The epidemiology of bipolar affective disorder

Population-based affective-disorder-related biomedical/biophysical multi-hyper-morbidity across the lifespan: A 16-year population study

BACKGROUND

There are few if any life-span population-based studies of psychiatric disorder-associated biomedical and biophysical disorders and diseases (morbidity).

AIM

To scope the present state of research regarding the biomedical and biophysical morbidity associated with affective and mental disorder in epidemiological samples, and to examine the life-span relationship between affective disorders and biomedical/biophysical disorders to illustrate a novel approach employing the odds ratio to represent the intensity of biomedical and biophysical morbidity associated in time in a population.

METHODS

A repeatable systematic literature search of PubMed was represented in summary. Additionally, a regional population-based dataset was constructed and analyzed to represent the age- and sex-specific diagnoses (International Classification of Diseases Version 9, ICD-9) for those with and without affective disorder. The analysis presents a novel index of the relative age-specific frequency of life-span biomedical and biophysical diagnoses associated with affective disorder.

RESULTS

The volume of biomedical and biophysical morbidity associated with mental disorder literature has increased, yet few studies measure comprehensive temporal hyper-morbidity (over-representation of diseases over time, either before or after the index diagnostic event) in populations. Further, there have been only a few population-based studies examining the morbidity associated with affective disorder and only one that examines the full diagnostic range of lifespan morbidity. Substantial differences arose between males and females with more females than males having greater frequencies of diagnoses. The age-specific distributions of the maximum proportional diagnosis frequency ratios for each sex illustrate the greatest diagnosis-specific differences when comparing the biomedical and biophysical diagnoses of those with and without affective disorder when the same diagnosis was represented in each grouping at the same age.

CONCLUSION

Clinical research needs to focus on more than one or two comorbid biomedical or biophysical disorders at a time. Comprehensive population-based examination of the lifespan biomedical and biophysical multi-morbidity associated with affective disorder has the potential to directly inform clinical practice. Representing the proportional ratios of age-specific frequency of diagnoses for the full range of ICD-9 diagnoses is a novel analytical model. Diagnostic frequency appears a viable representation of a given disease state, such as affective disorder. Fortunately, the WPA has developed a global education section to better understand the biomedical and biophysical morbidity associated with all psychiatric disorders. This has been identified by the WPA as the psychiatric practice challenge of the 21^st century.

Epidémiologie de la dépression : données récentes I. Epidémiologie descriptive

Les auteurs font la revue des études récentes concernant l’épidémiologie de la dépression. Les études épidémiologiques de la dépression dans la population générale sont difficiles à interpréter, du fait de différences dans l'identification des cas et de variations dans les procédures de diagnostic entre les études. Mais il y a eu un progrés considérable avec le récent développement des méthodes d’identifications de cas, fiables et valides, comme les RDC et le DSM-III. D’autres problémes méthodologiques concernent le choix de la population et le choix des différentes mesures du risque.

Des données examinées, on peut tirer les estimations suivantes : la prévalence sur six mois de la dépression majeure est de 1% à 3% chez l’homme, et 3% à 5% chez la femme; la prévalence sur la vie entiere (proportion des sujets qui ont déjà présenté le trouble) est de 3% à 6% chez l’homme et 5% à 10% chez la femme. L’estimation du risque morbide (ou risque sur la vie entiére) est plus difficile. Le principal probléme provient de l’effet de cohorte de naissance: il semble que les taux de troubles affectifs majeurs sont en train d’augmenter dans les cohortes nées apres la Seconde Guerre mondiale.

Aussi, les auteurs proposent une estimation des risques sur la vie entiére qui ne peut être que prudente: 6 à 10% chez l’homme, 12 à 20% chez la femme. Ils envisagent aussi l’épidemiologie de la dépression sous l’angle de la mortalité: les troubles affectifs sont associés non seulement à un haut risque de suicide mais aussi à une mortalité générale augmentée.

Depressive symptoms in early- and late-onset older bipolar patients compared with younger ones

OBJECTIVES

The aim of this study was to determine clinical and outcome differences between older bipolar patients with early onset (EO) and late onset (LO) of the illness and between younger and EO older patients with a bipolar disorder under long-term treatment in an outpatient clinical setting.

