Reliability and relationship of various ages of onset criteria for major affective disorder

Managing Mandibular Osteoradionecrosis

OBJECTIVE

Mandibular osteoradionecrosis (MORN) is a morbid complication of head and neck radiation therapy. Recent advances in surgical and medical therapies underscore the need for a shift in traditional treatment paradigms and a disease grading system that can guide appropriate management.

DATA SOURCES

Pubmed/MEDLINE.

REVIEW METHODS

We conducted a detailed review of publications related to MORN, specifically focusing on its staging and management techniques. Articles meeting inclusion criteria were synthesized into a final narrative review.

CONCLUSION

There has been a paradigm shift away from hyperbaric oxygen therapy in the management of MORN. Growing evidence for the efficacy of pentoxifylline and tocopherol in early-stage disease and novel surgical techniques to manage moderate and late-stage disease warrant an updated staging stratification which is proposed.

IMPLICATIONS FOR PRACTICE

This review summarizes the clinical efficacy of established and novel therapeutic modalities currently available in treating MORN, emphasizing the significant advances achieved over the last decade. It introduces a contemporary staging and treatment algorithm which incorporates traditional, evidence-supported surgical and medical management with effective early intervention strategies.

Using density of antecedent events and trajectory path analysis to investigate family-correlated patterns of onset of bipolar I disorder: a comparison of cohorts from Europe and USA

BACKGROUND

Major contributors to the global burden of bipolar disorders (BD) are the early age at onset (AAO) and the co-occurrence of non-mood disorders before and after the onset of BD. Using data from two independent cohorts from Europe and the USA, we investigated whether the trajectories of BD-I onset and patterns of psychiatric comorbidities differed in (a) individuals with or without a family history (FH) of BD, or (b) probands and parents who both had BD-I.

METHODS

First, we estimated cumulative probabilities and AAO of comorbid mental disorders in familial and non-familial cases of BD-I (Europe, n = 573), and sex-matched proband-parent pairs of BD-I cases (USA, n = 194). Then we used time to onset analyses to compare overall AAO of BD-I and AAO according to onset polarity. Next, we examined associations between AAO and polarity of onset of BD-I according to individual experiences of comorbidities. This included analysis of the density of antecedent events (defined as the number of antecedent comorbidities per year of exposure to mental illness per individual) and time trend analysis of trajectory paths plotted for the subgroups included in each cohort (using R² goodness of fit analysis).

RESULTS

Earlier AAO of BD-I was found in FH versus non-FH cases (log rank test = 7.63; p = 0.006) and in probands versus parents with BD-I (log rank test = 15.31; p = 0.001). In the European cohort, AAO of BD-I was significantly associated with factors such as: FH of BD (hazard ratio [HR]: 0.60), earlier AAO of first non-mood disorder (HR: 0.93) and greater number of comorbidities (HR: 0.74). In the USA cohort, probands with BD-I had an earlier AAO for depressive and manic episodes and AAO was also associated with e.g., number of comorbidities (HR: 0.65) and year of birth (HR: 2.44). Trajectory path analysis indicated significant differences in density of antecedents between subgroups within each cohort. However, the time trend R² analysis was significantly different for the European cohort only.

CONCLUSIONS

Estimating density of antecedent events and comparing trajectory plots for different BD subgroups are informative adjuncts to established statistical approaches and may offer additional insights that enhance understanding of the evolution of BD-I.

Genome-wide association study of early-onset bipolar I disorder in the Han Taiwanese population

The search for susceptibility genes underlying the heterogeneous bipolar disorder has been inconclusive, often with irreproducible results. There is a hope that narrowing the phenotypes will increase the power of genetic analysis. Early-onset bipolar disorder is thought to be a genetically homogeneous subtype with greater symptom severity. We conducted a genome-wide association study (GWAS) for this subtype in bipolar I (BPI) disorder. Study participants included 1779 patients of Han Chinese descent with BPI disorder recruited by the Taiwan Bipolar Consortium. We conducted phenotype assessment using the Chinese version of the Schedules for Clinical Assessment in Neuropsychiatry and prepared a life chart with graphic depiction of lifetime clinical course for each of the BPI patient recruited. The assessment of onset age was based on this life chart with early onset defined as ≤20 years of age. We performed GWAS in a discovery group of 516 early-onset and 790 non-early-onset BPI patients, followed by a replication study in an independent group of 153 early-onset and 320 non-early-onset BPI patients and a meta-analysis with these two groups. The SNP rs11127876, located in the intron of CADM2, showed association with early-onset BPI in the discovery cohort (P = 7.04 × 10^-8) and in the test of replication (P = 0.0354). After meta-analysis, this SNP was demonstrated to be a new genetic locus in CADM2 gene associated with early-onset BPI disorder (P = 5.19 × 10^-8).

Role of age at onset in the clinical presentation of bipolar disorder in Indian population

OBJECTIVE

The objective of this study was to determine any association of age at onset (AAO) with clinical presentation of bipolar disorder (BD) and family history of illness.

MATERIALS AND METHODS

A hospital-based cross-sectional observational study was conducted including 162 patients having a diagnosis of BD current episode manic. Individuals were divided into three subgroups according to AAO, i.e., early-onset BD (EOBD) (AAO ≤21 years), intermediate-onset BD (AAO - 22-34 years), and late-onset BD (AAO ≥35 years). The subgroups were compared on clinical variables; items of the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAM-D), and Scale for the Assessment of Positive Symptoms (SAPS); and family history of illness.

RESULTS

The early-onset group had significantly more episodes per year than the other groups (P < 0.001). The prevalence of family history of mood disorder was also significantly higher in the early-onset group than the other subgroups. AAO was found to be significantly associated with different items of YMRS, HAM-D, and SAPS. The early-onset group had higher rating on irritability, motor activity-energy, sexual interest, depressed mood, delusions, and thought disorders, whereas the late-onset group had higher rating on elevated mood.

CONCLUSION

EOBD can be considered as a specific phenotype of BD, which is more homogenous, severe, and inheritable form of illness.

Psychiatric and psychological features of children at high-risk for bipolar disorder

BACKGROUND

Psychological/psychiatric features of high risk children (HR) for bipolar disorder are majorly overlooked. We aimed to compare psychological profiles (eg. anger level/ management, attachment/stress-coping mechanisms and emotional regulation difficulties) of HR with healthy controls.

METHOD

Total of 60 children in HR and 55 children in control group were evaluated using Trait Anger Scale (TAS), Anger Expression Scale (AES), Inventory of Parent/Peer Attachment (IPPA), Coping Style Scale (CSS) and Difficulties in Emotion Regulation Scale (DERS).

RESULTS

AXE/In and AXE/Con subscales of AES, "trust" and "communication" facets of IPPA-Peer and "communication" facet of IPPA-Parent were significantly lower in HR. They scored higher in "helpless" and lower in "submissive" and "optimistic" subscales of CSS. HR scored higher only in "lack of emotional awareness" facet of DERS.

LIMITATIONS

Self-reported scales which we used, may be susceptible to subjective personal characteristics. Also cross-sectional design of our study may have captured only a fraction of rapidly changing developmental processes.

CONCLUSIONS

Lower AXE/In and AXE/Con scores of HR are similar to Type-A Behavior Pattern which is includes agressiveness and impulsiveness. Higher "helpless", and lower "submissive" and "optimistic" scores may reflect emotionally disregulated coping mechanisms which may lead to the risk of developing future depressive episodes. Lower "communication" in IPPA may show a disturbance in executive function of language. Lack of emotional awareness can be examined in line with alexithymia; but further studies are needed to explain these aspects.

Characteristics of bipolar I and II disorder: A study of 8766 individuals

OBJECTIVES

Large-scale studies on phenotypic differences between bipolar disorder type I (BDI) and type II (BDII) are scarce.

METHODS

Individuals with BDI (N = 4806) and BDII (N = 3960) were compared with respect to clinical features, illness course, comorbid conditions, suicidality, and socioeconomic factors using data from the Swedish national quality assurance register for bipolar disorders (BipoläR).

RESULTS

BDII had higher rate of depressive episodes and more frequent suicide attempts than BDI. Furthermore, the BDII group were younger at first sign of mental illness and showed higher prevalence of psychiatric comorbidity but were more likely to have completed higher education and to be self-sustaining than the BDI group. BDII more frequently received psychotherapy, antidepressants, and lamotrigine. BDI patients had higher rate of hospitalizations and elated episodes, higher BMI, and higher rate of endocrine, nutritional, and metabolic diseases. BDI were more likely to receive mood stabilizers, antipsychotic drugs, electroconvulsive therapy, and psychoeducation.

