Diagnostic criteria for bipolarity based on an international sample of 5,635 patients with DSM-IV major depressive episodes

Shortening of telomere length may be associated with inflammatory cytokine levels in patients with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is hypothesized to be associated with accelerated biological aging. Telomere length (TL) is a biomarker of aging, and although TL decreases with each cell division, the rate of telomere shortening may be affected by inflammation. We aimed to investigate whether TL is decreased in BD patients and to determine the association between TL and inflammatory markers in such patients.

METHODS

137 BD patients and 118 healthy controls (HCs) were recruited. Leukocyte TL and plasma levels of cytokines [tumor necrosis factor (TNF)-α, interleukin (IL)-8, IL-6, IL-10, transforming growth factor (TGF)-β1], C-reactive protein (CRP), and brain-derived neurotrophic factor (BDNF) were assessed.

RESULTS

TL did not differ significantly between the BD patients and HCs after adjustment for potential confounding factors (P = 0.79). TL was significantly negatively associated with age (β = -0.007, P < 0.001). In addition, log TNF-α levels were significantly negatively associated with TL (P = 0.009), in both the BD patients (P = 0.02) and HCs (P = 0.05).

CONCLUSION

We found a significant association between TNF-α levels and TL shortening in both BD patients and HCs. However, BD patients did not display increased TL shortening relative to HCs. Studies that involve larger sample sizes and control for the heterogeneity of BD participants will be needed.

How to treat major depressive disorder with shorter-duration hypomanic episodes? A case report

Here we report on a case of a 61-year-old female patient with 7-year history of major depressive disorder with shorter-duration hypomanic episodes who was prescribed with antidepressants which turned out to be ineffective. After a COVID-19 infection, the patient's clinical presentation became sufficient for the diagnosis of bipolar disorder and she was consistently effective on a mood stabilizer and an atypical antipsychotic. The course of treatment in this case suggests bipolar disorder is not a binary disorder, but a continuous spectrum disorder. For patients suffering from major depressive disorder with shorter-duration hypomanic episodes, mood stabilizers and atypical antipsychotics are possibly more suitable than antidepressants.

The diagnosis of bipolar disorder in children and adolescents: Past, present and future

AIMS

This article examines the ongoing debate concerning the diagnosis of bipolar disorder in children and adolescents. This contentious issue has generated robust discussion over the past two decades without consensus, and as such the true prevalence of so-called paediatric bipolar disorder (PBD) remains unknown. In this article we offer a solution to break this deadlock.

METHODS

Recent meta-analyses and additional literature concerning the definition and prevalence of PBD was critically reviewed with a view to understanding the perspectives of those developing the taxonomy of PBD, and those engaged in research and clinical practice.

RESULTS

A key finding is the lack of iteration and meaningful communication between the various groups interested in PBD that stems from deep-seated problems within our classificatory systems. This undermines our research efforts and complicates clinical practice. These problems make the already difficult diagnosis of bipolar disorder in adults even more challenging to transpose to younger populations, and additional complexities arise when parsing clinical phenomenology from normative developmental changes in youth. Therefore, in those manifesting bipolar symptoms post-puberty, we argue for the use of adolescent bipolar disorder to describe bipolar symptoms whereas in pre-pubertal children, we propose a reconceptualisation that allows symptomatic treatment to be advanced whilst requiring critical review of these symptoms over time.

CONCLUSION

Significant changes in our current taxonomy are necessary and to be clinically meaningful, these revisions to our diagnoses need to be developmentally-informed.

Bipolar disorder in the International Classification of Diseases-Eleventh version: A review of the changes, their basis, and usefulness

The World Health Organization’s 11^th 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, 5^th 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.

Comorbidities, Depression Severity, and Circadian Rhythms Disturbances as Clinical Correlates of Duration of Untreated Illness in Affective Disorders

Background and Objectives: Affective disorders, namely bipolar (BDs) and depressive disorders (DDs) are characterized by high prevalence and functional impairment. From a dimensional point of view, BDs and DDs can be considered as psychopathological entities lying on a continuum. A delay in treatment initiation might increase the burden associated with affective disorders. The aim of this study is to analyze the correlates of a long duration of untreated illness (DUI) in these conditions. Materials and Methods: Subjects with BDs and DDs, both in- and outpatients, were recruited. Long DUI was defined according to previous research criteria as >2 years for BDs or >1 year for DDs. Socio-demographic, clinical and psychopathological characteristics of the recruited subjects were collected. Bivariate analyses were performed to compare subjects with a long and short DUI (p < 0.05). Results: In our sample (n = 61), 34.4% of subjects presented a long DUI. A long DUI was significantly associated with longer overall illness duration (p = 0.022) and a higher rate of psychiatric (p = 0.048) and physical comorbidities (p = 0.023). As for psychopathological features, depressive symptoms were more severe in the long DUI subgroup, as demonstrated by a higher score at the Clinical Global Impression-severity of depression (p = 0.012) item and at the anxiety/depression factor of the Positive and Negative Syndrome Scale (p = 0.041). Furthermore, subjects with a long DUI displayed more severe disruption of circadian rhythms, as evaluated by the Biological Rhythms Interview for Assessment in Neuropsychiatry total (p = 0.044) and social domain (p = 0.005) scores and by the Hamilton Depression Rating Scale diurnal variation items (18a: p = 0.029, 18b: p = 0.047). Conclusions: A long DUI may underpin higher clinical severity, as well as worse illness course and unfavorable prognosis in affective disorders. Intervention strategies targeting comorbidities, depressive symptoms and circadian rhythms may decrease disease burden in subjects with a long DUI.

White matter abnormalities in adults with bipolar disorder type-II and unipolar depression

Discerning distinct neurobiological characteristics of related mood disorders such as bipolar disorder type-II (BD-II) and unipolar depression (UD) is challenging due to overlapping symptoms and patterns of disruption in brain regions. More than 60% of individuals with UD experience subthreshold hypomanic symptoms such as elevated mood, irritability, and increased activity. Previous studies linked bipolar disorder to widespread white matter abnormalities. However, no published work has compared white matter microstructure in individuals with BD-II vs. UD vs. healthy controls (HC), or examined the relationship between spectrum (dimensional) measures of hypomania and white matter microstructure across those individuals. This study aimed to examine fractional anisotropy (FA), radial diffusivity (RD), axial diffusivity (AD), and mean diffusivity (MD) across BD-II, UD, and HC groups in the white matter tracts identified by the XTRACT tool in FSL. Individuals with BD-II (n = 18), UD (n = 23), and HC (n = 24) underwent Diffusion Weighted Imaging. The categorical approach revealed decreased FA and increased RD in BD-II and UD vs. HC across multiple tracts. While BD-II had significantly lower FA and higher RD values than UD in the anterior part of the left arcuate fasciculus, UD had significantly lower FA and higher RD values than BD-II in the area of intersections between the right arcuate, inferior fronto-occipital and uncinate fasciculi and forceps minor. The dimensional approach revealed the depression-by-spectrum mania interaction effect on the FA, RD, and AD values in the area of intersection between the right posterior arcuate and middle longitudinal fasciculi. We propose that the white matter microstructure in these tracts reflects a unique pathophysiologic signature and compensatory mechanisms distinguishing BD-II from UD.

