Psychopharmacology Unit, University of Toronto, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
| | - Allan H Young
- Department of Psychological Medicine, King's College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - Peter M Haddad
- Neuroscience and Psychiatry Unit, University of Manchester, Manchester, UK
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Persons JE, Coryell WH, Solomon DA, Keller MB, Endicott J, Fiedorowicz JG. Mixed state and suicide: Is the effect of mixed state on suicidal behavior more than the sum of its parts? Bipolar Disord 2018; 20:35-41. [PMID: 28833953 PMCID: PMC6237077 DOI: 10.1111/bdi.12538] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 07/29/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To assess whether suicidal behavior during mixed states exceeds that expected from the manic or depressive components alone. METHODS This study included 429 participants with bipolar disorder from the National Institute of Mental Health Collaborative Depression Study (CDS). Mood and suicidal behavior were captured using the Longitudinal Interval Follow-up Evaluation and the Schedule of Affective Disorders and Schizophrenia. Suicidal behavior during each mood state, relative to euthymia, was analyzed using Cox regression to allow for repeated events, with a frailty term to account for intra-participant correlation. Mixed states were modeled as a depression-by-mania interaction. RESULTS Individuals with a history of mixed states were at higher risk of suicidal behavior and spent more time depressed, compared to subjects with no such history. In bipolar I disorder, risk increased during episodes of mania (hazard ratio [HR]: 1.96, 95% confidence interval [CI]: 1.28-2.99, P = .0019) and depression (HR: 5.49, 95% CI: 4.01-7.51, P < .0001) and there was a less than additive effect of mixed states. In bipolar II disorder, risk was increased during episodes of depression (HR: 3.66, 95% CI: 2.51-5.35, P < .0001) and there was no excess risk during mixed states beyond that attributable to the depressed component. Most of the excess risk (71%) among those with a history of mixed states was attributable to a depression predominant course of illness. CONCLUSIONS Individuals with mixed states are at high risk of suicidal behavior, largely due to more time spent depressed. Clinicians should aggressively treat depression to mitigate suicide risk for patients with or without mixed states.
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Affiliation(s)
- Jane E. Persons
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA.,Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - William H. Coryell
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - David A. Solomon
- Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI, USA.,UpToDate, Waltham, MA, USA
| | - Martin B. Keller
- Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI, USA
| | - Jean Endicott
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Jess G. Fiedorowicz
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA.,Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA.,Department of Internal Medicine, The University of Iowa, Iowa City, IA, USA.,Francois M. Abboud Cardiovascular Research Center, The University of Iowa, Iowa City, IA, USA.,Iowa Neuroscience Institute, The University of Iowa, Iowa City, IA, USA.,The Obesity Research and Education Initiative, The University of Iowa, Iowa City, IA, USA
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27
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Tohen M, Gold AK, Sylvia LG, Montana RE, McElroy SL, Thase ME, Rabideau DJ, Nierenberg AA, Reilly-Harrington NA, Friedman ES, Shelton RC, Bowden CL, Singh V, Deckersbach T, Ketter TA, Calabrese JR, Bobo WV, McInnis MG. Bipolar mixed features - Results from the comparative effectiveness for bipolar disorder (Bipolar CHOICE) study. J Affect Disord 2017; 217:183-189. [PMID: 28411507 DOI: 10.1016/j.jad.2017.03.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/09/2017] [Accepted: 03/28/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND DSM-5 changed the criteria from DSM-IV for mixed features in mood disorder episodes to include non-overlapping symptoms of depression and hypomania/mania. It is unknown if, by changing these criteria, the same group would qualify for mixed features. We assessed how those meeting DSM-5 criteria for mixed features compare to those meeting DSM-IV criteria. METHODS We analyzed data from 482 adult bipolar patients in Bipolar CHOICE, a randomized comparative effectiveness trial. Bipolar diagnoses were confirmed through the MINI International Neuropsychiatric Interview (MINI). Presence and severity of mood symptoms were collected with the Bipolar Inventory of Symptoms Scale (BISS) and linked to DSM-5 and DSM-IV mixed features criteria. Baseline demographics and clinical variables were compared between mood episode groups using ANOVA for continuous variables and chi-square tests for categorical variables. RESULTS At baseline, the frequency of DSM-IV mixed episodes diagnoses obtained with the MINI was 17% and with the BISS was 20%. Using DSM-5 criteria, 9% of participants met criteria for hypomania/mania with mixed features and 12% met criteria for a depressive episode with mixed features. Symptom severity was also associated with increased mixed features with a high rate of mixed features in patients with mania/hypomania (63.8%) relative to those with depression (8.0%). LIMITATIONS Data on mixed features were collected at baseline only and thus do not reflect potential patterns in mixed features within this sample across the study duration. CONCLUSIONS The DSM-5 narrower, non-overlapping definition of mixed episodes resulted in fewer patients who met mixed criteria compared to DSM-IV.