CONCLUSIONS

These results demonstrate clear differences between BDI and II and counter the notion that BDII is a milder form of BDI, but rather a more complex condition with regard to clinical course and comorbidity.

Epidémiologie de la dépression: données récentes. II — Epidémiologie analytique et épidémiologie d’évaluation

Les données provenant d’études récentes concernant l’épidémiologie analytique et l’épidémiologie d’évauation de la dépression sont examinées.

Au sujet de l’épidémiologie analytique, il peut être conclu de la littérature actuellement disponible que les principaux facteurs de risques pour la dépression majeure sont : a) Sociodémographiques, à savoir : être une femme, être jeune, séparé, divorcé, ou avoir des problèmes conjugaux (les auteurs soulignent en particulier que les différences entre les sexes, concernant la dépression, sont réelles et ne sont pas un artefact lié à la façon de relater les troubles ou au comportement vis-à-vis des soins), b) Environnementaux: facteurs prédisposants (les événements de vie qui surviennent durant l'enfance peuvent prédisposer un individu à la dépression à l’âge adulte) et facteurs précipitants (il y a relation entre la survenue d’événements de vie pendant la vie adulte et le début de la dépression), c) Familiaux: il y a une multiblication par 2 à 5 du taux de dépression majeure chez les parents de premier degré de sujets témoins par rapport à es témoins non malades. L’influence de l’hérédité génétique est supportée par des études de jumeaux et des études adoption, mais une large part de la variance ne peut être expliquée, d) Divers: qui concernent le cycle de reproduc- 10n de la femme (la période du post partum entraîne une augmentation du taux de dépression) et les variations saisonneres (pics au printemps et en automne).

En ce qui concerne l'épidémiologie d’évaluation, il est habituel de distinguer prévention primaire, secondaire et teriaie. Leur dessein est respectivement de diminuer l’incidence de la dépression, la prévalence de la dépression et les isques de chronicité et de la récurrence. Les efforts concernant la prévention primaire ne peuvent avoir qu’un effet imité. Dans le domaine de la prévention secondaire, il peut être conclu que beaucoup de dépressifs ne sont pas diaglostiqués ou ne sont pas traités. La prévention tertiaire a pour dessein de limiter deux risques: la chronicité et la récurence. Le premier pourrait être évalué à 15-20% à chaque épisode. Les facteurs de risques principaux seraient la présence un trouble psychiatrique non affectif ou d’une affection physique, une personnalité névrotique et un faible niveau le traitement. Pour le risque de récurrence, on peut considérer qu’entre 50 et 85% des patients ayant fait un épisode lépressif majeur feront au moins un autre épisode de dépression ultérieurement. Les facteurs de risques pourraient re un Stand nombre d’épisodes antérieurs, un antécédent d’épisode maniaque ou d’hypomanie, l’association à un ésordre psychiatrique non affectif ou à une affection physique, une histoire familiale de maladie affective ou un âge e début tardif.

Psychiatric comorbidities in bipolar disorders: An examination of the prevalence and chronology of onset according to sex and bipolar subtype

OBJECTIVES

Bipolar Disorder (BD) is frequently comorbid with other psychiatric disorders. However, few studies systematically examine which disorders are more likely to occur pre- or post-BD onset. We examine the prevalence and Age At Onset (AAO) of psychiatric conditions in adults with BD.

METHODS

A structured clinical interview was used to assess lifetime history and AAO of alcohol and cannabis misuse, suicide attempts, anxiety and eating disorders in a French sample of euthymic patients with BD (n = 739). Regression analyses were used to test for statistically significant associations between rates and AAO of comorbidities in BD groups stratified by sex or subtype.

RESULTS

Prevalence of alcohol and cannabis misuse was associated with male sex and BD-I subtype; whilst most anxiety and eating disorders were associated with female sex. The AAO of most comorbid conditions preceded that of BD, except for panic disorder, agoraphobia and alcohol misuse. Few variations were observed in AAO of comorbidities according to groups.

LIMITATIONS

All assessments were retrospective, so estimates of prevalence rates and especially exact AAO of some comorbidities are at risk of recall bias.

CONCLUSIONS

Sex and BD subtype are associated with different rates of comorbid disorders. However, there were minimal between group differences in median AAO of comorbidities. By describing the chronological sequence of comorbidities in BD we were able to demonstrate that a minority of comorbidities typically occurred post-onset of BD. This is noteworthy as these disorders might be amenable to interventions aimed at early secondary prevention.

Detection Study of Bipolar Depression Through the Application of a Model-Based Algorithm in Terms of Clinical Feature and Peripheral Biomarkers

Objectives: The nature of the diagnostic classification of mood disorder is a typical dichotomous data problem and the method of combining different dimensions of evidences to make judgments might be more statistically reliable. In this paper, we aimed to explore whether peripheral neurotrophic factors could be helpful for early detection of bipolar depression. Methods: A screening method combining peripheral biomarkers and clinical characteristics was applied in 30 patients with major depressive disorder (MDD) and 23 patients with depressive episode of bipolar disorder. By a model-based algorithm, some information was extracted from the dataset and used as a "model" to approach penalized regression model for stably differential diagnosis for bipolar depression. Results: A simple and efficient model of approaching the diagnosis of individuals with depressive symptoms was established with a fitting degree (90.58%) and an acceptable cross-validation error rate. Neurotrophic factors of our interest were successfully screened out from the feature selection and optimized model performance as reliable predictive variables. Conclusion: It seems to be feasible to combine different types of clinical characteristics with biomarkers in order to detect bipolarity of all depressive episodes. Neurotrophic factors of our interest presented its stable discriminant potentiality in unipolar and bipolar depression, deserving validation analysis in larger samples.

Secular trends in the age at onset of bipolar I disorder - Support for birth cohort effects from interational, multi-centre clinical observational studies

OBJECTIVE

To examine any association of birth decade, sex and exposure to alcohol and/or substance use disorders (ASUD) with age at onset (AAO) of bipolar I disorder (BD-I).

METHODS

Using data from a representative clinical sample of 3896 BD-I cases recruited from 14 European countries, we examined AAO distributions in individuals born in consecutive birth decades. Cumulative probabilities with Mantel-Cox log-rank tests, pairwise comparisons and Odds Ratios (OR) with 95% confidence intervals (95% CI) were employed to analyze AAO according to birth decade, sex, and presence or absence of an ASUD.

RESULTS

In the total sample, median AAO of BD-I decreased from about 41 years for those born in the 1930s to about 26 years for those born in the 1960s. In a sub-sample of 1247 individuals (selected to minimize confounding), AAO significantly decreased for males and females born in each consecutive decade between 1930 and 50 (OR: 0.65; 95% CI: 0.51, 0.81), and for cases with an ASUD as compared to without (OR: 0.77, 95% CI: 0.69, 0.87). The best fitting regression model identified an independent effect for each birth decade and an interaction between ASUD status and sex, with a consistently earlier AAO in males with an ASUD (OR: 0.79: 95% CI: 0.70, 0.91).

CONCLUSIONS

In BD-I cases diagnosed according to internationally recognized criteria and recruited to pan-European clinical observational studies, the AAO distributions are compatible with a birth cohort effect. A potentially modifiable risk factor, namely ASUD status, was associated with the observed reduction in AAO, especially in males.

Demographic and clinical differences between early- and late-onset bipolar disorders in a multicenter study in China

Little is known about the demographic and clinical differences between early-onset (EOB) and late-onset bipolar disorders (LOB) in Chinese patients. This multi-center study examined the demographic and clinical characteristics of EOB (≤21 years) and LOB (>21 years) in China. A consecutively recruited sample of 555 patients with bipolar disorder (BD) from 7 psychiatric hospitals and general hospital psychiatric units across China was examined. Patients' demographic and clinical characteristics were collected using a standardized protocol and data collection procedure. There were 181 (34.8%) patients with EOB and 339 (65.2%) with LOB. Univariate analyses revealed that compared to the LOB group, the EOB group were more likely to be older, unemployed, have a longer illness duration, have BD-I and misdiagnosed as schizophrenia but were less likely to be misdiagnosed as major depressive disorder and receiving antidepressants. Multivariate analyses revealed that unemployment and longer duration of illness were independently associated with EOB. The clinical differences between early-onset and late-onset BD patients in China were largely consistent with those found in Western countries. Early-onset BD appear to be associated with poorer outcomes. Prospective studies examining the long-term outcomes in relation to age-at-onset are needed.

