Short-term variability of mood ratings in unipolar and bipolar depressed patients

Alcohol Dependence Syndrome With Bipolar Affective Disorder and Hypomanic Current Episode: A Case Report

Studies have revealed that individuals with bipolar I and bipolar II have a past of substance abuse. The co-occurrence of bipolar disorder and alcoholism is frequent. Although various arguments have been put forward to explain the relationship between these disorders, it is still not fully understood. Since substance abuse is prevalent among bipolar patients, it would be beneficial to investigate the impact of substance abuse on clinical characteristics, as well as the progression of the illness. Thus, this study was carried out to investigate a case of alcohol dependence with bipolar disorder. A 49-year-old male visited the psychiatry outpatient department and then was admitted. The patient's chief complaints were alcohol consumption, cigarette smoking, daily drinking for 35 years, irritability/aggressiveness, boastful talk, overspending, and decreased need for sleep from the last 20 days. According to the literature, self-medicating with alcohol is not an effective treatment for alcoholism, unless it is being used to alleviate the psychological and neurochemical effects caused by alcohol. However, there has been limited research on how to treat individuals who have both alcoholism and another medical condition. A few studies have looked at the impact of medications like valproate, lithium, and naltrexone, as well as psychosocial interventions, in treating patients with bipolar disorder and alcoholism. However, more research is necessary to fully understand the best approach.

Reliability, validity and psychometric properties of the Greek version of the Altman self rating mania scale

BACKGROUND

Although self-rating mania scales have been developed, a lack of such instruments validated for the Greek population is noted. This study aims to examine the validity, reliability and psychometric properties of the Altman Self Rating Mania Scale (ASRM) adapted in Greek (G-ASRM).

METHODS

A sample of 86 consecutive inpatient and outpatient bipolar patients diagnosed by the DSM-5 criteria and 37 healthy controls were assessed by using the Young Mania Rating Scale (YMRS) and the Montgomery Asberg Depression Rating Scale (MADRS), and self-administered the G-ASRM. Factor analysis, test-retest analysis, measurement invariance tests, mean differences, Pearson's Correlation analysis and ROC analysis were used to confirm the validity of G-ASRM as a scale, test its reliability, study its psychometric properties in different subgroups and establish a cut-off value for indicating the presence of (hypo)mania in BD patients. Also, regression models were built to expose dependencies between YMRS and G-ASRM items.

RESULTS

Monofactoriality of the scale was verified, based on Exploratory Factor Analysis (EFA). Cronbach's alpha was 0.895. G-ASRM is highly correlated with YMRS (r = 0.856, p < 0.0005) and uncorrelated with MADRS (r = -0.051, p = 0.623). Test- retest r-coefficient was calculated at 0.85. The optimal cut-off score, set at ≥6 for (hypo)mania assessment, is in agreement with the results reported for the original version. Limitations of the study are that the scale was not normed on diagnostic groups other than bipolar, nor was it administered longitudinally, so as to assess its sensitivity to symptom changes overtime.

CONCLUSION

The G-ASRM can be validly and reliably used in the Greek population for the assessment of (hypo)mania in bipolar patients.

Symptom Profile and Clinical Course of Inpatients with Unipolar versus Bipolar Depression

BACKGROUND

Although differences in symptom profiles and outcome between depressive patients with an underlying major depressive disorder (MDD) and bipolar depression (BD) have been reported, studies with sequential short-interval assessments in a real-life inpatient setting are scarce.

OBJECTIVES

To examine potential differences in symptom profile and course of depressive symptomatology in depressive inpatients with underlying MDD and BD.

METHODS

A cohort of 276 consecutive inpatients with MDD (n = 224) or BD (n = 52) was followed during their hospitalization using routine outcome monitoring (ROM), which included a structured diagnostic interview at baseline (Mini-International Neuropsychiatric Interview Plus [MINI-Plus]) and repeated 17-item Hamilton Depression Rating Scale every 2 weeks. MDD and BD were compared regarding their symptom profiles and time to response and remission. Furthermore, the concordance between the MINI-Plus and clinical diagnosis was analyzed.

RESULTS

Patients were on average 52 and 47 years old in the MDD and BD group, respectively, and 66 versus 64% were female. Compared to patients with BD, patients with MDD scored higher on weight loss (p = 0.02), whereas the BD group showed a higher long-term likelihood of response (hazard ratio = 1.93, 95% confidence interval 1.16-3.20, p for interaction with time = 0.04). Although the same association was seen for remission, the interaction with time was not significant (p = 0.48). Efficiency between the MINI-Plus and clinical diagnosis of BD was high (0.90), suggesting that the MINI-Plus is an adequate ROM diagnostic tool.

CONCLUSIONS

In routine clinical inpatient care, minor differences in the symptom profile and the course of depressive symptomatology may be helpful in distinguishing MDD and BD, particularly when using sequential ROM assessments.

Vibroacoustic treatment to improve functioning and ability to work: a multidisciplinary approach to chronic pain rehabilitation

PURPOSE

To study the use of Vibroacoustic treatment and an added self-care intervention for improving the functioning and ability to work of patients with chronic pain and potential comorbid depressive and anxious symptoms.

MATERIALS AND METHODS

A mixed methods study with four single cases. Participants received bi-weekly Vibroacoustic practitioner-led treatment sessions for five weeks, followed by a one-month washout period without treatments. Then, participants conducted four self-care vibroacoustic sessions per week for five weeks, followed by another month-long washout period. Participants kept diaries of their experiences during this time. Quantitative scales included the World Health Organization Disability Assessment Schedule 2.0, Visual Analogue Scales (pain, mood, relaxation, anxiety, and ability to work), Beck's Depression Inventory-II, and Hospital Anxiety and Depression Scale (Anxiety only). The use of physiological markers was also explored.

RESULTS

The greatest improvement was from the practitioner-led sessions, but self-care was beneficial for pain relief and relaxation. Participants became more aware of sensations in their own bodies, and during washout periods noticed more clearly the treatment effects when symptoms returned. An added self-care phase to standard Vibroacoustic treatment could be beneficial for maintaining the effects from the more intensive Vibroacoustic treatment as part of multidisciplinary rehabilitation.Implications for rehabilitationChronic pain and comorbid mood disorders negatively impact functioning and ability to work.Vibroacoustic treatment with a self-care phase could be beneficial for managing the symptoms of chronic pain if implemented within a naturalistic multidisciplinary rehabilitation context.In four single cases, this study shows functioning, pain, and depression improved after Vibroacoustic treatment with self-care.

Alcohol use and bipolar disorders: Risk factors associated with their co-occurrence and sequence of onsets

BACKGROUND

Little is known about the sequence of onsets in patients affected by comorbid alcohol use and bipolar disorder. This study examines the risk factors associated with their co-occurrence and order of onset.

METHOD

The demographic, clinical, and temperament characteristics as well as the course of illness were analyzed within our sample of 1090 DSM-IV bipolar I manic patients. Our sample was categorized according to the presence of comorbid alcohol use disorder and the sequence of onsets of bipolar and alcohol use disorders i.e., alcohol first (AUD-BD) and bipolar first (BD-AUD).

RESULTS

Regression analyses revealed that alcohol use disorder (52.5%) was associated with the male gender, additional substance use disorders, as well as an irritable and a hyperthymic temperament. The AUD-BD group (6.6%) was older than the BD-AUD group (45.8%) and showed higher rates of comorbid sedative use, organic, and anxiety disorders with higher levels of irritable temperament, and a bipolar subtype characterized by depressive polarity at onset. The BD-AUD group had high levels of hyperthymic temperament with higher rates of comorbid stimulant use disorder and a manic polarity at onset.