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Affiliation(s)
- Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Health Sciences Center, Albuquerque, NM, USA.
| | - Alexandra K Gold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rebecca E Montana
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA; Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Dustin J Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Vivek Singh
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Terence A Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph R Calabrese
- Bipolar Disorders Research Center, University Hospital's Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Exclusion of overlapping symptoms in DSM-5 mixed features specifier: heuristic diagnostic and treatment implications. CNS Spectr 2017; 22:126-133. [PMID: 27869049 DOI: 10.1017/s1092852916000614] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This article focuses on the controversial decision to exclude the overlapping symptoms of distractibility, irritability, and psychomotor agitation (DIP) with the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mixed features specifier. In order to understand the placement of mixed states within the current classification system, we first review the evolution of mixed states. Then, using Kraepelin's original classification of mixed states, we compare and contrast his conceptualization with modern day definitions. The DSM-5 workgroup excluded DIP symptoms, arguing that they lack the ability to differentiate between manic and depressive states; however, accumulating evidence suggests that DIP symptoms may be core features of mixed states. We suggest a return to a Kraepelinian approach to classification-with mood, ideation, and activity as key axes-and reintegration of DIP symptoms as features that are expressed across presentations. An inclusive definition of mixed states is urgently needed to resolve confusion in clinical practice and to redirect future research efforts.
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Abstract
Mixed states address the relationships between episodes and the course of an illness, presenting significant clinical challenges. Recurrent affective disorders were described thousands of years ago as dimensional disturbances of the basic elements of behavior, combining the characteristics of what we would now consider manic and depressive episodes. It was recognized from the beginning that combinations of depressive and manic features are associated with a severe illness course, including increased suicide risk. Early descriptions of affective disorders formulated them as systemic illnesses, a concept supported by more recent data. Descriptions of affective disorders and their course, including mixed states, became more systematic during the 19th century. Structured criteria achieved importance with evidence that, in addition to early onset, frequent recurrence, and comorbid problems, mixed states had worse treatment outcomes than other episodes. In contrast to 2000 years of literature on recurrent affective episodes and mixed states, the unipolar-bipolar disorder distinction was formalized in the mid-20th century. Mixed-state criteria, initially developed for bipolar disorder, ranged from fully combined depression and mania to the DSM-5 criteria, no longer limited to bipolar disorder, of a primary depressive or manic episode with at least three symptoms of the other episode type. The challenges involved in understanding and identifying mixed states center largely on what drives them, including (1) their formulation as either categorical or dimensional constructs, (2) the specificity of their relationships to depressive or manic episodes, and (3) specificity for bipolar versus major depressive disorder. Their existence challenges the distinction between bipolar and major depressive disorders. The challenges involved in identifying the underlying physiological mechanisms go to the heart of these questions.
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Abstract
Various terms have been used to describe mania when it is accompanied by depressive symptoms. In this article, we attempt to define and discuss 3 of these terms: dysphoric mania, mixed state, and mania with mixed features specifier. We conclude that whatever term is used, it is important to be aware that mania is more often unpleasant than pleasant, and that the unpleasantness is not limited to depression.
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Abstract
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.
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Do Atypical Antipsychotics Have Antisuicidal Effects? A Hypothesis-Generating Overview. Int J Mol Sci 2016; 17:ijms17101700. [PMID: 27727180 PMCID: PMC5085732 DOI: 10.3390/ijms17101700] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/19/2016] [Accepted: 09/22/2016] [Indexed: 12/30/2022] Open
Abstract
Modern antipsychotic drugs are employed increasingly in the treatment of mood disorders as well as psychoses, stimulating interest in their possible contributions to altering suicidal risk. Clozapine remains the only treatment with an FDA-recognized indication for reducing suicidal risk (in schizophrenia). We carried out a systematic, computerized search for reports of studies involving antipsychotic drug treatment and suicidal behaviors. A total of 19 reports provide data with preliminary support for potential suicide risk-reducing effects of olanzapine, quetiapine, ziprasidone, aripiprazole, and asenapine in addition to clozapine, and provide some support for antipsychotic drug treatment in general. These preliminary findings encourage further testing of antipsychotics for effects on suicidal behavior, making use of explicit, pre-planned assessments of suicidal behavior.
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Kim W, Kim H, Citrome L, Akiskal HS, Goffin KC, Miller S, Holtzman JN, Hooshmand F, Wang PW, Hill SJ, Ketter TA. More inclusive bipolar mixed depression definitions by requiring fewer non-overlapping mood elevation symptoms. Acta Psychiatr Scand 2016; 134:189-98. [PMID: 26989836 DOI: 10.1111/acps.12563] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Assess strengths and limitations of mixed bipolar depression definitions made more inclusive than that of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) by requiring fewer than three 'non-overlapping' mood elevation symptoms (NOMES). METHOD Among bipolar disorder (BD) out-patients assessed with Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, we assessed prevalence, demographics, and clinical correlates of mixed vs. pure depression, using less inclusive (≥3 NOMES, DSM-5), more inclusive (≥2 NOMES), and most inclusive (≥1 NOMES) definitions. RESULTS Among 153 depressed BD, compared to less inclusive DSM-5 threshold, our more and most inclusive thresholds, yielded approximately two- and five-fold higher mixed depression rates (7.2%, 15.0%, and 34.6% respectively), and important statistically significant clinical correlates for mixed compared to pure depression (e.g. more lifetime anxiety disorder comorbidity, more current irritability), which were not significant using the DSM-5 threshold. CONCLUSION Further studies assessing strengths and limitations of more inclusive mixed depression definitions are warranted, including assessing the extent to which enhanced statistical power vs. other factors contributes to more vs. less inclusive mixed bipolar depression thresholds having more statistically significant clinical correlates, and whether 'overlapping' mood elevation symptoms should be counted.