METHODS

Three hundred ninety-five bipolar I and II outpatients were followed up for up to 7.7 years. Of these, 213 younger (<50 years) and 88 older (>60 years) patients were included. In the older subsample, 50 EO patients (onset <50 years) versus 38 LO patients (≥50 years) were analyzed. Likewise, younger versus EO older patients were compared.

RESULTS

The likelihood of LO older patients of being bipolar II was higher than for EO older patients. They were also diagnosed earlier than EO older patients. No other clinical differences at baseline and at the prospective follow-up were found. Compared with younger patients, EO older patients had more frequent depressive symptoms at baseline, suffered more major depressive episodes in the previous year and in the prospective follow-up, received more antidepressants at baseline, had higher rates of medical comorbid conditions and were less likely to be tobacco smokers.

CONCLUSIONS

Older patients constitute a meaningful proportion of bipolar patients under treatment. EO older patients suffered significantly from more frequent depressive symptoms than younger ones. LO older patients were predominantly bipolar II. So as bipolar illness progressed, depressive symptomatology became more frequent and manic episodes were less severe. Copyright © 2016 John Wiley & Sons, Ltd.

[Crosscultural aspects of bipolar disorder: results of a comparative study between French and Tunisian patients]

BACKGROUND

Bipolar disorders are one of the most potentially severe psychiatric disorders, implying a high degree of morbidity and incapacity for patients. Indeed, the World Health Organization in 1996 ranked them as the sixth most disabling condition worldwide. Major advances have been achieved in their understanding and management. However, too many patients do not yet benefit from them. As a matter of fact, bipolar disorders are still underestimated and under-recognized, being too often misdiagnosed with major depression or schizophrenia; the DSM-IV acknowledges the trend of clinicians to overdiagnose schizophrenia (rather than bipolar disorder), especially in ethnic groups and young people. Indeed, cultural factors may impact the symptomatology and the course of the disease. In particular, it has been shown by many authors that schizophrenia-like features are more likely to be found in southern countries. Similarly, the same authors have reported more manic than depressive episodes during the course of bipolar disorder.

OBJECTIVE

We aimed at comparing individuals with bipolar disorder living in two distinct geographic and cultural environments, namely France and Tunisia.

METHOD

Our study included two samples of 40 patients each, natives from the country, who were admitted during 2007 to the hospitals of Razi (Tunis, Tunisia) and Le Vinatier (Lyon, France) and suffering from a bipolar disorder according to the DSM-IV criteria. The French sample was constituted by all the patients meeting the inclusion criteria and the Tunisian one was selected by matching the patients by gender and duration of the disorder.

RESULTS

Our results were consistent with the existing literature, showing many similarities and some marked differences such as a greater rate of manic episodes in the onset and during the course of the illness as well. The main result was the type of the first episode: mania in three quarter cases in Tunisia and depressive in the same proportion in France. The same figures applied to the recurrences. Unipolar mania, in particular, was three times more common in Tunisia than in France.

DISCUSSION

Beyond the methodological biases (in-patients recruitment, diagnosis habits, cultural tolerance), these differences are also probably linked to climatic factors, such as temperature and photoperiod.

CONCLUSION

The early detection of bipolar disorder is of crucial importance to provide specific treatments to patients. In a world where psychiatrists are more and more exposed to meet patients from various backgrounds, it is necessary to be aware of culture-bound features. Besides, the primacy of mania, in southern countries, may be a key to deepen our understanding of bipolar disorder and consequently its management.