CONCLUSIONS

In the AUD-BD group, alcohol might have been used to reduce stress and tension caused by the presence of an irritable temperament as well as anxious and organic disorders, leading to first depressive episode. In the BD-AUD group, stimulant use might have triggered the first manic episode, and alcohol abuse result from mania severity.

Dynamical Patterns in Bipolar Depression

We examined dynamical patterns in the course of bipolar depression. We interviewed 55 individuals with bipolar I disorder using Modified Hamilton Rating Scale for Depression (MHRSD) for at least 20 months. Using a recently developed methodology, we categorized the level of instability and the nature of attractor patterns for each individual. Instability was related to the lifetime severity of depression as well as suicidality during the follow-up period. Individuals varied from 0 to 2 in the number of attractors. Relatively few individuals displayed only one attractor that fell within a depressive range; the most common patterns were instability and two attractors. Limitations and implications of these results are discussed.

Greater variation in affect is associated with lower fasting plasma glucose

Background

Depression and bipolar illness are associated with a 2–3 fold increase in the prevalence of diabetes. However, it is unknown whether variation in mood affects glucose metabolism. The aim of this study was to assess whether changes in affect were related to fasting plasma glucose and glycated haemoglobin.

Methods

379 men and 441 women who took part in the 2003 Health Survey for England and had valid data for GHQ12 and fasting blood glucose were included. Mood variability was assessed by the General Health Questionnaire 12 (GHQ12). Fasting plasma glucose and glycated haemoglobin (HbA_1c) were measured by standard laboratory methodology and their relationship to variability assessed using linear regression.

Results

There was a significant inverse relationship between fasting blood glucose, but not HbA_1c, and variability score (R² = 0.327, p = 0.02) after adjusting for sociodemographic factors, anthropometric measurements, lifestyle, and use of medication.

Conclusion

This study has shown an inverse association between changes in affect and fasting plasma glucose. This unexpected finding suggests that the association between affect and glucose is more complex than previously thought. Fasting blood glucose may reflect the operation of homeostatic mechanisms that are disturbed in certain mental states and are associated, therefore, with altered risk of diabetes and related metabolic conditions. This may have implications for the management of those with such conditions and with mental disorders.

Characteristics of depressive patients according to family history of affective illness: Findings from a French national cohort

BACKGROUND

Literature is scarce about the characteristics of mood disorder patients with a family history (FH) of affective illness. The aim of the current study was to compare the prominent features of depressive patients with a FH of mania (FHM), those of depressive patients with a FH of depression (FHD), and those of depressive patients with no FH of affective illness (FHO).

METHODS

As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 45 (9.1%) were classified as FHM, 210 (42.6%) as FHD, and 238 (48.3%) as FHO.

RESULTS

The main characteristics of FHM patients were a cyclothymic temperament, the presence of mixed features and diurnal variations of mood during depression, early sexual behaviour, a high number of mood episodes and hypomanic switches, high rates of suicide attempts and rapid cycling; diagnosis of bipolar disorder was more frequent in this group as well as comorbid obsessive compulsive disorder, posttraumatic stress disorder, bulimia, attention deficit/hyperactivity disorder and impulse control disorders. The FHD patients had more depressive temperament, generalized anxiety disorder, and anorexia nervosa. Compared to FHO, FHM and FHD showed an earlier age at onset, more comorbid anxiety disorders, as well as more psychotic features.

LIMITATIONS

The following are the limitations of this study: retrospective design, recall bias, and preferential enrolment of bipolar patients with a depressive predominant polarity.

CONCLUSIONS

In light of genetic studies conducted in affective disorder patients, our findings may support the hypothesis of genetic risks factors common to affective disorders and dimensions of temperament, that may extend to comorbid conditions specifically associated with bipolar or unipolar illness.

Prevalence and correlates of bipolar disorders in patients with eating disorders

BACKGROUND

To investigate the prevalence and correlates of bipolar disorders in patients with eating disorders (EDs), and to examine differences in effects between major depressive disorder and bipolar disorder on these patients.

METHODS

Sequential attendees were invited to participate in a two-phase survey for EDs at the general psychiatric outpatient clinics. Patients diagnosed with EDs (n=288) and controls of comparable age, sex, and educational level (n=81) were invited to receive structured interviews for psychiatric co-morbidities, suicide risks, and functional level. All participants also completed several self-administered questionnaires assessing general and eating-related pathology and impulsivity. Characteristics were compared between the control, ED-only, ED with major depressive disorder, and ED with bipolar disorder groups.

RESULTS

Patients with all ED subtypes had significantly higher rates of major depressive disorder (range, 41.3-66.7%) and bipolar disorder (range, 16.7-49.3%) than controls did. Compared to patients with only EDs, patients with comorbid bipolar disorder and those with comorbid major depressive disorder had significantly increased suicidality and functional impairments. Moreover, the group with comorbid bipolar disorder had increased risks of weight dysregulation, more impulsive behaviors, and higher rates of psychiatric comorbidities.

LIMITATIONS

Participants were selected in a tertiary center of a non-Western country and the sample size of individuals with bipolar disorder in some ED subtypes was small.

CONCLUSION

Bipolar disorders were common in patients with EDs. Careful differentiation between bipolar disorder and major depressive disorder in patients with EDs may help predict associated psychopathology and provide accurate treatment.

Predominant polarity in bipolar disorders: Further evidence for the role of affective temperaments

BACKGROUND

Literature suggests bipolars may differ in several features according to predominant polarity, but the role of temperaments remains controversial.

METHODS

The EPIDEP study was designed to identify bipolar patients among a large sample of major depressives. Only bipolars were included in the current study. Patients were subtyped as predominantly depressive (PD) and predominantly manic and hypomanic (PM) according to a broad (more episodes of a given polarity) and a narrow (2/3 of episodes of one polarity over the other) definition, and compared on their characteristics.

RESULTS

Among 278 bipolars, 182 (79.8%) could be subtyped as PD and 46 (20.2%) as PM (broad definition); the respective proportions were of 111 (81.6%) and 25 (18.4%) using narrow definition. Expanding the definition added little in detecting differences between groups. Compared to PDs, PMs showed more psychosis, rapid cycling, stressors at onset, family history of affective illness, and manic first episode polarity; they also received more antipsychotics and lithium. The PDs showed more chronic depression, comorbid anxiety, and received more antidepressants, anticonvulsants and benzodiazepines. The following independent variables were associated with manic/hypomanic predominant polarity: cyclothymic temperament, first hospitalization≤25 years, hyperthymic temperament, and alcohol use (only for broad definition).

LIMITATION

Cross-sectional design, recall bias.

CONCLUSIONS

Study findings are in accord with literature except for suicidality and mixicity which were related to predominant mania, and explained by higher levels of cyclothymic and hyperthymic temperaments. Temperaments may play a key role in the subtyping of bipolar patients according to predominant polarity, which warrants confirmation in prospective studies.

Gender differences in a cohort of major depressive patients: further evidence for the male depression syndrome hypothesis

BACKGROUND

Previous studies have shown that major depressive patients may differ in several features according to gender, but the existence of a specific male depressive syndrome remains controversial.

METHODS

As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 125 (27.7%) were of male gender, whereas 317 (72.3%) were female, after exclusion of bipolar I patients.