Presence and Overlap of Bipolar Symptoms and Borderline Features during Major Depressive Episodes

BACKGROUND

Bipolar symptoms and borderline personality features occur in both unipolar and bipolar major depressive episodes (MDEs). We investigated their prevalence, severity, co-occurrence and overlap.

METHODS

We interviewed 124 psychiatric outpatients with MDE using the Structured Clinical Interview for DSM-IV-TR Axis I and II Disorders, the Borderline Personality Disorder Severity Index (BPDSI-IV), and about past (hypo)manic episodes, and stratified them according to the principal diagnosis into subcohorts of major depressive disorder (MDD, n = 50), bipolar disorder (BD, n = 43), and borderline personality disorder (BPD, n = 31). We quantified (hypo)manic symptoms using a novel semi-structured interview (MIXed symptoms during MDE, MIX-MDE) with good psychometric qualities.

RESULTS

The subcohorts did not differ in MDE severity. They differed significantly in some (hypo)manic symptoms being present on most days in 24% of MDD, 30% of BD, and 42% of BPD subcohort, but only 5% of the BD subcohort fulfilled the DSM-5 mixed features. The mean MIX-MDE scores were 5.7 (SD 4.0), 12.0 (8.2) and 10.5 (7.5), and BPDSI-IV scores 15.6 (7.0), 17.2 (6.2) and 26.9 (8.7), respectively (both p < 0.001). (Hypo)manic days and unspecific symptoms of distractibility and irritability inflated the correlation of observed (hypo)manic symptoms and borderline features.

LIMITATIONS

Moderate sample size, limited age variation (18-50 years); no previous validation of MIX-MDE.

CONCLUSIONS

Presence of some mixed and borderline features is common in MDEs, with overlap and diagnosis-specific differences. Unspecific symptoms of irritability and distractibility and the aggravating impact of hypomania on perceived BPD features blur the differential diagnosis.

How Does Adding the DSM-5 Criterion Increased Energy/Activity for Mania Change the Bipolar Landscape?

According to DSM-IV, the criterion (A) for diagnosing hypomanic/manic episodes is mood change (i.e., elevated, expansive or irritable mood). Criterion (A) was redefined in DSM-5 in 2013, adding increased energy/activity in addition to mood change. This paper examines a potential change of prevalence data for bipolar I or II when adding increased energy/activity to the criterion (A) for the diagnosis of hypomania/mania. Own research suggests that the prevalence of manic/hypomanic episodes drops by at least one third when using DSM-5 criteria. Whether this has positive or negative impact on clinical practice and research still needs further evaluation.

Correlates, Course, and Outcomes of Increased Energy in Youth with Bipolar Disorder

OBJECTIVES

Compare longitudinal trajectories of youth with Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV Bipolar Disorder (BD), grouped at baseline by presence/absence of increased energy during their worst lifetime mood episode (required for DSM-5).

METHODS

Participants from the parent Course and Outcome of Bipolar Youth study (N = 446) were assessed utilizing The Schedule for Affective Disorders and Schizophrenia for School-Age Children (KSADS), KSADS Mania Rating Scale (KMRS), and KSADS Depression Rating Scale (KDRS). Youth were grouped at baseline into those with increased energy (meeting DSM-5 Criteria A for mania) vs. without increased energy (meeting DSM-IV, but not DSM-5, Criteria A for mania), for those who had worst lifetime mood episode recorded (n = 430). Youth with available longitudinal data had the presence/absence of increased energy measured, as well as psychiatric symptomatology/clinical outcomes (evaluated via the Adolescent Longitudinal Interval Follow-Up Evaluation), at each follow-up for 12.5 years (n = 398).

RESULTS

At baseline, the increased energy group (based on endorsed increased energy during worst lifetime mood episode; 86% of participants) vs. the without increased energy group, were more likely to meet criteria for BD-I and BD Not Otherwise Specified, had higher KMRS/KDRS total scores, and displayed poorer family/global psychosocial functioning. However, frequency of increased energy between groups was comparable after 5 years, and no significant group differences were found on clinical/psychosocial functioning outcomes after 12.5 years.

LIMITATIONS

Secondary data limited study design; groupings were based on one time point.

CONCLUSIONS

Results indicate no clinically relevant longitudinal group differences.

Number of episodes in bipolar disorder: The case for more thoughtful conceptualization and measurement

OBJECTIVES

Number of mood episodes (NoE) may be an important prognostic indicator in bipolar disorder, with implications for treatment. However, NoE has been conceptualized and measured inconsistently throughout the literature. This review examines the construct of NoE in bipolar disorder, with the aim of enhancing its conceptualization and measurement.

METHODS

A critical evaluation of literatures on important correlates of NoE, conceptually and phenomenologically overlapping features, and previous studies considering and measuring this construct was undertaken.

RESULTS

The literature indicates that despite frequent use, NoE has been inconsistently defined and measured. Multiple studies have linked NoE with important clinical factors, including relapse, functioning, cognitive impairment and the effectiveness of both pharmacological and psychosocial interventions, yet conclusions are limited by its inconsistent treatment. Additionally, it seems evident that that NoE may best be treated as a fuzzy construct (rather than precise figure), with yet to be defined overlaps with clinical variables such as age at onset and severity. Attempts to measure this construct have varied in comprehensiveness and structure.

CONCLUSIONS

The NoE construct may have important implications for individuals with bipolar disorders. However, more consistent and systematic definition and assessment of NoE is required to advance this literature and clarify its role. Recommendations aimed at advancing the conceptualization and the measurement of NoE are provided. Conceptualization may be advanced by considering and exploring relationships between NoE and factors with which it overlaps, while measurement may best be improved with increased consistency and balancing accuracy with feasibility.

Hypomania/Mania by DSM-5 definition based on daily smartphone-based patient-reported assessments

INTRODUCTION

The DSM-5 has introduced elevated/irritable mood and increased activity/ energy as equal and necessary criterion A symptoms for a diagnosis of (hypo)mania. The impact of these changes is poorly elucidated. The aim of the study was to investigate differences in the prevalence of elevated/irritable mood with and without co-occurring increased activity, and the associations between these, in patients with an ICD-10 and DSM-IV diagnosis of BD, using real life daily smartphone-based patient-reported measures of mood, irritability and activity.

METHODS

Data from two RCTs investigating the effect of smartphone-based treatment in patients with BD were combined. Patients with BD (N = 117) evaluated mood, irritability and activity level daily for six to nine months via a smartphone-based system. Analyses in this study are exploratory post hoc analyses based on previously published data.