Health-related quality of life and functioning in remitted bipolar I outpatients

The aim of this study was to characterize the health-related quality of life (HR-QOL) and functioning in 90 bipolar I remitted outpatients. According to Diagnostic and Statistical Manual of Mental Disorders IV remission specifiers, patients were categorized into 4 groups: group 1, fully remitted; group 2, less than 2 months remitted; group 3, with persisting manic symptoms; group 4, with persisting depressive symptoms. The severity of psychopathology was evaluated by using the Bech-Rafaelsen Mania-Melancholia Scale. The HR-QOL, functioning, and insight were assessed via the medical outcomes study 36-item short form, the global assessment of functioning scale, and the scale to assess unawareness of mental disorder, respectively. Fully remitted patients reported the highest scores in almost all domains of medical outcomes study 36-item short form, and had significantly higher scores on physical functioning, general health, social functioning, and mental health compared to patients with persisting depressive symptoms. Furthermore, patients with persisting manic symptoms reported significantly higher scores on general health, vitality and mental health than the group with persisting depressive symptoms. In contrast, the global assessment of functioning scale score differed among the 4 groups, with fully remitted patients reporting higher, although not statistically significant, scores than the other groups. Our data suggest that the persistence of depressive or manic symptoms seem to affect self-report measures of HR-QOL. An affectively biased cognition may explain the gap between patient's perception of functioning and estimated functional adjustment, as assessed by clinicians.

Quality of life and its correlates in patients with bipolar disorder stabilized on lithium prophylaxis

The quality of life (QOL) of 50 bipolar disorder patients in remission (stabilized on lithium prophylaxis) was assessed and compared with that of clinically stable patients with schizophrenia (n = 20) and healthy subjects (n = 20). World Health Organization Quality of Life-Bref (WHOQOL-BREF) and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) were used to assess QOL in the three groups of subjects. The factors that contribute or influence QOL (i.e. stressful life events, social support, daily hassles) were also studied using standardized instruments in the study group. It was found that, compared to schizophrenia group, the bipolar group had significantly better QOL in all the domains of Q-LES-Q and the domains of general well-being, physical health and psychological health of the WHOQOL-Bref. The bipolar group had similar QOL scores in all other domains and higher scores in leisure time activity domain of Q-LES-Q, in comparison to the healthy group. The QOL in the bipolar group was better in patients who were younger and had a lesser severity of daily hassle. The present findings suggest that euthymic patients with bipolar disorder have a QOL that is comparable to that of healthy subjects. In contrast, patients with clinically stable schizophrenia have a poorer QOL. Occurrence of daily hassles contributes significantly to QOL in patients with bipolar disorder. However, the relatively limited variance explained by the independent variables included in the study, suggests the need to examine other (perhaps non-clinical) factors that may affect QOL.

Rates and predictors of developing a manic or hypomanic episode 1 to 2 years following a first hospitalization for major depression with psychotic features

INTRODUCTION

Although the presence of psychosis during major depression has been identified as a predictor of later developing mania or hypomania, to our knowledge there have been no studies examining rates and predictors of developing a manic or hypomanic episode in patients who were admitted for their first psychiatric hospitalization for major depressive disorder with psychosis (MDDP).

METHODS

Patients admitted for their first psychiatric hospitalization, with a Diagnostic and Statistical Manual of Mental Disorders (fourth edition) diagnosis of MDDP, were recruited from three sites (N = 157) and evaluated prospectively for up to 2 years to identify new symptoms of mania or hypomania. Family history was assessed using the Family History-Research Diagnostic Criteria Interview. Clinical and demographic factors associated with developing a manic or hypomanic episode were identified using stepwise logistic regression.

RESULTS

Thirteen percent (n = 21) of patients with MDDP developed mania or hypomania within the follow-up period. Family history of affective disorders and age at onset of MDDP were not predictive of switch. MDDP patients who were treated with antidepressants were four times less likely to develop mania or hypomania than those who were not treated with antidepressants, after controlling for site differences.

CONCLUSIONS

Our findings suggest that within the first 1 to 2 years following first hospitalization for MDDP, a subset of patients will develop mania or hypomania. Additionally, our data suggest that antidepressant exposure does not increase the risk of, and may be protective against, developing a manic or hypomanic episode in patients hospitalized for MDDP.

