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Mesbah R, Koenders MA, Spijker AT, de Leeuw M, van Hemert AM, Giltay EJ. Dynamic time warp analysis of individual symptom trajectories in individuals with bipolar disorder. Bipolar Disord 2024; 26:44-57. [PMID: 37269209 DOI: 10.1111/bdi.13340] [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: 06/04/2023]
Abstract
BACKGROUND Manic and depressive mood states in bipolar disorder (BD) may emerge from the non-linear relations between constantly changing mood symptoms exhibited as a complex dynamic system. Dynamic Time Warp (DTW) is an algorithm that may capture symptom interactions from panel data with sparse observations over time. METHODS The Young Mania Rating Scale and Quick Inventory of Depressive Symptomatology were repeatedly assessed in 141 individuals with BD, with on average 5.5 assessments per subject every 3-6 months. Dynamic Time Warp calculated the distance between each of the 27 × 27 pairs of standardized symptom scores. The changing profile of standardized symptom scores of BD participants was analyzed in individual subjects, yielding symptom dimensions in aggregated group-level analyses. Using an asymmetric time-window, symptom changes that preceded other symptom changes (i.e., Granger causality) yielded a directed network. RESULTS The mean age of the BD participants was 40.1 (SD 13.5) years old, and 60% were female participants. Idiographic symptom networks were highly variable between subjects. Yet, nomothetic analyses showed five symptom dimensions: core (hypo)mania (6 items), dysphoric mania (5 items), lethargy (7 items), somatic/suicidality (6 items), and sleep (3 items). Symptoms of the "Lethargy" dimension showed the highest out-strength, and its changes preceded those of "somatic/suicidality," while changes in "core (hypo)mania" preceded those of "dysphoric mania." CONCLUSION Dynamic Time Warp may help to capture meaningful BD symptom interactions from panel data with sparse observations. It may increase insight into the temporal dynamics of symptoms, as those with high out-strength (rather than high in-strength) could be promising targets for intervention.
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Affiliation(s)
- R Mesbah
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
- Mental Health Care PsyQ Kralingen, Department of Mood Disorders, Rotterdam, The Netherlands
| | - M A Koenders
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
- Faculty of Social Sciences, Leiden University, Institute of Psychology, Leiden, The Netherlands
| | - A T Spijker
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
- Mental Health Care Rivierduinen, Leiden, The Netherlands
| | - M de Leeuw
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
- Mental Health Care Rivierduinen, Bipolar Disorder Outpatient Clinic, Leiden, The Netherlands
| | - A M van Hemert
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
| | - E J Giltay
- Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
- Health Campus The Hague, Leiden University, The Hague, The Netherlands
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2
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Malhi GS, Jadidi M, Bell E. The diagnosis of bipolar disorder in children and adolescents: Past, present and future. Bipolar Disord 2023; 25:469-477. [PMID: 37433682 DOI: 10.1111/bdi.13367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
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.
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Affiliation(s)
- Gin S Malhi
- Academic Department of Psychiatry, Faculty of Medicine and Health, Kolling Institute, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- CADE Clinic and Mood-T, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Maedeh Jadidi
- Academic Department of Psychiatry, Faculty of Medicine and Health, Kolling Institute, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- CADE Clinic and Mood-T, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Erica Bell
- Academic Department of Psychiatry, Faculty of Medicine and Health, Kolling Institute, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- CADE Clinic and Mood-T, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
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3
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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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4
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Mineo L, Rodolico A, Spedicato GA, Aguglia A, Bolognesi S, Concerto C, Cuomo A, Goracci A, Maina G, Fagiolini A, Amore M, Aguglia E. Exploration of mood spectrum symptoms during a major depressive episode: The impact of contrapolarity-Results from a transdiagnostic cluster analysis on an Italian sample of unipolar and bipolar patients. Eur Psychiatry 2022; 65:e30. [PMID: 35638732 PMCID: PMC9158398 DOI: 10.1192/j.eurpsy.2022.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Subthreshold hypomania during a major depressive episode challenges the bipolar-unipolar dichotomy. In our study we employed a cross-diagnostic cluster analysis - to identify distinct subgroups within a cohort of depressed patients. Methods A k-means cluster analysis— based on the domain scores of the Mood Spectrum Self-Report (MOODS-SR) questionnaire—was performed on a data set of 300 adults with either bipolar or unipolar depression. After identifying groups, between-clusters comparisons were conducted on MOODS-SR domains and factors and on a set of sociodemographic, clinical and psychometric variables. Results Three clusters were identified: one with intermediate depressive and poor manic symptomatology (Mild), one with severe depressive and poor manic symptomatology (Moderate), and a third one with severe depressive and intermediate manic symptomatology (Mixed). Across the clusters, bipolar patients were significantly less represented in the Mild one, while the DSM-5 “Mixed features” specifier did not differentiate the groups. When compared to the other patients, those of Mixed cluster exhibited a stronger association with most of the illness-severity, quality of life, and outcomes measures considered. After performing pairwise comparisons significant differences between “Mixed” and “Moderate” clusters were restricted to: current and disease-onset age, psychotic ideation, suicidal attempts, hospitalization numbers, impulsivity levels and comorbidity for Cluster B personality disorder. Conclusions In the present study, a clustering approach based on a spectrum exploration of mood symptomatology led to the identification of three transdiagnostic groups of patients. Consistent with our hypothesis, the magnitude of subthreshold (hypo)manic symptoms was related to a greater clinical severity, regardless of the main categorical diagnosis.