RESULTS

Compared to women, men were more often married, had more associated mixed features, with more bipolar disorder NOS, more hyperthymic temperaments, and less depressive temperaments. Women had an earlier age at onset of depression, more depressive episodes and suicide attempts. A higher family loading was shown in men for bipolar disorder, alcohol use disorder, impulse control disorders and suicide, whereas their family loading for major depressive disorder was lower. Men displayed more comorbidities with alcohol use, impulse control, and cardiovascular disorders, with lower comorbidities with eating, anxiety and endocrine/metabolic disorders. The following independent variables were associated with male gender: hyperthymic temperament (+), alcohol use disorder (+), impulse control disorders (+), and depressive temperament (-).

LIMITATIONS

The retrospective design and the lack of specific tools to assess the male depressive syndrome.

CONCLUSION

Study findings may lend support to the male depression syndrome concept and draw attention to the role of hyperthymic temperament, soft bipolarity as well as comorbidities as determinants of this syndrome. The latter could help recognize an entity which is probably underdiagnosed, but conveys a high risk of suicide and cardiovascular morbidity.

The role of emotional control in the regulation of mood in parents of children with mucopolysaccharidosis

The aim of our study was to evaluate whether, on the basis of variables related to emotional control, we can anticipate mood change in parents of chronically ill children. Fifty-four parents of children with diagnosed mucopolysaccharidosis participated in the study that was carried out during a rehabilitation programme for children with rare metabolic diseases. To assess emotional control, a Polish adaptation of the Courtauld Emotional Control Scale was used, and mood was measured with the UWIST Mood Adjective Checklist (UMACL). Mood was assessed twice, at an interval of 8 days, on the dimensions of hedonic tone, tense arousal and energetic arousal. The baseline level of each mood dimension accounted for about 30% of the mood variance measured after 8 days. After excluding the part of the mood variance associated with the baseline level, the variables related to emotional control appeared to be significant predictors of the mood assessed 8 days later. For hedonic tone, variables related to emotional control explained 15% of the variance; for tense arousal, it was 14% of the variance; and for energetic arousal, it was 10% of the variance. Depending on the type of emotion and the degree of control, differences in tendencies to respond with a particular mood were observed.

Psychomotor Retardation, Attention Deficit and Executive Dysfunctional in Young Non-hospitalised Un-medicated Non-psychotic Unipolar Depression Patients

BACKGROUND

Neuropsychological deficits have been reported in patients with Major Depressive Disorder (MDD) during an acute episode. The reaction time gives an idea about integrity and the processing ability of central nervous system. The simple reaction time task is an attention seeking task that focuses primarily on speed of processing (executive function). Psychomotor retardation (i.e., delay at the output which includes perceptual decision, planning, motor process) is a constant and probably central feature of depression.

AIMS

The purpose of present study was to evaluate the neuropsychological functioning in young non-hospitalised un-medicated non-psychotic unipolar depression by focusing on tasks related to prefrontal cortex functioning.

MATERIALS AND METHODS

Newly diagnosed young antidepressant-free, clinically depressed patients (20 males and 24 females, n=44) and healthy controls (24 males and 27 females, n=51) pair-wise matched on gender, age (mean age 25±4) were included in this study. All patients were diagnosed with major depressive episode according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Both the patients and healthy controls performed a simple reaction time task with components of alerting auditory and visual orientation of attention by an instrument response analyzer. Statistical Analysis : The performances were expressed in mean ± standard deviation of the reaction time by using the Student's unpaired t-test.

RESULTS

Patients with unipolar depression relative to controls were impaired on psychomotor performance and deficits in sustained attention remained significant.

CONCLUSIONS

These findings suggest deficits in sustained attention as vulnerability marker for unipolar depression. With further methodologically sound research, the changes in neuropsychological function associated with treatment response may provide a means of evaluating different treatment strategies in major depression.

Religious involvement in major depression: protective or risky behavior? The relevance of bipolar spectrum

BACKGROUND

Religiosity has been reported to be inversely related to depression and to suicide as well, but there is a lack of studies on its impact on bipolar disorder and especially, on depressed patients belonging to the bipolar spectrum.

METHODS

As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 234 (55.2%) could be classified as with high religious involvement (HRI), and 190 (44.8%) as with low religious involvement (LRI), on the basis of their ratings on the Duke Religious Index (DRI).

RESULTS

Compared to LRI, HRI patients did not differ with respect to their religious affiliation but had a later age at onset of their affective illness with more hospitalizations, suicide attempts, associated hypomanic features, switches under antidepressant treatment, prescription of tricyclics, comorbid obsessive compulsive disorder, and family history of affective disorder in first-degree relatives. The following independent variables were associated with religious involvement: age, depressive temperament, mixed polarity of first episode, and chronic depression. The clinical picture of depressive patients with HRI was evocative of chronic mixed depressive episodes described in bipolar III patients within the spectrum of bipolar disorders.

LIMITATIONS

Retrospective design, recall bias, lack of sample homogeneity, no assessment of potential protective and risk factors, and not representative for all religious affiliations.

CONCLUSIONS

In depressive patients belonging to the bipolar spectrum, high religious involvement associated with mixed features may increase the risk of suicidal behavior, despite the existence of religious affiliation.

Is coping well a matter of personality? A study of euthymic unipolar and bipolar patients

BACKGROUND

Euthymic bipolar disorder (BD) patients often demonstrate better clinical outcomes than remitted patients with unipolar illness (UP). Reasons for this are uncertain, however, personality and coping styles are each likely to play a key role. This study examined differences between euthymic BD and UP patients with respect to the inter-relationship between personality, coping style, and clinical outcomes.

METHODS

A total of 96 UP and 77 BD euthymic patients were recruited through the CADE Clinic, Royal North Shore Hospital in Sydney, and assessed by a team comprising Psychiatrists and Psychologists. They underwent a structured clinical diagnostic interview, and completed self-report measures of depression, anxiety, stress, personality, coping, social adjustment, self-esteem, dysfunctional attitudes, and fear of negative evaluation.

RESULTS

Compared to UP, BD patients reported significantly higher scores on levels of extraversion, adaptive coping, self-esteem, and lower scores on trait anxiety and fear of negative evaluation. Extraversion correlated positively with self-esteem, adaptive coping styles, and negatively with trait anxiety and fear of negative evaluation. Trait anxiety and fear of negative evaluation correlated positively with eachother, and both correlated negatively with self-esteem and adaptive coping styles. Finally, self-esteem correlated positively with adaptive coping styles.

LIMITATIONS

The results cannot be generalised to depressive states of BD and UP, as differences in the course of illness and types of depression are likely to impact on coping and clinical outcomes, particularly for BD.

CONCLUSIONS

During remission, functioning is perhaps better 'preserved' in BD than in UP, possibly because of the protective role of extraversion which drives healthier coping styles.

How assess drugs in the treatment of acute bipolar mania?