Biological risk factors in late life depression

A number of biological risk factors have been tentatively identified for unipolar and bipolar disorder in the elderly. The list includes genetic factors as well as medical illness in general and vascular disease in particular. Most of these risk factors have been identified on the basis of cross sectional studies rather than longitudinal studies. There is a need for long term epidemiologic and prevention studies (in the case of modifiable risk factors). The modifiable risk factors include medical illness in general and vascular disease in particular. An example is the use of antidepressants following stroke to prevent the onset of depression. Of particular interest is the role of vascular risk factors and MRI changes suggesting subtle cerebrovascular disease in the development of depression and bipolar disorder in late life. The changes have been established using both clinical samples and in the case of depression in cross sectional epidemiologic samples. The location of these cerebrovascular changes has contributed to our understanding of the regions of the brain implicated in the pathophysiology of depression. Further longitudinal and preventive studies are needed to conclusively demonstrate these as biological risk factors.

Time-related cognitive deficiency in four different types of depression

Mild cognitive impairment often occurs in depressive illness. But it is unknown whether the occurrence or severity of cognitive deficits has diagnostic specificity. It is of interest to investigate whether there are time-related differences in cognitive functions characteristic of different kinds of depressive diagnoses, and therefore whether such differences might help to distinguish between types of depressive disorder. Eighty inpatients with a DSM-IV depressive episode (unipolar, bipolar, dysthymic and schizoaffective disorder, depressive type) were assessed with a series of neuropsychological tests at the beginning and at the end of their hospital stays. A group of 62 matched healthy controls were assessed with the same series of tests at comparable intervals. The diagnostic sub-groups could not be distinguished by cognitive parameters in the time-course. At the time of admission the inpatient group had a worse performance than the control group. After a significant decrease of their mean depression score, the patients still continued to show an outcome worse than the controls. We conclude that the variation of cognitive dysfunction with time in depression seems to be a phenomenon which does not depend on the kind of depressive sub-diagnosis. The results indicate that cognitive deficits might persist longer than the period of illness, but this seems to be true for all depressive sub-diagnoses.

Impact of comorbid affective and alcohol use disorders on suicidal ideation and attempts

The effect of concurrent affective and alcohol use disorders on suicidal ideation and behavior was investigated. The Diagnostic Interview Schedule Version III-R (DIS) was administered to 307 adult veteran men ranging in age from 23 to 78. Participants were classified into one of four groups based on their final DIS diagnosis-lifetime unipolar depression and lifetime bipolar I disorder with or without a lifetime alcohol use disorder. Logistic regression analyses indicated that veterans with a major affective disorder were at greater risk for suicidality than veterans without an affective disorder. However, veterans with unipolar depression were at no greater risk for suicidality than those with bipolar I disorder. Unipolar and bipolar I disorders with a concurrent alcohol use disorder were always associated with an increased risk for suicidality.

Bipolar disorder in late life: a review

Although there is a broad base of literature on depression among elderly patients and on mania in younger patients, there is a relative paucity of information on bipolar disorder in the elderly population. While the quantities of data reflect the relative prevalences of these illnesses, there is evidence to suggest that classification of mania in the elderly with respect to age of onset, natural course, family history, and pathophysiology may be useful in understanding the heterogeneous etiologies of this syndrome. This paper presents a review of the literature on the incidence and course of illness in late-life bipolar disorder. Further, dilemmas of diagnostic classification in relation to associated risk factors will be discussed.

Divalproate augmentation in lithium-resistant rapid cycling mania in four geriatric patients

This report describes four geriatric patients, with rapid cycling bipolar disorder, who were treated successfully with divalproex sodium in combination with lithium carbonate, noting that both drugs were necessary for clinical remission of symptoms. Divalproex sodium may actually enhance the sensitivity to lithium carbonate in this population, potentially leading to treatment with lower lithium concentrations. This strategy has an advantage in enabling a greater safety range in the use of lithium carbonate in elderly patients. This report further raises questions as to the nature of rapid cycling illness in the "old-old" population.

Bipolar mood disorders in the elderly

Age effects on early-onset bipolar illness may include changes in affective features and recovery. Age effects on the pharmacokinetics of lithium are clinically relevant. Average age at onset is relatively late among geriatric bipolars. Late-onset bipolar disorder is associated with lower rate of familial illness than early-onset cases and greater medical and neurologic comorbidity. The limited literature available points to the need for further studies of geriatric bipolar disorder. In such investigation, the distinction between age and age at onset effects provides a framework within which to enhance knowledge of psychopathology, to expand understanding of natural history and the impact of therapeutic interventions, and to study mechanisms.