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Affiliation(s)
- W Kim
- Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine, Seoul, South Korea
| | - H Kim
- Department of Psychiatry, Ilsan Paik Hospital, Inje University School of Medicine, Goyang, South Korea
| | - L Citrome
- New York Medical College, Valhalla, NY, USA
| | - H S Akiskal
- International Mood Centre, University of California and Veterans Administration Hospital, San Diego, CA, USA
| | - K C Goffin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S Miller
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - J N Holtzman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - F Hooshmand
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - P W Wang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S J Hill
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - T A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Patterns of response to aripiprazole, lithium, haloperidol, and placebo across factor scores of mania. Int J Bipolar Disord 2015; 3:11. [PMID: 25945321 PMCID: PMC4418976 DOI: 10.1186/s40345-015-0026-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/31/2015] [Indexed: 12/03/2022] Open
Abstract
Background A previous factor analysis of Young Mania Rating Scale and Montgomery-Åsberg Depression Rating Scale items identified composite factors of depression, mania, sleep disturbance, judgment/impulsivity, and irritability/hostility as major components of psychiatric symptoms in acute mania or mixed episodes in a series of trials of antipsychotics. However, it is unknown whether these factors predict treatment outcome. Methods Data from six double-blind, randomized, controlled clinical trials with aripiprazole in acute manic or mixed episodes in adults with bipolar I disorder were pooled for this analysis and the previously identified factors were examined for their value in predicting treatment outcome. Treatment efficacy was assessed for aripiprazole (n = 1,001), haloperidol (n = 324), lithium (n = 155), and placebo (n = 694) at baseline, days 4, 7, and 10, and then weekly to study end. Mean change in factor scores from baseline to week 3 was assessed by receiver operating characteristics curves for percentage factor change at day 4 and week 1. Results Subjects receiving aripiprazole, haloperidol, and lithium significantly improved mania factor scores versus placebo. Factors most predictive of endpoint efficacy for aripiprazole were judgment/impulsivity at day 4 and mania at week 1. Optimal factor score improvement for outcome prediction was approximately 40% to 50%. Early efficacy predicted treatment outcome across all factors; however, response at week 1 was a better predictor than response at day 4. Conclusions This analysis confirms clinical benefits in early treatment/assessment for subjects with bipolar mania and suggests that certain symptom factors in mixed or manic episodes may be most predictive of treatment response.
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Piccinni A, Veltri A, Costanzo D, Vanelli F, Franceschini C, Moroni I, Domenici L, Origlia N, Marazziti D, Akiskal HS, Dell'Osso L. Decreased plasma levels of brain-derived neurotrophic factor (BDNF) during mixed episodes of bipolar disorder. J Affect Disord 2015; 171:167-70. [PMID: 25305432 DOI: 10.1016/j.jad.2014.08.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 08/29/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Brain-derived neurotrophic factor (BDNF) is a neurotrophin involved in neurogenesis and neuroplasticity. Decreased blood levels of BDNF have been found during acute manic and depressive states. BDNF has been proposed as a biomarker in illness phases of mood disorders. No information is available regarding BDNF levels during the mixed states of bipolar disorder (BD). The aim of this study was to evaluate BDNF levels during mixed episodes of BD patients and compare them with those of healthy subjects and depressed patients. METHODS Plasma BDNF levels were measured by an ELISA assay in 18 patients with major depressive episode (MDE), 19 patients with mixed episode (ME) and 15 healthy subjects (HS). RESULTS BDNF levels were significantly higher in HS, as compared with patients׳ samples (HS vs. MDE patients: p<001; HS vs. ME patients: p=.022). No significant differences were found between BDNF levels of ME and MDE patients. The severity of illness as assessed by CGI-S was significantly higher in ME than in MDE patients (p=.01). LIMITATIONS The small sample size may have weakened the power of statistical analyses. All patients received mood-stabilizing and antidepressant treatments which have been reported to influence peripheral BDNF levels. CONCLUSIONS Our results are consistent with previous studies showing reduced BDNF during both manic and depressive episodes. This finding supports the role of BDNF as a state-marker of mood episodes, and may represent a contribution to a unitary approach model between unipolar and BDs, as well as to the manic-depressive spectrum model.
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Affiliation(s)
- Armando Piccinni
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy.
| | - Antonello Veltri
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
| | - Davide Costanzo
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
| | - Federica Vanelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
| | - Caterina Franceschini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
| | - Ilenia Moroni
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
| | - Luciano Domenici
- Neuroscience Institute, National Research Council, Via Moruzzi 1, 56124 Pisa, Italy; Department DISCAB, University of L'Aquila, Via Vetoio, 67100 L'Aquila, Italy
| | - Nicola Origlia
- Neuroscience Institute, National Research Council, Via Moruzzi 1, 56124 Pisa, Italy
| | - Donatella Marazziti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
| | | | - Liliana Dell'Osso
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126 Pisa, Italy
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Temperament synergies in risk for and protection against depressive symptoms: A prospective replication of a three-way interaction. JOURNAL OF RESEARCH IN PERSONALITY 2014. [DOI: 10.1016/j.jrp.2014.09.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
The DSM-5 definition of mixed features "specifier" of manic, hypomanic and major depressive episodes captures sub-syndromal non-overlapping symptoms of the opposite pole, experienced in bipolar (I, II, and not otherwise specified) and major depressive disorders. This combinatory model seems to be more appropriate for less severe forms of mixed state, in which mood symptoms are prominent and clearly identifiable. Sub-syndromal depressive symptoms have been frequently reported to co-occur during mania. Similarly, manic or hypomanic symptoms during depression resulted common, dimensionally distributed, and recurrent. The presence of mixed features has been associated with a worse clinical course and high rates of comorbidities including anxiety, personality, alcohol and substance use disorders and head trauma or other neurological problems. Finally, mixed states represent a major therapeutic challenge, especially when you consider that these forms tend to have a less favorable response to drug treatments and require a more complex approach than non-mixed forms.