Duration of untreated illness in first-treatment bipolar I disorder in relation to clinical outcome and cannabis use

There is little knowledge about the role of the duration of untreated bipolar (DUB) illness in first-treatment bipolar disorder I (BD I), its association with symptoms at start of first treatment, and development over the first year, and limited knowledge about factors that influence the length of DUB. Substance use has shown to delay identification of primary psychiatric disorders, and while cannabis use is common in BD the role of cannabis in relationship to DUB is unclear. The aim of the present study is to examine the associations between DUB and key clinical outcomes at baseline in BD I, and at one year follow-up, and to evaluate the influence of cannabis use. Patients with first-treatment BD I (N=62) completed comprehensive clinical evaluations, which included both DUB and the number of previous episodes. There were no significant associations between DUB and key clinical outcomes. Longer duration from first manic episode to treatment was associated with risk of starting excessive cannabis use after onset of the bipolar disorder. The main finding is the lack of significant associations between features of previous illness episodes and clinical outcomes. Long duration of untreated mania seems to increase the risk for later cannabis use.

Is age of onset associated with severity, prognosis, and clinical features in bipolar disorder? A meta-analytic review

OBJECTIVES

To identify clinical characteristics and adverse outcomes associated with an earlier age of onset of bipolar disorder.

METHODS

A comprehensive search yielded 15 empirical papers comparing clinical presentation and outcomes in individuals with bipolar disorder grouped according to age of onset (total N=7370). The following variables were examined to determine odds ratios (ORs) and 95% confidence intervals (CIs): presence of Axis I comorbidity, rapid cycling, psychotic symptoms, mixed episodes (DSM-IV), lifetime suicide attempts, lifetime alcohol and substance abuse, symptom severity, and treatment delay.

RESULTS

Early age of onset was found to be associated with longer delay to treatment (Hedges' g=0.39, P=.001), greater severity of depression (Hedges' g=0.42, P<.001), and higher levels of comorbid anxiety (OR=2.34, P<.001) and substance use (OR=1.80, P<.001). Surprisingly, no association was found between early age of onset and clinical characteristics such as psychotic symptoms or mixed episodes as defined by DSM-IV.

CONCLUSIONS

Earlier age of onset of bipolar disorder is associated with factors that can negatively impact long-term outcomes such as increased comorbidity. However, no association was found between early onset and indicators of severity or treatment resistance such as psychotic symptoms. Clinical features found to have the strongest relationship with early age of onset were those potentially amenable to pharmacological and psychological treatment. Results highlight the importance of early identification and provide potential areas of focus for the development of early intervention in bipolar disorder.

Using admixture analysis to examine birth-cohort effects on age at onset of bipolar disorder

OBJECTIVE

It is suggested that age at onset (AAO) of bipolar I disorder (BP-I) is decreasing. We tested for a birth-cohort effect on AAO using admixture analysis.

METHOD

A clinical sample of 3896 BP-I cases was analysed using two approaches: (i) in a subsample with untruncated AAO × birth year distribution (n = 1865), we compared the best-fitting model for the observed AAO in patients born ≤1960 and >1960, (ii) to control for potential confounders, two separate subsamples born ≤1960 and >1960 were matched for age at interview (n = 250), and a further admixture analysis was undertaken.

RESULTS

The two approaches indicated that the proportion of cases in the early AAO category was significantly greater in cases born >1960; manic onsets were also more frequent in the early onset BP-I cases born >1960.

CONCLUSION

The decrease in AAO of BP-I in recent birth-cohorts appears to be associated with an increase in the proportion of cases in the early onset subgroup; not with a decrease in the mean AAO in each putative subgroup. This could indicate temporal changes in exposure to risk factors for mania.

Diagnosis of bipolar disorder in primary and secondary care: what have we learned over a 10-year period?

BACKGROUND

Studies suggest that misdiagnosis of bipolar disorders (BD) is frequent in primary care. This study aimed to evaluate agreement between referral for BD by general practitioners (GP) and BD diagnosis by secondary care psychiatrists, and to evaluate the impact of age, gender, and BD type on agreement.

METHODS

The study was conducted at Hôpital du Sacré-Coeur de Montréal׳s "Module Evaluation/Liaison" (MEL), which establishes/clarifies psychiatric diagnoses requested mainly from GPs and directs patients to appropriate treatment and care. Socio-demographic variables, reason for referral, and psychiatric diagnosis were compiled for patients assessed from 1998 to 2010. GP-psychiatrist agreement was established for BD type, gender, and age group (18-25, 26-35, 36-45, >45) using Cohen׳s Kappa coefficient (Κ).

RESULTS

From 1998 to 2010, MEL psychiatrists received 18,111 requests and carried out 10,492 (58%) assessments. There were 583 referrals for BD suspicion, while 640 assessments (6.1%) received a BD diagnosis (40.3% type I, 40.5% type II). The overall K was 0.35 (95% CI [0.31, 0.38]), and was significantly higher for type I than type II (I=0.35, 95% CI [0.30, 0.39]; II=0.25, 95% CI [0.21, 0.30]), though age group and gender had no impact.

LIMITATIONS

Reasons for referral were converted into keywords and categories to facilitate agreement analyses. Only the main psychiatric diagnosis was available.

CONCLUSIONS

Our study suggests diagnosing BD remains strenuous, regardless of age and gender, though BD type I seems better understood by primary care GPs. The true measure of BD diagnosis remains a critical issue in clinical practice.

Predicting bipolar disorder on the basis of phenomenology: implications for prevention and early intervention

OBJECTIVE

Bipolar disorder is a multifaceted illness and there is often a substantial delay between the first onset of symptoms and diagnosis. Early detection has the potential to curtail illness progression and disorder-associated burden but it requires a clear understanding of the initial bipolar prodrome. This article summarizes the phenomenology of bipolar disorder with an emphasis on the initial prodrome, the evolution of the illness, and the implications for prevention and early intervention.

METHODS

A literature review was undertaken using Medline, Web of Science, and a hand search of relevant literature using keywords (e.g., phenomenology, initial or early symptoms, risk factors, and predictors/prediction). Findings from the literature were reviewed and synthesized and have been put into a clinical context.

RESULTS

Bipolar disorder is a recurrent, persistent, and disabling illness that typically develops in adolescence or early adulthood. The literature search yielded 28 articles, in which mood lability, nonspecific, non-mood symptoms, and cyclothymic temperament were the most cited prodromal features.

CONCLUSIONS

A small number of key prospective studies have provided evidence in support of an initial bipolar prodrome; however, methodological differences across studies have prohibited its clear delineation. It is, therefore, not currently possible to anticipate those who will develop bipolar disorder solely on the basis of early phenomenology. Accurate characterization of the bipolar disorder prodrome through high-quality, prospective research studies with adequate control groups will ultimately facilitate prompt and accurate diagnosis.

Public health significance of bipolar disorder: implications for early intervention and prevention

OBJECTIVES

Early intervention and preventive strategies have become major targets of research and service development in psychiatry over the last few years. Compared to schizophrenia, bipolar disorder (BD) has received limited attention in this regard. In this paper, we review the available literature in order to explore the public health significance of BD and the extent to which this may justify the development of early intervention strategies for this disorder.

METHODS

The main computerized psychiatric literature databases were accessed. This included Medline and PsychInfo, using the following keywords: bipolar, early intervention, staging model, burden, caregiver, public health, and manic depression.

RESULTS

BD is often recurrent and has an impact that goes well beyond symptomatic pathology. The burden it incurs is linked not only to its cardinal clinical features, but also to cognitive dysfunction, poor functional outcome, poor physical health, high rate of comorbidities, and suicide. At a societal level, BD induces enormous direct and indirect costs and has a major impact on caregivers. The available literature reveals a usually long delay between illness onset and the start of treatment, and the absence of specific guidelines for the treatment of the early phase of BD.

CONCLUSIONS

Considering the major impact of BD on patients and society, there is an urgent need for the development of early intervention strategies aimed at earlier detection and more specific treatment of the early phase of the disorder.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The relationship between clinical outcomes and quality of life in first-episode mania: a longitudinal analysis

OBJECTIVES

  Despite growing attention to the relationship between bipolar disorder (BD) and quality of life (QoL), there remains a lack of information about QoL in the early stages of BD, and about the course of QoL in people with BD over time. Here, we report on QoL and symptomatic outcomes over a 1.5-year period in a Canadian sample of first-episode mania patients.