Seasonal variation in bipolar disorder

BACKGROUND

In patients with bipolar disorder, admissions for manic and depressive episodes frequently display a seasonal pattern. We examined this variation and compared the patterns with the seasonal admission rates for schizophrenia.

METHOD

Patients with bipolar disorder or schizophrenia were identified from the Finnish Hospital Discharge Register of in-patient admissions to all psychiatric hospitals during the years 1969-91. They were included in the analysis if the first admission had occurred before 30 years of age. A total of 295 bipolar patients were found, and a sample of 295 schizophrenic patients was randomly selected for comparison.

RESULTS

There was no seasonal variation among all hospital admissions for bipolar disorder or schizophrenia. However, the first admission for a depressive compared with a manic episode of bipolar disorder occurred significantly more often in the autumn (33% v. 21% respectively). The peak difference occurred during the week after the autumnal equinox in September.

CONCLUSION

Our findings suggest that there is no seasonal variation in bipolar disorder, although in some patients the clinical course might be influenced by the autumn, as far as the likelihood of a first admission for depression is concerned.

Comparative efficacy of lithium and amitriptyline in the maintenance treatment of recurrent unipolar depression: a randomised study

The present study, including 81 depressive patients, compares the prophylactic efficacy of lithium and amitriptyline in recurrent unipolar depression over a treatment period of 2.5 years in a randomised multicentre design. Hospitalisation, re-emergence of depressive or subdepressive recurrences, unwanted side-effects and need of concomitant psychotropic medication were considered to indicate treatment failures. Average dosage for amitriptyline was 98 +/- 37 mg/day, average lithium blood level was 0.59 +/- 0.12 mmol/l. Survival analyses demonstrated a significant superiority of lithium (P = 0.015) regarding the outcome criteria 'recurrences and/or subclinical recurrences' and non-significantly better results of lithium compared to amitriptyline concerning 'recurrence' (P = 0.059) or 'recurrence and/or concomitant medication' (P = 0.066).

Treatment-resistant depression in children and adolescents

Treatment resistance in depressed children and adolescents cannot yet be defined fully because of the paucity of controlled studies that demonstrate efficacy. Therefore, this article addresses several of the age-specific, developmental considerations that may impinge upon treatment response. Areas covered include familial-genetic, psychosocial, and neuroimaging studies in addition to a review of controlled studies to date.

Premorbid abnormalities in mania, schizomania, acute schizophrenia and chronic schizophrenia

The aim of this study was to examine the hypothesis that differences in outcome among affective and non-affective psychoses are associated with differences in the degree of developmental deviance. We conducted a retrospective survey of first contact cases treated over a 20-year period in a psychiatric hospital serving a catchment area in South London. All patients with non-depressive functional psychosis residing in the catchment area who received their first psychiatric treatment between 1965 and 1984 were included in the study. Cases were classified according to the relative chronicity of their illness into four non-overlapping groups: mania, schizomania, acute schizophrenia and chronic schizophrenia. There was a linear trend in the association between illness chronicity and proxy measures of development deviance, such as premorbid unemployment, single status and poor academic achievement. Compared to individuals with mania, schizophrenic patients had a 3-6 times increased risk of premorbid abnormality. For patients with schizomania and acute schizophrenia, the risk was 1.5-3 times greater than for manic subjects. We conclude that the prevalence of premorbid abnormalities is highest among chronic schizophrenia, but similar disturbances also occur, to a lesser degree, in less disabling affective and non-affective psychotic disorders.

Unipolar depression in adolescents: clinical outcome in adulthood

OBJECTIVE

This study examined the longitudinal clinical course and adult sequelae of adolescent unipolar major depressive disorder (MDD) using a controlled longitudinal design.

METHOD

Subjects were 28 adolescents (15.4 +/- 1.3 years) with systematically diagnosed unipolar MDD and 35 group-matched control subjects who participated in a cross-sectional electroencephalogram sleep and neuroendocrine study. Using standardized instruments, interviewers who were blind to subjects' initial diagnoses conducted follow-up clinical assessments 7.0 +/- 0.5 years later in 94% of the original cohort.