RESULTS

During the follow-up period, patients reported elevated mood 8.0% of the time, irritability 28.4% of the time and increased activity 20.6% of the time. Co-occurring elevated/irritable mood and activity were prevalent 0.12% of the time for four consecutive days (duration criteria for a hypomanic episode) compared to 24% of the time with elevated/irritable mood without co-occurring increased activity. In linear mixed effect models accommodating for inter-individual and intra-individual variation, there was a statistically significant positive association between mood and activity (B: 0.14, 95% CI: 0.046; 0.24, p = 0.004). There was no association between irritability and activity (p = 0.23).

CONCLUSION

Based on real life daily assessments, the prevalence of (hypo)manic episodes is substantial reduced as a result of the introduction of DSM-5 and with potentially clinical consequences.

The role of different patterns of psychomotor symptoms in major depressive episode: Pooled analysis of the BRIDGE and BRIDGE-II-MIX cohorts

BACKGROUND

Psychomotor agitation (PA) or retardation (PR) during major depressive episodes (MDEs) have been associated with depression severity in terms of treatment-resistance and course of illness.

OBJECTIVES

We investigated the possible association of psychomotor symptoms (PMSs) during a MDE with clinical features belonging to the bipolar spectrum.

METHODS

The initial sample of 7689 MDE patients was divided into three subgroups based on the presence of PR, PA and non-psychomotor symptom (NPS). Univariate comparisons and multivariate logistic regression models were performed between subgroups.

RESULTS

A total of 3720 patients presented PR (48%), 1971 showed PA (26%) and 1998 had NPS (26%). In the PR and PA subgroups, the clinical characteristics related to bipolarity, along with the diagnosis of bipolar disorder (BD), were significantly more frequent than in the NPS subgroup. When comparing PA and PR patients, the former presented higher rates of bipolar spectrum features, such as family history of BD (OR = 1.39, CI = 1.20-1.61), manic/hypomanic switches with antidepressants (OR = 1.28, CI = 1.11-1.48), early onset of first MDE (OR = 1.40, CI = 1.26-1.57), atypical (OR = 1.23, CI = 1.07-1.42) and psychotic features (OR = 2.08, CI = 1.78-2.44), treatment with mood-stabilizers (OR = 1.39, CI = 1.24-1.55), as well as a BD diagnosis according to both the DSM-IV criteria and the bipolar specifier criteria. When logistic regression model was performed, the clinical features that significantly differentiated PA from PR were early onset of first MDE, atypical and psychotic features, treatment with mood-stabilizers and a BD diagnosis according to the bipolar specifier criteria.

CONCLUSIONS

Psychomotor symptoms could be considered as markers of bipolarity, illness severity, and treatment complexity, particularly if PA is present.

Patterns of response to antidepressants in major depressive disorder: Drug resistance or worsening of depression are associated with a bipolar diathesis

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.

The implications of hypersomnia in the context of major depression: Results from a large, international, observational study

According to the DSM-5, "reduction in the need for sleep" is the only sleep-related criteria for mixed features in depressive episodes. We aimed at studying the prevalence, clinical correlates and the role of hypersomnia in a sample of acutely depressed patients. Secondarily, we factors significantly increasing the odds of hypersomnia were studied. We conducted a post-hoc analysis of the BRIDGE-II-Mix study. Variables were compared between patients with hypersomnia (SLEEP+) and with insomnia (SLEEP-) with standard bivariate tests. A stepwise backward logistic regression model was performed with SLEEP+ as dependent variable. A total of 2514 subjects were dichotomized into SLEEP+ (n = 423, 16.8%) and SLEEP- (n = 2091, 83.2%). SLEEP+ had significant higher rates of obese BMI (p < 0.001), BD diagnosis (p = 0.027), severe BD (p < 0.001), lifetime suicide attempts (p < 0.001), lower age at first depression (p = 0.004) than SLEEP-. Also, SLEEP+ had significantly poorer response to antidepressants (AD) such as (hypo)manic switches, AD resistance, affective lability, or irritability (all 0<0.005). Moreover, SLEEP+ had significantly higher rates of mixed-state specifiers than SLEEP- (all 0 < 0.006). A significant contribution to hypersomnia in our regression model was driven by metabolic-related features, such as "current bulimia" (OR = 4.21) and "overweight/obese BMI (OR = 1.42)". Globally, hypersomnia is associated with poor outcome in acute depression. Hypersomnia is strongly associated with mixed features and bipolarity. Metabolic aspects could influence the expression of hypersomnia, worsening the overall clinical outcome. Along with commonly used screening tools, detection of hypersomnia has potential, costless discriminative validity in the differential diagnosis unipolar and bipolar depression.

Bipolar spectrum in major depressive disorders

Growing evidence for the spectrum concept of most mental disorders, particularly mood disorders, has challenged the arbitrary distinctions inherent in the contemporary categorical diagnostic classification system. Detection of manic symptoms in the context of episodes of depression is particularly important because of the implications for differential treatment of bipolar vs unipolar depression. The purpose of this study is to characterize the magnitude and clinical correlates of subthreshold manic syndromes or symptoms among people with major depressive disorder (MDD) compared to those without a history of manic symptoms. We defined two subthreshold manifestations-manic syndrome or symptoms-that did not include a criterion for duration. In the context of MDD, we found that the clinical correlates of those with the subthreshold manic syndrome were more similar to those with bipolar-II disorder than to MDD alone, whereas those with manic symptoms only were intermediate between those with subthreshold manic syndrome and MDD alone. These results confirm the spectrum concept of mania and suggest that a manic syndrome should be considered when evaluating people with MDD.

Design limitations to bipolar II treatment efficacy studies: A challenge and a revisionist strategy

BACKGROUND

Trials examining medication efficacy for bipolar II disorder commonly employ a set of standardized interval measures to assess outcomes. The key issue is whether such interval measures pick up changes in the severity, duration and frequency of depressive, hypomanic and euthymic episodes.

METHOD

We examine the application of measures most commonly used to monitor progress in nine studies involving participants with a bipolar II disorder and published in journals with a moderate to high impact factor.

RESULTS

Studies rarely provided interval details for assessing depressive and hypomanic symptoms. None specified whether ratings of depressive and hypomanic symptoms were based on severity, duration or number of symptoms, and none recorded any data on euthymic periods.

LIMITATIONS

Our sample of reviewed studies was small and our analyses focused only on the three most commonly used outcome measures. We advocate for complementary subjective daily mood monitoring strategies but recognize that such strategies need to be validated in future studies.