METHODS

  Patients (n = 63) with DSM-IV-TR BD type I recovering from a recent episode of mania were recruited from a university-based hospital setting in Vancouver, BC, Canada and assessed at six monthly intervals for 18 months. In addition to symptomatic and cognitive assessments, two self-report QoL scales [the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Medical Outcomes Study Short Form 36 (SF-36)] were administered.

RESULTS

  Baseline QoL scores were high, with mean Q-LES-Q scores at 70% of the maximum possible score; QoL continued to show a trend towards improvement over time. Multiple hierarchical regressions were used to explore predictors of QoL over time, finding that: (i) length of illness and severity of depressive symptoms at baseline predicted Q-LES-Q scores at both baseline and six months; (ii) the number of previous depressive episodes and severity of depression at baseline and 12 months all predicted QoL at 12 months; and (iii) only severity of depressive symptoms at 12 months predicted QoL at 18 months.

CONCLUSIONS

  Our observation that QoL in patients who have recently experienced an episode of mania can be relatively preserved offers hope, both for healthcare providers and for those newly diagnosed. Further, that severity of depressive symptoms even in the early stages of the disease was the consistent predictor of QoL suggests that depressive symptoms need to be aggressively treated to improve QoL.

A 16-year prospective study of prodromal features prior to BPI onset in well Amish children

BACKGROUND

Longitudinal research of well Amish children over 16 years to identify the pattern and frequency of prodromal symptoms/behaviors associated with onset of BPI disorder during childhood or adolescence.

METHODS

Parental informants were interviewed annually using structured and semi-structured interviews to record medical, developmental and behavioral/symptomatic data for their children in two samples. The bipolar sample had 115 children with a BPI parent. The control sample had 106 children of well parents, with and without a positive family history for mood disorders. A panel of clinicians assigned risk ratings independently and blind to family relations.

RESULTS

Eight children, age 13 or older, onset with BPI in the bipolar sample compared with one in the control sub-sample (well parent of a BPI sibling). The specific "pre-school" behaviors/symptoms that most identified children with BPI from well children in control samples were: sensitivity, crying, hyper-alertness, anxiety/worry and somatic complaints. During school years, parents reported mood (sad) and energy changes (low not high) decreased sleep and fearfulness as key symptoms.

LIMITATIONS

The sample of 9 BPI onsets is small. However, a variable age of onset means many children remain at risk. Although not statistically significant, 34.6% of the bipolar sample youngsters carry risk ratings compared to 15.2% among controls.

CONCLUSIONS

The miniclusters of prodromal features that emerged pre-school (ages 1-6), were "episodic" through childhood (7-12) and appeared to mimic adult recurrent illness. Prepubertal onset with mania did not occur. The pattern of prodromal symptoms has clinical relevance for its potential predictive value for onset with BPI disorder and early intervention.

Symptoms and behaviors prior to the first major affective episode of bipolar II disorder. An exploratory study

BACKGROUND

Few studies have investigated the initial prodrome of bipolar disorders, and none has explicitly addressed bipolar II disorder (BD-II). We explored symptoms and behaviors preceding the first major affective episode (FMAE) of BD-II to generate hypotheses concerning possible clinical targets for early intervention.

METHODS

In-depth interviews of 15 BD-II patients and 22 family informants were carried out. Clinical diagnoses were reassessed. The textual data of transcribed interviews were analyzed utilizing qualitative methodology supplemented by quantitative analyses.

RESULTS

All patients experienced clinically significant symptoms and behaviors at an average of more than a decade before the FMAE. Anxiety and depression-type symptoms were the most common. Two distinct subgroups were identified based on prominent and enduring personal characteristics prior to the FMAE. The individuals in one of the subgroups were described as very well-functioning, whereas the individuals in the other subgroup were characterized by neurocognitive deficits, relatively low academic and social functioning, and pronounced irritability and aggressiveness. Furthermore, it is possible that these individuals experience earlier prodromal symptom onset, earlier FMAEs, and more symptoms than individuals without these characteristics.

LIMITATIONS

This is a retrospective and hypothesis-generating qualitative study. The hypotheses generated need to be tested in future studies.

CONCLUSIONS

Prodromal clinical phenomenology is too nonspecific to predict the occurrence of the FMAE of BD-II. However, identifiable subgroups may exist. We hypothesize that neurocognitive deficits together with pronounced irritability and aggressiveness may constitute a vulnerability marker for a subgroup of individuals who subsequently develop BD-II. This subgroup may be of potential interest for early identification.

Genome-wide association analysis of age at onset and psychotic symptoms in bipolar disorder

Genome-wide association studies (GWAS) have identified several susceptibility loci for bipolar disorder (BP), most notably ANK3. However, most of the inherited risk for BP remains unexplained. One reason for the limited success may be the genetic heterogeneity of BP. Clinical sub-phenotypes of BP may identify more etiologically homogeneous subsets of patients, which can be studied with increased power to detect genetic variation. Here, we report on a mega-analysis of two widely studied sub-phenotypes of BP, age at onset and psychotic symptoms, which are familial and clinically significant. We combined data from three GWAS: NIMH Bipolar Disorder Genetic Association Information Network (GAIN-BP), NIMH Bipolar Disorder Genome Study (BiGS), and a German sample. The combined sample consisted of 2,836 BP cases with information on sub-phenotypes and 2,744 controls. Imputation was performed, resulting in 2.3 million SNPs available for analysis. No SNP reached genome-wide significance for either sub-phenotype. In addition, no SNP reached genome-wide significance in a meta-analysis with an independent replication sample. We had 80% power to detect associations with a common SNP at an OR of 1.6 for psychotic symptoms and a mean difference of 1.8 years in age at onset. Age at onset and psychotic symptoms in BP may be influenced by many genes of smaller effect sizes or other variants not measured well by SNP arrays, such as rare alleles.

The impact of age at onset of bipolar I disorder on functioning and clinical presentation

OBJECTIVES

Recent studies have proposed the existence of three distinct subgroups of bipolar 1 disorder based on age at onset (AAO). The present study aims to investigate potential clinical and functional differences between these subgroups in an Australian sample.

METHODS

Participants (n = 239) were enrolled in the Bipolar Comprehensive Outcomes Study (BCOS), a 2-year longitudinal, observational, cross-sectional study. Assessment measures included the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAMD21), Clinical Global Impressions Scale (CGI-BP), SF-36, SLICE/Life Scale, and the EuroQol (EQ-5D). Participants were also asked about their age at the first major affective episode.

RESULTS

Three AAO groups were compared: early (AAO < 20, mean = 15.5 ± 2.72; 44.4% of the participants); intermediate (AAO 20-39, mean = 26.1 ± 4.8; 48.14% of the participants) and late (AAO > 40, mean = 50.6 ± 9.04; 7.4% of the participants). Higher rates of depression, suicidal ideation and binge drinking were reported by the early AAO group. This group also reported poorer quality of life in a number of areas. The early AAO group had a predominant depressive initial polarity and the intermediate group had a manic predominance.

CONCLUSION

Early AAO is associated with an adverse outcome.

Classifying mood disorders by age-at-onset instead of polarity

BACKGROUND

Polarity is the pillar of the current categorical unipolar-bipolar division of mood disorders. However, genetic studies on these polarity-based phenotypes have been largely inconclusive. Recent clinical and epidemiological studies seem to support more of a continuum than a splitting of mood disorders. A reshaping of the classification of mood disorders thus seems required. Age-at-onset and recurrence have been suggested to be more clinically and genetically useful in the phenotyping of mood disorders.

STUDY AIM

To test a classification of mood disorders based on age-at-onset, and to delineate its phenotypes.

METHODS

A total of 441 consecutive bipolar II disorder (BP-II) and 289 unipolar major depressive disorder (MDD) outpatients, presenting for treatment of a major depressive episode (MDE) in a clinical and research private practice, were assessed by a mood disorder specialist psychiatrist (FB) using a Structured Clinical Interview for the DSM-IV, modified for better probing past hypomania [Benazzi, F. Bipolar disorder-focus on bipolar II disorder and mixed depression. Lancet 2007a;369: 935-945]. The sample was divided according to age-at-onset. Age-at-onset was defined by the age at onset of the first MDE. Early-age-at-onset (EO) was defined as age at onset before 21 years, late-age-at-onset (LO) as onset at or after age 21 years. The study's current goal had not been planned when data were recorded between 1999 and 2006. Variables were compared in EO versus LO mood disorders, investigating phenotype differences. The main focus was on 'classic' diagnostic validators: MDE clinical picture, gender, course, and family history. Age, gender, BP-II, and mania/hypomania family history (possible confounding) were controlled for in the analyses. Logistic regression was used.