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Affiliation(s)
- Ludovico Mineo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Alessandro Rodolico
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Department of Neurosciences, Genoa, Italy
| | - Simone Bolognesi
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Carmen Concerto
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Alessandro Cuomo
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Arianna Goracci
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, University Hospital San Luigi Gonzaga, Turin, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Mario Amore
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Department of Neurosciences, Genoa, Italy
| | - Eugenio Aguglia
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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5
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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: 2] [Impact Index Per Article: 1.0] [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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6
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Rodríguez AM, de Mendiola Etxezarraga XP. Lithium Plus Olanzapine: One of the Most Effective Combinations for Bipolar Disorder. A Case Report and a Concise Review of the Literature. CURRENT PSYCHIATRY RESEARCH AND REVIEWS 2021. [DOI: 10.2174/2666082218666211221090624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
The recurrent nature of Bipolar Disorder (BD) is the main cause of disability associated with the illness. Despite the proliferation of drugs approved for the maintenance phase of BD, the relapse rate is still high. The combination of drugs, especially the potentiation of mood-stabilizers with second-generation antipsychotics, may reduce the risk of relapse and rehospitalization. However, studies on the efficacy of specific combinations are scarce.
Case presentation:
The clinical case of a 28-year-old woman involuntarily admitted to an Acute Psychiatric Unit is presented. She suffers a manic postpartum episode with mixed and psychotic features. During the hospitalization, she is successfully treated with a combination of lithium plus olanzapine. In the discussion, a concise narrative review of the scientific literature on the efficacy of such a combination in BD is made.
Conclusion:
The association of lithium plus olanzapine is one of the combinations with most evidence on its efficacy in BD, especially in mixed-featured episodes. Tolerability concerns should not be an obstacle to its use, although they must be considered
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Affiliation(s)
- Aitzol Miguélez Rodríguez
- Psychiatry Service. OSI Araba. Hospital Universitario Araba. Sede Santiago. Vitoria-Gasteiz, Araba, Basque , Spain
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7
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Yatham LN, Chakrabarty T, Bond DJ, Schaffer A, Beaulieu S, Parikh SV, McIntyre RS, Milev RV, Alda M, Vazquez G, Ravindran AV, Frey BN, Sharma V, Goldstein BI, Rej S, O'Donovan C, Tourjman V, Kozicky JM, Kauer-Sant'Anna M, Malhi G, Suppes T, Vieta E, Kapczinski F, Kanba S, Lam RW, Kennedy SH, Calabrese J, Berk M, Post R. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) recommendations for the management of patients with bipolar disorder with mixed presentations. Bipolar Disord 2021; 23:767-788. [PMID: 34599629 DOI: 10.1111/bdi.13135] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines provided clinicians with pragmatic treatment recommendations for bipolar disorder (BD). While these guidelines included commentary on how mixed features may direct treatment selection, specific recommendations were not provided-a critical gap which the current update aims to address. METHOD Overview of research regarding mixed presentations in BD, with treatment recommendations developed using a modified CANMAT/ISBD rating methodology. Limitations are discussed, including the dearth of high-quality data and reliance on expert opinion. RESULTS No agents met threshold for first-line treatment of DSM-5 manic or depressive episodes with mixed features. For mania + mixed features second-line treatment options include asenapine, cariprazine, divalproex, and aripiprazole. In depression + mixed features, cariprazine and lurasidone are recommended as second-line options. For DSM-IV defined mixed episodes, with a longer history of research, asenapine and aripiprazole are first-line, and olanzapine (monotherapy or combination), carbamazepine, and divalproex are second-line. Research on maintenance treatments following a DSM-5 mixed presentation is extremely limited, with third-line recommendations based on expert opinion. For maintenance treatment following a DSM-IV mixed episode, quetiapine (monotherapy or combination) is first-line, and lithium and olanzapine identified as second-line options. CONCLUSION The CANMAT and ISBD groups hope these guidelines provide valuable support for clinicians providing care to patients experiencing mixed presentations, as well as further influence investment in research to improve diagnosis and treatment of this common and complex clinical state.
