Profiles of "manic" symptoms in bipolar I, bipolar II and major depressive disorders

Crocin (bioactive compound of Crocus sativus L.) potently restores REM sleep deprivation-induced manic- and obsessive-compulsive-like behaviors in female rats

Rapid-eye movement (REM) sleep deprivation (SD) can induce manic-like behaviors including hyperlocomotion. On the other hand, crocin (one of the main compounds of Crocus sativus L. or Saffron) may be beneficial in the improvement of mental and cognitive dysfunctions. Also, crocin can restore the deleterious effects of SD on mental and cognitive processes. In this study, we investigated the effect of REM SD on female rats' behaviors including depression- and anxiety-like behaviors, locomotion, pain perception, and obsessive-compulsive-like behavior, and also, the potential effect of crocin on REM SD effects. We used female rats because evidence on the role of REM SD in modulating psychological and behavioral functions of female (but not male) rats is limited. REM SD was induced for 14 days (6h/day), and crocin (25, 50, and 75 mg/kg) was injected intraperitoneally. Open field test, forced swim test, hot plate test, and marble burying test were used to assess rats' behaviors. The results showed REM SD-induced manic-like behavior (hyperlocomotion). Also, REM SD rats showed decreased anxiety- and depression-like behavior, pain subthreshold (the duration it takes for the rat to feel pain), and showed obsessive compulsive-like behavior. However, crocin at all doses partially or fully reversed REM SD-induced behavioral changes. In conclusion, our results suggested the possible comorbidity of OCD and REM SD-induced manic-like behavior in female rats or the potential role of REM SD in the etiology of OCD, although more studies are needed. In contrast, crocin can be a possible therapeutic choice for decreasing manic-like behaviors.

Polysomnographic features of insomnia occurring in major depressive disorder, generalized anxiety disorder and bipolar mania: Comparison with primary insomnia and association with metabolic indicators

BACKGROUND

Insomnia is very common in psychiatric disorders, but the polysomnographic (PSG) characteristics of insomnia in various psychiatric disorders are still not agreed upon. This study aimed to investigate the characteristics of PSG and its relationship with metabolic indicators in insomnia patients with affective disorders and primary insomnia (PI) patients.

METHODS

A total of 38 patients with PI, 44 major depressive disorder patients with insomnia (DI), 49 generalized anxiety disorder patients with insomnia (GI), and 19 bipolar mania patients with insomnia (BI) were included. PSG was used to detect sleep problems in subjects, and biochemical indicators were also collected.

RESULTS

The results of this study found that subjects with BI were lower on REM sleep latency (RL), awakenings number (AN), number of microarousals (NM), and apnea-hypopnea index (AHI) than those with DI and GI, and lower on RL and AN than those with PI. Subjects with PI had lower NM and AHI than those with DI and GI. Patients with DI had a higher RL than those with GI. All results passed Bonferroni correction (p < 0.00078). No differences in biochemical indices were found among the four groups of subjects. Also, AHI was found to be positively correlated with free triiodothyronine (FT3) and fasting blood glucose in subjects.

CONCLUSION

This study suggests that various psychiatric disorders may have their characteristics in terms of PSG parameters, which prompted us to focus on the PSG characteristics of these disorders when assessing them, as well as to focus on their biochemical indicators.

Clinical and Sociodemographic Profile of Psychomotor Agitation in Mental Health Hospitalisation: A Multicentre Study

Psychomotor agitation is characterised by an increase in psychomotor activity, restlessness and irritability. People with psychomotor agitation respond by over-reacting to both intrinsic and extrinsic stimuli, experiencing stress and/or altered cognition. The objective of this study is to assess the clinical and sociodemographic profile of psychomotor agitation in patients with severe mental disorders. The study was carried out in Spain by means of multicentre cross-sectional convenience sampling involving 140 patients who had been admitted to psychiatric hospital units and had experienced an episode of psychomotor agitation between 2018 and 2021.Corrigan's Agitated Behaviour Scale was used to assess psychomotor agitation. The results show that the predominant characteristic in psychomotor agitation is aggressiveness, which is also the most reported factor in patients with severe mental disorder. Patients who also have anxiety develop psychomotor agitation symptoms of moderate/severe intensity. The clinical and sociodemographic profile found in our study is consistent with other studies on the prevalence of psychomotor agitation.

Adaptive Solutions to the Problem of Vulnerability During Sleep

Sleep is a behavioral state whose quantity and quality represent a trade-off between the costs and benefits this state provides versus the costs and benefits of wakefulness. Like many species, we humans are particularly vulnerable during sleep because of our reduced ability to monitor the external environment for nighttime predators and other environmental dangers. A number of variations in sleep characteristics may have evolved over the course of human history to reduce this vulnerability, at both the individual and group level. The goals of this interdisciplinary review paper are (1) to explore a number of biological/instinctual features of sleep that may have adaptive utility in terms of enhancing the detection of external threats, and (2) to consider relatively recent cultural developments that improve vigilance and reduce vulnerability during sleep and the nighttime. This paper will also discuss possible benefits of the proposed adaptations beyond vigilance, as well as the potential costs associated with each of these proposed adaptations. Finally, testable hypotheses will be presented to evaluate the validity of these proposed adaptations.

Shared postulations between bipolar disorder and polycystic ovary syndrome pathologies

INTRODUCTION

Women with bipolar disorder (BD) present a high prevalence of polycystic ovary syndrome (PCOS) and other reproductive disorders even before diagnosis or treatment of the disease. Postulations on the potential molecular mechanisms of comorbid PCOS in women with BD remain limited to influence of medications and need further extension.

OBJECTIVES

This review focuses on evidence suggesting that common metabolic and immune disorders may play an important role in the development of BD and PCOS.