CONCLUSIONS

We argue that interval ratings undertaken weekly or over longer periods may compromise efficacy data. We recommend that userguides be developed to ensure standard outcome measures are employed consistently across trials, and that specific details be published in trial papers about how measures were employed and what mood episode characteristics were measured at each assessment. We also argue for daily ratings to be used as an outcome measure to provide data on severity, frequency and duration of depressive, hypomanic and euthymic periods in intervention studies of those with a bipolar II disorder.

Plasma oxytocin levels in major depressive and bipolar II disorders

Oxytocin may play a role in mood regulation. Research has shown the plasma oxytocin level of patients with bipolar I disorder (BD I) during a manic episode was significantly higher than that of BD I patients of other statuses, and also that of healthy subjects. However, whether or not a difference in the level of oxytocin exists between patients with major depressive disorder (MDD) and those with BD II is unclear. This study aimed to investigate the plasma oxytocin levels in MDD and BD II patients in a depressive episode. 119 healthy controls, 135 BD II patients, and 97 MDD patients were enrolled. All of the BD II and MDD patients were drug-naïve, with baseline depressive status 17-item Hamilton Depression Rating Scale scores >15. The plasma oxytocin level of the BD II patients was significantly higher than that of the MDD patients and controls at baseline. After treatment, the plasma oxytocin level of the BD II patients increased significantly; however, in the MDD group, the oxytocin level decreased slightly after treatment. Our findings suggested more significant plasma oxytocin dysregulation in the patients in the BD II group than in the MDD patients and controls, both before and after treatment.

Aggressiveness in depression: a neglected symptom possibly associated with bipolarity and mixed features

OBJECTIVE

To evaluate aggressiveness during a major depressive episode (MDE) and its relationship with bipolar disorder (BD) in a post hoc analysis of the BRIDGE-II-MIX study.

METHOD

A total of 2811 individuals were enrolled in this multicenter cross-sectional study. MDE patients with (MDE-A, n = 399) and without aggressiveness (MDE-N, n = 2412) were compared through chi-square test or Student's t-test. A stepwise backward logistic regression model was performed.

RESULTS

MDE-A group was more frequently associated with BD (P < 0.001), while aggressiveness was negatively correlated with unipolar depression (P < 0.001). At the logistic regression, aggressiveness was associated with the age at first depressive episode (P < 0.001); the severity of mania (P = 0.03); the diagnosis of BD (P = 0.001); comorbid borderline personality disorder (BPD) (P < 0.001) but not substance abuse (P = 0.63); no current psychiatric treatment (P < 0.001); psychotic symptoms (P = 0.007); the marked social/occupational impairment (P = 0.002). The variable most significantly associated with aggressiveness was the presence of DSM-5 mixed features (P < 0.001, OR = 3.815). After the exclusion of BPD, the variable of lifetime suicide attempts became significant (P = 0.013, OR = 1.405).

CONCLUSION

Aggressiveness seems to be significantly associated with bipolar spectrum disorders, independently from BPD and substance abuse. Aggressiveness should be considered as a diagnostic criterion for the mixed features specifier and a target of tailored treatment strategy.

Obesity in patients with major depression is related to bipolarity and mixed features: evidence from the BRIDGE-II-Mix study

OBJECTIVES

The Bipolar Disorders: Improving Diagnosis, Guidance and Education (BRIDGE)-II-Mix study aimed to estimate the frequency of mixed states in patients with a major depressive episode (MDE) according to different definitions. The present post-hoc analysis evaluated the association between obesity and the presence of mixed features and bipolarity.

METHODS

A total of 2811 MDE subjects were enrolled in a multicenter cross-sectional study. In 2744 patients, the body mass index (BMI) was evaluated. Psychiatric symptoms, and sociodemographic and clinical variables were collected, comparing the characteristics of MDE patients with (MDE-OB) and without (MDE-NOB) obesity.

RESULTS

Obesity (BMI ≥30) was registered in 493 patients (18%). In the MDE-OB group, 90 patients (20%) fulfilled the DSM-IV-TR criteria for bipolar disease (BD), 225 patients (50%) fulfilled the bipolarity specifier criteria, 59 patients (13%) fulfilled DSM-5 criteria for MDEs with mixed features, and 226 patients (50%) fulfilled Research-Based Diagnostic Criteria for an MDE. Older age, history of (hypo)manic switches during antidepressant treatment, the occurrence of three or more MDEs, atypical depressive features, antipsychotic treatment, female gender, depressive mixed state according to DSM-5 criteria, comorbid eating disorders, and anxiety disorders were significantly associated with the MDE-OB group. Among (hypo)manic symptoms during the current MDE, psychomotor agitation, distractibility, increased energy, and risky behaviors were the variables most frequently associated with MDE-OB group.

CONCLUSIONS

In our sample, the presence of obesity in patients with an MDE seemed to be associated with higher rates of bipolar spectrum disorders. These findings suggest that obesity in patients with an MDE could be considered as a possible marker of bipolarity.

Antidepressant-induced hypomania/mania in patients with major depression: Evidence from the BRIDGE-II-MIX study

BACKGROUND

The issue of antidepressant-induced mood switches to hypomania, mania, or mixed states within the course of mayor depressive disorder (MDD) has been a controversial topic. The present post-hoc analysis of the BRIDGE-II-MIX study focuses on the clinical features of patients with history of antidepressant-induced hypomania/mania (AIHM) in a large international sample of patients with major depressive episode (MDE).

METHODS

2811 subjects with major depression were enrolled in this multicentre cross-sectional study. Current mixed symptoms, socio-demographic and other clinical variables were collected and compared among MDD-AIHM, MDD and BD patients.

RESULTS

475 patients out of 2811 had history of AIHM (16.90%). In the MDD-AIHM group, familiarity for BD and rates of atypical features and comorbid anxiety, eating and borderline personality disorders were similar to BD and significantly more frequent compared to MDD group. MDD-AIHM patients had more frequently more than 3 episodes and reported higher rates of treatment resistance, mood lability and irritability following treatment with antidepressants. Frequencies of depression with mixed features and (hypo)manic symptoms were similar in patients of MDD-AIHM and BD groups and significantly higher in both groups than in MDD.

LIMITATIONS

there were widely varying rates of hospitalized patients across countries and the participating centres were not randomly selected.

CONCLUSIONS

Our results strongly support the DSM-5 inclusion of MDD patients with AIHM within the rubric of bipolar disorder. Differences with other MDD and BD were also observed suggesting the possibility that MDD-AIHM may represent a specific sub-population, particularly sensitive to exogenous input from antidepressants.

Increased Activity or Energy as a Primary Criterion for the Diagnosis of Bipolar Mania in DSM-5: Findings From the STEP-BD Study

OBJECTIVE

DSM-5 describes "a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy" as a primary criterion for mania. Thus, increased energy or activity is now considered a core symptom of manic and hypomanic episodes. Using data from the Systematic Treatment Enhancement Program for Bipolar Disorder study, the authors analyzed point prevalence data obtained at the initial visit to assess the diagnostic validity of this new DSM-5 criterion. The study hypothesis was that the DSM-5 criterion would alter the prevalence of mania and/or hypomania.