RESULTS

First, EO was regressed on each variable, one at a time, to find significant associations. Second, EO was regressed on all of the variables whose odds ratio (OR) was statistically significant in the previous analyses in order to find independent predictors. Independent predictors of EO mood disorder were history of hypomania, high recurrence, atypical depression, and family history of mania/hypomania. Controlling for BP-II (in addition to age and gender) did not impact the findings. The highest OR was that between EO and high recurrence (OR=4.00). Distinguishing MDE symptoms of EO mood disorder included hypersomnia and psychomotor agitation when controlling for age and gender, and, by controlling also for BP-II, hypersomnia only.

DISCUSSION

A close association among EO mood disorder, high recurrence, and bipolarity (history of hypomania, family history of mania/hypomania) was found. Compared to most previous studies testing EO versus LO in bipolar (mainly BP-I) or in unipolar MDD samples, the present study tested a mixed BP-II and MDD sample and controlled for polarity, reducing, as much as possible, the impact of polarity on the findings. EO (below age 21 years) was distinguished by hypersomnic depression, high recurrence, high history of hypomania, and high history of mania/hypomania. Replications are needed, especially in mixed samples also including BP-I. Results, if replicated, could have implications not only for clinical and genetic studies, but also for treatment (e.g., mood stabilizers could have better long-term effects than antidepressants in EO mood disorders, antidepressants could have negative long-term effects on EO).

The proximal prodrome to first episode mania--a new target for early intervention

OBJECTIVE

Affective psychoses and bipolar disorders have been neglected in the development of early intervention strategies. This paper aims to gather current knowledge on the early phase of bipolar disorders in order to define new targets for early intervention.

METHODS

Literature review based on the main computerized databases (MEDLINE, PUBMED and PSYCHLIT) and hand search of relevant literature.

RESULTS

Based on current knowledge, it is likely that an approach aiming at the identification of impending first-episode mania is the most realistic and manageable strategy to promote earlier treatment. During the period preceding the onset of the first manic episode, patients go through a prodromal phase marked by the presence of mood fluctuation, sleep disturbance, and other symptoms such as irritability, anger, or functional impairment. Additionally, various risk factors and markers of vulnerability to bipolar disorders have been identified.

CONCLUSIONS

In the few months preceding first-episode mania, patients go through a prodrome phase (proximal prodrome) that could become an important target for early intervention. However, considering the low specificity of the symptoms observed during this phase, criteria defining high-risk profiles to first-episode mania should also include certain risk factors or markers of vulnerability. While more research is needed in high-risk groups (e.g., bipolar offspring), retrospective studies conducted in first-episode mania cohorts could provide valuable information about this critical phase of the illness.

Bipolar II disorder: arguments for and against a distinct diagnostic entity

OBJECTIVE

As a commitment to the International Society for Bipolar Disorders (ISBD), a Task Force was developed to investigate the diagnostic value of bipolar II disorder.

METHODS

Task Force members worked jointly reviewing all relevant literature (original articles, reviews, letters, book chapters and congress presentations) that included 'bipolar II disorder' and/or 'hypomania' as key words.

RESULTS

Bipolar II disorder appears to be a reasonably valid and reliable diagnostic category yet often underdiagnosed or misdiagnosed as unipolar disorder or personality disorder. Moreover, it is officially recognized as a mental disorder in DSM-IV-TR but not in ICD-10, and many clinicians still regard it as a milder form of manic-depressive illness, despite data supporting high morbidity and mortality rates. In fact, bipolar II may be the most prevalent bipolar phenotype, although current diagnostic boundaries are seen as quite restrictive concerning the required duration for hypomania (4 days), the exclusion of hypomanic episodes potentially triggered by antidepressants and other substances, and the negligence of hypomanic mixed states. The course of bipolar II disorder is characterized by depressive predominant polarity, and its treatment is still controversial and poorly evidence-based.

CONCLUSIONS

Bipolar II disorder is supported as a distinct category within mood disorders, but the definition and boundaries deserve a greater clarification in the DSM-V and ICD-11.

Prevention of bipolar disorder in at-risk children: theoretical assumptions and empirical foundations

This article examines how bipolar symptoms emerge during development, and the potential role of psychosocial and pharmacological interventions in the prevention of the onset of the disorder. Early signs of bipolarity can be observed among children of bipolar parents and often take the form of subsyndromal presentations (e.g., mood lability, episodic elation or irritability, depression, inattention, and psychosocial impairment). However, many of these early presentations are diagnostically nonspecific. The few studies that have followed at-risk youth into adulthood find developmental discontinuities from childhood to adulthood. Biological markers (e.g., amygdalar volume) may ultimately increase our accuracy in identifying children who later develop bipolar I disorder, but few such markers have been identified. Stress, in the form of childhood adversity or highly conflictual families, is not a diagnostically specific causal agent but does place genetically and biologically vulnerable individuals at risk for a more pernicious course of illness. A preventative family-focused treatment for children with (a) at least one first-degree relative with bipolar disorder and (b) subsyndromal signs of bipolar disorder is described. This model attempts to address the multiple interactions of psychosocial and biological risk factors in the onset and course of bipolar disorder.

Early age at onset of bipolar disorder is associated with more severe clinical features but delayed treatment seeking

OBJECTIVE

Our aim was to obtain a comprehensive view of differences between bipolar disorder (BD) patients with onset at early versus adult age in a representative study cohort.

METHODS

In the Jorvi Bipolar Study (JoBS), 1,630 psychiatric in- and outpatients were systematically screened for BD using the Mood Disorder Questionnaire (MDQ). A total of 191 bipolar I and II patients with a current DSM-IV episode were interviewed to obtain information about age at onset of mood symptoms, clinical course, treatment, comorbidity, and functional status. The patients were classified as either early onset (<18 years) or adult onset.

RESULTS

One-third of subjects with BD (58/191, 30%) had early onset. This was associated with female gender, more lifetime psychotic symptoms, greater overall comorbidity, and a greater length of time from first episode to treatment.

CONCLUSIONS

Although BD patients with early age at onset have more severe clinical features and illness course, the delays from first episode to treatment and to correct diagnosis are longer than for those with adult onset disorder. To reduce morbidity rates related to the most severe forms of BD, the recognition and diagnosis of BD during adolescence needs to be improved.

Social and symptomatic outcomes of first-episode bipolar psychoses in an early intervention service

AIM

We aimed to establish the relative proportions of all diagnoses in people aged 14-35 years presenting to an early intervention in psychosis service, and to compare demographic variables, symptoms and outcomes between the bipolar psychoses and other psychoses at 3-6 months and 1 year post referral.

METHODS

Prospective 3- to 6-month diagnostic and symptomatic assessments were carried out. Diagnoses were established using the Diagnostic Interview for Psychoses - Diagnostic Module. Symptoms and outcomes were assessed using standardized instruments at 3-6 months and 1 year. Bipolar diagnoses were grouped together in a bipolar group (n=16) and compared with all other diagnoses, in a non-bipolar group (n=62). Parallel analysis was carried out using groups of lifetime elevated, expansive or irritable mood (n=32) and no lifetime elevated, expansive or irritable mood (n=46).

RESULTS

Bipolar disorders account for 20.5% of all new presentations to our service. Differences in outcomes over the range of psychotic diagnoses relate to early presence of negative symptoms. Psychoses with bipolar diagnoses or lifetime elevated, expansive or irritable mood showed lower rates of negative symptoms than other psychoses and had a higher quality of life and higher function at 3-6 months and 1 year.

CONCLUSIONS

Planning for future early intervention services should take the high rate of affective psychoses and their need for diagnosis-specific, evidence-based treatments into account. Lifetime elevated, expansive or irritable mood may predict improved outcomes in early psychoses, possibly mediated by lower levels of negative symptoms.