RESULTS

The literature covered in this review suggests that metabolic and immune disorders, including the dysfunction of the hypothalamic-pituitary-adrenal axis, chronic inflammatory state, gut microbial alterations, adipokine alterations and circadian rhythm disturbance, are observed in patients with BD and PCOS. Such disorders may be responsible for the increased prevalence of PCOS in the BD population and indicate a susceptibility gene overlap between the two diseases. Current evidence supports postulations of common metabolic and immune disorders as endophenotype in BD as well as in PCOS.

CONCLUSIONS

Metabolic and immune disorders may be responsible for the comorbid PCOS in the BD population. The identification of hallmark metabolic and immune features common to these two diseases will contribute to the clarification of the effect of BD on the reproductive endocrine function and development of symptomatic treatments targeting the biomarkers of the two diseases.

Visual Event-Related Potentials under External Emotional Stimuli in Bipolar I Disorder with and without Hypersexuality

Hypersexuality is related to functions of personality and emotion and is a salient symptom of bipolar I disorder especially during manic episode. However, it is uncertain whether bipolar I disorder with (BW) and without (BO) hypersexuality exhibits different cerebral activations under external emotion stimuli. In 54 healthy volunteers, 27 BW and 26 BO patients, we administered the visual oddball event-related potentials (ERPs) under external emotions of Disgust, Erotica, Fear, Happiness, Neutral, and Sadness. Participants’ concurrent states of mania, hypomania, and depression were also evaluated. The N1 latencies under Erotica and Happiness were prolonged, and the P3b amplitudes under Fear and Sadness were decreased in BW; the P3b amplitudes under Fear were increased in BO. The parietal, frontal, and occipital activations were found in BW, and the frontal and temporal activations in BO under different external emotional stimuli, respectively. Some ERP components were correlated with the concurrent affective states in three groups of participants. The primary perception under Erotica and Happiness, and voluntary attention under Fear and Sadness, were impaired in BW, while the voluntary attention under Fear was impaired in BO. Our study indicates different patterns of visual attentional deficits under different external emotions in BW and BO.

Psychometric Characteristics and Sociodemographic Adaptation of the Corrigan Agitated Behavior Scale in Patients With Severe Mental Disorders

Background: Severe mental disorder (SMD) is understood in a first approximation as a disorder of thought, emotion, or behavior of long duration, which entails a variable degree of disability and social dysfunction. One of the most widely used assessment scales for agitated behavior, in its English version, is the Corrigan Agitated Behavior Scale (ABS); several studies have demonstrated solid psychometric properties of the English version, with adequate internal consistency. Objective: The objective of this study was to evaluate the psychometric properties of the Spanish version of the ABS Corrigan scale, in a sample of patients with severe mental disorders. The psychometric analyses of the Spanish version of the ABS Corrigan included tests of the reliability and validity of its internal structure. Results: The structure of the factorial loads of the analyzed elements is consistent with the hypothesized three-dimensional construction referred to in the original ABS. The results suggest that the reliability and validity of the three dimensions are acceptable (First 0.8, Second 0.8, and Third 0.7). The internal consistency of the Spanish version of the complete ABS and of each of the three domains that compose it is high, with values very close to those found in the original version, with approximate figures of 0.9. Conclusion: In our study, the three domains aim to explain 64.1% of the total variance of the scale, which exceeds the 50% found in the original version.

Circadian Rhythms in Mood Disorders

Altered behavioral rhythms are a fundamental diagnostic feature of mood disorders. Patients report worse subjective sleep and objective measures confirm this, implicating a role for circadian rhythm disruptions in mood disorder pathophysiology. Molecular clock gene mutations are associated with increased risk of mood disorder diagnosis and/or severity of symptoms, and mouse models of clock gene mutations have abnormal mood-related behaviors. The mechanism by which circadian rhythms contribute to mood disorders remains unknown, however, circadian rhythms regulate and are regulated by various biological systems that are abnormal in mood disorders and this interaction is theorized to be a key component of mood disorder pathophysiology. A growing body of evidence has begun defining how the interaction of circadian and neurotransmitter systems influences mood and behavior, including the role of current antidepressants and mood stabilizers. Additionally, the hypothalamus-pituitary-adrenal (HPA) axis interacts with both circadian and monoaminergic systems and may facilitate the contribution of environmental stressors to mood disorder pathophysiology. The central role of circadian rhythms in mood disorders has led to the development of chronotherapeutics, which are treatments designed specifically to target circadian rhythm regulators, such as sleep, light, and melatonin, to produce an antidepressant response.

Is the 4-factor model of symptomology equivalent across bipolar disorder subtypes?

Background

Research with the BDS_x (Bipolar Disorder Symptom Scale) suggests a 4-factor structure of responses: two depression (cognitive, somatic) and two hypo/mania factors (elation/loss of insight, affrontive symptoms). The two depression and two hypo/mania factors are correlated; and affrontive symptoms of hypo/mania (e.g., furious, disgusted, argumentative) are positively correlated with both depression factors suggesting pathways for mixed symptom presentation. This grouping of affrontive symptoms of hypo/mania organically emerged in exploratory research and has subsequently been supported in confirmatory analyses between samples and over time. The BDS_x has been clinically validated with BD outpatients.

Results

Over 19 days, we recruited an international sample of 784 adults with BD using micro-targeted, social media advertising (M  =  44.48 years, range 18–82). All participants indicated that they had BD (subtype, if known) and had been diagnosed with BD (month, year). This sample size was sufficient to confirm the 4-factor model across subtypes and compare the three (BD I, BD II, BD NOS). Responses to 19 of 20 BDS_x items were psychometrically consistent across BD subtypes. Only responses to the ‘hopeless’ item were significantly higher for those with BD II.