Bipolar affective disorder is a serious mental disease associated with significant morbidity and mortality. Good-quality research available to guide treatment strategies remains insufficient, particularly with regard to manic or hypomanic episodes. A critical review of the various stages of mania might be helpful for pharmaceutical companies and investigators as a prerequisite for the clinical evaluation of potential antimanic properties of medications. The main difficulty is with a comparison between anticonvulsants, antipsychotics, and mood stabilizers such as lithium (with equal efficacy in the acute phase and the prevention of recurrent manic episodes). No consensus has been reached with regard to the treatment of bouts of acute mania in various parts of the world. Controlled clinical trials have, at last, provided irrefutable evidence of the activity of lithium, which has long been used alone, as well as that of divalproate or its derivatives and, to a lesser extent, carbamazepine. The new antipsychotic agents have more recently established their efficacy, especially aripiprazole, asenapine, quetiapine; olanzapine, risperidone, and ziprasidone (not sure where the paradox is). In Europe, haloperidol is still the reference substance used in clinical trials despite the fact that it is not officially indicated in the treatment of mania. In the USA, lithium, divalproate, or antipsychotics can be prescribed as first-line treatment. In Europe, lithium remains the first-line medication, whereas divalproate and atypical antipsychotic agents are used only as second-line therapy. Although both types of medication (antipsychotics, normothymic agents, and/or anticonvulsants) have proved to be clinically effective in the management of mania by reducing the mania scores overall, the same does not apply, however, to all symptoms of mania. Factorial approaches to mania have all shown that since there are several clinical forms of mania, several clusters of manic symptoms can be identified. Antipsychotic and normothymic agents and/or anticonvulsants do not appear to have the same effects on each of these identifiable clusters of symptoms, mainly psychotic features. We believe that it is vitally important for future clinical trials of mania treatment to focus on the treatment effect by adopting a factorial approach to characterization of the episode using an appropriate methodological structure. These questions highlight the uncertainty shrouding the very structure of manic episodes, namely that these are predominantly of a thymic or psychotic nature. The Europeans undoubtedly consider mania to be more of a thymic episode and prefer lithium as the first-line treatment, whereas the Americans believe that psychotic symptoms dominate and widely prescribe antipsychotic agents. However, from the standpoint of clinical trials currently available, even though antipsychotic agents are certainly effective in reducing the scores on the mania scales, it is not clear whether they can be considered purely as antimania treatments.

Self-assessment and characteristics of mixed depression in the French national EPIDEP study

BACKGROUND

Studies on mixed depression have been conducted so far on the basis of DSM-IV manic symptoms, i.e., a list of 7 symptoms which may provide limited information on the subsyndromal features associated with a full depressive episode.

METHODS

As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 102 (23.8%) were classified as mixed depressives (≥3 hypomanic symptoms), and 146 (34%) as pure depressives (0 hypomanic symptom), after exclusion of bipolar I patients; hypomanic symptoms were assessed with the Multiple Visual Analog Scales of Bipolarity (MVAS-BP, 26 items) of Ahearn-Carroll in a self assessment format. A narrower definition of mixed depression, resting on those MVAS-BP items referring to DSM-IV hypomanic symptoms was also tested, as a sensitivity analysis.

RESULTS

Compared to pure depressives, mixed depressive patients had more psychotic symptoms, atypical features and suicide attempts during their index episode; their illness course was characterized by early age at onset, frequent episodes, rapid cycling, and comorbidities. Mixed depressive patients were more frequently bipolar with a family history of bipolar disorder, alcohol abuse, and suicide. A dose-response relationship was found between intradepression hypomania and several clinical features, including temperament measures. The following independent variables were associated with mixed depression: hyperthymic temperament, cyclothymic temperament, irritable temperament, and alcohol abuse. Using the narrower definition of mixed depression missed risk factors such as suicidality and comorbidities.

LIMITATIONS

The following are the limitations of this study: retrospective design, recall bias, lack of sample homogeneity, no cross-validation of findings by hetero-evaluation of hypomanic symptoms.

CONCLUSIONS

EPIDEP data showed the feasibility and face validity of self-assessment of intradepressive hypomania. They replicated previous findings on the severity and high suicidal risk of mixed depression profile. They confirmed, for mixed depression, that mixed states occur when mood episodes are superimposed upon temperaments of opposite polarity. They finally suggested that a definition of mixed depression only based on DSM-IV-TR hypomanic symptoms may not allow to identify the most unstable subforms of the entity.

Underestimating the severity of bipolar depression: a comparison of the Hamilton Depression Rating Scale items

BACKGROUND

The Hamilton Depression Rating Scale (HDRS) is a clinician-rated instrument to assess the severity of depressive symptoms that does not account for the differences between bipolar (BP) and unipolar (UP) disorders. This study attempts to evaluate differences in the total scores of the HDRS, Beck Depression Inventory (BDI), and Global Assessment of Functioning (GAF) ratings of patients with bipolar II (BP-II) and UP depression. Each factor and item of the HDRS was compared between the two groups in order to identify specific symptoms.

METHODS

588 patients with bipolar II disorder (n=101) and major depressive disorder (n=487) were enrolled in this study. All participants completed the BDI and individually interviewed using HDRS. Each participant was also evaluated with regard to global functioning.

RESULTS

The BP group scored lower on the total HDRS and all of the factors. The BP and UP groups did not differ in terms of BDI and GAF. With regard to the individual items of HDRS, the BP group scored lower on items associated with 'Depressed mood', 'Work and interest', 'Somatic, gastro', and 'Hypochondriasis'.

LIMITATIONS

There was a significant age differences between the two groups.

CONCLUSIONS

The results of this study suggest that the severity of bipolar depression may be less well-recognized by the HDRS due to the different presentations of depressive symptoms. Thus, the clinician should be careful not to underestimate the sincerity of patients' reports when evaluating depression.

Depression across mood disorders: review and analysis in a clinical sample

OBJECTIVES

In this article we aimed to: (1) review literature concerning the clinical and psychopathologic characteristics of Bipolar (BP) depression; (2) analyze an independent sample of depressed patients to identify any demographic and/or clinical feature that may help in differentiating mood disorder subtypes, with special attention to potential markers of bipolarity.

METHODS

A sample of 291 depressed subjects, including BP -I (n = 104), BP -II (n = 64), and unipolar (UP) subjects with (n = 53) and without (n = 70) BP family history (BPFH), was examined to evidence potential differences in clinical presentation and to validate literature-derived markers of bipolarity. Demographic and clinical variables and, also, single items from the Hamilton Depression Rating Scale (HDRS), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Young Mania Rating Scale (YMRS) were compared among groups.

RESULTS

UP subjects had an older age at onset of mood symptoms. A higher number of major depressive episodes and a higher incidence of lifetime psychotic features were found in BP subjects. Items expressing depressed mood, depressive anhedonia, pessimistic thoughts, and neurovegetative symptoms of depression scored higher in UP, whereas depersonalization and paranoid symptoms' scores were higher in BP. When compared with UP, BP I had a significantly higher incidence of intradepressive hypomanic symptoms. Bipolar family history was found to be the strongest predictor of bipolarity in depression.

CONCLUSIONS

Overall, our findings confirm most of the classical signs of bipolarity in depression and support the view that some features, such as BPFH, together with some specific symptoms may help in detecting depressed subjects at higher risk for BP disorder.

Mood swing and mood stabilizer: how specific are these terms?

BACKGROUND

In the DSM-IIIR in 1987, the category title for depressive and bipolar disorders was changed from affective disorders to mood disorders. Within a short period of time thereafter, mood swing and mood stabilizer became very commonly used terms in psychiatry with bipolar implications.

METHODS

Terms and definitions in recent texts, articles, and dictionaries pertaining to mood fluctuations have been reviewed.

RESULTS

The term mood was seldom part of psychiatric terminology until the late 1970s. Mood swing and mood stabilizer as used in the psychiatric literature are primarily nonspecific and often misleading concepts--particularly as a basis for treatment decisions. Affective fluctuations and shifts to irritability and/or anger in persons with personality and depressive disorders are being viewed by many in the mental health field as cyclically biphasic--between depressed to elated--which is clearly at variance with research findings.

CONCLUSIONS

More data-based research on mood variations is needed to authoritatively remedy this situation.