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Affiliation(s)
- Giulio Perugi
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy,
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Davison KM, Kaplan BJ. Lipophilic Statin Use and Suicidal Ideation in a Sample of Adults With Mood Disorders. CRISIS 2014; 35:278-82. [DOI: 10.1027/0227-5910/a000260] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Mood disorders are associated with a high risk of suicide. Statin therapy has been implicated in this relationship. Aims: To further clarify reported associations between suicide and cholesterol in mental health conditions, we conducted an analysis of dietary, clinical, and suicidal ideation measures in community-living adults with mood disorders. Method: Data were used from a cross-sectional study of a randomly selected community-based sample (> 18 years; n = 97) with verified mood disorders. Dietary (e.g., fat, iron, vitamin intakes), clinical (e.g., current depression and mania symptoms, medications), and sociodemographic (age, sex, and income) measures were analyzed using bivariate statistics and Poisson regression with robust variance. Results: Participants were predominantly female (71.1%) with bipolar disorder (59.8%); almost one-third (28.9%) were taking lipophilic statins. The prevalence of suicidal ideation was more than 2.5 times in those taking statins, PR = 2.59, 95% CI 1.27–5.31, p < .05. The prevalence ratio for suicidal ideation was 1.10, 95% CI 1.06–1.15, p < .001, for each unit increase in mania symptom scores. No associations between suicidal ideation and dietary intake measures were identified. Conclusion: Individuals with mood disorders may be susceptible to neuropsychiatric effects of cholesterol-lowering drugs, which warrants further research.
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Affiliation(s)
- Karen M. Davison
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
- Health Science Program, Kwantlen Polytechnic University, Surrey, BC, Canada
| | - Bonnie J. Kaplan
- Department of Paediatrics, Department of Community Health Sciences, University of Calgary, AB, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, AB, Canada
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Saunders EF, Nazir R, Kamali M, Ryan KA, Evans S, Langenecker S, Gelenberg AJ, McInnis MG. Gender differences, clinical correlates, and longitudinal outcome of bipolar disorder with comorbid migraine. J Clin Psychiatry 2014; 75:512-9. [PMID: 24816075 PMCID: PMC4211932 DOI: 10.4088/jcp.13m08623] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 11/07/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Migraine is a common comorbidity of bipolar disorder and is more prevalent in women than men. We hypothesized comorbid migraine would be associated with features of illness and psychosocial risk factors that would differ by gender and impact outcome. METHOD A retrospective analysis was conducted to assess association between self-reported, physician-diagnosed migraine, clinical variables of interest, and mood outcome in subjects with DSM-IV bipolar disorder (N = 412) and healthy controls (N = 157) from the Prechter Longitudinal Study of Bipolar Disorder, 2005-2010. Informed consent was obtained from all participants. RESULTS Migraine was more common in subjects with bipolar disorder (31%) than in healthy controls (6%) and had elevated risk in bipolar disorder women compared to men (OR = 3.5; 95% CI, 2.1-5.8). In men, migraine was associated with bipolar II disorder (OR = 9.9; 95% CI, 2.3-41.9) and mixed symptoms (OR = 3.5; 95% CI, 1.0-11.9). In comparison to absence of migraine, presence of migraine was associated with an earlier age at onset of bipolar disorder by 2 years, more severe depression (β = .13, P = .03), and more frequent depression longitudinally (β = .13, P = .03). Migraine was correlated with childhood emotional abuse (P = .01), sexual abuse (P = 4 × 10⁻³), emotional neglect (P = .01), and high neuroticism (P = 2 × 10⁻³). Protective factors included high extraversion (P = .02) and high family adaptability at the trend level (P = .08). CONCLUSIONS Migraine is a common comorbidity with bipolar disorder and may impact long-term outcome of bipolar disorder, particularly depression. Clinicians should be alert for migraine comorbidity in women and in men with bipolar II disorder. Effective treatment of migraine may impact mood outcome in bipolar disorder as well as headache outcome. Joint pathophysiologic mechanisms between migraine and bipolar disorder may be important pathways for future study of treatments for both disorders.