Conclusions

When comparing models, it appears that affrontive symptoms are significantly and uniformly associated with hypo/mania and both depression factors across subtypes. In contrast to BD diagnostic criteria, this suggests that affrontive symptoms are central to the clinical presentation of hypo/mania and mixed symptomology across BD subtypes.

Clinical and genetic differences between bipolar disorder type 1 and 2 in multiplex families

The two major subtypes of bipolar disorder (BD), BD-I and BD-II, are distinguished based on the presence of manic or hypomanic episodes. Historically, BD-II was perceived as a less severe form of BD-I. Recent research has challenged this concept of a severity continuum. Studies in large samples of unrelated patients have described clinical and genetic differences between the subtypes. Besides an increased schizophrenia polygenic risk load in BD-I, these studies also observed an increased depression risk load in BD-II patients. The present study assessed whether such clinical and genetic differences are also found in BD patients from multiplex families, which exhibit reduced genetic and environmental heterogeneity. Comparing 252 BD-I and 75 BD-II patients from the Andalusian Bipolar Family (ABiF) study, the clinical course, symptoms during depressive and manic episodes, and psychiatric comorbidities were analyzed. Furthermore, polygenic risk scores (PRS) for BD, schizophrenia, and depression were assessed. BD-I patients not only suffered from more severe symptoms during manic episodes but also more frequently showed incapacity during depressive episodes. A higher BD PRS was significantly associated with suicidal ideation. Moreover, BD-I cases exhibited lower depression PRS. In line with a severity continuum from BD-II to BD-I, our results link BD-I to a more pronounced clinical presentation in both mania and depression and indicate that the polygenic risk load of BD predisposes to more severe disorder characteristics. Nevertheless, our results suggest that the genetic risk burden for depression also shapes disorder presentation and increases the likelihood of BD-II subtype development.

Symptom continuum reported by affective disorder patients through a structure-validated questionnaire

BACKGROUND

Affective disorders, such as major depressive (MDD), bipolar I (BD I) and II (BD II) disorders, are overlapped at a continuum, but their exact loci are not clear. The self-reports from patients with affective disorders might help to clarify this issue.

METHODS

We invited 738 healthy volunteers, 207 individuals with BD I, 265 BD II, and 192 MDD to answer a 79 item-MATRIX about on-going affective states.

RESULTS

In study 1, all 1402 participants were divided random-evenly and gender-balanced into two subsamples; one subsample was used for exploratory factor analysis, and another for confirmatory factor analysis. A structure-validated inventory with six domains of Overactivation, Psychomotor Acceleration, Distraction/ Impulsivity, Hopelessness, Retardation, and Suicide Tendency, was developed. In study 2, among the four groups, MDD scored the highest on Retardation, Hopelessness and Suicide Tendency, whereas BD I on Distraction/ Impulsivity and Overactivation.

CONCLUSION

Our patients confirmed the affective continuum from Suicide Tendency to Overactivation, and described the different loci of MDD, BD I and BD II on this continuum.

Reviewing the diagnostic validity and utility of mixed depression (depressive mixed states)

Objective

To review the diagnostic validity and utility of mixed depression, i.e. co-occurrence of depression and manic/hypomanic symptoms.

Methods

PubMed search of all English-language papers published between January 1966 and December 2006 using and cross-listing key words: bipolar disorder, mixed states, criteria, utility, validation, gender, temperament, depression-mixed states, mixed depression, depressive mixed state/s, dysphoric hypomania, mixed hypomania, mixed/dysphoric mania, agitated depression, anxiety disorders, neuroimaging, pathophysiology, and genetics. A manual review of paper reference lists was also conducted.

Results

By classic diagnostic validators, the diagnostic validity of categorically-defined mixed depression (i.e. at least 2–3 manic/hypomanic symptoms) is mainly supported by family history (the current strongest diagnostic validator). Its diagnostic utility is supported by treatment response (negative effects of antidepressants). A dimensionally-defined mixed depression is instead supported by a non-bi-modal distribution of its intradepression manic/hypomanic symptoms.

Discussion

Categorically-defined mixed depression may have some diagnostic validity (family history is the current strongest validator). Its diagnostic utility seems supported by treatment response.

Examining the Influence of Social Support on Psychological Distress in a Canadian Population with Symptoms of Mania

Individuals who experience symptoms of mania in the form of a manic episode (ME) are at a greater risk of experiencing psychological distress. Given that a ME is a period during which one can become extremely socially dysfunctional, the potential influence of social support is especially important to explore. The primary objective of this study was to examine whether perceived social support predicts psychological distress in a sample of Canadian adults who have self-reported ME symptoms within the last 12-months. Using a cross-sectional, national datafile, 220 Canadians between 20 and 64 years who met the criteria for a ME within the last 12-months were investigated using the Social Provisions Scale (SPS), and the Kessler Psychological Distress Scale (K10). Results indicated that the ME sample experienced significantly higher distress and significantly lower perceived social support than the adult Canadian population. Further, social support in the form of reassurance of worth was associated with lower levels of psychological distress, but only for the male ME sample, and the overall (male and female combined) ME sample. Despite some limitations, this study adds to the research on mania as its own experience outside of comorbidities and indicates the important and specific role social support plays in terms of psychological well-being.

Network analysis of mood symptoms in adolescents with or at high risk for bipolar disorder

OBJECTIVES

Network analyses of psychopathology examine the relationships between individual symptoms in an attempt to establish the causal interactions between symptoms that may give rise to episodes of psychiatric disorders. We conducted a network analysis of mood symptoms in adolescents with or at risk for bipolar spectrum disorders.