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Affiliation(s)
- Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Trisha Chakrabarty
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - David J Bond
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ayal Schaffer
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Serge Beaulieu
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Sagar V Parikh
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Roumen V Milev
- Department of Psychiatry, Queens University, Kingston, Ontario, Canada
| | - Martin Alda
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gustavo Vazquez
- Department of Psychiatry, Queens University, Kingston, Ontario, Canada
| | - Arun V Ravindran
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Benicio N Frey
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Verinder Sharma
- Departments of Psychiatry and Obstetrics & Gynaecology, Western University, London, Ontario, Canada
| | | | - Soham Rej
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Claire O'Donovan
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Valerie Tourjman
- Department of Psychiatry and addiction, University of Montreal, Montreal, QC, Canada
| | | | - Marcia Kauer-Sant'Anna
- Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gin Malhi
- Department of Psychiatry, University of Sydney, Sydney, Australia
| | - Trisha Suppes
- Department of Psychiatry and Behavioural Sciences, Stanford School of Medicine and VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Eduard Vieta
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Flavio Kapczinski
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Shigenobu Kanba
- Department of Neuropsychiatry, Kyushu University, Fukuoka, Japan
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sidney H Kennedy
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Calabrese
- Department of Psychiatry, Western Reserve University, Cleveland, Ohio, USA
| | - Michael Berk
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia
| | - Robert Post
- Department of Psychiatry, George Washington University, Washington, District of Columbia, USA
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8
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Panchal P, Kim JA, Sankar A, Goldman D, Villa LM, Millard H, Carrubba E, Lecza B, Merikangas KR, Silverman WK, Swartz HA, Blumberg HP. Changing gears in the treatment of bipolar disorder through integrated use of electronic devices. Bipolar Disord 2021; 23:418-419. [PMID: 33638233 PMCID: PMC9587895 DOI: 10.1111/bdi.13065] [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] [Received: 02/17/2021] [Accepted: 02/21/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Priyanka Panchal
- Mood Disorders Research Program, Department of Psychiatry,
Yale School of Medicine, New Haven, CT, USA
| | - Jihoon A. Kim
- Mood Disorders Research Program, Department of Psychiatry,
Yale School of Medicine, New Haven, CT, USA
| | - Anjali Sankar
- Mood Disorders Research Program, Department of Psychiatry,
Yale School of Medicine, New Haven, CT, USA
| | - Danielle Goldman
- Mood Disorders Research Program, Department of Psychiatry,
Yale School of Medicine, New Haven, CT, USA,Interdepartmental Neuroscience Program, Yale School of
Medicine, New Haven, CT, USA
| | - Luca M. Villa
- Mood Disorders Research Program, Department of Psychiatry,
Yale School of Medicine, New Haven, CT, USA
| | - Hun Millard
- Mood Disorders Research Program, Department of Psychiatry,
Yale School of Medicine, New Haven, CT, USA,Child Study Center, Yale School of Medicine, New Haven, CT,
USA
| | - Erin Carrubba
- Mood Disorders Research Program, Department of Psychiatry,
Yale School of Medicine, New Haven, CT, USA
| | - Bernadette Lecza
- Mood Disorders Research Program, Department of Psychiatry,
Yale School of Medicine, New Haven, CT, USA
| | | | | | - Holly A. Swartz
- Department of Psychiatry, University of Pittsburgh,
Pittsburgh, PA, USA
| | - Hilary P. Blumberg
- Mood Disorders Research Program, Department of Psychiatry,
Yale School of Medicine, New Haven, CT, USA,Child Study Center, Yale School of Medicine, New Haven, CT,
USA,Department of Radiology and Biomedical Imaging, Yale School
of Medicine, New Haven, CT, USA
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9
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Bell E, Boyce P, Porter RJ, Bryant RA, Malhi GS. Irritability in Mood Disorders: Neurobiological Underpinnings and Implications for Pharmacological Intervention. CNS Drugs 2021; 35:619-641. [PMID: 34019255 DOI: 10.1007/s40263-021-00823-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 12/28/2022]
Abstract
Feeling irritable is a common experience, both in health and disease. In the context of psychiatric illnesses, it is a transdiagnostic phenomenon that features across all ages, and often causes significant distress and impairment. In mood disorders, irritability is near ubiquitous and plays a central role in diagnosis and yet, despite its prevalence, it remains poorly understood. A neurobiological model of irritability posits that, in children and adolescents, it is consequent upon deficits in reward and threat processing, involving regions such as the amygdala and frontal cortices. In comparison, in adults with mood disorders, the few studies that have been conducted implicate the amygdala, orbitofrontal cortices, and hypothalamus; however, the patterns of activity in these areas are at variance with the findings in youth. These age-related differences seem to extend to the neurochemistry of irritability, with links between increased monoamine transmission and irritability evident in adults, but aberrant levels of, and responses to, dopamine in youth. Presently, there are no specific treatments that have significant efficacy in reducing irritability in mood disorders. However, treatments that hold some potential and warrant further exploration include agents that act on serotonergic and dopaminergic systems, especially as irritability may serve as a prognostic indicator for overall clinical responsiveness to specific medications. Therefore, for understanding and treatment of irritability to advance meaningfully, it is imperative that an accurate definition and means of measuring irritability are developed. To achieve this, it is necessary that the subjective experience of irritability, both in health and illness, is better understood. These insights will inform an accurate, comprehensive, and valid interrogation of the qualities of irritability in health and illness, and allow not only a clinical appreciation of the phenomenon, but also a deeper understanding of its important role within the development and manifestation of mood disorders.
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Affiliation(s)
- Erica Bell
- Department of Psychiatry, Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia.
- Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.
- Department of Psychiatry, CADE Clinic, Royal North Shore Hospital, Level 3, Main Hospital Building, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.
| | - Phil Boyce
- Department of Psychiatry, Westmead Hospital and the Westmead Clinical School, Wentworthville, NSW, 2145, Australia
- Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Richard J Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Gin S Malhi
- Department of Psychiatry, Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
- Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
- Department of Psychiatry, CADE Clinic, Royal North Shore Hospital, Level 3, Main Hospital Building, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
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10
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Abstract
This perspective piece is a detailed analysis of the critique by Gordon Parker of the mood disorders clinical practice guidelines (MDcpg2020), in which he claims that bipolar II disorder has been 'banished' despite its formal status in current taxonomies. In this article, I defend the reasoning used by the Committee to adopt a dimensional model for describing and managing mood disorders, in particular bipolar disorder. I also robustly contend the many erroneous inferences made by him in his Viewpoint regarding management recommendations within the MDcpg2020 and demonstrate that there is no valid justification for subtyping bipolar disorder - especially in the manner proposed by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Thus, I argue that it was appropriate for the MDcpg2020 Committee to pursue an alternative model to the usual subtyping of bipolar disorder into 'thing one' and 'thing two' and conclude that the now clearly redundant model of Bipolar II should be altogether removed from our lexicon and clinical practice. Indeed, it is time to develop new and alternative models for defining bipolar disorder and among these a dimensional model should be given consideration.