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Affiliation(s)
- Erika F.H. Saunders
- Department of Psychiatry, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA,University of Michigan Department of Psychiatry, Ann Arbor, MI,University of Michigan Depression Center, Ann Arbor, MI
| | - Racha Nazir
- Department of Psychiatry, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Masoud Kamali
- University of Michigan Department of Psychiatry, Ann Arbor, MI,University of Michigan Depression Center, Ann Arbor, MI
| | - Kelly A. Ryan
- University of Michigan Department of Psychiatry, Ann Arbor, MI,University of Michigan Depression Center, Ann Arbor, MI
| | - Simon Evans
- University of Michigan Department of Psychiatry, Ann Arbor, MI,University of Michigan Depression Center, Ann Arbor, MI
| | - Scott Langenecker
- University of Michigan Department of Psychiatry, Ann Arbor, MI,University of Michigan Depression Center, Ann Arbor, MI,Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois
| | - Alan J. Gelenberg
- Department of Psychiatry, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Melvin G. McInnis
- University of Michigan Department of Psychiatry, Ann Arbor, MI,University of Michigan Depression Center, Ann Arbor, MI
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Perugi G, Medda P, Swann AC, Reis J, Rizzato S, Mauri M. Phenomenological subtypes of severe bipolar mixed states: a factor analytic study. Compr Psychiatry 2014; 55:799-806. [PMID: 24582325 DOI: 10.1016/j.comppsych.2014.01.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 01/15/2014] [Accepted: 01/21/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The correct identification of bipolar mixed states (MS) has important implications for clinical practice. The aim of the study was to define the multidimensional psychopathological structure of severe MS. To our knowledge, no factor analytical studies including only patients with MS, have been conducted before. METHODS In the first week of hospitalization, we evaluated by HAM-D-17, YMRS, BPRS and CGI, 202 Bipolar I inpatients with MS according to DSM-IV criteria referred for an ECT trial. A Principal-component analysis followed by Varimax rotation was performed on the 24-item BPRS. The relationships among different symptomatological subtypes and other clinical characteristics were explored. RESULTS Six interpretable factors were extracted: Psychotic-positive symptoms, Mania, Disorientation-Unusual Motor Behaviour, Depression, Negative Symptoms and Anxiety. On the basis of the highest z-scores, we found 6 "dominant" BPRS factor groups, that were statistically distinct and without significant overlap in the main symptomatological presentation. Only 29 (14.4%) of our patients could be described as "Dominant Manic" and 48 (23.8%) as "Dominant Depressive"; most importantly 125 (61.9%) were neither predominately-manic nor predominately-depressive. Variables including age, number of previous episodes, suicidal behavior and HAM-D and YMRS scores significantly differentiated the subtypes. CONCLUSION At least in the most severe forms, MS appears to represent more than the superposition of affective symptoms of opposite polarity. Anxiety, perplexity, psychotic experiences, motor disturbances and grossly disorganized behavior seem to arise from protracted intra-episodic instability and presence of a drive state influencing the mood state and the emotional resonance.
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Affiliation(s)
- Giulio Perugi
- Clinica Psichiatrica, Dipartmento di Medicina Sperimentale, University of Pisa, Pisa, Italy.
| | - Pierpaolo Medda
- Clinica Psichiatrica, Dipartmento di Medicina Sperimentale, University of Pisa, Pisa, Italy
| | - Alan C Swann
- Department of Psychiatry, The University of Texas Health Science Center, Houston, TX, USA
| | - Joao Reis
- Serviço de Psiquiatria e Saúde Mental, Hospital de Santa Maria - CHLN, Lisboa, Portugal - Faculdade de Medicina de Lisboa, Universidade de Lisboa
| | - Salvatore Rizzato
- Clinica Psichiatrica, Dipartmento di Medicina Sperimentale, University of Pisa, Pisa, Italy
| | - Mauro Mauri
- Clinica Psichiatrica, Dipartmento di Medicina Sperimentale, University of Pisa, Pisa, Italy
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41
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Vieta E, Grunze H, Azorin JM, Fagiolini A. Phenomenology of manic episodes according to the presence or absence of depressive features as defined in DSM-5: Results from the IMPACT self-reported online survey. J Affect Disord 2014; 156:206-13. [PMID: 24439831 DOI: 10.1016/j.jad.2013.12.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 11/22/2013] [Accepted: 12/23/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to describe the phenomenology of mania and depression in bipolar patients experiencing a manic episode with mixed features as defined in the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5). METHODS In this multicenter, international on-line survey (the IMPACT study), 700 participants completed a 54-item questionnaire on demographics, diagnosis, symptomatology, communication of the disease, impact on life, and treatment received. Patients with a manic episode with or without DSM-5 criteria for mixed features were compared using descriptive and inferential statistics. RESULTS Patients with more than 3 depressive symptoms were more likely to have had a delay in diagnosis, more likely to have experienced shorter symptom-free periods, and were characterized by a marked lower prevalence of typical manic manifestations. All questionnaire items exploring depressive symptomatology, including the DSM-5 criteria defining a manic episode as "with mixed features", were significantly overrepresented in the group of patients with depressive symptoms. Anxiety associated with irritability/agitation was also more frequent among patients with mixed features. LIMITATIONS Retrospective cross-sectional design, sensitive to recall bias. Two of the 6 DSM-5 required criteria for the specifier "with mixed features" were not explored: suicidality and psychomotor retardation. CONCLUSIONS Bipolar disorder patients with at least 3 depressive symptoms during a manic episode self-reported typical symptomatology. Anxiety with irritability/agitation differentiated patients with depressive symptoms during mania from those with "pure" manic episodes. The results support the use of DSM-5 mixed features specifier and its value in research and clinical practice.