METHODS

The sample consisted of 272 treatment-seeking adolescents with or at high risk for bipolar disorder who had at least subsyndromal depressive or (hypo)manic symptoms. Based on symptom scores assessed via semi-structured interviews, we constructed the network of depressive and manic symptoms and identified the most central symptoms and symptom communities within the network. We used bootstrapping analyses to determine the reliability of network parameters.

RESULTS

Symptoms within the depressive and manic mood poles were more related to each other than to symptoms of the opposing mood pole. Four communities were identified, including a depressive symptom community and three manic symptom communities. Fatigue and depressed mood were the strongest individual symptoms within the overall network (ie the most highly correlated with other symptoms), followed by motor hyperactivity. Mood lability and irritability were found to be "bridge" symptoms that connected the two mood poles.

CONCLUSIONS

Symptoms of activity/energy (ie fatigue and hyperactivity) and depressed mood are the most prominent mood symptoms among youth with bipolar spectrum disorders. Mood lability and irritability represent potential warning signs of emergent episodes of either polarity. Targeting these central and bridge symptoms would lead to more efficient assessments and therapeutic interventions for bipolar disorder.

To what extent should expert psychiatric witnesses comment on criminal culpability?

Following the Court of Appeal case of R v Edwards in England and Wales, there has been increasing pressure for expert psychiatric witnesses to comment explicitly on how a defendant’s mental disorder affects their culpability. Culpability is the degree to which a person can be held morally or legally responsible for their conduct, but defining culpability has proved difficult. Mental disorder does not translate easily into degrees of legal culpability. Although psychiatric evidence will often be central to such cases, the determination of culpability is a matter for the court, and experts should not comment on it explicitly. Nevertheless, certain areas of psychiatry may have a bearing on culpability, and ways in which experts may comment on these are suggested. Given the pressure on judges to determine culpability, experts need to be honest about the limits of medical science to answer legal questions and the professional necessity to remain within their area of expertise.

Visual event-related potentials in external emotional conditions in bipolar disorders I and II

OBJECTIVES

Mutual influences of cognitive and emotional functions occur in bipolar disorder, but specific alterations in relation to external emotional stimuli in bipolar I (BD I) and II (BD II) subtypes remain unknown. This study aimed to explore the effects of external emotional stimuli on cerebral attentional function in BD I and BD II.

METHODS

We tested visual oddball event-related potentials (ERPs) during various external emotional stimuli (Disgust, Fear, Erotica, Happiness, Neutral and Sadness) in 31 patients with BD I, 19 BD II and 47 healthy volunteers. Participants' concurrent affective states were also evaluated.

RESULTS

The ERP N2 latencies during Fear and Happiness were prolonged, P3 amplitudes during Disgust and Erotica were decreased in BD I; P3 amplitudes during Disgust, Erotica, Happiness and Neutral conditions were decreased in BD II. Increased frontal and parietal and decreased temporal and occipital activations were found in BD I, while increased occipital and parietal and decreased frontal and limbic activations in BD II in relation to different external emotions. ERP components were not correlated with concurrent affective states in patients.

CONCLUSIONS

Automatic attention during Happiness and Fear, and voluntary attention during Disgust and Erotica conditions were impaired in BD I; and voluntary attention during Disgust, Happiness, Erotica and Neutral conditions was impaired in BD II. Our study illustrates different patterns of visual attentional deficits associated with different external emotional stimuli in BD I and BD II.

Sleep Disturbance in Bipolar Disorder: Neuroglia and Circadian Rhythms

The worldwide prevalence of sleep disorders is approximately 50%, with an even higher occurrence in a psychiatric population. Bipolar disorder (BD) is a severe mental illness characterized by shifts in mood and activity. The BD syndrome also involves heterogeneous symptomatology, including cognitive dysfunctions and impairments of the autonomic nervous system. Sleep abnormalities are frequently associated with BD and are often a good predictor of a mood swing. Preservation of stable sleep-wake cycles is therefore a key to the maintenance of stability in BD, indicating the crucial role of circadian rhythms in this syndrome. The symptom most widespread in BD is insomnia, followed by excessive daytime sleepiness, nightmares, difficulty falling asleep or maintaining sleep, poor sleep quality, sleep talking, sleep walking, and obstructive sleep apnea. Alterations in the structure or duration of sleep are reported in all phases of BD. Understanding the role of neuroglia in BD and in various aspects of sleep is in nascent state. Contributions of the different types of glial cells to BD and sleep abnormalities are discussed in this paper.

Psychomotor agitation in subjects hospitalized for an acute exacerbation of Schizophrenia

The aims of this study were to establish the prevalence of moderate and severe psychomotor agitation in patients hospitalized for an active phase of schizophrenia, the associations between psychomotor agitation and patients' demographic and clinical variables, the intra-individual stability of the agitated/non-agitated dichotomy in independent psychotic breakdowns. The study was performed on a database relative to 630 inpatients hospitalized with a diagnosis of schizophrenia. Psychomotor agitation was measured with the Positive and Negative Syndrome Scale - Excited Component (PANSS-EC). Prevalence of moderate and severe psychomotor agitation was 40.5% and 23.7%, respectively. Non-agitated patients were older, with longer illness history and duration of untreated psychosis, were more frequently on antipsychotic medication, had lower incidence of recent use of substances, and functioned better before the index hospitalization than moderately and/or severely agitated patients. Non-agitated patients had lower scores for total PANSS and Emsley's positive and anxiety dimensions. Compared with the severely agitated group, non-agitated and moderately agitated patients scored more in Emsley's depression dimension. Poor functioning before index hospital admission, higher scores for negative subscale and Emsley's positive dimension and use of substances exerted an effect on risk of psychomotor agitation.