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Affiliation(s)
- Gin S Malhi
- Academic Department of Psychiatry, Kolling Institute, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW, Australia.,CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
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11
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Diagnosing and treating major depressive episodes that lie along the mood disorders spectrum: focus on depression with mixed features. CNS Spectr 2021. [PMID: 33715657 DOI: 10.1017/s1092852921000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Growing evidence indicates that historical descriptions of mixed depression-broadly defined as major depressive episodes with subthreshold manic or hypomanic (hypo/manic) symptoms-are incredibly clinically relevant in this day-and-age. However, the first operational definition of mixed depression did not occur in the modern nomenclature until 2013 with publication of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), and there has not been enough time to evaluate these criteria empirically. Thus, the most valid operational definition of a mixed depressive episode is still unknown, widely accepted treatment guidelines are not available, and no treatment has regulatory approval for mixed depression-whether associated with bipolar I disorder, bipolar II disorder, or major depressive disorder. This is despite seven drugs having regulatory indications for mixed episodes, defined as the co-occurrence of syndromal depression and syndromal mania, and now recognized as mania with mixed features by DSM-5. Indeed, we found only two randomized, placebo-controlled trials in patients with protocol defined mixed depression, one with ziprasidone and one with lurasidone. Both studies were positive, suggesting treatment with second-generation antipsychotics may be helpful for mixed depressive episodes associated with bipolar II or unipolar disorder. We found no randomized control trial of antidepressant monotherapy in mixed depression and many clinical reports that such treatment may worsen mixed depression Randomized, placebo-controlled trials of antidepressants, antipsychotics, and mood stabilizers-alone and in combination-in individuals with carefully defined mixed depression are needed before firm treatment guidelines can be produced.
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Aguglia A, Cuomo A, Amerio A, Bolognesi S, Di Salvo G, Fusar-Poli L, Goracci A, Surace T, Serafini G, Aguglia E, Amore M, Fagiolini A, Maina G. A new approach for seasonal pattern: is it related to bipolarity dimension? Findings from an Italian multicenter study. Int J Psychiatry Clin Pract 2021; 25:73-81. [PMID: 33399494 DOI: 10.1080/13651501.2020.1862235] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aims of this study were to assess the impact of seasonal pattern on several clinical dimensions in inpatients with a current major depressive episode and to evaluate clinical differences between unipolar and bipolar depression according to seasonal pattern. METHODS Study participants were 300 patients affected by major depressive disorder (MDD) or bipolar disorder (BD) currently experiencing a major depressive episode (MDE) and were recruited at three University Medical Centres in Italy. All study subjects completed several evaluation scales for depressive and hypomanic symptoms, quality of life and functioning, impulsiveness, and seasonal pattern. RESULTS Several differences between BD with and without seasonal pattern, MDD with and without seasonal pattern but in particular between BD and MDD with seasonal pattern were found. Patients with MDE with seasonal pattern had more frequently received a longitudinal diagnosis of BD. CONCLUSIONS A large number of patients with BD and seasonal pattern, but also a considerable number of patients with MDD and seasonal pattern, endorsed manic items during a current MDE. Seasonal pattern should be associated with a concept of bipolarity in mood disorders and not only related to bipolar disorder. A correct identification of seasonal patterns may lead to the implementation of personalised pharmacological treatment approaches.KEY POINTSHigh prevalence of mixed features in mood disorders with seasonal pattern, supporting the need for a dimensional approach to major depressive disorder and bipolar disorder.Significant percentage of patients with a primary diagnosis of major depressive disorder had seasonal pattern.Significant percentage of patients with a primary diagnosis of major depressive disorder reported (hypo)manic symptomatology.
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Affiliation(s)
- Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessandro Cuomo
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Andrea Amerio
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Mood Disorders Program, Tufs Medical center, Boston, MA, USA
| | - Simone Bolognesi
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Gabriele Di Salvo
- Rita Levi Montalcini Department of Neuroscience, University of Turin, University Hospital San Luigi Gonzaga, Turin, Italy
| | - Laura Fusar-Poli
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Arianna Goracci
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Teresa Surace
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Eugenio Aguglia
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Mario Amore
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, University Hospital San Luigi Gonzaga, Turin, Italy
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13
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Malhi GS, Bell E, Bassett D, Boyce P, Bryant R, Hazell P, Hopwood M, Lyndon B, Mulder R, Porter R, Singh AB, Murray G. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry 2021; 55:7-117. [PMID: 33353391 DOI: 10.1177/0004867420979353] [Citation(s) in RCA: 236] [Impact Index Per Article: 78.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility. METHODS Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders. RESULTS The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg2020) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care. CONCLUSION The MDcpg2020 builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. MOOD DISORDERS COMMITTEE Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.