METHOD

The authors compared prevalence, clinical characteristics, validators, and outcome in patients meeting the DSM-5 criteria (i.e., DSM-IV criteria plus the DSM-5 criterion of increased activity or energy) and those who did not meet the new DSM-5 criterion (i.e., who only met DSM-IV criteria).

RESULTS

All 4,360 participants met DSM-IV criteria for bipolar disorder, and 310 met DSM-IV criteria for a manic or hypomanic episode. When the new DSM-5 criterion of increased activity or energy was added as a coprimary symptom, the prevalence of mania and hypomania was reduced. Although minor differences were noted in clinical and concurrent validators, no changes were observed in longitudinal outcomes.

CONCLUSIONS

The findings confirm that including increased activity or energy as part of DSM-5 criterion A decreases the prevalence of manic and hypomanic episodes but does not affect longitudinal clinical outcomes.

The Differential Levels of Inflammatory Cytokines and BDNF among Bipolar Spectrum Disorders

OBJECTIVE

Emerging evidence suggests that inflammation and neurodegeneration underlies bipolar disorder. To investigate biological markers of cytokines and brain-derived neurotrophic factor between bipolar I, bipolar II, and other specified bipolar disorder with short duration hypomania may support the association with inflammatory dysregulation and bipolar disorder and, more specifically, provide evidence for other specified bipolar disorder with short duration hypomania patients were similar to bipolar II disorder patients from a biological marker perspective.

METHODS

We enrolled patients with bipolar I disorder (n=234), bipolar II disorder (n=260), other specified bipolar disorder with short duration hypomania (n=243), and healthy controls (n=140). Their clinical symptoms were rated using the Hamilton Depression Rating Scale and Young Mania Rating Scale. Inflammatory cytokine (tumor necrosis factor-α, C-reactive protein, transforming growth factor-β1, and interleukin-8) and brain-derived neurotrophic factor levels were measured in each group. Multivariate analysis of covariance and linear regression controlled for possible confounders were used to compare cytokine and brain-derived neurotrophic factor levels among the groups.

RESULTS

Multivariate analysis of covariance adjusted for age and sex and a main effect of diagnosis was significant (P<.001). Three of the 5 measured biomarkers (tumor necrosis factor-α, transforming growth factor-β1, and interleukin-8) were significantly (P=.006, .01, and <.001) higher in all bipolar disorder patients than in controls. Moreover, covarying for multiple associated confounders showed that bipolar I disorder patients had significantly higher IL-8 levels than did bipolar II disorder and other specified bipolar disorder with short duration hypomania patients in multivariate analysis of covariance (P=.03) and linear regression (P=.02) analyses. Biomarkers differences between bipolar II disorder and other specified bipolar disorder with short duration hypomania patients were nonsignificant.

CONCLUSION

The immunological disturbance along the bipolar spectrum was most severe in bipolar I disorder patients. Other specified bipolar disorder with short duration hypomania patients and bipolar II disorder patients did not differ in these biological markers.

The Prevalence and Diagnostic Validity of Short-Duration Hypomanic Episodes and Major Depressive Episodes

Current diagnostic criteria for a hypomanic episode, as outlined in both the fourth and fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and DSM-5), require a minimum duration of four consecutive days of symptoms of mood elevation. The 4-day criterion for duration of hypomania has been challenged as arbitrary and lacking empirical support, with many arguing that shorter-duration hypomanic episodes are highly prevalent and that those experiencing these episodes are clinically more similar to patients with bipolar disorder than to those with unipolar major depressive disorder. We review the current evidence regarding the prevalence, diagnostic validity, and longitudinal illness correlates of shorter-duration hypomanic episodes and summarize the arguments for and against broadening the diagnostic criteria for hypomania to include shorter-duration variants. Accumulating findings suggest that patients with major depressive episodes and shorter-duration hypomanic episodes represent a complex clinical phenotype, perhaps best conceptualized as being on the continuum between those with unipolar depressive episodes alone and those with DSM-5-defined bipolar II disorder. Further investigation is warranted, ideally involving large prospective, controlled studies, to elucidate the diagnostic and treatment implications of depression with shorter-duration hypomanic episodes.

Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines

A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.

Evidence for the continuous latent structure of mania and depression in out-patients with bipolar disorder: results from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

BACKGROUND

Evidence supporting the continuous latent structure of mood phenomena has not been incorporated into psychiatric diagnostic systems, in part because the evidence has been incomplete. For example, no studies have investigated the boundary between 'sick' and 'well' periods in individuals with bipolar disorder, despite agreement that characterization of mood disorders as having a discrete episodic course is inaccurate. The present study examined the validity of mood episode symptom thresholds in out-patients with bipolar disorder using multiple methodologies: taxometrics and information-theoretic latent distribution modeling (ITLDM), to evaluate the continuity/discontinuity of mood symptoms; and structural equation mixture modeling (SEMM), to evaluate the continuity/discontinuity of associations between mood symptoms and general functioning.

METHOD

A total of 3721 out-patients with bipolar disorder from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) were available for analysis. Data were collected at participants' baseline STEP-BD visit. Taxometric [maximum covariance/means above minus below a cut (MAXCOV/MAMBAC) with simulated comparison data], ITLDM and SEMM methods were applied twice, once to the Montgomery-Åsberg Depression Rating Scale and again to the Young Mania Rating Scale.

RESULTS

Taxometric results unequivocally supported a continuous interpretation of the data. ITLDM results favored many valued 'discrete metrical' models, suggesting that mood symptoms have continuous, but potentially non-normally distributed, latent structures in out-patients with bipolar disorder. Finally, SEMM results demonstrated that latent associations between mood symptoms and general functioning were linear.

CONCLUSIONS

Results from the present study argue against the validity of DSM mood episode thresholds and argue for a graded continuum of care of bipolar symptom management.

Body mass, cardiovascular risk and metabolic characteristics of young persons presenting for mental healthcare in Sydney, Australia

OBJECTIVES

To determine the body mass, cardiovascular and metabolic characteristics of young people presenting for mental healthcare.

DESIGN

Cross-sectional assessments of body mass, cardiovascular and metabolic risk factors.

SETTING

Two primary-care based sites in Sydney, Australia for young people in the early stages of mental disorders.

PARTICIPANTS

A clinical sample of young people (12-30 years) with mental health problems.

OUTCOME MEASURES

Daily smoking rates, body mass index (BMI), blood glucose and lipids, blood pressure (BP) and pulse rate.