Clinical characteristics of patients with bipolar disorder and premorbid traumatic brain injury: a cross-sectional study

BACKGROUND

About one in ten diagnosed with bipolar disorder (BD) has experienced a premorbid traumatic brain injury (TBI), while not fulfilling the criteria of bipolar and related disorder due to another medical condition (BD due to TBI). We investigated whether these patients have similar clinical characteristics as previously described in BD due to TBI (i.e. more aggression and irritability and an increased hypomania/mania:depression ratio) and other distinct clinical characteristics.

METHODS

Five hundred five patients diagnosed with BD type I, type II, or not otherwise specified, or cyclothymia were interviewed about family, medical, and psychiatric history, and assessed with the Young Mania Rating Scale (YMRS) and the Inventory of Depressive Symptoms Clinician Rated 30 (IDS-C₃₀). Principal component analyses of YMRS and IDS-C₃₀ were conducted. Bivariate analyses and logistic regression analyses were used to compare clinical characteristics between patients with (n = 37) and without (n = 468) premorbid TBI.

RESULTS

Premorbid TBI was associated with a higher YMRS disruptive component score (OR 1.7, 95% CI 1.1-2.4, p = 0.0077) and more comorbid migraine (OR 4.6, 95% CI 1.9-11, p = 0.00090) independently of several possible confounders. Items on disruptive/aggressive behaviour and irritability had the highest loadings on the YMRS disruptive component. Premorbid TBI was not associated with an increased hypomania/mania:depression ratio.

CONCLUSIONS

Disruptive symptoms and comorbid migraine characterize BD with premorbid TBI. Further studies should examine whether the partial phenomenological overlap with BD due to TBI could be explained by a continuum of pathophysiological effects of TBI across the diagnostic dichotomy. Trial registration ClinicalTrials.gov: NCT00201526. Registered September 2005 (retrospectively registered).

Circadian rhythm in bipolar disorder: A review of the literature

Sleep disturbances and circadian rhythm dysfunction have been widely demonstrated in patients with bipolar disorder (BD). Irregularity of the sleep-wake rhythm, eveningness chronotype, abnormality of melatonin secretion, vulnerability of clock genes, and the irregularity of social time cues have also been well-documented in BD. Circadian rhythm dysfunction is prominent in BD compared with that in major depressive disorders, implying that circadian rhythm dysfunction is a trait marker of BD. In the clinical course of BD, the circadian rhythm dysfunctions may act as predictors for the first onset of BD and the relapse of mood episodes. Treatments focusing on sleep disturbances and circadian rhythm dysfunction in combination with pharmacological, psychosocial, and chronobiological treatments are believed to be useful for relapse prevention. Further studies are therefore warranted to clarify the relation between circadian rhythm dysfunction and the pathophysiology of BD to develop treatment strategies for achieving recovery in BD patients.

Cerebral processing of facial emotions in bipolar I and II disorders: An event-related potential study

BACKGROUND

Behavioral results have shown that bipolar disorder patients have impaired recognition of facial emotions, but the detailed information processing of facial emotions in patients with bipolar I (BD I) and II (BD II) disorders remain unknown.

METHODS

We tested the cerebral event-related potentials to the static facial expressions of Neutral, Happiness, Anger and Sadness in 39 adult patients with BD I, 22 BD II, and 54 healthy volunteers. Participants' affective states were measured with the Mood Disorder Questionnaire, the Hypomania Checklist-32, and the Plutchik-van Praag Depression Inventory.

RESULTS

Over-processed right occipitotemporal cortex during N1 time window to Neutral and Happiness, and during P3b window to Sadness were found in BD I; prolonged N1 latencies to Neutral and Happiness, declined P3b amplitude to Sadness, negative correlation between P3b latency to Sadness and depression, and attenuated superior frontal activity during P3b window to Sadness were found in BD II; and the right-side dominance during facial emotion processing were found in both BD I and BD II.

LIMITATIONS

We didn't record the personality traits or medication used in patients, nor included other facial emotions such as fear and disgust.

CONCLUSIONS

When responding to facial emotions, both BD I and BD II showed a right-side processing dominance; BD I displayed enhanced processing in the right occipitotemporal cortex during structural encoding and categorical processing of facial emotions; while BD II displayed generalized impairments, less involvement of superior frontal cortex to negative emotions, and reduced ability to process negative emotions which was associated with depression.

Psychopathological Features of Bipolar Depression: Italian Validation of the Bipolar Depression Rating Scale (I-BDRS)

Background: Aim of the study was the validation of the Bipolar Disorder Rating Scale (BDRS) in an Italian population. Secondary aim was the evaluation of differences between unipolar and bipolar depression and between bipolar I and II depressed patients.

Method: 125 Bipolar Disorder and 60 Major Depressive Disorder patients were administered an Italian translation of the BDRS (I-BDRS), Hamilton Depression Rating Scale (HDRS), Montgomery-Asberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS) and Temperament and Character Inventory-Revised (TCI-R).

Results: I-BDRS showed considerable validity and reliability. Factor analysis found 3 subscales, two linked to depressive symptoms and one to mixed symptoms. Measures concerning depression (MADRS and HAM-D) were positively related to the I-BDRS's subscales, but mostly to the two subscales measuring depression. In mixed symptoms, the mean of the bipolar group was significantly higher than the unipolar group suggesting that the BDRS was able to distinguish between unipolar and bipolar depressed patients.