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Affiliation(s)
- Gin S Malhi
- The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Erica Bell
- The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | | | - Philip Boyce
- Department of Psychiatry, Westmead Hospital and the Westmead Clinical School, Wentworthville, NSW, Australia.,Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Philip Hazell
- Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne and Professorial Psychiatry Unit, Albert Road Clinic, Melbourne, VIC, Australia
| | - Bill Lyndon
- The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, NSW, Australia
| | - Roger Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Ajeet B Singh
- The Geelong Clinic Healthscope, IMPACT - Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Greg Murray
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, VIC, Australia
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14
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McIntyre RS, Berk M, Brietzke E, Goldstein BI, López-Jaramillo C, Kessing LV, Malhi GS, Nierenberg AA, Rosenblat JD, Majeed A, Vieta E, Vinberg M, Young AH, Mansur RB. Bipolar disorders. Lancet 2020; 396:1841-1856. [PMID: 33278937 DOI: 10.1016/s0140-6736(20)31544-0] [Citation(s) in RCA: 369] [Impact Index Per Article: 92.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 06/11/2020] [Accepted: 07/07/2020] [Indexed: 12/17/2022]
Abstract
Bipolar disorders are a complex group of severe and chronic disorders that includes bipolar I disorder, defined by the presence of a syndromal, manic episode, and bipolar II disorder, defined by the presence of a syndromal, hypomanic episode and a major depressive episode. Bipolar disorders substantially reduce psychosocial functioning and are associated with a loss of approximately 10-20 potential years of life. The mortality gap between populations with bipolar disorders and the general population is principally a result of excess deaths from cardiovascular disease and suicide. Bipolar disorder has a high heritability (approximately 70%). Bipolar disorders share genetic risk alleles with other mental and medical disorders. Bipolar I has a closer genetic association with schizophrenia relative to bipolar II, which has a closer genetic association with major depressive disorder. Although the pathogenesis of bipolar disorders is unknown, implicated processes include disturbances in neuronal-glial plasticity, monoaminergic signalling, inflammatory homoeostasis, cellular metabolic pathways, and mitochondrial function. The high prevalence of childhood maltreatment in people with bipolar disorders and the association between childhood maltreatment and a more complex presentation of bipolar disorder (eg, one including suicidality) highlight the role of adverse environmental exposures on the presentation of bipolar disorders. Although mania defines bipolar I disorder, depressive episodes and symptoms dominate the longitudinal course of, and disproportionately account for morbidity and mortality in, bipolar disorders. Lithium is the gold standard mood-stabilising agent for the treatment of people with bipolar disorders, and has antimanic, antidepressant, and anti-suicide effects. Although antipsychotics are effective in treating mania, few antipsychotics have proven to be effective in bipolar depression. Divalproex and carbamazepine are effective in the treatment of acute mania and lamotrigine is effective at treating and preventing bipolar depression. Antidepressants are widely prescribed for bipolar disorders despite a paucity of compelling evidence for their short-term or long-term efficacy. Moreover, antidepressant prescription in bipolar disorder is associated, in many cases, with mood destabilisation, especially during maintenance treatment. Unfortunately, effective pharmacological treatments for bipolar disorders are not universally available, particularly in low-income and middle-income countries. Targeting medical and psychiatric comorbidity, integrating adjunctive psychosocial treatments, and involving caregivers have been shown to improve health outcomes for people with bipolar disorders. The aim of this Seminar, which is intended mainly for primary care physicians, is to provide an overview of diagnostic, pathogenetic, and treatment considerations in bipolar disorders. Towards the foregoing aim, we review and synthesise evidence on the epidemiology, mechanisms, screening, and treatment of bipolar disorders.
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Affiliation(s)
- Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Pharmacology, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada.
| | - Michael Berk
- Institute for Mental and Physical Health and Clinical Translation Strategic Research Centre, School of Medicine, Deakin University, Melbourne, VIC, Australia; Mental Health Drug and Alcohol Services, Barwon Health, Geelong, VIC, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia; Centre for Youth Mental Health, Florey Institute for Neuroscience and Mental Health, Melbourne, VIC, Australia; Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Elisa Brietzke
- Department of Psychiatry, Adult Division, Kingston General Hospital, Kingston, ON, Canada; Department of Psychiatry, Queen's University School of Medicine, Queen's University, Kingston, ON, Canada; Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Benjamin I Goldstein
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Youth Bipolar Disorder, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Carlos López-Jaramillo
- Department of Psychiatry, Faculty of Medicine, University of Antioquia, Medellín, Colombia; Mood Disorders Program, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Lars Vedel Kessing
- Copenhagen Affective Disorders Research Centre, Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark; Department of Psychiatry, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gin S Malhi
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Academic Psychiatry, Northern Sydney Local Health District, Sydney, Australia
| | | | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amna Majeed
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Eduard Vieta
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Maj Vinberg
- Department of Psychiatry, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Psychiatric Research Unit, Psychiatric Centre North Zealand, Hillerød, Denmark
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and Maudsley National Health Service Foundation Trust, Bethlem Royal Hospital, London, UK
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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15
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Malhi GS, Bell E, Boyce P, Bassett D, Berk M, Bryant R, Gitlin M, Hamilton A, Hazell P, Hopwood M, Lyndon B, McIntyre RS, Morris G, Mulder R, Porter R, Singh AB, Yatham LN, Young A, Murray G. The 2020 Royal Australian and New Zealand College of psychiatrists clinical practice guidelines for mood disorders: Bipolar disorder summary. Bipolar Disord 2020; 22:805-821. [PMID: 33296123 DOI: 10.1111/bdi.13036] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To provide a succinct, clinically useful summary of the management of bipolar disorder, based on the 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (MDcpg2020 ). METHODS To develop the MDcpg2020 , the mood disorders committee conducted an extensive review of the available literature to develop evidence-based recommendations (EBR) based on National Health and Medical Research Council (NHMRC) guidelines. In the MDcpg2020 , these recommendations sit alongside consensus-based recommendations (CBR) that were derived from extensive deliberations of the mood disorders committee, drawing on their expertise and clinical experience. This guideline summary is an abridged version that focuses on bipolar disorder. In collaboration with international experts in the field, it synthesises the key recommendations made in relation to the diagnosis and management of bipolar disorder. RESULTS The bipolar disorder summary provides a systematic approach to diagnosis, and a logical clinical framework for management. It addresses the acute phases of bipolar disorder (mania, depression and mixed states) and its longer-term management (maintenance and prophylaxis). For each phase it begins with Actions, which include important strategies that should be implemented from the outset wherever possible. These include for example, lifestyle changes, psychoeducation and psychological interventions. In each phase, the summary advocates the use of Choice medications for pharmacotherapy, which are then used in combinations along with additional Alternatives to manage acute symptoms or maintain mood stability and provide prophylaxis. The summary also recommends the use of electroconvulsive therapy (ECT) for each of the acute phases but not for maintenance therapy. Finally, it briefly considers bipolar disorder in children and its overlap in adults with borderline personality disorder. CONCLUSIONS The bipolar disorder summary provides up to date guidance regarding the management of bipolar disorder, as set out in the MDcpg2020 . The recommendations are informed by evidence and clinical expertise and experience. The summary is intended for use by psychiatrists, psychologists and primary care physicians but will be of interest to anyone involved in the management of patients with bipolar disorder.