RESULTS

Of 1005 young people who had their BMI determined (62% female; 19.0±3.5 years), three quarters (739/1005) also had BP recordings and one-third (298/1005) had blood sampling. Clinically, 775 were assigned to one of three diagnostic categories (anxious-depression: n=541; mania-fatigue, n=104; developmental-psychotic n=130). The profile of BMI categories approximated that of the comparable segments of the Australian population. Older age, lower levels of social functioning and higher systolic BP were all associated with high BMI. In a subset (n=129), current use of any psychotropic medication was associated (p<0.05) with increased BMI. Almost one-third of cases were current daily smokers (compared to population rate of 11%). Males had a higher proportion of raised glucose and high-density lipoprotein (HDL) compared to females (9.3% and 34.1% vs 2.1% and 5.9%, respectively). Overall, there was no relationship between BMI and fasting glucose but significant relationships with triglycerides and HDL were noted. Furthermore, there were no significant relationships between diagnostic subgroup and metabolic profiles.

CONCLUSIONS

Daily smoking rates are increased among young people presenting for mental healthcare. However, these young people do not demonstrate adverse cardiometabolic profiles. The high levels of smoking, and association of BMI with adverse social circumstances, suggest that risk factors for chronic disease are already present and likely to be compounded by medication and social disadvantage.

A potential interaction between COMT and MTHFR genetic variants in Han Chinese patients with bipolar II disorder

Bipolar II disorder (BP-II), characterized by recurrent dysregulation of mood, is a serious and chronic psychiatric illness. However, BP-II is commonly under-recognized, even in psychiatric settings. Because dopaminergic disturbance is thought to be involved in the development of bipolar disorder (BPD), it seems essential to investigate dopamine-related genes like the catechol-O-methyltransferase (COMT) gene, which are involved in dopamine metabolism, and the methylenetetrahydrofolate reductase (MTHFR) gene, which may affect COMT methylation and COMT function. The current study examined the association and interaction of the COMT Val158Met and MTHFR C677T variants with BP-II. Nine hundred seventy-eight participants were recruited: 531 with BP-II and 447 healthy controls. The genotypes of the COMT and MTHFR polymorphisms were determined using a polymerase chain reaction-restriction fragment length polymorphism analysis. Logistic regression analysis showed a significant interaction effect of the COMT Val158Met Val/Val genotype and the MTHFR C677T C/T + T/T genotype (P = 0.039) for the protective effect on the odds of developing BP-II. Our findings support preliminary evidence that the COMT and MTHFR genes interact in BP-II, and they imply the connection of both dopaminergic pathways and methylation pathways in the pathogenesis of BP-II.

Correlation of plasma brain-derived neurotrophic factor and metabolic profiles in drug-naïve patients with bipolar II disorder after a twelve-week pharmacological intervention

OBJECTIVE

Brain-derived neurotrophic factor (BDNF) is thought to be involved in the pathophysiology of bipolar disorder (BD) and metabolic syndrome. We investigated the correlation between plasma BDNF with mood symptoms and metabolic indices in patients with BD-II over a 12-week pharmacological intervention.

METHOD

Drug-naïve patients with BD-II (n=117) were recruited. Metabolic profiles [cholesterol, triglyceride, HbA1C, fasting serum glucose, body mass index (BMI)] and plasma BDNF wtrun "tblautotrun "tblsctrun "tbl_contere measured at baseline and 2, 8, and 12 weeks after beginning medication. To adjust within-subject dependence over repeated assessments, multiple linear regressions with generalized estimating equation methods were used.

RESULTS

Seventy-six (65.0%) patients completed the intervention. Plasma BDNF levels were significantly associated with BMI (P=9.6E-5), low-density lipoprotein (P=0.034) and total (P=0.001) cholesterol, but not with the Hamilton Depression Rating Scale-17 and Young Mania Rating Scale scores over the 12-week treatment.

CONCLUSION

We found initial evidence of a positive correlation between plasma BDNF levels and BMI, low-density lipoprotein and total cholesterol in drug-naïve patients with BD-II. The specific function of BDNF in regulating and maintaining peripheral metabolic health requires additional investigation.

Atypical features and treatment choices in bipolar disorders: a result of the National Bipolar Mania Pathway Survey in China

In this study, we examined the point prevalence rate of atypical features in bipolar disorder, and estimated the potential impact of these features on treatment practices in China. Using the atypical features criteria of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV), we documented the atypical symptoms in 3 906 consecutive participants with bipolar disorder enrolled at 26 psychiatric services across China. We further assessed the association between atypical features and the treatment approaches, including the prescription of antidepressants. The overall point prevalence rate of atypical features was 9.1% among patients with various bipolar disorder subtypes. When the definition was broadened to include atypical features B, the overall rate increased to 11.8%. Interestingly, among patients with the mixed state and remission subtypes, there was a significant difference in the rates of antidepressant medication usage between patients who met and those who did not meet the criteria for atypical features B. These findings indicate a trend of using antidepressants for these two types of patients with atypical features. Further, for both mixed state and remission patients, treatment approaches were related to atypical features B. Our findings provide evidence to assist clinicians to readily recognize atypical features in bipolar subtypes and can propose treatments based on these diagnoses.

Elevated levels of IL-6 and IL-18 in manic and hypomanic states in rapid cycling bipolar disorder patients

Inflammatory system dysregulation may be involved in the pathophysiology of bipolar disorder with peripheral cytokine levels varying between affective states; however, the evidence is based primarily on case-control studies and limited by methodological issues. The objectives of the present study were to assess alterations of peripheral cytokine levels between affective states in rapid cycling bipolar disorder patients and to compare these with levels in healthy control subjects. In a longitudinal design, repeated measurements of plasma levels of IL-6, IL-10, IL-18, IL-1β and TNF-α were obtained in affective states of varying polarity during 6-12 months in 37 rapid cycling bipolar disorder patients and compared with repeated measurements in 40 age- and gender matched healthy control subjects, using rigorous laboratory-, clinical- and statistical methodology. Adjusting for demographical, clinical- and lifestyle factors, levels of IL-6 (p<0.05) and IL-18 (p<0.005) were significantly elevated in rapid cycling bipolar disorder patients in a manic/hypomanic state, compared with a depressed and a euthymic state. Compared with healthy control subjects, unadjusted levels of IL-6 (p<0.05) and IL-18 (p<0.05) were elevated in manic/hypomanic bipolar disorder patients. Levels of IL-10 and IL-1β were undetectable in the majority of samples; high TNF-α assay variability was found. The results support a role for altered peripheral immune response signaling in rapid cycling bipolar disorder and suggest that IL-6 and IL-18 could be markers of manic episodes.