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Affiliation(s)
- Eduard Vieta
- Bipolar Disorder Programme, Institute of Neuroscience, University of Barcelona Hospital Clínic, IDIBAPS, CIBERSAM, C/Villarroel 170, Barcelona 08036, Catalonia, Spain.
| | - Heinz Grunze
- Institute of Neuroscience, Academic Psychiatry, Newcastle upon Tyne, NE4 5PL, UK
| | - Jean-Michel Azorin
- Hospital Ste. Marguerite, 270 Bd Sainte Marguerite, 13274 Marseille, France
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, School of Medicine, Siena, Italy; Department of Mental Health, University of Siena Medical Center, Siena, Italy
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Altinbas K, Ozerdem A, Prieto ML, Fuentes ME, Yalin N, Ersoy Z, Aydemir O, Quiroz D, Oztekin S, Geske JR, Feeder SE, Angst J, Frye MA. A multinational study to pilot the modified Hypomania Checklist (mHCL) in the assessment of mixed depression. J Affect Disord 2014; 152-154:478-82. [PMID: 24070907 DOI: 10.1016/j.jad.2013.07.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 07/31/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mixed depression is a common, dimensional phenomenon that is increasingly recognized in unipolar and bipolar disorders. We piloted a modified version of the Hypomania Checklist (mHCL-32) to assess the prevalence and clinical correlates of concurrent manic (hypo) symptoms in depressed patients. METHODS The mHCL-32, Young Mania Rating Scale (YMRS) and Hamilton Rating Scale for Depression (HAMD-24) were utilized in the assessment of unipolar (UP=61) and bipolar (BP=44) patients with an index major depressive episode confirmed by the Structured Clinical Interview for DSM-IV (SCID). Differential mHLC-32 item endorsement was compared between UP and BP. Correlation analyses assessed the association of symptom dimensions measured by mHCL-32, YMRS and HAMD-24. RESULTS There was no significant difference between mood groups in the mean mHCL-32 and YMRS scores. Individual mHLC-32 items of increased libido, quarrels, and caffeine intake were endorsed more in BP vs. UP patients. The mHCL-32 active-elevated subscale score was positively correlated with the YMRS in BP patients and negatively correlated with HAMD-24 in UP patients. Conversely, the mHCL-32 irritable-risk taking subscale score was positively correlated with HAMD-24 in BP and with YMRS in UP patients. LIMITATIONS Small sample size and cross-sectional design. CONCLUSION Modifying the HCL to screen for (hypo) manic symptoms in major depression may have utility in identifying mixed symptoms in both bipolar vs. unipolar depression. Further research is encouraged to quantify mixed symptoms with standardized assessments.
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Affiliation(s)
- Kursat Altinbas
- Department of Psychiatry, Canakkale Onsekiz Mart University, Canakkale, Turkey
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Mixed-state bipolar I and II depression: time to remission and clinical characteristics. J Affect Disord 2014; 152-154:340-6. [PMID: 24144581 DOI: 10.1016/j.jad.2013.09.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 09/06/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND We compared the time to achieve remission and the clinical characteristics of patients with bipolar depressive mixed state and those with bipolar depressive non-mixed state. METHODS The subjects (N=131) were inpatients diagnosed between 2006 and 2012 with bipolar I or II disorder, depression and were classified into the following three groups: "pure depressive state" (PD, n=70), "sub-threshold mixed state" (SMX, n=38), and "depressive mixed state" (DMX, n=23). Diagnosis of a DMX was in accordance with Benazzi's definition: three or more manic symptoms in a depressive episode. The subjects' charts were retrospectively reviewed to ascertain the time to achieve remission from the index episode and to identify other factors, such as demographic and clinical characteristics, specific manic symptoms, and pharmacological treatment, that may have contributed to remission. RESULTS The time to achieve remission was significantly longer in the DMX (p=0.022) and SMX (p=0.035) groups than in the PD group. Adjustment for covariates using a Cox proportional hazards model did not change these results. Clinically, subjects with a DMX were more likely to have manic symptoms in the index episode, especially inflated self-esteem and psychomotor agitation than those in the PD. LIMITATIONS We investigated only inpatients and therefore could not comment on outpatients. CONCLUSIONS These findings showed that sub-syndromal manic symptoms in bipolar depression had different clinical characteristics and a more severe illness course, including a longer time to achieve remission, than did a pure depressive state.
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Maurel M, Belzeaux R, Fakra E, Cermolacce M, Dassa D, Dubois M, Micoulaud Franchi JA, Corréard N, Azorin JM. [Clinical description of mixed mania]. Encephale 2013; 39 Suppl 3:S145-8. [PMID: 24359852 DOI: 10.1016/s0013-7006(13)70113-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
DSM-IV mixed states have become the mixed mania and mixed depression in the new DSM-5. One noticeable point is the introduction of nine cations, among which the "with mixed features" specification. These non exclusive specifications may contribute to a more precise identification of mixed clinical pictures, and therefore to offer a more efficient therapeutic answer. Different dimensional approaches are widely documented. They allow the isolation of a mixed factor which is clinically associated with two other specifications: anxious distress and psychotic features. These severity markers may encourage clinicians to be alert about the risk of misdiagnosis, and cautious in the management of these clinical situations.