Mood reactivity to daily events in patients with remitted bipolar disorder

Information about mood reactions to naturally occurring stress in remitted bipolar patients may help elucidate the mechanism by which stressors influence the propensity to manic or depressive relapse in these patients. Using the experience sampling method (ESM), we therefore investigated negative and positive mood states and their reactivity to daily hassles and uplifts in 38 outpatients with remitted bipolar disorder and 38 healthy volunteers. Multilevel regression analyses confirmed that mean levels of negative affect (NA) were higher and positive affect (PA) lower in bipolar patients. Reactivity of NA and PA to hassles and uplifts in bipolar patients was similar to controls and was unrelated to the number of previous episodes. Bipolar patients with subsyndromal depressive symptoms, however, showed particularly large NA responses to daily hassles, which they also rated as more stressful. Subsyndromal depressive symptoms in patients with remitted bipolar disorder thus appear to increase sensitivity to everyday stressors.

Suicidal behaviour in a French Cohort of major depressive patients: characteristics of attempters and nonattempters

BACKGROUND

Epidemiological and clinical studies indicate that major depressive disorder is the leading cause of suicidal behaviour and that bipolar II subjects carry the highest risk. Identification of risk factors is therefore essential to prevent suicide in this population.

METHODS

As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1month apart, 155 (33.7%) were classified as suicide attempters, and 295 (66.3%) as nonattempters, after exclusion of bipolar I patients.

RESULTS

Compared to nonattempters, attempters had a longer duration of illness, longer delays before seeking help and correct diagnosis and a higher number of previous episodes; they were more frequently rapid cyclers, with fewer free intervals between episodes. Lifetime suicide attempts were associated with more comorbid bulimia and substance abuse. Bipolar II spectrum disorders, depressive, cyclothymic and irritable temperaments were overrepresented in attempters, as well as family history of both affective disorder and suicide attempts. The following independent variables were associated with lifetime suicide attempts: higher number of previous depressive episodes, multiple hospitalizations, cyclothymic temperament, rapid cycling and earlier age at onset.

LIMITATIONS

Retrospective design, recall bias, lack of sample homogeneity, and insufficient assessment of hypomanic features during index depression.

CONCLUSIONS

In major depressive disorders, family history, age at onset, illness course, comorbidity and cyclothymic temperament alongside other indices of bipolarity may help predict suicidal behaviour. Longer delays to seeking help and diagnosis in attempters emphasize the importance of early recognition of bipolar spectrum disorders.

Risk factors associated with lifetime suicide attempts in bipolar I patients: findings from a French National Cohort

Risk factors that may be associated with suicide attempts in bipolar disorder are still a matter of debate. We compared demographic, illness course, clinical, and temperamental features of suicide attempters vs those of nonattempters in a large sample of bipolar I patients admitted for an index manic episode. One thousand ninety patients (attempters = 382, nonattempters = 708) were included in the study. Multivariate analysis evidenced 8 risk factors associated with lifetime suicide attempts as follows: multiple hospitalizations, depressive or mixed polarity of first episode, presence of stressful life events before illness onset, younger age at onset, no free intervals between episodes, female sex, higher number of previous episodes, and cyclothymic temperament. These characteristics may help identify subjects at risk for suicide attempt throughout the course of bipolar disorder. We finally propose to integrate such characteristics into a stress-diathesis model of suicidal behavior, adapted to bipolar patients.

Toward the delineation of mania subtypes in the French National EPIMAN-II Mille Cohort. Comparisons with prior cluster analytic investigations

BACKGROUND

Knowledge about psychopathologic presentations of mania in current clinical practice has to be refined in order to improve diagnosis and treatment.

METHODS

One thousand ninety manic patients included in the French National Study EPIMAN-II Mille were submitted to a cluster analysis on the basis of multiple variables related to the history of bipolar illness and symptoms of the current episode.

RESULTS

Four clusters were identified: "classic mania" (29.3% of patients) with less severe mania; "psychotic mania" (22.7%) with psychotic symptoms, more severe mania, younger age and social impairment; "depressive mania" (30.4%) characterized by female gender, suicide attempts, high number of previous episodes and residual symptoms; and "dual mania" (17.6%) characterized by male gender, substance use, earlier onset and poor compliance. Patients groups also differed in manic symptoms, marital status, stressors preceding illness onset, prior diagnoses, first episode polarity and temperamental characteristics.

LIMITATIONS

Cross-sectional assessment of patients.

CONCLUSIONS

In comparing our findings with those of four prior cluster analytic studies, we integrate clinical characteristics of mania subtypes found in this very large representative French sample in contemporary practice, we suggest how such convergence of data may help improve earlier recognition, differential response to different treatments, and prevention of these subtypes. We finally suggest that such subtyping might provide clues to phenotype delineation suitable for pharmacogenetic investigations.

Diagnostic guidelines for bipolar depression: a probabilistic approach

OBJECTIVES

There are currently no accepted diagnostic criteria for bipolar depression for either research or clinical purposes. This paper aimed to develop recommendations for diagnostic criteria for bipolar I depression.

METHODS

Studies on the clinical characteristics of bipolar and unipolar depression were reviewed. To identify relevant papers, literature searches using PubMed and Medline were undertaken.

RESULTS

There are no pathognomonic characteristics of bipolar I depression compared to unipolar depressive disorder. There are, however, replicated findings of clinical characteristics that are more common in both bipolar I depression and unipolar depressive disorder, respectively, or which are observed in unipolar-depressed patients who 'convert' (i.e., who later develop hypo/manic symptoms) to bipolar disorder over time. The following features are more common in bipolar I depression (or in unipolar 'converters' to bipolar disorder): 'atypical' depressive features such as hypersomnia, hyperphagia, and leaden paralysis; psychomotor retardation; psychotic features, and/or pathological guilt; and lability of mood. Furthermore, bipolar-depressed patients are more likely to have an earlier age of onset of their first depressive episode, to have more prior episodes of depression, to have shorter depressive episodes, and to have a family history of bipolar disorder. The following features are more common in unipolar depressive disorder: initial insomnia/reduced sleep; appetite, and/or weight loss; normal or increased activity levels; somatic complaints; later age of onset of first depressive episode; prolonged episodes; and no family history of bipolar disorder.

CONCLUSIONS

Rather than proposing a categorical diagnostic distinction between bipolar depression and major depressive disorder, we would recommend a 'probabilistic' (or likelihood) approach. While there is no 'point of rarity' between the two presentations, there is, rather, a differential likelihood of experiencing the above symptoms and signs of depression. A table outlining draft proposed operationalized criteria for such an approach is provided. The specific details of such a probabilistic approach need to be further explored. For example, to be useful, any diagnostic innovation should inform treatment choices.

Development and validation of the Affective Self Rating Scale for manic, depressive, and mixed affective states

Most rating scales for affective disorders measure either depressive or hypomanic/manic symptoms and there are few scales for hypomania/mania in a self-rating format. We wanted to develop and validate a self-rating scale for comprehensive assessment of depressive, manic/hypomanic and mixed affective states. We developed an 18-item self-rating scale starting with the DSM-IV criteria for depression and mania, with subscales for depression and mania. The scale was evaluated on 61 patients with a diagnosis of affective disorder, predominantly bipolar disorder type I, using Montgomery-Asberg Depression Rating Scale (MADRS), Hypomania Interview Guide-Clinical version (HIGH-C) and Clinical Global Impression scale, modified for bipolar patients (CGI-BP) as reference scales. Internal consistency of the scale measured by Cronbach's alpha was 0.89 for the depression subscale and 0.91 for the mania subscale. Spearman's correlation coefficients (two-tailed) between the depression subscale and MADRS was 0.74 (P<0.01) and between mania subscale and HIGH-C 0.80 (P<0.01). A rotated factor analysis of the scale supported the separation of symptoms in the mania and depression subscale. We established that the self-rating scales sensitivity to identify mixed states, with combined cut-offs on the MADRS and HIGH-C as reference, was 0.90 with a specificity of 0.71. The study shows that the Affective Self Rating Scale is highly correlated with ratings of established interview scales for depression and mania and that it may aid the detection of mixed affective states.