Elevated levels of plasma brain derived neurotrophic factor in rapid cycling bipolar disorder patients

Impaired neuroplasticity may be implicated in the pathophysiology of bipolar disorder, involving peripheral alterations of the neurotrophins brain derived neurotrophic factor (BDNF) and neurotrophin 3 (NT-3). Evidence is limited by methodological issues and is based primarily on case-control designs. The aim of this study was to investigate whether BDNF and NT-3 levels differ between patients with rapid cycling bipolar disorder and healthy control subjects and whether BDNF and NT-3 levels alter with affective states in rapid cycling bipolar disorder patients. Plasma levels of BDNF and NT-3 were measured in 37 rapid cycling bipolar disorder patients and in 40 age- and gender matched healthy control subjects using enzyme-linked immunosorbent assay (ELISA). In a longitudinal design, repeated measurements of BDNF and NT-3 were evaluated in various affective states in bipolar disorder patients during a 6-12 months period and compared with repeated measurements in healthy control subjects. Careful attention was given to standardization of all procedures and adjustment for potential confounders of BDNF and NT-3. In linear mixed models, adjusting for demographical and lifestyle factors, levels of BDNF were significantly elevated in bipolar disorder patients in euthymic- (p<0.05), depressed- (p<0.005) and manic/hypomanic (p<0.005) states compared with healthy control subjects. Within bipolar disorder patients, adjusting for medication, there was no significant difference in BDNF levels between affective states, with equally elevated levels present in euthymic-, depressive- and manic/hypomanic patients. Levels of BDNF were higher in patients with longer duration of illness compared with patients with shorter duration of illness. We found no difference in NT-3 levels between bipolar disorder patients in any affective state compared with healthy control subjects and no difference in NT-3 levels between affective states in bipolar disorder patients. The results suggest that BDNF may be a marker related to illness stage in bipolar disorder, not varying with affective states in rapid cycling bipolar disorder patients. Due to the nature of comparison, it cannot be excluded that the finding of elevated BDNF levels in bipolar disorder patients compared with healthy controls could be influenced by medication.

The bipolar spectrum: conceptions and misconceptions

OBJECTIVE

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

METHOD

Narrative review based on historical and empirical studies.

RESULTS

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

CONCLUSIONS

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

Is the DSM-5 duration criterion valid for the definition of hypomania?

BACKGROUND

DSM-IV and DSM-5 impose a 4 day duration criterion for hypomanic episodes yet several studies have suggested that such an imposition may be invalid. We report a study involving a large sample pursuing the likely salience of the DSM duration criterion.

METHODS

We analyzed data on hypomanic symptoms provided by two bipolar screening measures - the Mood Disorders Questionnaire (MDQ) and the Mood Swings Questionnaire (MSQ) in a sample of 501 patients meeting DSM and other symptom criteria for a bipolar II disorder (BP II) and contrasted data for 186 meeting the DSM minimum duration of 4 days and 315 experiencing episodes lasting less than 4 days (i.e. 'standard' vs. 'brief' groups).

RESULTS

The brief group reported slightly less severe hypomanic episodes, but the two groups did not differ on a number of illness correlates including age of onset of depressive and of hypomanic episodes, or by rates of depressive and bipolar conditions in first-degree family members.

LIMITATIONS

The possibility of false positive BP II diagnoses, especially with brief hypomanic episodes, must be conceded while our examination of clinical symptoms was limited to two measures.

CONCLUSIONS

This study is consistent with previous studies suggesting that the DSM duration of 4 or more days for a diagnosis of a hypomanic episode is unnecessary to the clinical definition of a BP II disorder. Its preservation is likely to exclude a substantive number of those with a true BP II condition.

DSM-IV diagnosis in depressed primary care patients with previous psychiatric ICD-10 bipolar disorder

BACKGROUND

In the past 20 years, much evidence has accumulated against the overly restrictive diagnostic concepts of hypomania in DSM-IV and DSM-IV-TR. We tested DSM-IV-TR and a broader modified version (DSM-IV-TRm) for their ability to detect bipolarity in patients who had been treated for bipolar disorders (BD) in psychiatric settings, and who now consulted general practitioners (GPs) for new major depressive episodes (MDE).

METHODS

Bipolact II was an observational, single-visit survey involving 390 adult patients attending primary care for MDE (DSM-IV-TR criteria) in 201 GP offices in France. The participating GPs (53.3 ± 6.5 years old, 80.1% male) were trained by the Bipolact Educational Program, and were familiar with the medical care of depressive patients.

RESULTS

Of the 390 patients with MDE, 129 (33.1%) were previously known as bipolar patients (ICD-10 criteria). Most of the latter bipolar patients (89.7%) had previously been treated with antidepressants. Only 9.3% of them met DMS-IV-TR criteria for BD. Conversely, 79.1% of the 129 bipolar patients met DMS-IV-TRm criteria for BD and showed strong associations with impulse control disorders and manic/hypomanic switches during antidepressant treatment.

LIMITATIONS

Limited training of participating GPs, recall bias of patients, and the study not being representative for untreated bipolar patients.

CONCLUSIONS

Very few ICD-10 bipolar patients consulting French GPs for MDE met DSM-IV-TR criteria for bipolar diagnosis, which suggests that DSM-IV-TR criteria are insufficient and too restrictive for the diagnosis of BD. DSM-IV-TRm was more sensitive, but 20% of bipolar patients were undetected.

Evidence-based definitions of bipolar-I and bipolar-II disorders among 5,635 patients with major depressive episodes in the Bridge Study: validity and comorbidity

The definitions of bipolar-I (BP-I) and bipolar-II (BP-II) disorders are currently under revision by the APA and by the WHO. We provide evidence of a revised set of criteria for bipolar disorders and major depressive disorder (MDD) which could serve to strengthen the construct and predictive validity of both disorders and enable more incisive studies of treatments and courses of both disorders. In the diagnostic Bridge Study of 5,635 patients with major depressive episodes from 18 countries (Europe, North Africa, Near East and Far East) leading psychiatrists in each country assessed a pre-specified group of symptoms, illness course, family history and duration of episodes; these data allowed tests of several definitions of bipolarity. The primary revised specifier diagnosis of BP-I disorder included manic episodes based on an additional category A criterion (increased activity/energy) and did not apply any exclusion criteria. The revised BP-II disorders included hypomanic episodes of 1-3 days. Family history and illness course validators (history of mania/hypomania among first degree relatives, 2 or more lifetime episodes and first symptoms having occurred before age 30) discriminated clearly between patients with bipolar-I or bipolar-II disorders meeting bipolarity specifier criteria and those with MDD. Specifier definitions provided better discrimination between MDD and the two bipolar subgroups. Patterns of concurrent comorbidities also differed significantly between patients meeting criteria for MDD compared with those meeting bipolar specifier criteria. Comorbidity patterns differed between bipolar-I and bipolar-II patients. This study provides evidence for the validity of modified (specifier) BP-I and BP-II definitions that incorporate illness course and family history which reduce ambiguities of major depressive episodes between bipolar-I and bipolar-II disorders and MDD.