RESULTS

The depressed group showed high rates of recurrence of MDD episodes during the interval period (69%). They also had elevated rates of new-onset bipolar disorder (19%). Twenty-three percent of subjects with an initial diagnosis of MDD had no additional depressive episodes after the index assessment. The rate of new onset of depression in the controls was 21%. Low socioeconomic status predicted recurrence of depressive episodes in the MDD group. MDD subjects with recurrence(s) and controls with new onset of depression during the follow-up period had significant psychosocial morbidity, as evidenced by disruption in interpersonal relationships and dissatisfaction with life and decrease in global functioning, compared with both MDD subjects with no further episodes and control subjects who had never been psychiatrically ill. These psychosocial deficits persisted remission from depressive episode(s).

CONCLUSIONS

Adolescent unipolar MDD predicts continued risk for recurrences with persistence of depressive episodes and psychosocial morbidity into adulthood. A sizable minority, however, have sustained periods of remission associated with good social adjustment.

Primary structure of the serotonin transporter in unipolar depression and bipolar disorder

Genetic factors have been implicated in the etiology of affective disorders but due to the complex inheritance patterns of these disorders, identification of the responsible gene(s) has so far been unsuccessful. Decreased platelet serotonin (5-HT) transport and reduced binding of imipramine or paroxetine to brain and platelet 5-HT uptake sites/transporters in patients with depression and suicide victims define the 5-HT transporter (5-HTT) as a candidate gene. The primary structure of the 5-HTT was analyzed in 17 patients meeting DSM-III-R diagnostic criteria for major depressive or bipolar disorder and in 4 healthy controls using polymerase chain reaction (PCR-) amplification and sequencing of complementary deoxyribose nucleic acid (cDNA) synthesized from platelet 5-HTT messenger ribose nucleic acid (mRNA). Direct PCR sequencing of the protein coding region failed to reveal changes in the deduced amino acid sequence of the platelet/brain 5-HTT (40,000 base pairs sequence screened), although a conservative single-base substitution representing a silent polymorphism was found. The results provide preliminary evidence that alterations in the primary structure of 5-HTT are not generally involved in the pathogenesis of unipolar depression and manic-depressive illness.

Rate and predictors of prepubertal bipolarity during follow-up of 6- to 12-year-old depressed children

OBJECTIVE

To investigate the rate and predictors of onset of DSM-III bipolar I and bipolar II disorders among 6- to 12-year-old prepubertal subjects with DSM-III major depressive disorder (MDD) who were followed for a 2- to 5-year period.

METHODS

This was a prospective, blindly rated study of 79 children with MDD and 31 normal control children matched for age, gender, and socioeconomic status. Subjects and a second informant were assessed at 4-month intervals using the Kiddie Schedule for Affective Disorders and Schizophrenia-Present Episode Version-1986 modified to include 4-month interval ratings and to include DSM-III diagnoses. Family history (FH) was assessed using the FH-Research Diagnostic Criteria obtained from the mother about the subject's first- and second-degree relatives.

RESULTS

Bipolarity developed in 31.7% (N = 25) of the children with MDD at a mean age of 11.2 +/- 2.0 years and 80% were prepubertal. Loaded FH and multigenerational FH were significantly associated with bipolar I. Neither prior nor current use of tricyclic antidepressants nor atypical depressive features were predictive.

CONCLUSIONS

These findings strongly support the need to educate families of children with prepubertal-onset MDD about the possibility of the emergence of manic and hypomanic symptoms to encourage early recognition and appropriate treatment.

Self-esteem in recovered bipolar and unipolar out-patients

The hypothesis of a low self-esteem in depressive patients was tested using the Rosenberg Self-Esteem Scale in 24 recovered unipolar and 27 recovered bipolar patients, compared with a normal control group of 26 subjects matched for age and sex. The hypothesis was confirmed only for unipolars; bipolar patients presented a self-esteem score not significantly different from normal scores. Self-esteem was not related to clinical characteristics of the affective disorder, suggesting that low self-esteem may be a basic component of a depression-prone personality. The investigation of the relationship between self-esteem and social adjustment confirmed the presence of social conformism in bipolar patients and rigidly set low self-esteem in unipolar patients. These results should stimulate the evaluation of different psychotherapeutic treatments in the long-term psychosocial management of affectively ill patients.