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Affiliation(s)
- M Maurel
- SHU Psychiatrie Adultes-Pavillon Solaris, Hôpital Sainte-Marguerite.
| | - R Belzeaux
- SHU Psychiatrie Adultes-Pavillon Solaris, Hôpital Sainte-Marguerite
| | - E Fakra
- SHU Psychiatrie Adultes-Pavillon Solaris, Hôpital Sainte-Marguerite
| | - M Cermolacce
- SHU Psychiatrie Adultes-Pavillon Solaris, Hôpital Sainte-Marguerite
| | - D Dassa
- Pôle de Psychiatrie Centre, Hôpital de la Conception, Bd Baille, 13006 Marseille, France
| | - M Dubois
- Pôle de Psychiatrie Centre, Hôpital de la Conception, Bd Baille, 13006 Marseille, France
| | | | - N Corréard
- SHU Psychiatrie Adultes-Pavillon Solaris, Hôpital Sainte-Marguerite
| | - J-M Azorin
- SHU Psychiatrie Adultes-Pavillon Solaris, Hôpital Sainte-Marguerite
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45
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Clinical subtypes of severe bipolar mixed states. J Affect Disord 2013; 151:1076-82. [PMID: 24074482 DOI: 10.1016/j.jad.2013.08.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aim of the present study was to identify different clinical subtypes in severe, treatment resistant bipolar mixed state (MS). METHOD The sample comprised 202 Bipolar I patients currently in MS referred for an Electro-convulsive Therapy (ECT) trial and evaluated in the first week of hospitalization and one week after the ECT course. Principal component factor analysis (PCA) followed by Varimax rotation was performed on 21 non-overlapping items selected from Hamilton rating-scale for depression (HAMD) and from Young mania rating-scale (YMRS) at baseline evaluation. Cluster subtypes derived from the factor scores were compared in clinical variables and final HAMD, YMRS, Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression (CGI) scores. RESULTS The principal-component analysis extracted 6 interpretable factors explaining 55.9% of the total variance. Cluster analysis identified four groups, including respectively 63 (31.2%) subjects with Agitated-Irritable Mixed-Depression, 59 (29.2%) with Psychotic Mixed-Mania, 17 (8.5%) with Anxious-Irritable-Psychotic Mixed-Mania, and 63 (31.2%) with Retarded-Psychotic Mixed-Depression. The four clusters were statistically distinct and did not show significant overlap in the main symptomatological presentation. Cluster subtypes reported differences in number of past mood episodes, duration of the current episode, suicide attempts, lifetime comorbidity with panic and eating disorders, baseline and final rating-scale scores and rate of remission after ECT trial. CONCLUSIONS Our study indicates that, at least in severe treatment resistant MS, multiple depressive and manic subtypes can be observed with substantial differences in terms of clinical presentation, course, associated comorbidities and treatment response.
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Belzeaux R, Ibrahim E, Azorin JM, Fakra E, Maurel M, Pringuey D, Kaladjian A, Dassa D, Corréard N, Dubois E, Micoulaud-Franchi JA, Cermolacce M. Modèles physiopathologiques des états mixtes. Encephale 2013; 39 Suppl 3:S167-71. [DOI: 10.1016/s0013-7006(13)70117-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Powers RL, Russo M, Mahon K, Brand J, Braga RJ, Malhotra AK, Burdick KE. Impulsivity in bipolar disorder: relationships with neurocognitive dysfunction and substance use history. Bipolar Disord 2013; 15:876-84. [PMID: 24028391 PMCID: PMC3855192 DOI: 10.1111/bdi.12124] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 05/27/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Impulsivity is a core feature in bipolar disorder. Although mood symptoms exacerbate impulsivity, self-reports of impulsivity are elevated, even during euthymia. Neurocognitive processes linked to impulsivity (e.g., attention, inhibition) are also impaired in patients with bipolar disorder, and a high frequency of comorbidities associated with impulsivity, such as substance use disorders, further highlights the clinical relevance of this dimension of the illness. Our objective was to assess the relationship between impulsivity and cognition in bipolar disorder. METHODS We evaluated impulsivity in 98 patients with bipolar disorder and its relationship with symptoms, cognition, and substance use history. We assessed self-reports of trait impulsivity [Barrett Impulsiveness Scale (BIS)] and impulsive behaviors on the Iowa Gambling Task (IGT). A comprehensive clinical and neurocognitive battery was also completed. Patients were compared with 95 healthy controls. RESULTS Patients with bipolar disorder had higher scores versus healthy controls on all BIS scales. Performance on the IGT was significantly impaired and patients showed a tendency toward more erratic choices. Depressive symptoms were positively correlated with trait impulsivity and with an increased tendency to attend more readily to losses versus gains on the IGT. We found no significant associations between impulsivity and neurocognition in the full bipolar sample; however, when sub-grouped based on substance abuse history, significant relationships were revealed only in subjects without a substance abuse history. CONCLUSIONS Our data support prior reports of increased trait impulsivity and impairment on behavioral tasks of impulsiveness in bipolar disorder and suggest a differential relationship between these illness features that is dependent upon history of substance abuse.