Conclusion: I-BDRS is a valid scale for the measurement of depression in BD patients, with a notable internal consistency (Cronbach's α 0.82), a significant consistency between items/total (Cronbach's α from 0.80 to 0.82) and positive correlation with other scales (MADRS r = 0.67, p < 0.001; HDRS r = 0.81, p < 0.001; YMRS r = 0.46 p < 0.0001). The mixed state sub-scale shows usefulness in differentiating bipolar from unipolar patients. I-BDRS could be a sensitive tool, both in pure depression and in mixed states, and could be used in the everyday screening and treatment of Bipolar Disorder.

Electrocardiographic and Electrooculographic Responses to External Emotions and Their Transitions in Bipolar I and II Disorders

Bipolar disorder has two main types, bipolar I (BD I) and II (BD II), which present different affective states and personality characteristics, they might present different modes of emotional regulation. We hypothesized that the electrocardiogram and electrooculogram to external emotions are different in BD I and BD II. We asked 69 BD I and 54 BD II patients, and 139 healthy volunteers to undergo these tests in response to disgust, erotica, fear, happiness, neutral, and sadness, and their transitions. Their affective states were also measured. The heart rate in BD I was significantly higher under background fear after target neutral. The eyeball movement was quicker in BD I under target happiness after background disgust; in BD I under target sadness after background disgust; and in BD I under background disgust after target neutral. Some electrocardiographic and electrooculographic changes were correlated with affective states in patients. BD I and BD II had different physiological responses to external emotions and their transitions, indicating different pathophysiologies and suggesting different emotional-therapies for BD I and BD II.

Subjective and objective sleep discrepancy in symptomatic bipolar disorder compared to healthy controls

BACKGROUND

Bipolar disorder (BD) is associated with sleep misperception. The objective of this study was to investigate the correlation between subjective and objective measures of sleep in persons with symptomatic bipolar disorder (BDS) compared to healthy controls (HC).

METHODS

We studied 24 BDS and 30 HC subjects similar in age, race and sex. Subjective sleep was measured with Pittsburgh Sleep Quality Index (PSQI) and objective sleep with 7-days of actigraphy. Absolute discrepancy variables were calculated by subtracting objective sleep latency (SL) and total sleep time (TST) on actigraphy from their respective subjective estimates from PSQI. Mood symptoms were measured with Young Mania Rating Scale and Hamilton Depression Rating Scale.

RESULTS

In the BDS group, subjective TST did not significantly correlate with objective TST, while it correlated in the HC group. The BDS group had significantly higher absolute discrepancy between subjective and objective SL and TST compared to the HC group. Multivariable regression analysis showed that severity of depression was associated with greater absolute discrepancy between subjective and objective TST within the BDS group.

LIMITATIONS

Subjects are from a tertiary care center and were on medications for treatment of BD symptoms.

CONCLUSION

There is low correlation between subjective and objective TST in BDS subjects and more severe depressive symptoms are associated with greater absolute discrepancy in TST. Objective rather than subjective measures of sleep, such as actigraphy, may be needed to evaluate sleep in BD subjects. Cognitive-behavioral interventions to address sleep misperception and associated depressed mood may be indicated in BD.

Hypnotic susceptibility and affective states in bipolar I and II disorders

BACKGROUND

Highly hypnotizable individuals have impaired executive function, elevated motor impulsivity and increased emotional sensitivity, which are sometimes found in bipolar disorder patients. It is then reasonable to assume that certain aspects of hypnotic susceptibility differ with the types of bipolar disorder.

METHODS

The Stanford Hypnotic Susceptibility Scale: Form C (SHSS:C) test, the Mood Disorder Questionnaire (MDQ), the Hypomanic Checklist-32 (HCL-32) and the Plutchick-van Praag Depression Inventory (PVP) were applied to 62 patients with bipolar I disorder, 33 bipolar II disorder, and 120 healthy volunteers.

RESULTS

The passing rate of the SHSS:C 'Moving hands apart' item was higher in bipolar I patients than in controls, whereas for 'Mosquito hallucination' the rate was lower. Bipolar I and II patients scored significantly higher on MDQ, HCL-32 and PVP scales than controls. The passing rates of 'Mosquito hallucination' in controls, 'Arm rigidity' in bipolar I, and 'Age regression' in bipolar II predicted the respective MDQ scores.

CONCLUSION

In contrast to cognitive suggestions, bipolar I patients followed motor suggestions more often under hypnosis. Furthermore, both bipolar disorder patients and healthy volunteers demonstrated associations between mania levels and certain hypnotic susceptibility features. Our study aids in better understanding the altered conscious states in bipolar disorders, and encourages the use of related psychotherapy for these patients.

Measures of the DSM-5 mixed-features specifier of major depressive disorder

During the past two decades, a number of studies have found that depressed patients frequently have manic symptoms intermixed with depressive symptoms. While the frequency of mixed syndromes are more common in bipolar than in unipolar depressives, mixed states are also common in patients with major depressive disorder. The admixture of symptoms may be evident when depressed patients present for treatment, or they may emerge during ongoing treatment. In some patients, treatment with antidepressant medication might precipitate the emergence of mixed states. It would therefore be useful to systematically inquire into the presence of manic/hypomanic symptoms in depressed patients. We can anticipate that increased attention will likely be given to mixed depression because of changes in the DSM-5. In the present article, I review instruments that have been utilized to assess the presence and severity of manic symptoms and therefore could be potentially used to identify the DSM-5 mixed-features specifier in depressed patients and to evaluate the course and outcome of treatment. In choosing which measure to use, clinicians and researchers should consider whether the measure assesses both depression and mania/hypomania, assesses all or only some of the DSM-5 criteria for the mixed-features specifier, or assesses manic/hypomanic symptoms that are not part of the DSM-5 definition. Feasibility, more so than reliability and validity, will likely determine whether these measures are incorporated into routine clinical practice.