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Affiliation(s)
- Gin S Malhi
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Erica Bell
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Philip Boyce
- Department of Psychiatry, Westmead Hospital and the Westmead Clinical School, Wentworthville, NSW, Australia.,Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | | | - Michael Berk
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia.,Orygen, The National Centre of Excellence in Youth Mental Health, The Florey Institute and the Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Michael Gitlin
- Department of Psychiatry, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Amber Hamilton
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Philip Hazell
- Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne and Professorial Psychiatry Unit, Albert Road Clinic, Melbourne, VIC, Australia
| | - Bill Lyndon
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Grace Morris
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Roger Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Ajeet B Singh
- The Geelong Clinic Healthscope, IMPACT - Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Allan Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - Greg Murray
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, VIC, Australia
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16
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Bell E, Boyce P, Porter RJ, Bryant RA, Malhi GS. Could irritability be the key to unlocking the enigma of mixed states? Bipolar Disord 2020; 22:781-784. [PMID: 33113262 DOI: 10.1111/bdi.13029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Erica Bell
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Philip Boyce
- Department of Psychiatry, Westmead Hospital and the Westmead Clinical School, Wentworthville, NSW, Australia.,Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Richard J Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Gin S Malhi
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
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17
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McIntyre RS, Lipsitz O, Rodrigues NB, Lee Y, Cha DS, Vinberg M, Lin K, Malhi GS, Subramaniapillai M, Kratiuk K, Fagiolini A, Gill H, Nasri F, Mansur RB, Suppes T, Ho R, Rosenblat JD. The effectiveness of ketamine on anxiety, irritability, and agitation: Implications for treating mixed features in adults with major depressive or bipolar disorder. Bipolar Disord 2020; 22:831-840. [PMID: 32406161 DOI: 10.1111/bdi.12941] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine the effectiveness of intravenous (IV) ketamine on anxiety, irritability, agitation, and suicidality, in adults with treatment-resistant major depressive disorder (MDD) or bipolar disorder (BD). METHOD Adults (N = 201) with treatment-resistant MDD or BD received repeat-dose IV ketamine treatment at a community-based clinic. Mixed features were measured using symptoms of anxiety, irritability, and agitation (AIA), as measured by the Generalized Anxiety Disorder-7 (GAD-7) scale. The Quick Inventory for Depressive Symptomatology Self-Report-16 (QIDS-SR16 ) was used to measure overall treatment response, and the QIDS-SR16 suicidal ideation (SI) item was used to measure change in SI symptoms with ketamine treatment. The anxiety, irritability, and agitation items on the GAD-7 were used to assess effectiveness of IV ketamine in treating symptoms of mixed features. RESULTS In this retrospective analysis, 113 participants met AIA criteria. Participants with AIA experienced a significantly greater reduction in overall depressive symptoms (F(1, 558) = 9.49, P = .002), SI (F(1, 558) = 3.103, P = .079), anxiety (F(1, 198) = 5.52, P = .007), irritability (F(1, 198) = 28.35, P < .001), and agitation as measured by "trouble relaxing" (F(1, 198) = 6.70, P = .010) from baseline compared to the non-AIA group, regardless of number of treatments received. CONCLUSIONS Our preliminary results suggest that IV ketamine is effective in rapidly treating AIA and SI in adults with treatment-resistant mood disorders. This observation suggests that IV ketamine could be considered a treatment alternative for adults with MDD or BD presenting with mixed features.