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Affiliation(s)
- Robyn L Powers
- Department of Psychiatry Research, The Zucker Hillside Hospital–North Shore Long Island Jewish Health System, Glen Oaks
| | - Manuela Russo
- Departments of Psychiatry and Neuroscience, Mount Sinai School of Medicine, New York
| | - Katie Mahon
- Departments of Psychiatry and Neuroscience, Mount Sinai School of Medicine, New York
| | - Jesse Brand
- Department of Psychiatry Research, The Zucker Hillside Hospital–North Shore Long Island Jewish Health System, Glen Oaks
| | - Raphael J Braga
- Department of Psychiatry Research, The Zucker Hillside Hospital–North Shore Long Island Jewish Health System, Glen Oaks,Departments of Psychiatry and Molecular Medicine, Hofstra North Shore–LIJ School of Medicine at Hofstra University, Hempstead
| | - Anil K Malhotra
- Department of Psychiatry Research, The Zucker Hillside Hospital–North Shore Long Island Jewish Health System, Glen Oaks,Departments of Psychiatry and Molecular Medicine, Hofstra North Shore–LIJ School of Medicine at Hofstra University, Hempstead,Center for Psychiatric Neuroscience, The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Katherine E Burdick
- Departments of Psychiatry and Neuroscience, Mount Sinai School of Medicine, New York
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First controlled treatment trial of bipolar II hypomania with mixed symptoms: quetiapine versus placebo. J Affect Disord 2013; 150:37-43. [PMID: 23521871 DOI: 10.1016/j.jad.2013.02.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 02/15/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To compare the efficacy and safety of adjunctive quetiapine (QTP) versus placebo (PBO) for patients with bipolar II disorder (BDII) currently experiencing mixed hypomanic symptoms in a 2-site, randomized, placebo-controlled, double-blind, 8-week investigation. METHODS Participants included 55 adults (age 18-65 years) who met criteria for BDII on the Structured Clinical Interview for DSM-IV-TR (SCID). Entrance criteria included a stable medication regimen for ≥2 weeks and hypomania with mixed symptoms (>12 on the Young Mania Rating Scale [YMRS] and >15 on the Montgomery Asberg Depression Rating Scale [MADRS] at two consecutive visits 1-3 days apart). Participants were randomly assigned to receive adjunctive quetiapine (n=30) or placebo (n=25). RESULTS Adjunctive quetiapine demonstrated significantly greater improvement than placebo in Clinical Global Impression for Bipolar Disorder Overall Severity scores (F(1)=10.12, p=.002) and MADRS scores (F(1)=6.93, p=.0138), but no significant differences were observed for YMRS scores (F(1)=3.68, p=.069). Side effects of quetiapine were consistent with those observed in previous clinical trials, with sedation/somnolence being the most common, occurring in 53.3% with QTP and 20.0% with PBO. CONCLUSIONS While QTP was significantly more effective than PBO for overall and depressive symptoms of BDII, there was no significant difference between groups in reducing symptoms of hypomania. Hypomania improved across both groups throughout the study.
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Abstract
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.
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Affiliation(s)
- Alan C Swann
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at Houston, 1941 East Road, Room 3216, Houston, TX 77054, USA.
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Pacchiarotti I, Nivoli AMA, Mazzarini L, Kotzalidis GD, Sani G, Koukopoulos A, Scott J, Strejilevich S, Sánchez-Moreno J, Murru A, Valentí M, Girardi P, Vieta E, Colom F. The symptom structure of bipolar acute episodes: in search for the mixing link. J Affect Disord 2013; 149:56-66. [PMID: 23394711 DOI: 10.1016/j.jad.2013.01.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 01/11/2013] [Accepted: 01/11/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The nature of mixed mood episodes is still a matter of controversy amongst experts. Currently, the approach to this syndrome is mainly categorical and very restrictive. The factor-structure of bipolar mood episodes has not been studied yet. We performed a dimensional analysis of the structure of bipolar episodes aimed at identifying a factor deconstructing mixed episodes; furthermore, we analyzed correlations of factors emerging from the factorial analysis of the Brief Psychiatric Rating Scale (BPRS) with Temperament Evaluation of Memphis-Pisa-Paris-San Diego (TEMPS-A) and predominant polarity. METHOD 187 consecutive bipolar I inpatients hospitalized for DSM-IV-TR acute mood episodes (depressive, manic or mixed) underwent a standardized assessment, including the 24-item Brief Psychiatric Rating Scale (BPRS 4.0), the 21-item Hamilton Depression Rating Scale (HDRS-21), the Young Mania Rating Scale (YMRS) and the TEMPS-A. Principal factor analysis was performed on BPRS-24 items. RESULTS This analysis revealed five factors corresponding to "psychosis", "euphoric mania", "mixity", "dysphoria" and "inhibited depression", capturing 71.89% of the rotated variance. The mixity factor was characterized by higher rates of suicidal ideation, more mixed episodes, higher frequencies of antidepressant (AD) use, depressive predominant polarity and anxious temperament. DISCUSSION The factor-structure of the BPRS in inpatients with bipolar I disorder with an acute episode of any type is pentafactorial; one factor identified is the mixity factor, which is independent from other factors and characterized by anxiety and motor hyperactivity and by the absence of motor retardation. Our results should prompt reconsideration of proposals for DSM-5 diagnostic criteria for the mixed features specifier. Limitations of the study include the relative small sample, the absence of drug-naïve patients and the use of rating scales no specific for mixed states.
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Affiliation(s)
- Isabella Pacchiarotti
- Bipolar Disorders Programme, Institute of Clinical Neuroscience, Hospital Clínic, Universitat de Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalunya, Spain
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