Factor structure of the Comprehensive Adolescent Severity Inventory (CASI): results of reliability, validity, and generalizability analyses

This article describes the results of psychometric work conducted on the Comprehensive Adolescent Severity Inventory (CASI) among 205 in-treatment substance-abusing adolescents. Four dimensions, each composed of component subscales, resulted from standard psychometric analyses: Chemical Dependency, Psychosocial Functioning, Delinquency, and Risk Behavior. Each dimension had high internal consistency (alpha coefficients for the component subscales comprising each clinical dimension range from .78 to .96) and test-retest reliability (intraclass correlation coefficients range from .88 to .96 and all are significant at p < .0001.). Concurrent validity and specificity of the CASI dimensions also were found: significant and substantial variance in NIMH Diagnostic Interview Schedule for Children-Revised (DISC-IV) and Brief Symptom Inventory (BSI) scores was associated with relevant CASI dimensions; CASI dimensions that theoretically should show no significant relationship with divergent pathology were not associated. The dimensions forecasted substantial variance in adolescent functioning posttreatment discharge, supporting predictive validity. Finally, the dimensional clinical structure was found to be generalizable over male and female adolescents, younger and older adolescents, and adolescents from different ethnic groups. These results provide further evidence for the CASI's promise in research and practice as an adolescent-specific assessment instrument that comprehensively assesses multidimensional areas of functioning within a developmental context of measurement. Limitations of the study along with future work currently being conducted on the CASI are discussed.

Pharmacological treatment in the early phase of bipolar disorders: what stage are we at?

OBJECTIVE

To review available guidelines, explore treatment strategies currently applied, identify critical issues and propose direction for new developments.

METHOD

Literature review based on Medline search and hand search of relevant literature.

RESULTS

Pharmacological treatment of the early phase of bipolar disorders lacks specific guidelines. Mood stabilizers are often prescribed after many years of illness, antipsychotic medications are frequently prescribed and often for extensive periods of time, and adherence to medication is relatively poor. In addition, mania is frequently misdiagnosed, and there is limited knowledge on which to base identification of bipolar depression and identification of the initial prodrome to bipolar disorders.

CONCLUSIONS

There is an urgent need for more research in the early phases of bipolar disorders to develop means to identify patients earlier and to develop approaches that would address the specific needs of this population in a more adequate manner.

A 10-year prospective study of prodromal patterns for bipolar disorder among Amish youth

OBJECTIVE

Prospective study of well children at risk of bipolarity to identify the frequency and pattern of potentially prodromal symptoms/behaviors for bipolar disorder type I (BPI) disorder.

METHOD

A total of 110 at-risk children with a BPI parent and 112 children with well parents were studied. Ten-year data collection used structured and semistructured annual interviews covering developmental, medical, and behavioral features. Randomized histories for 222 children were submitted blindly for risk rating of bipolarity by a panel of clinicians.

RESULTS

Children in the bipolar sample had an overall risk rating of 41% as compared with 16% for control children. Features noted more frequently among the at-risk group were anxious/worried, attention poor/distractable in school, easily excited, hyper alert, mood changes/labile, role impairment in school, somatic complaints, and stubborn/determined. Five additional manic-like behaviors became more evident among at-risk adolescents at the 10-year follow-up: high energy, decreased sleep, problems with thinking/concentration, and excessive and loud talking.

CONCLUSIONS

The children of a parent with BPI manifested, episodically, mini clusters of potentially prodromal characteristics more frequently than the children of normal controls. None of these children met any of the sets of diagnostic criteria for prepubertal bipolar disorder.

Psychopathology in the offspring of parents with bipolar disorder: a controlled study

BACKGROUND

To examine the risk for psychopathology in offspring at risk for bipolar disorder and the course of psychiatric disorders in these youth.

METHODS

Using structured diagnostic interviews (Structured Clinical Interview for DSM-IV [SCID] and Kiddie Schedule for Affective Disorders and Schizophrenia [K-SADS]), psychiatric diagnoses of 117 nonreferred offspring of parents with diagnosed bipolar disorder were compared with those of 171 age- and gender-matched offspring of parents without bipolar disorder or major depression.

RESULTS

Compared with offspring of parents without mood disorders, high-risk youth had elevated rates of major depression and bipolar disorder, anxiety, and disruptive behavior disorders. High-risk offspring also had significantly more impaired Global Assessment of Functioning (GAF) scores, higher rates of psychiatric treatment, and higher rates of placement in special education classes. Disruptive behavior disorders, separation anxiety disorder, generalized anxiety disorder (GAD), social phobia, and depression tended to have their onset in early or middle childhood, whereas bipolar disorder, obsessive-compulsive disorder (OCD), panic disorder, and substance use disorder had onset most frequently in adolescence.

CONCLUSIONS

These findings support the hypothesis that offspring of parents with bipolar disorder are at significantly increased risk for developing a wide range of severe psychiatric disorders and accompanying dysfunction. Early disruptive behavior and anxiety disorders, as well as early-onset depression, may be useful markers of risk for subsequent bipolar disorder in high-risk samples.

The clinical characteristics of DSM-IV bipolar I and II disorders: baseline findings from the Jorvi Bipolar Study (JoBS)

OBJECTIVE

To obtain a comprehensive view of the clinical epidemiology of bipolar I and II disorder in secondary-level psychiatric settings.

METHODS

In the Jorvi Bipolar Study (JoBS), 1630 non-schizophrenic psychiatric in- and outpatients in three Finnish cities were screened for bipolar I and II disorders with the Mood Disorder Questionnaire. Diagnoses were made using semistructured SCID-I and -II interviews. Information collected included clinical history, current episode, symptom status, and other characteristics.

RESULTS

A total of 191 patients with bipolar disorder (90 bipolar I and 101 bipolar II) were included in the JoBS. The majority of bipolar II (50.5%) and many bipolar I (25.6%) patients were previously undiagnosed; the remainder had a median 7.8 years delay from first episode to diagnosis. Despite several lifetime episodes, 26 and 58% of bipolar I and II patients, respectively, had never been hospitalized. A polyphasic episode was current in 51.3%, rapid cycling in 32.5%, and psychotic symptoms in 16.2% of patients. Mixed episodes occurred in 16.7% of bipolar I, and depressive mixed states in 25.7% of bipolar II patients.

CONCLUSION

Even in psychiatric settings, bipolar disorders usually go undetected, or recognized only after a long delay. A significant proportion of not only bipolar II, but also bipolar I patients are never hospitalized. Polyphasic episodes and rapid cycling are prevalent in both types. Depressive mixed states are at least as common among bipolar II patients as mixed episodes among bipolar I.

Long-term implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD)

BACKGROUND

Early onset of mood symptoms in bipolar disorder has been associated with poor outcome in many studies; however, the factors that might contribute to poor outcome have not been adequately investigated.

METHODS

The first consecutive 1000 adult bipolar patients enrolled in the National Institute of Mental Health's Systematic Treatment Enhancement Program for Bipolar Disorder were assessed at study entry to determine details of their age of onset of mood symptoms. Clinical course, comorbidity, and functional status and quality of life were compared for groups with very early (age < 13 years), early (age 13-18 years), and adult (age > 18 years) onset of mood symptoms.

RESULTS

Of 983 subjects in whom age of onset could be determined, 272 (27.7%) experienced very early onset, and 370 (37.6%) experienced early onset. Earlier onset was associated with greater rates of comorbid anxiety disorders and substance abuse, more recurrences, shorter periods of euthymia, greater likelihood of suicide attempts and violence, and greater likelihood of being in a mood episode at study entry.

CONCLUSIONS

Very early or early onset of bipolar disorder might herald a more severe disease course in terms of chronicity and comorbidity. Whether early intervention might modify this risk merits further investigation.

A re-evaluation of the role of antidepressants in the treatment of bipolar depression: data from the Stanley Foundation Bipolar Network

OBJECTIVES

The risk-to-benefit ratio of the use of unimodal antidepressants (ADs) as adjuncts to mood stabilizers continues to be an area of controversy and disagreement among experts in the field. This paper reviews new data on: (1) depression in bipolar illness, (2) switch rates on ADs and (3) risks of AD discontinuation that are pertinent to the ongoing discussion and recommendations.

METHODS

In the first study reviewed, 258 outpatients with bipolar illness were assessed prospectively on a daily basis using the National Institute of Mental Health-Life Chart Method (NIMH-LCM) for 1 year. In the second study, 127 bipolar depressed patients were randomized to 10 weeks of sertraline, bupropion, or venlafaxine, as adjuncts to mood stabilizers; non-responders were re-randomized and responders were offered a year of continuation treatment. In the final study, Altshuler et al. retrospectively and prospectively assessed the risk of depressive relapses in patients who remained on ADs after 2 months of euthymia compared with those who discontinued ADs.