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Affiliation(s)
- Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada.,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada.,Brain and Cognition Discovery Foundation, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Orly Lipsitz
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada.,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Nelson B Rodrigues
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada.,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Yena Lee
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada.,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Danielle S Cha
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada
| | - Maj Vinberg
- Psychiatric Research Unit, Psychiatric Centre North Zealand, Hillerød and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kangguang Lin
- Department of Affective Disorder, the Affiliated Brain Hospital of Guangzhou Medical University, (Guangzhou Huiai Hospital), Guangzhou Medical University, Guangzhou, China.,Laboratory of Emotion and Cognition, the Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou Medical University, Guangzhou, China
| | - Gin S Malhi
- Department of Psychiatry, Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Mehala Subramaniapillai
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada.,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Kevin Kratiuk
- Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Andrea Fagiolini
- Department of Molecular Medicine, School of Medicine, University of Siena, Siena, Italy
| | - Hartej Gill
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada.,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
| | - Flora Nasri
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Trisha Suppes
- VA Health Care System, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Roger Ho
- Department of Psychological Medicine, National University of Singapore, Singapore
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada.,Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada.,Brain and Cognition Discovery Foundation, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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18
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Malhi GS, Bell E, Singh AB, Bassett D, Berk M, Boyce P, Bryant R, Gitlin M, Hamilton A, Hazell P, Hopwood M, Lyndon B, McIntyre RS, Morris G, Mulder R, Porter R, Yatham LN, Young A, Murray G. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders: Major depression summary. Bipolar Disord 2020; 22:788-804. [PMID: 33320412 DOI: 10.1111/bdi.13035] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To provide a succinct, clinically useful summary of the management of major depression, based on the 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (MDcpg2020 ). METHODS To develop the MDcpg2020 , the mood disorders committee conducted an extensive review of the available literature to develop evidence-based recommendations (EBR) based on National Health and Medical Research Council (NHMRC) guidelines. In the MDcpg2020 , these recommendations sit alongside consensus-based recommendations (CBR) that were derived from extensive deliberations of the mood disorders committee, drawing on their expertise and clinical experience. This guideline summary is an abridged version that focuses on major depression. In collaboration with international experts in the field, it synthesises the key recommendations made in relation to the diagnosis and management of major depression. RESULTS The depression summary provides a systematic approach to diagnosis, and a logical clinical framework for management. The latter begins with Actions, which include important strategies that should be implemented from the outset. These include lifestyle changes, psychoeducation and psychological interventions. The summary advocates the use of antidepressants in the management of depression as Choices and nominates seven medications that can be trialled as clinically indicated before moving to Alternatives for managing depression. Subsequent strategies regarding Medication include Increasing Dose, Augmenting and Switching (MIDAS). The summary also recommends the use of electroconvulsive therapy (ECT), and discusses how to approach non-response. CONCLUSIONS The major depression summary provides up to date guidance regarding the management of major depressive disorder, as set out in the MDcpg2020 . The recommendations are informed by research evidence in conjunction with clinical expertise and experience. The summary is intended for use by psychiatrists, psychologists and primary care physicians, but will be of interest to all clinicians and carers involved in the management of patients with depressive disorders.
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Affiliation(s)
- Gin S Malhi
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Erica Bell
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Ajeet B Singh
- The Geelong Clinic Healthscope, IMPACT - Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | | | - Michael Berk
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia.,Orygen, The National Centre of Excellence in Youth Mental Health, The Florey Institute and the Department of Psychiatry, The University of Melbourne, Parkville, Vic., Australia
| | - Philip Boyce
- Department of Psychiatry, Westmead Hospital and the Westmead Clinical School, Wentworthville, NSW, Australia.,Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Michael Gitlin
- Department of Psychiatry, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Amber Hamilton
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Philip Hazell
- Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne and Professorial Psychiatry Unit, Albert Road Clinic, Melbourne, Vic., Australia
| | - Bill Lyndon
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Grace Morris
- Department of Psychiatry, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Roger Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Allan Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - Greg Murray
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, VIC, Australia
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Cuomo A, Aguglia A, Aguglia E, Bolognesi S, Goracci A, Maina G, Mineo L, Rucci P, Sillari S, Fagiolini A. Mood spectrum symptoms during a major depressive episode: Differences between 145 patients with bipolar disorder and 155 patients with major depressive disorder. Arguments for a dimensional approach. Bipolar Disord 2020; 22:385-391. [PMID: 31630470 DOI: 10.1111/bdi.12855] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several studies have challenged the traditional unipolar-bipolar dichotomy in favor of a more dimensional approach. OBJECTIVE To evaluate the differences in mood spectrum between patients with bipolar disorder (BD) and major depressive disorder (MDD) during a major depressive episode (MDE). METHOD Study participants were 145 patients with BD and 155 patients with MDD recruited at three University Medical Centers in Italy. All study subjects met Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for MDE and completed the Mood Spectrum-Self-Report-Last Month questionnaire. RESULTS Patients with BD endorsed more items in the mood manic/hypomanic and energy depressive subdomains of the MOODS-SR questionnaire. Significant differences were also found for specific depressive and manic items, which were more frequently endorsed by patients with BD. A large number of patients with BD, but also a considerable number of patients with MDD, endorsed manic items during a depressive episode. CONCLUSIONS There are differences between BD and MDD in terms of the number and type of mood spectrum items that are endorsed during a MDE, which may help to identify patients with BD when a retrospective assessment of a history of mania or hypomania is not possible or not reliable. A high number of patients with BD and a considerable number of patients with MDD endorsed several items in the manic section of the mood, energy, and cognition domains, this confirming the centrality of mixed features in patients with mood disorders and the need for a unitary, dimensional, descriptive and dynamic approach to MDD and BD, such as the recently proposed ACE (Activity, Cognition, Energy) model.