The International College of Neuropsychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 1: Background and Methods of the Development of Guidelines

BACKGROUND

This paper includes a short description of the important clinical aspects of Bipolar Disorder with emphasis on issues that are important for the therapeutic considerations, including mixed and psychotic features, predominant polarity, and rapid cycling as well as comorbidity.

METHODS

The workgroup performed a review and critical analysis of the literature concerning grading methods and methods for the development of guidelines.

RESULTS

The workgroup arrived at a consensus to base the development of the guideline on randomized controlled trials and related meta-analyses alone in order to follow a strict evidence-based approach. A critical analysis of the existing methods for the grading of treatment options was followed by the development of a new grading method to arrive at efficacy and recommendation levels after the analysis of 32 distinct scenarios of available data for a given treatment option.

CONCLUSION

The current paper reports details on the design, method, and process for the development of CINP guidelines for the treatment of Bipolar Disorder. The rationale and the method with which all data and opinions are combined in order to produce an evidence-based operationalized but also user-friendly guideline and a specific algorithm are described in detail in this paper.

Polysomnographic characteristics of bipolar hypomanic patients: Comparison with unipolar depressed patients

BACKGROUND

Sleep profile in bipolar disorder has received little attention in comparison to sleep studies in major depressive disorders. Specific sleep abnormalities especially in REM sleep parameters have been detected in depression. The current study aimed at investigating whether bipolar disorder shares the same polysomnographic (PSG) changes or not.

METHODS

All night polysomnographic assessments were made for 20 patients diagnosed to have hypomania, in addition to 20 patients with major depression and 20 healthy matched controls. All participants were examined using Standardized Sleep Questionnaire, SCID-I for psychiatric diagnosis, based on DSM-IV criteria, YMRS (for hypomanic patients), HAMD (for major depression patients), and all-night polysomnography (for all subjects).

RESULTS

The two patient groups differed significantly from controls in their sleep profile, especially regarding sleep continuity measures, Short REML (Rapid Eye Movement Latency), with increased REMD (Rapid Eye Movement sleep density). High similarity was found in EEG sleep profile of the two patient groups, though the changes were more robust in patients with depression

LIMITATIONS

A relatively small sample size, the absence of follow up assessment, lack of consideration of other variables like body mass index, nicotine and caffeine intake.

CONCLUSION

Similarity in EEG sleep profile between Bipolar disorder patients and patients with major depression suggests a common biological origin for both conditions, with the difference being "quantitative" rather than "qualitative". This quantitative difference in sleep efficiency and SWS (Slow wave sleep), being higher in hypomania, might explain the rather "refreshing" nature of sleep in hypomanic patients, compared to depression.

Mixed depression: clinical features and predictors of its onset associated with antidepressant use

BACKGROUND

Mixed depression (MxD) is narrowly defined in the DSM-IV and somewhat broader in the DSM-5, although both exclude psychomotor agitation as a diagnostic criterion. This article proposes a clinical description for defining MxD, which emphasizes psychomotor excitation.

METHODS

Two hundred and nineteen consecutive outpatients were diagnosed with an MxD episode using criteria proposed by Koukopoulos et al. [Acta Psychiatr Scand 2007;115(suppl 433):50-57]; we here report their clinical features and antidepressant-related effects.

RESULTS

The most frequent MxD symptoms were: psychic agitation or inner tension (97%), absence of retardation (82%), dramatic description of suffering or weeping spells (53%), talkativeness (49%), and racing or crowded thoughts (48%). MxD was associated with antidepressants in 50.7% of patients, with similar frequency for tricyclic antidepressants (45%) versus selective serotonin reuptake inhibitors (38.5%). Positive predictors of antidepressant-associated MxD were bipolar disorder type II diagnosis, higher index depression severity, and higher age at index episode. Antipsychotic or no treatment was protective against antidepressant-associated MxD.

CONCLUSIONS

MxD, defined as depression with excitatory symptoms, can be clinically identified, is common, occurs in both unipolar depression and bipolar disorder, and is frequently associated with antidepressant use. If replicated, this view of MxD could be considered a valid alternative to the DSM-5 criteria for depression with mixed features.

The Zuckerman-Kuhlman personality questionnaire in bipolar I and II disorders: a preliminary report

Patients with bipolar disorder have tendencies of higher impulsivity and sensation seeking, they might contribute differently to the emotional states of bipolar I (BD I) and II (BD II). We administered the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ), the Plutchik-van Praag Depression Inventory (PVP), the Mood Disorder Questionnaire (MDQ), and the Hypomania Checklist (HCL-32) in 23 patients with BD I, 22 BD II, and 64 healthy volunteers. Both BD I and II scored higher on ZKPQ Impulsive sensation seeking (and its Impulsivity facet), Neuroticism-anxiety and Aggression-hostility, and on PVP and HCL-32 scales than controls did; BD I scored higher on MDQ and General sensation seeking facet than controls did. Compared to BD II, BD I scored higher on Impulsive sensation seeking (and General sensation seeking) and on MDQ. Moreover, General sensation seeking predicted MDQ, and Activity predicted HCL-32 in BD I. Aggression-hostility predicted HCL-32 in BD II. General sensation seeking predicted MDQ and HCL-32, and together with Neuroticism-anxiety, predicted PVP in controls. Our study suggests that Impulsive sensation seeking, and its General sensation seeking facet might help to delineate the two types of bipolar disorder.

Transcultural adaption and validation of the Spanish version of the Bipolar Depression Rating Scale (BDRS-S)

BACKGROUND

The Bipolar Depression Rating Scale (BDRS) arguably better captures symptoms in bipolar depression especially depressive mixed states than traditional unipolar depression rating scales. The psychometric properties of the Spanish adapted version, BDRS-S, are reported.