Ribosomal DNA transcription in the anterior cingulate cortex is decreased in unipolar but not bipolar I depression

The anterior cingulate cortex (AC) is consistently implicated in the pathophysiology of depression. However, it is not clear whether unipolar and bipolar depression display distinct neuropathological features. Therefore, the objective of this post-mortem study was to re-evaluate this important issue. Brains from 9 patients with major depressive disorder (MDD) and 11 patients with bipolar disorder (BD) subtype I depression as well as 24 matched controls were analysed. The argyrophilic nucleolar organiser region (AgNOR) silver-staining method was applied on paraffin-embedded brain sections in order to assess the transcriptional activity of ribosomal DNA (rDNA) in layer III and V pyramidal neurons of the dorsal and ventral AC in both hemispheres. An AgNOR area decrease suggestive of a diminished transcriptional activity of rDNA was found in the MDD group both versus controls and versus the BD group. The effect was specific for the right hemisphere and dorsal AC and was restricted to layer V pyramidal neurons. The results suggest that only patients with MDD display region-specific chronic hypoactivity of these output neurons, which are critical for mood regulation. Furthermore, in our cohort, unipolar and bipolar I depression could be differentiated relative to the presumed AC hypoactivity and psychotropic medication did not counteract the observed effect.

Evaluating differential developmental trajectories to adolescent-onset mood and psychotic disorders

BACKGROUND

It is an open question as to whether differential developmental trajectories, potentially representing underlying pathophysiological processes, can form the basis of a more useful typology in young persons who present for mental health care.

METHODS

A cohort of 605 young people was recruited from youth mental health services that target the early phases of anxiety, mood or psychotic disorders. Participants were assigned to one of three clinical sub-types (anxious-depression; mania-fatigue; developmental-psychotic) according to putative developmental trajectories.

RESULTS

The distribution of subtypes was: 51% anxiety-depression, 25% mania-fatigue and 24% developmental-psychotic, with key differences in demographic, clinical, family history and neuropsychological characteristics. When analyses were limited to 286 cases with 'attenuated' or sub-threshold syndromes, the pattern of differences was similar. Multinomial logistic regression demonstrated that compared to the developmental-psychotic subtype, both the mania-fatigue and anxiety-depression subtypes were younger and more depressed at presentation, but less functionally impaired. Other discriminating variables between the developmental-psychotic and mania-fatigue sub-types were that the latter were significantly more likely to have a family history of bipolar disorder but have less likelihood of impaired verbal learning; whilst the anxious-depression group were more anxious, more likely to have a family history of depression, and had a higher premorbid IQ level.

CONCLUSIONS

This cross-sectional evaluation provides preliminary support for differing developmental trajectories in young persons presenting for mental health care. Prospective follow-up is needed to examine the predictive validity of this approach and its relationships to underlying pathophysiological mechanisms.

The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders

OBJECTIVE

The risk-benefit profile of antidepressant medications in bipolar disorder is controversial. When conclusive evidence is lacking, expert consensus can guide treatment decisions. The International Society for Bipolar Disorders (ISBD) convened a task force to seek consensus recommendations on the use of antidepressants in bipolar disorders.

METHOD

An expert task force iteratively developed consensus through serial consensus-based revisions using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new or reworded items and items that needed to be rerated. This process resulted in the final ISBD Task Force clinical recommendations on antidepressant use in bipolar disorder.

RESULTS

There is striking incongruity between the wide use of and the weak evidence base for the efficacy and safety of antidepressant drugs in bipolar disorder. Few well-designed, long-term trials of prophylactic benefits have been conducted, and there is insufficient evidence for treatment benefits with antidepressants combined with mood stabilizers. A major concern is the risk for mood switch to hypomania, mania, and mixed states. Integrating the evidence and the experience of the task force members, a consensus was reached on 12 statements on the use of antidepressants in bipolar disorder.

CONCLUSIONS

Because of limited data, the task force could not make broad statements endorsing antidepressant use but acknowledged that individual bipolar patients may benefit from antidepressants. Regarding safety, serotonin reuptake inhibitors and bupropion may have lower rates of manic switch than tricyclic and tetracyclic antidepressants and norepinephrine-serotonin reuptake inhibitors. The frequency and severity of antidepressant-associated mood elevations appear to be greater in bipolar I than bipolar II disorder. Hence, in bipolar I patients antidepressants should be prescribed only as an adjunct to mood-stabilizing medications.

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

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

Bipolar disorders in DSM-5: strengths, problems and perspectives

The diagnostic classification of mood disorders by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) had two major shortcomings: an underdiagnosis of bipolar disorders and a large proportion of treated patients had to be allocated to the vague NOS groups ‘not otherwise specified’. Several new subthreshold groups of depression, bipolar disorders and mixed states are now operationally defined in DSM-5. In addition, hypomanic and manic episodes occurring during antidepressant treatments are, under certain conditions, accepted as criteria for bipolar disorders. The diagnosis of bipolarity now requires, as entry criterion A, not only the presence of elated or irritable mood but also the association of these symptoms with increased energy/activity. This restriction will unfortunately change the diagnoses of some patients from DSM-IV bipolar I and II disorders to subdiagnostic bipolar syndromes. Nonetheless, overall, DSM-5 is a step in the right direction, specifying more subdiagnostic categories with an improved dimensional approach to severity. DSM-5 may also have an impact on patient selection for placebo-controlled drug trials with antidepressants.

Quetiapine monotherapy in bipolar II depression: combined data from four large, randomized studies

BACKGROUND

Despite being present in up to 1% of the population, few controlled trials have examined the efficacy of treatments for bipolar II depression. Pooled data are presented from four placebo-controlled studies (BOLDER I [5077US/0049] and II [D1447C00135]; EMBOLDEN I [D1447C00001] and II [D1447C00134]) that evaluated the efficacy of quetiapine monotherapy for depressive episodes in patients with bipolar II disorder.

METHODS

All studies included an 8-week, double-blind treatment phase in which patients were randomly assigned to treatment with quetiapine 300 mg/day, quetiapine 600 mg/day, or placebo. Outcome measures included the change from baseline in MADRS total score at week 8, effect sizes, and MADRS response and remission rates.

RESULTS AND DISCUSSION

Improvements in mean MADRS total scores from baseline to week 8 were significantly greater with quetiapine 300 and 600 mg/day (-15.58 [n = 283] and -14.88 [n = 289]; p < 0.001) compared with placebo (-11.61 [n = 204]). The MADRS effect sizes were 0.44 for quetiapine 300 mg/day and 0.47 for 600 mg/day (p < 0.001 vs placebo). Significantly higher proportions of patients receiving quetiapine, at both doses, than placebo-treated patients achieved response and remission at week 8 (p < 0.01). Common adverse events associated with quetiapine (both doses) included dry mouth, somnolence, sedation, dizziness, and headache. Rates of mania and hypomania were similar for quetiapine and placebo. Quetiapine monotherapy demonstrated significant efficacy compared with placebo and was generally well tolerated in the treatment of bipolar II depression.