Clinical and psychometric characterization of depression in mixed mania: a report from the French National Cohort of 1090 manic patients

BACKGROUND

Despite extensive research recently focused on mixed mania, it is uncertain as how best to define it clinically, psychometrically (which has major bearing on its prevalence), and the methodology needed for future research. This topic is also of historical interest, because Magnan (1890) [Magnan, V., 1890. La Folie Intermittente. G Masson, Paris.] suggested that "combined [mixed] states" linked Falret's "circular insanity" with Baillarger's "dual insanity" (both described in 1854). This work eventually led to the Kraepelinian synthesis of all manic, mixed, and depressive states into the unitary rubric of "manic-depressive insanity (1899/1921).

METHOD

EPIMAN-II Thousand" (EPIMAN-II MILLE) is a French national collaborative study, which involved training 317 psychiatrists working in different sites representative of psychiatric practice in France. We recruited 1090 patients hospitalized for acute DSM-IV mania. assessed at index admission by the following measures: the Mania Rating Scale (MRS), the Beigel-Murphy Scale (MSRS), a newly derived checklist of depressive symptoms least contaminated by mania, MADRS for severity of depression, and the SAPS for psychotic features.

RESULTS

The rate of mixed mania, as defined by at least 2 depressive symptoms, was 30%. Even with this broad definition, we found significantly higher female representation. This clinical sub-type of mania was characterized by high frequency of past diagnostic errors, particularly those of anxiety and personality disorders. Refined definition of co-exiting depression was obtained from an abbreviated version of the MADRS (6 items), with distinct "emotional-cognitive" symptoms, and "psychomotor inhibition" factors, both of which were separable from an "irritable" factor linked to lability and poor judgment. Mixed mania was psychometrically best identified by a MADRS score of 6 (80% sensitivity, 94% specificity) and validated by a mixed polarity of first episodes, a higher rate of recurrence, psychotic features, and suicide attempts.

LIMITATION

Cross-sectional study.

CONCLUSIONS

The data deriving from EPIMAN, the largest and only national study ever conducted on mania, provide definitive characterization of the clinical and psychotic structure of mixed mania, which accounts for 1 out of 3 patients who present with mania. This figure is more accurate than higher rates reported in the literature because, in describing "mixity", we eliminated depressive features that could be contaminated by mania. Despite the prominent affective features described herein, the bipolar nature of mixed mania is often missed, with the result that these patients are diagnosed as having anxiety and/or personality disorders. It is of great public health significance for psychiatrists to recognize the bipolar nature of this condition that has been known as a major phase of manic-depressive illness since at least Magnan, a disciple of Falret and Baillarger.

A novel technique to evaluate fluctuations of mood: implications for evaluating course and treatment effects in bipolar/affective disorders

OBJECTIVES

Several psychiatric conditions are associated with frequent fluctuations of affect. In this study, we propose a new technique to uniformly score depression and mania objectively and use a new mathematical technique to model the frequent fluctuations in mood using simulated data. Our main aim is to examine the usefulness of this measure for evaluating treatment effects or course of illness, especially in bipolar or unipolar affective illness to quantify mood fluctuations.

METHODS

We use a prototypical model, which takes into account the mean, the standard deviation (SD) and the coefficient of variation (CV = SD*100/mean) of the mood scores of the subjects over a user-defined period. We utilize simulated data of subjects for euthymia, minor depression, minor mania, severe depression, severe mania and cyclic bipolar illness (manic depression, MDP). We propose an objective method to quantify the mood of the subjects at weekly intervals (the interval can be user-defined) using a scale of 1-9 (1-4 = degrees of depression, 5 = euthymia, 6-9 = degrees of mania). These scores can be sampled according to the convenience and feasibility of the measurements, which can be derived from various clinical scales or by observation of the subjects in hospitals or other environments. We derive a new mathematical technique to arrive at a normalized measure for each of these conditions of simulated data in addition to the mean, SD and approximate entropy (ApEn).

RESULTS

We utilize three sets of data, one to train the model to classify the condition of the subjects and the other two to test the reliability of the technique. We are able to successfully classify the condition of the subjects over a 52-timepoint period (length can be days or weeks depending upon the sampling rate). The New Index (NI) correlates significantly only with the mean (r(2) = 0.78), but not with the SD or ApEn score.

CONCLUSIONS

These results indicate that it may be beneficial to reduce data according to the techniques we propose so that there is greater uniformity within which to compare future studies to evaluate treatment effects, not only in rapid-cycling MDP but also in other affective disorders. This method may be suitable for the meta-analysis of several studies, although different scales have been used in each of those studies. Our measure derived from simulated data has shown sufficient deviation of all the abnormal states from the euthymic state. The advantages and pitfalls of these techniques are further discussed to evaluate affect in various disorders. However, future prospective studies must address the importance of this measure in comparison with mean, SD and ApEn scores or other nonlinear measures of these time series. We are evaluating other nonlinear dynamic models, which may provide a continuous measure with which to identify different degrees of fluctuation of mood.

Bipolar II and the bipolar spectrum

In studies made in the last decade, patients consulting doctors because of depression and anxiety have very often turned out to suffer from bipolar type II and similar conditions with alternating depression and hypomania/mania (the bipolar spectrum disorders - BP). Specifically, about every second patient seeking consultation because of depression has been shown to suffer from BP, mainly bipolar type II. BP is often concealed by other psychiatric conditions, e.g. recurrent depression, psychosis, anxiety, addiction, personality disorder, attention-deficit hyperactivity disorder and eating disorder. BP shows strong heredity. Relatives of patients with BP also have a high frequency of the psychiatric conditions just mentioned. Conversion ("switching") from recurrent unipolar depressions (recurrent UP) to BP is common in very long longitudinal studies (over decades). Mood-stabilizing medicines are recommended to a great extent in the treatment of BP, since anti-depressive medicines are often not effective and involve a substantial risk of inducing mood swings. Particularly in the long-term pharmacological treatment of depression in BP anti-depressive medicines may worsen the condition, e.g. inducing a symptom triad of dysphoria, irritability and insomnia: ACID (antidepressant-associated chronic irritable dysphoria).

Distinctions between bipolar and unipolar depression

This is a review of the studies comparing unipolar and bipolar depression, with focus on the course, symptomatology, neurobiology, and psychosocial literatures. These are reviewed with one question in mind: does the evidence support diagnosing bipolar and unipolar depressions as the same disorder or different? The current nomenclature of bipolar and unipolar disorders has resulted in research that compares these disorders as a whole, without considering depression separately from mania within bipolar disorder. Future research should investigate two broad categories of depression and mania as separate disease processes that are highly comorbid.