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Affiliation(s)
- Alessandro Cuomo
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics Maternal and Child Health, University of Genova, Genova, Italy
| | - Eugenio Aguglia
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Simone Bolognesi
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Arianna Goracci
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Giuseppe Maina
- Department of Mental Health, Azienda Ospedaliero-Universitaria San Luigi Gonzaga, University of Torino, Torino, Italy
| | - Ludovico Mineo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Paola Rucci
- Department of Medicine and Public Health - Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Silvia Sillari
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics Maternal and Child Health, University of Genova, Genova, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
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20
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Malhi GS, Bell E. Prepubertal bipolar disorder: a diagnostic quandary? Int J Bipolar Disord 2020; 8:20. [PMID: 32307595 PMCID: PMC7167385 DOI: 10.1186/s40345-020-00187-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/17/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Gin S Malhi
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, Australia.
- Department of Academic Psychiatry, Northern Sydney Local Health District, St Leonards, NSW, Australia.
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.
- CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Level 3, Main Hospital Building, St Leonards, NSW, 2065, Australia.
| | - Erica Bell
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Academic Psychiatry, Northern Sydney Local Health District, St Leonards, NSW, Australia
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
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21
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Abstract
The construct of mixed states is a robust clinical entity with a high variability of prevalence according to different diagnostic criteria. Despite the changes over the years, current official diagnostic criteria still have poor clinical usefulness. Premorbid characteristics with a potential high clinical importance such as temperament, personality, and emotional reactivity are understudied in patients with mixed states and excluded from the current nosologic systems. The authors provide an overview of current nosography and clinical pictures of mixed states and discuss the role of temperament, personality, and emotional reactivity in mixed states.
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Abstract
The issue of categorical vs. dimensional classification of bipolar disorder continues to generate controversy as it has for generations. Despite the evidence that no psychiatric disorder has discrete boundaries separating pathological and nonpathological states, and within a disorder, no clear differences separate subtypes-which would suggest a more dimensional approach-there are valid reasons to continue with our current categorical system, which distinguishes bipolar I from bipolar II disorder. Complicating the issue, a number of interested constituencies, including patients and their families, clinicians, scientists/researchers, and governmental agencies and insurance companies have different interests and needs in this controversy. This paper reviews both the advantages and disadvantages of continuing the bipolar I/bipolar II split vs. redefining bipolar disorder as one unified diagnosis. Even with one unified diagnosis, other aspects of psychopathology can be used to further describe and classify the disorder. These include both predominant polarity and categorizing symptoms by ACE-activity, cognition and energy. As a field, we must decide whether changing our current classification before we have a defining biology and genetic profile of bipolar disorder is worth the disruption in our current diagnostic system.
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Affiliation(s)
- Michael Gitlin
- Department of Psychiatry, Geffen School of Medicine at UCLA, Los Angeles, USA.
| | - Gin S Malhi
- CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, St Leonards, USA.,Discipline of Psychiatry, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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23
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Porcu A, Gonzalez R, McCarthy MJ. Pharmacological Manipulation of the Circadian Clock: A Possible Approach to the Management of Bipolar Disorder. CNS Drugs 2019; 33:981-999. [PMID: 31625128 DOI: 10.1007/s40263-019-00673-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bipolar disorder (BD) is a mood disorder with genetic and neurobiological underpinnings, characterized primarily by recurrent episodes of mania and depression, with notable disruptions in rhythmic behaviors such as sleep, energy, appetite and attention. The chronobiological links to BD are further supported by the effectiveness of various treatment modalities such as bright light, circadian phase advance, and mood-stabilizing drugs such as lithium that have effects on the circadian clock. Over the past 30 years, the neurobiology of the circadian clock has been exquisitely described and there now exists a detailed knowledge of key signaling pathways, neurotransmitters and signaling mechanisms that regulate various dimensions of circadian clock function. With this new wealth of information, it is becoming increasingly plausible that new drugs for BD could be made by targeting molecular elements of the circadian clock. However, circadian rhythms are multidimensional and complex, involving unique, time-dependent factors that are not typically considered in drug development. We review the organization of the circadian clock in the central nervous system and briefly summarize data implicating the circadian clock in BD. We then consider some of the unique aspects of the circadian clock as a drug target in BD, discuss key methodological considerations and evaluate some of the candidate clock pathways and systems that could serve as potential targets for novel mood stabilizers. We expect this work will serve as a roadmap to facilitate the development of compounds acting on the circadian clock for the treatment of BD.
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Affiliation(s)
- Alessandra Porcu
- Department of Psychiatry and Center for Circadian Biology, University of California San Diego, La Jolla, CA, 92093, USA
| | - Robert Gonzalez
- Department of Psychiatry, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, 17033-0850, USA
| | - Michael J McCarthy
- Department of Psychiatry and Center for Circadian Biology, University of California San Diego, La Jolla, CA, 92093, USA. .,Psychiatry Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr MC116A, San Diego, CA, 92161, USA.
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Affiliation(s)
- Gin S Malhi
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,Department of Academic Psychiatry, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Erica Bell
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,Department of Academic Psychiatry, Northern Sydney Local Health District, St Leonards, NSW, Australia.,CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
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25
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Affiliation(s)
- Gin S Malhi
- 1 Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,2 Department of Academic Psychiatry, Northern Sydney Local Health District, St Leonards, NSW, Australia.,3 CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Lauren Irwin
- 1 Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,2 Department of Academic Psychiatry, Northern Sydney Local Health District, St Leonards, NSW, Australia.,3 CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
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