RESULTS

Despite intensive naturalistic treatment, the 258 outpatients with bipolar illness followed prospectively for 1 year showed three times as many days depressed as days manic, re-emphasizing the considerable depressive morbidity that remains in bipolar disorder despite the number of treatment options available. In the study of bipolar depressed patients randomized to one of three ADs, a range of severities and durations of hypomanic to manic switches were discerned following 175 trials of AD augmentation of treatment with a mood stabilizer. Of the acute 10-week trials, 9.1% were associated with switches into hypomania or mania and another 9.1% with a week or more of hypomania alone (with no to minimal dysfunction). In 73 continuation phase AD trials, 16.4 and 19.2% were similarly associated with hypomanic to manic and hypomanic switches, respectively. In the Altshuler et al. studies, those who remained well on any AD for more than 2 months (only 15-20% of those initially treated) and who continued on ADs showed a lesser rate of relapse into depression over 1 year (35 and 36% in the first and second study, respectively) compared with those who discontinued their ADs (68 and 70% relapsing into depression). Surprisingly, this continuation of ADs was associated with no increase in the rate of switching into mania compared with those stopping ADs.

CONCLUSIONS

These data reveal that depression and depressive cycling remain a substantial problem in some two-thirds of intensively treated bipolar outpatients. Acute AD augmentation was associated with a modest response rate and 18.2% switched into a hypomanic to manic episode, and 35.6% of the continuation trials showed these two types of switches. Two separate studies suggest that in the very small subgroup who remain well on ADs for at least 2 months, one should consider continuation of this AD augmentation treatment, because AD discontinuation appears associated with a substantially increased risk of depression relapse over the subsequent year with no reduced risk of switching into mania.

The initial prodrome to bipolar affective disorder: prospective case studies

BACKGROUND

The initial prodrome to bipolar disorder has received very little attention to date, with most of the available data only addressing the prodrome to relapse. This study presents several prospective case studies of the initial prodrome to bipolar affective disorder.

METHODS

Three patients are presented who developed bipolar disorder during their treatment at the Personal Assessment and Crisis Evaluation Clinic (PACE). They were prospectively interviewed over a 12-month period using standard clinical research interviews.

RESULTS

These patients met the criteria for bipolar disorder by the end of the treatment period. Depressive symptoms were the main reason for their first clinical presentation, with mania developing at a later date. Other comorbidities were observed before they were diagnosed with bipolar disorder.

LIMITATIONS

The generalisability of our findings was constrained because of the small sample size. Furthermore, our findings are likely to be influenced by the intake criteria used at PACE, a clinic that primarily aims at identifying patients at risk of psychosis rather than bipolar disorder.

CONCLUSION

Our study provides information about the initial prodrome to bipolar disorder, which has previously been neglected in research studies. We found there were no prodrome features that clearly distinguished between patients who go on to develop bipolar disorder and those who develop schizophrenia. We hope our prospective data will be the starting point for subsequent studies, with the aim of applying these findings to developing suitable preventative interventions for bipolar disorder.

Prophylaxis latency and outcome in bipolar disorders

OBJECTIVE

To analyze new and reviewed findings to evaluate relations between treatment response and latency from onset of bipolar disorder (BD) to the start of mood-stabilizer prophylaxis.

METHOD

We analyzed our own new data and added findings from research reports identified by computerized searching.

RESULTS

We found 11 relevant studies, involving 1485 adult patients diagnosed primarily with BD. Reported latency to prophylaxis averaged 9.6 years (SD 1.3), and follow-up in treatment averaged 5.4 years (SD 3.1). Greater illness intensity and shorter treatment latency were closely associated, resulting in a greater apparent reduction in morbidity with earlier treatment. However, this finding was not sustained after correction for pretreatment morbidity, and treatment latency did not predict morbidity during treatment. Therefore, assessments based on improvement with treatment, or without correction for pretreatment morbidity, can be misleading.

CONCLUSIONS

Available evidence does not support the proposal that delayed prophylaxis may limit response to prophylactic treatment in BD and related disorders.

Issues in the treatment of bipolar disorder

Bipolar disorder is a chronic, recurring illness that requires long-term prophylactic treatment. However, treatment is often complicated by misdiagnosis and inappropriate medication selection. A number of therapies are available for the treatment of bipolar disorder and the ultimate therapeutic choice depends on the individual patient's current symptoms, disease history, and comorbid illnesses. However, research is needed to improve the overall prognosis for patients with bipolar depression, particularly because approximately 20% of patients commit suicide. Mania is the most dramatic expression of bipolar disorder and may overshadow the impact of the depressive phase of the illness. Compared with mania, episodes of bipolar depression are more frequent, of longer duration, and are associated with higher rates of morbidity and mortality. Therefore, successful treatment and prevention of bipolar depression remains an essential treatment goal.

Prospective study of prodromal features for bipolarity in well Amish children

OBJECTIVE

A prospective study of psychiatrically well Amish children to determine differences in the frequency and pattern of clinical features that may be prodromal for bipolar I disorder.

METHOD

Children with a bipolar I parent (n = 100) and children of well parents in a matched control sample (n = 110) were assessed annually for 7 years with semistructured interviews covering medical/developmental features and symptoms/behaviors that are possibly prodromal for bipolarity. Randomized histories of these 210 children were evaluated blindly by 4 clinicians for independent ratings of risk for bipolarity.

RESULTS

Thirty-eight percent of the children of bipolar parents were rated as at risk compared with 17% of children in the control sample. Most control sample children with risk ratings had well parents with a bipolar sibling (i.e., family history positive). Children with family histories negative for mental illness rarely received even a low risk rating. Clinical features significantly (p <or=.05) more frequent among children of a bipolar parent included mood lability, low energy, anxious/worried, hyper-alert, attention problems/distractible and school role impairment, easily excited, sensitivity, somatic complaints, and stubborn/determined.

CONCLUSION

Mini-clusters of early possible predictors suggest a natural history of episodic prodromal features rather than the chronic symptom pattern sometimes described for children at risk for bipolar disorder.

Early age at onset as a risk factor for poor outcome of bipolar disorder

The primary aim of our study was to investigate the effect of the age at onset (AAO) of Bipolar Disorder (BP) on the clinical course of the illness. We studied 320 subjects with a diagnosis of BP I or BP II who had been previously recruited for a genetic research protocol. All subjects gave their informed consent to participate in the study. Each subject was interviewed using the SCID I. The main clinical variables were compared between subjects with early (</=18 years) and later (>/=18 years) age at onset of BP (chi square tests and t-tests for independent samples). In addition, a logistic regression analysis was applied to the variables that were significantly related to earlier onset of BP in the exploratory analyses. We found a significantly earlier AAO in subjects with anxiety disorders (t=2.44, P=0.015) and rapid cycling course (t=3.16, P=0.002). When we compared a number of clinical characteristics between early and later onset of BP, subjects with early AAO had more frequent suicidal ideation/attempts (chi(2)=12.12, P=0.002), Axis I comorbidity (chi(2)=8.12, P=0.004), substance use disorders (chi(2)=5.45, P=0.019) and rapid cycling course (chi(2)=9.87, P=0.002). The Odds Ratios associated with these variables were: 1.407 (suicide ideation), 1.646 (Axis I comorbidity), 1.468 (substance abuse), and 2.082 (rapid cycling course). Overall, these results suggest a role of early AAO as a significant predictor of poor outcome in BP and, if replicated, they may have important clinical implications.

Does prophylaxis-delay in bipolar disorder influence outcome? Results from a long-term study of 147 patients

OBJECTIVE

This study investigated the impact of latency (the time between illness onset and initiation of prophylactic treatment) on the outcome of prophylaxis in bipolar disorders.

METHOD

The effect of prophylaxis delay (latency) on the course of illness was assessed in 147 patients. Dependent variables were: reduction of days spent in the hospital (prior to vs. during prophylaxis), time to first recurrence, and Morbidity-Index during prophylaxis (lithium or carbamazepine). Latency and other independent variables were tested using a multivariate approach.

RESULTS

Latency (9.3 years on average) had no significant effect on the subsequent response. Illness severity prior to prophylaxis, however, did predict the relative response. The course of illness during treatment could not be predicted by any one factor.

CONCLUSION

The delay in initiating prophylaxis appears to have no influence on prophylaxis outcome. Instead, those whose illness was more severe were treated earlier and these patients subsequently showed a relatively greater response. If severity is not controlled for as part of the analysis, latency may be mistaken as an important predictor for response.