The dark side of bipolarity: detecting bipolar depression in its pleomorphic expressions

The depressive expressions of bipolar disorders have long been neglected. Current data, from both clinical and epidemiologic studies, indicate that such expressions far exceed the manic forms in both cross-section and during follow-up course. Thus, mania occurs in 1% of the population at large; bipolar depression afflicts at least 5 times more people. Much of the new literature on this subject has emphasized its high prevalence, morbidity, and mortality. There has been relatively less attention paid to the phenomenology of bipolar depression as it presents clinically. This special issue (volume 84/2-3, 2005) is devoted to a systematic data-based in-depth examination of the different clinical expressions of bipolar depression including, among others, retarded depression, agitated and/or activated depression, mood-labile depression, irritable-hostile depression, atypical depression, anxious depression, depressive mixed state, and resistant depression. Both bipolar I (BP-I), and the more prevalent yet relatively understudied bipolar II (BP-II), are covered. We trust that this extensive coverage of the "darker" side of bipolarity will set the stage for a much needed renaissance in its complex phenotypic expressions-and its delimitation from unipolar depression (UP). The phenomenology of BP-I depression ranges from depressive stupor to agitated psychosis, whereas UP depression expresses itself in psychic anxiety, and insomnia, as well as retardation. BP-II compared with UP is more likely to have atypical features, mood lability, hostility, activation, biographical instability, multiple anxiety comorbidities, suicidal tendencies, and to be rated as less "objectively" depressed. These findings are complex and do not fully agree with the conventional characterization of BP as retarded and UP as anxious and agitated. The inconsistency between the conventional and the phenomenology described herein is largely due to depressive mixed states, which tend to destabilize BP-II, and may account for the "contradictory" relationships of affect, sleep, drive, and psychomotor activity in mood disorders.

Bipolar II vs. unipolar depression: psychopathologic differentiation by dimensional measures

BACKGROUND

Clinical presentations of depression in bipolar disorder are varied, inconsistent and often confusing. Most previous studies have focused on bipolar I (BP-I). Given that bipolar II (BP-II) is the more common bipolar phenotype, which is often confused with unipolar (UP), the aim of the current analyses is to delineate the symptomalogic differences between BP II vs. UP MDD in a large national sample.

METHODS

The data derived from the French National EPIDEP study (n = 452 DSM-IV major depressives), subdivided into BP-II (n = 196) and UP (n = 256). The BP II group included major depressives with both spontaneous and antidepressant-associated hypomania based on our finding of similarity in rates of familial bipolarity in the two subgroups. At index presentation, depression was assessed by the clinician (using HAM-D and the Rosenthal Atypical Depression Scale) and by the patient (using the Multi-Visual Analog Scale of Bipolarity, MVAS-BP). Principal component analyses (PCA with varimax rotation) were conducted on HAM-D and MVAS-BP in the total population and separately in BP-II and UP. We performed inter-group comparative tests (UP vs. BP-II) on factorial scores derived from PCAs and correlation tests between these factorial scores.

RESULTS

The PCA on "HAM-D + Rosenthal scale" showed the presence of nine major factors: F1-2 "weight changes", F3-4 "sleep disturbances", F5 "sadness-guilt", F6 "retardation-fatigue", F7 "somatic", F8 "diurnal variation" and F9 "insight-delusion". The PCA on MVAS-BP revealed the presence of eight principal components: F1 "psychomotor retardation", F2 "central pain", F3 "somatic", F4 "social contact", F5 "worry", F6 "loss of interest", F7 "guilt" and F8 "anger". Despite uniformity in global intensity of depression, significant differences were observed as follows: higher score on "psychomotor retardation" (p = 0.03), "loss of interest" (p = 0.057) and "insomnia" (p = 0.05) in the UP group, and higher score on "hypersomnia" (p = 0.008) in the BP-II group. Correlation analyses between clinician- and self-rating revealed the presence of higher number of significant coefficients in the UP vs. BP-II group (p < or =0.001).

LIMITATION

A three-way comparison between BP-I, BP-II and UP may have yielded somewhat different results.

CONCLUSION

Our data indicate greater psychomotor retardation, stability and uniformity in the clinical picture of strictly defined UP depression. By contrast, bipolar II depression appeared to be characterized, despite the hypersomnic tendency, by psychomotor activation. This would indicate greater mixed features than those observed in UP. Moreover, in BP-II, there was less agreement between clinician vs. self-rating on the presence of various features of depression. Taken together, these findings explain why BP-II depression is missed by clinicians as a genuine depression.

Approximate entropy of symptoms of mood: an effective technique to quantify regularity of mood

OBJECTIVES

Several psychiatric conditions are associated with lability of affect. In this study, we investigated regularity of mood using APEN (Approximate Entropy) on daily subjective ratings using a Visual Analog Scale with 11 items pertaining to mood.

METHODS

APEN was applied to the data in a double-blind placebo controlled investigation on the effects of fluoxetine (n=19), pemoline (n=18) and placebo (n=20) in normal controls. These subjects rated their subjective feelings daily at the end of each day. We analysed 56 data point time series (each value was obtained on each day) after the three experimental conditions.

RESULTS

While the mean or the SD of all the 56 points was not significantly different among the three conditions, APEN was highly and significantly lower for pemoline compared with fluoxetine and placebo. There was no significant correlation between average APEN and mean or SD (standard deviation). The one symptom that explained most of this difference among the groups after drug administration was the feeling of 'happiness'.

CONCLUSIONS

This result indicates that there was a more consistent subjective sense of happiness during the 8-week period of pemoline administration compared with the other two drugs. Though this study was not designed to address the efficacy of mood stabilizing drugs, such daily subjective ratings may be useful in future studies that evaluate the stability of mood. APEN has been used in several different fields of research with small data sets and this study extends its possible use to evaluate changes in mood in certain populations such as patients with bipolar disorders.

The feasibility of self-assessment of dysphoric mania in the French national EPIMAN study

BACKGROUND

There is presently considerable uncertainty on how to best assess mixed mania. The present contribution explores the feasibility of discriminating manic and dysphoric manic states on the basis of self-rating in the acute phase of the illness.

METHODS

In the French four-site national EPIMAN study of 104 patients devoted to the clinical evaluation and subclassification of mania, we used the Multiple Visual Analog Scales of Bipolarity (MVAS-BP, 26 items) of Ahearn-Carroll in a self-assessment format. The study was conducted on consecutive patients hospitalized for an acute DSM-IV mania. The severity of mania was measured by the Beigel-Murphy scale (MSRS) assessed by psychiatrists. When mania abated, temperaments according to Akiskal and Mallya were administered in their French version.

RESULTS

Principal component analysis revealed a general factor explaining 33% of the variance and, after rotation, seven factors defining different dimensions of the phenomenology of mania. The factorial scores, as well as the dimensional scores of the Carrol-Klein model significantly distinguished pure versus dysphoric mania made on clinical grounds. Gender seemed to influence two factors: high 'anxious-depressive' score in females (which is in line with female overrepresentation in mixed mania), vs. high score in males on the 'gregariousness' factor (which represents social disinhibition of the hyperthymic temperament known to be more prevalent in men).

LIMITATION

Cross-sectional correlational study in need of longitudinal validation.

CONCLUSIONS

EPIMAN data deriving from a national clinical population showed the feasiblity and face validity of self-assessment in acute mania, in particular its dysphoric subtype. Temperament in women seemed to contribute to the genesis of mixed (dysphoric) mania in accordance with Akiskal's hypothesis of opposition of temperament and polarity of bipolar episodes in mixed states. Self-assessment was capable of capturing accurately the subthreshold depressive symptomatology of mixed mania, which can be missed in hetero-evaluation by hasty clinical interview.

Toward a refined phenomenology of mania: combining clinician-assessment and self-report in the French EPIMAN study

BACKGROUND

Because manic patients lack insight, they are generally considered unreliable observers of their own psychopathology. The present analyses sought to examine to what extent patient reports could improve formal diagnostic criteria for mania--and be validated against the Carroll-Klein (CK) psychobiological model of bipolarity.

METHOD

104 DSM-IV acutely manic (hospitalized) patients provided self-assessment on the Ahearn--Carroll scale, the Multiple Visual Analogue Scales of Bipolarity (MVAS-BP). A principal component analysis (PCA) was performed on MVAS-BP, and the data on factorial scores were then compared to dimensional scores according to the CK model and to factors on the Beigel-Murphy Manic State Rating Scale (MSRS) completed by psychiatrists.