A retrospective case-note study of bipolar disorder in old age

In a replication of an earlier published study, case notes of 75 elderly in-patients with bipolar affective disorder were examined. Few of the patients had experienced a manic episode before the age of 40. Mean age of onset of affective disorder was 46 years, and first manic episode at 60 years. Cerebral insults before the first manic attacks were recorded in a substantial number of cases, and a family history of mental illness was less common among this group. Bipolar affective disorder is relatively common as a reason for admission of elderly patients.

Rapid cycling mood disorder in the elderly

Rapid cycling mood disorder is an unusual and difficult syndrome to recognize in the elderly. A case of this disorder is presented in a patient with subtle central nervous system dysfunction who was treated for depression with tricyclic antidepressants. CNS dysfunction and antidepressants have both been identified as risk factors for rapid cycling. Successful treatment with carbamazepine lends credence to the concept of limbic system dysregulation being an underlying, important factor in cyclical affective disorder.

The Zurich study. III. Diagnosis of depression

A 23- to 24-year-old age group representative of the general population of the Canton of Zurich, was used to detect depression. The classifications obtained by means of the Feighner, RDC and DSM-III criteria are compared with our own concept, which differs in some aspects. A minimum of 2 weeks of depression is labeled as EDE (extensive depressive episode). Instead of the presence of a minimum number of depressive symptoms, social impairment at work is first examined as a case-defining criterion (EDE[WORK]); in a second step, a diagnostic threshold of three, and five, depressive symptoms for males and females respectively is adopted (EDE[SYM]). The consequences are presented relating to prevalence, incidence, sex distribution, overlap with other diagnostic concepts, severity, bipolarity and family history. An unequal sex distribution in depression is shown to be an artifact of definition. Preference should go to a case-definition that could be specifically adapted to a given problem. On the whole, the DSM-III and EDE(WORK) criteria appear to be too broad. We will henceforth prefer the RDC and EDE(SYM) criteria, which both, however, necessitate further methodological and empirical study.

Bipolar outcome in the course of depressive illness. Phenomenologic, familial, and pharmacologic predictors

Twenty percent of a cohort of 206 outpatient depressives with no past bipolar history switched during prospective observation. These 41 probands developed manic periods on the average of 6.4 years (median 4, range 1-25) after their first depressive episode. The change in polarity occurred throughout the life span, but was most common in adolescence and early adulthood. The following variables were found useful in predicting this outcome: onset less than or equal to 25 years, bipolar family history, loaded pedigrees, precipitation by childbirth, hypersomnic-retarded phenomenology, and pharmacologically-mobilized hypomania. Although the respective sensitivities of these findings were relatively low (32-71%), their specificities ranged from 69% to 100% for bipolar outcome; the diagnostic specificity of any 3 of these variables when combined was 98%. When compared with nonbipolar depression, bipolar disorder was seldom chronologically secondary to nonaffective psychiatric disorders. These findings suggest that many young depressives with lethargy and oversleeping are not manifesting a "neurotic" disorder, but rather a precursor of primary bipolar affective disorder. Finally, a psychotically depressed adolescent or young adult with positive bipolar family history should be observed for eventual bipolar outcome, especially when the clinical presentation is that of stupor.

MMPI state dependency during the course of bipolar psychosis

Minnesota Multiphasic Personality Inventory (MMPI) profiles completed during unambiguous manic, depressed, and euthymic periods were compared in a sample of 22 bipolar (manic-depressive) patients, 13 females and 9 males, drawn from an outpatient psychiatry clinic; each patient was "multiplex-selected" in that each had a first-degree relative with a severe psychiatric disorder. Both the manic and depressed phase MMPIs revealed significant and prototypical signs of psychopathology corresponding with the clinical picture. In contrast, the mean remission profile was entirely within normal limits. At least in some individuals, bipolar disorder seems to be associated with complete restitution of normality.