Test-retest reliability of self-reported age at onset of selected psychiatric diagnoses in general health care

OBJECTIVE

To investigate reliability of self-reported age at onset of frequent mental disorders and its association with patient and disorder characteristics.

METHOD

A total of 1031 primary care patients with at least one lifetime psychiatric diagnosis were asked to report age at onset of their disorders at baseline and after 1 year. Intraclass correlation coefficients (ICC) for age at onset information were calculated for individual disorders.

RESULTS

ICC were high and lay between 0.6790 (generalized anxiety disorder) and 0.7977 (dysthymia). Factors associated with reliability are different for different disorders: gender for depressive episodes, gross national product per year per inhabitant for dysthymia, age for pain disorder, years of formal education for dysthymia, generalized anxiety disorder, and agoraphobia, and number of lifetime diagnoses for depression and agoraphobia.

CONCLUSION

Self-reported age at onset is reliable. Further research on factors associated with reliability should focus on interview conditions and subject parameters during interview.

Parental attitudes towards early intervention in children at high risk for affective disorders

BACKGROUND

Parents volunteered to complete surveys on attitudes toward treatment intervention in children at a theoretically high (20-30%) or very high (70%) risk for affective disorders because of an assumed uni-lineal or bi-lineal family history of bipolar illness.

METHODS

Questions focused on examining at what ages and stage of symptom and syndrome evolution parents would wish their child to begin treatment with different types of therapeutic approaches and clinical trial designs. Sixty percent of the respondents had a personal history of unipolar or bipolar affective disorders.

RESULTS

In 156 completed surveys, 83% of parents favored acute medication intervention and 67% favored long-term medication treatment for those children at very high risk at or before the development of severe symptoms (i.e. even prior to meeting full diagnostic thresholds). On the average, parents indicated that they would enter their child in a trial of: two types of psychotherapy at a point in illness evolution between moderate and severe symptoms, two types of open medications between severe symptoms and a definite diagnosis, two blind medications at a definite diagnosis, and a blind trial of placebo and medication after a definite diagnosis but before multiple recurrences of the illness. Parents, primarily on the basis of perceived safety, would allow their children to use medications that have been found to be effective in adults.

LIMITATIONS

In addition to a number of methodological limitations, responders to the survey were self-selected.

CONCLUSIONS

The results indicate a willingness on the part of most parents to treat a child at high risk for affective illness early in the course of symptom evolution, even prior to a full syndromic illness or diagnosis. This and other parental views of the risk-benefit and ethical dimensions of early intervention may be helpful in the initiation and design of studies aimed at assessing the efficacy of early interventions in childhood-onset bipolar illness and its prodromes.

The Stanley Foundation Bipolar Treatment Outcome Network. II. Demographics and illness characteristics of the first 261 patients

BACKGROUND

Since recent NIMH Bipolar Disorder Workshops highlighted the dearth of longitudinal and controlled studies of bipolar illness, the Stanley Foundation Bipolar Network (SFBN) has recruited a large cohort of patients with bipolar disorder to begin to address these issues. This report describes the demographics and course of illness characteristics of this study population.

METHODS

The first 261 outpatients to be diagnosed by the Structured Clinical Interview for DSM-IV (SCID) and complete a detailed patient and a brief clinician questionnaire are described. All patients met DSM-IV criteria for bipolar I (n=211), bipolar II (n=42), or NOS (n=5) or schizoaffective (n=3), bipolar type. Chi-square and t-tests were used to examine statistically significant associations among important demographic and descriptive items.

RESULTS

The general demographic and illness characteristics were similar to those in many bipolar clinical samples and not dissimilar from those reported in epidemiological surveys. The majority of patients had been hospitalized, with almost half reporting a worsening of illness over time, and two-thirds were not asymptomatic between episodes. First treatment for patients had been delayed by an average of 10 years from illness onset (by SCID). Almost a third of patients had attempted suicide at least once, and 30% reported current suicidal ideation at study entry. A total of 62% reported moderate to severe impact of the illness on occupational functioning. Early onset bipolar illness (< or =17 years old) was associated with increased frequency of mood switches, worsening course of illness, and history of early abuse (physical, verbal, or sexual).

CONCLUSION

The SFBN represents a sample of predominantly BP I patients largely recruited from the community who will be followed in detail longitudinally, participate in clinical trials, and thus help advance our understanding and treatment of this life-threatening medical disorder. While there is a broad range of illness characteristics and severity, the majority of patients have been severely impacted by their illness despite the availability of multiple conventional treatment approaches in the community. These data further underscore the need for development of new and earlier treatment interventions.

LIMITATION

The SFBN population is limited by the lack of random selection and represents a cohort willing to be treated and followed intensively in academic tertiary referral centers. While its characteristics are similar to many clinical study populations, the generalizability to non-clinic populations remains uncertain.

The Stanley Foundation Bipolar Treatment Outcome Network. I. Longitudinal methodology

The NIMH-Stanley Foundation Bipolar Treatment Outcome Network, a multisite clinical trials network, has been established to address many of the neglected areas of research in bipolar illness. The Network was designed so that it would be able to conduct randomized clinical trials at several different levels of methodologic rigor (blinded and open-label) both in academic and community practice settings in order to better assess long-term efficacy of existing treatments and develop new ones. In this fashion, large numbers of representative patients with bipolar disorder have been enrolled with an additional focus of elucidating possible clinical and biological predictors of treatment response. The unique focus of the Network is its systematic longitudinal approach to illness so that patients can be assessed comprehensively over the long-term in sequential randomized clinical trials at critical clinical decision points where data on relative efficacy are inadequate. Bipolar I and bipolar II patients with a range of illness variants and comorbidities are included. Daily prospective ratings of severity of mania and depression and associated degree of functional impairment are completed on the NIMH-Life Chart Method and a modified Clinical Global Impressions Scale for Bipolar Illness (CGI-BP) is utilized. More detailed cross-sectional ratings for depression (Inventory of Depressive Symptomatology), mania (Young Mania Rating Scale), and psychosis (Positive and Negative Syndrome Scale) are additionally used at academic centers. This article describes the rationale for the Network, its guiding principles, methods, and study design to systematically assess the highly variable course of bipolar illness and its response to current and future treatments.

Prodromal symptoms before onset of manic-depressive disorder suggested by first hospital admission histories

OBJECTIVE

A priority for research on manic-depressive or bipolar I disorder (BPI) for children and adolescents has been to search for early predictors of the illness.

METHOD

Medical record data were reviewed and systematically coded for a sample of 58 adult patients (32 males/26 females) with confirmed diagnoses of BPI to identify prodromal features and possible patterns of symptoms from the Amish Study.

RESULTS

The most frequently reported symptoms included episodic changes in mood (depressed and irritable) and energy plus anger dyscontrol, with no significant gender differences. A progression of ages is seen for the most commonly reported symptoms prior to age 16. The time interval was 9 to 12 years between appearance of the first symptoms and onset of a documented BPI syndrome.

CONCLUSIONS

The data suggest testable hypotheses about specific symptoms and behaviors that may be useful for the early detection of children at highest risk for developing manic-depressive disorder.

Early and late onset bipolar disorders: two different forms of manic-depressive illness?

BACKGROUND

Conflicting results in genetic studies of bipolar disorders may be due to the clinical and genetic heterogeneity of the disease. Age at onset of bipolar disorders may be a key indicator for identifying more homogeneous clinical subtypes. We tested whether early onset and late onset bipolar illness represent two different forms of bipolar illness in terms of clinical features, comorbidity and familial risk.

METHODS

Among a consecutively recruited sample of 210 bipolar patients, we compared early onset (n=58) and late onset (n=39) bipolar patients; the cut-off points were age at onset before 18 years and after 40 years for the two subgroups. The subgroups were compared by independent t tests and a contingency table by raw chi-square test. Morbid risk among first-degree relatives was measured by the survival analysis method.

RESULTS

The early onset group had the most severe form of bipolar disorder with more psychotic features (P=0.03), more mixed episodes (P=0.01), greater comorbidity with panic disorder (P=0.01) and poorer prophylactic lithium response (P=0.04). First degree relatives of early onset patients also had a higher risk of affective disorders (P=0.0002), and exhibit the more severe phenotype, i.e bipolar disorder.

CONCLUSION

Our data suggest that early and late onset bipolar disorders differ in clinical expression and familial risk and may therefore be considered to be different subforms of manic-depressive illness.