RESULTS

The PCA identified a general factor accounting for 33% of the total variance; after varimax rotation, seven independent factors emerged, essentially in coherence with the signs and symptoms of DSM-IV mania, except for the 'social disinhibition' factor, which does not figure out as a distinct criterion in DSM-IV. Strong correlations were obtained (r > or = 0.80) between the four major factors of MVAS-BP and the four dimensional categories of the CK model: 'Consummatory Reward' with F1 'Elation and Inflated Self-esteem' (r=0.93), 'Incentive Reward' with F2 'Activation' (r=0.84), 'Psychomotor Pressure' with F3 'Acceleration' (r=0.85), and 'Central Pain' with F4 'Anxiety-Depression' (r=0.84). The F2 'Activation' appeared to be strongly correlated (r > or = 0.70) to all categories of the CK model. Correlational analysis between the factor structure of MVAS-BP and the MSRS showed significant coefficients on the scores assessing the emotional factors of 'Elation' and 'Depression.' Among the MVAS-BP factors, only 'Activation' was correlated to the majority of clinician ratings as obtained by the MSRS.

CONCLUSIONS

These findings provide overall construct validity to the DSM-IV criteria for mania. Self-assessment of this disorder appears feasible and potentially useful in practice; lack of insight, poor judgment, and distractibility obviously require assessment by a clinician. Although our data are correlational and require prospective validation, they nonetheless suggest that (1) activation should be raised to the status of the stem criterion for mania, (2) to specify mood as elated, depressive, anxious, or irritable, and (3) to give individual status to social disinhibition (indiscriminate gregariousness) as a core pathological behavior in mania. Combining clinician- and self-observation thus produces a more precise and complete phenomenology of mania. We finally submit that the foregoing reformulation provides a psychobiological basis to the manic construct as formulated in the Carroll-Klein model.

Relationship between social rhythms and mood in patients with rapid cycling bipolar disorder

Disruptions in the sleep-wake cycle frequently characterize affective illness and have led to a number of theories linking sleep-wake and/or circadian rhythm disturbance to affective illness. Recently, researchers have expanded these chronobiological theories to include the role of lifestyle regularity, or daily social rhythms. In this study, the Social Rhythm Metric (SRM) was used to explore the relationship between social rhythms and mood in patients with rapid cycling bipolar disorder and to compare the social rhythms of patients with those of healthy control subjects. Patients' SRM scores and activity level indices were significantly lower than those of control subjects. In addition, the timing of five, mostly morning, activities was phase delayed in patients compared to control subjects. Patients also demonstrated a phase delay in the timing of morning activities during depression compared to hypomania or euthymia. The phase changes in the timing of morning activities are consistent with other data implicating morning zeitgebers in the pathophysiology of rapid cycling bipolar disorder.

Direct assessment of improvement in winter depression with a visual analogue scale: high reliability and validity

Reliability and validity of direct visual analogue scale (VAS) ratings of improvement were assessed in 162 patients with Seasonal Affective Disorder, Winter Depression type (W-SAD), after light treatment for 6 consecutive days. The patients were rated with the Montgomery-Asberg Depression Rating Scale (MADRS) and a scale for the 'atypical' symptoms hypersomnia, hyperphagia and carbohydrate craving (the ATYP scale) before and after treatment. After treatment the patients also self-rated their global improvement on a 10-cm VAS, with anchoring points of 'No improvement' and 'Complete improvement'. VAS ratings were repeated several times, with 1-4 weeks between assessments, in a follow-up period, always referring to improvement in relation to baseline, and accompanied by a statement whether there had been any change since the former VAS rating. Shortly after treatment there was a mean reduction of 59.8% on the MADRS and 57.1% on the ATYP score, and 58.4% improvement as measured by the VAS. VAS rating correlated highly with percentage reduction of MADRS scores (r=0.85) and somewhat less with reduction of ATYP scores (r=0.64). VAS ratings in the follow-up period showed an extremely high test-retest reliability (r=0.96) for two consecutive ratings between which the patient stated that there had been no definite change. The results support the use of VAS ratings for assessment of global improvement after light treatment in patients suffering from W-SAD; use in other kinds of depression and with other types of treatment remains to be explored.

Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN)

BACKGROUND

This research derives from the French national multisite collaborative study on the clinical epidemiology of mania (EPIMAN). Our aim is to establish the validity of dysphoric mania along a "spectrum of mixity" extending into mixed mania with subthreshold depressive manifestations; to demonstrate the feasibility of obtaining clinically meaningful data on this entity on a national level; and to characterize the contribution of temperamental attributes and gender in its origin.

METHODS

EPIMAN involves training 23 French psychiatrists in four different sites, representing four regions of France; to rigorously apply a common protocol deriving from the criteria of DSM-IV and McElroy et al.; the use of such instruments as the Beigel-Murphy, Ahearn-Carroll, modified HAM-D; and measures of affective temperaments based on the Akiskal-Mallya criteria; obtaining data on comorbidity, and family history (according to Winokur's approach as incorporated into the FH-RDC); and prospective follow-up for at least 12 months. The present report concerns the clinical and temperamental features of 104 manic patients during the acute hospital phase.

RESULTS

Dysphoric mania (DM defined conservatively with fullblown depressive admixtures of five or more symptoms) occurred in 6.7%; the rate of dysphoric mania defined broadly (DM, presence of > or = 2 depressive symptoms) was 37%. Depressed mood and suicidal thoughts had the best positive predictive values for mixed mania. In comparison to pure mania (0-1 depressive symptoms), DM was characterized by female over-representation; lower frequency of such typical manic symptomatology as elation, grandiosity, and excessive involvement; higher prevalence of associated psychotic features; higher rate of mixed states in first episodes; and complex temperamental dysregulation along primarily depressive, but also cyclothymic, and irritable dimensions; such irritability was particularly apparent in mixed mania at the lowest threshold of depressive admixtures of two symptoms only.

LIMITATION

In a study involving hospitalized affectively unstable psychotic patients, it was difficult to assure that psychiatrists making the clinical diagnoses would be blind to the temperamental measures. However, bias was minimized by the systematic and/or semi-structured nature of all evaluations.

CONCLUSIONS

Mixed mania, defined cross-sectionally by the simultaneous presence of at least two depressive symptoms, represents a prevalent and clinically distinct form of mania. Subthreshold depressive admixtures with mania actually appear to represent the more common expression of dysphoric mania. Moreover, an irritable dimension appears to be relevant to the definition of the expression of mixed mania with the lowest threshold of depressive symptoms. Neither an extreme, nor an endstage of mania, "mixity" is best conceptualized as intrusion of mania into its "opposite" temperament - especially that defined by lifelong depressive traits - and favored by female gender. These data suggest that reversal from a temperament to an episode of "opposite" polarity represents a fundamental aspect of the dysregulation that characterizes bipolar disorder. In both men and women with hyperthymic temperament, there appears "protection" against depressive symptom formation during a manic episode which, accordingly, remains relatively "pure". Because men have higher rates of this temperament, pure mania is overrepresented in men; on the other hand, the depressive temperament in manic women seems to be a clinical marker for the well-known female tendency for depression, hence the higher prevalence of mixed mania in women.

The use of visual analog scales in mood disorders: a critical review

Patient-rated visual analog scales are a useful tool in the measurement of mood. The historical development of such scales and their design are reviewed. The simplicity of these scales promotes high compliance and, in addition, they have been shown to be both reliable and valid. While clinician-rated measurements of mood are an accepted standard, self-report of symptoms provides complementary and important information about the course and variability of illness from the patient's perspective.