METHODS

The BDRS was translated into Spanish by two independent psychiatrists fluent in English and Spanish. After its back-translation into English, the BDRS-S was administered to 69 DSMI-IV bipolar I and II patients who were recruited from two Spanish psychiatric hospitals. The Hamilton Depression Rating Scale (HDRS), the Montgomery-Asberg Depression Rating Scale (MADRS) and the Young Mania Rating Scale (YMRS) were concurrently administered. 42 patients were reviewed via video by four psychiatrists blind to the psychopathological status of those patients. In order to assess the BDRS-S intra-rater or test-retest validity, 22 subjects were assessed by the same investigator performing two evaluations within five days.

RESULTS

The BDRS-S had a good internal consistency (Cronbach׳s α=0.870). We observed strong correlations between the BDRS-S and the HDRS (r=0.874) and MADRS (r=0.854) and also between the mixed symptom cluster score of the BDRS-S and the YMRS (r=0.803). Exploratory factor analysis revealed a three factor solution: psychological depressive symptoms cluster, somatic depressive symptoms cluster and mixed symptoms cluster.

LIMITATIONS

A relatively small sample size for a 20-item scale.

CONCLUSIONS

The BDRS-S provides solid psychometric performance and in particular captures depressive or mixed symptoms in Spanish bipolar patients.

A clinically useful self-report measure of the DSM-5 mixed features specifier of major depressive disorder

BACKGROUND

To acknowledge the clinical significance of manic features in depressed patients, DSM-5 included criteria for a mixed features specifier for major depressive disorder (MDD). In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we modified our previously published depression scale to include a subscale assessing the DSM-5 mixed features specifier.

METHODS

More than 1100 psychiatric outpatients with MDD or bipolar disorder completed the Clinically Useful Depression Outcome Scale (CUDOS) supplemented with questions for the DSM-5 mixed features specifier (CUDOS-M). To examine discriminant and convergent validity the patients were rated on clinician severity indices of depression, anxiety, agitation, and irritability. Discriminant and convergent validity was further examined in a subset of patients who completed other self-report symptom severity scales. Test-retest reliability was examined in a subset who completed the CUDOS-M twice. We compared CUDOS-M scores in patients with MDD, bipolar depression, and hypomania.

RESULTS

The CUDOS-M subscale had high internal consistency and test-retest reliability, was more highly correlated with another self-report measure of mania than with measures of depression, anxiety, substance use problems, eating disorders, and anger, and was more highly correlated with clinician severity ratings of agitation and irritability than anxiety and depression. CUDOS-M scores were significantly higher in hypomanic patients than depressed patients, and patients with bipolar depression than patients with MDD.

LIMITATIONS

The study was cross-sectional, thus we did not examine whether the CUDOS-M detects emerging mixed symptoms when depressed patients are followed over time. Also, while we examined the correlation between the CUDOS-M and clinician ratings of agitation and irritability, we did not examine the association with a clinician measure of manic symptomatology such as the Young Mania Rating Scale

CONCLUSIONS

In the present study of a large sample of psychiatric outpatients, the CUDOS-M was a reliable and valid measure of the DSM-5 mixed features specifier for MDD.

The significance of mixed states in depression and mania

The DSM-5 definition of mixed features "specifier" of manic, hypomanic and major depressive episodes captures sub-syndromal non-overlapping symptoms of the opposite pole, experienced in bipolar (I, II, and not otherwise specified) and major depressive disorders. This combinatory model seems to be more appropriate for less severe forms of mixed state, in which mood symptoms are prominent and clearly identifiable. Sub-syndromal depressive symptoms have been frequently reported to co-occur during mania. Similarly, manic or hypomanic symptoms during depression resulted common, dimensionally distributed, and recurrent. The presence of mixed features has been associated with a worse clinical course and high rates of comorbidities including anxiety, personality, alcohol and substance use disorders and head trauma or other neurological problems. Finally, mixed states represent a major therapeutic challenge, especially when you consider that these forms tend to have a less favorable response to drug treatments and require a more complex approach than non-mixed forms.

A multinational study to pilot the modified Hypomania Checklist (mHCL) in the assessment of mixed depression

BACKGROUND

Mixed depression is a common, dimensional phenomenon that is increasingly recognized in unipolar and bipolar disorders. We piloted a modified version of the Hypomania Checklist (mHCL-32) to assess the prevalence and clinical correlates of concurrent manic (hypo) symptoms in depressed patients.

METHODS

The mHCL-32, Young Mania Rating Scale (YMRS) and Hamilton Rating Scale for Depression (HAMD-24) were utilized in the assessment of unipolar (UP=61) and bipolar (BP=44) patients with an index major depressive episode confirmed by the Structured Clinical Interview for DSM-IV (SCID). Differential mHLC-32 item endorsement was compared between UP and BP. Correlation analyses assessed the association of symptom dimensions measured by mHCL-32, YMRS and HAMD-24.

RESULTS

There was no significant difference between mood groups in the mean mHCL-32 and YMRS scores. Individual mHLC-32 items of increased libido, quarrels, and caffeine intake were endorsed more in BP vs. UP patients. The mHCL-32 active-elevated subscale score was positively correlated with the YMRS in BP patients and negatively correlated with HAMD-24 in UP patients. Conversely, the mHCL-32 irritable-risk taking subscale score was positively correlated with HAMD-24 in BP and with YMRS in UP patients.

LIMITATIONS

Small sample size and cross-sectional design.

CONCLUSION

Modifying the HCL to screen for (hypo) manic symptoms in major depression may have utility in identifying mixed symptoms in both bipolar vs. unipolar depression. Further research is encouraged to quantify mixed symptoms with standardized assessments.

Differentiating bipolar I and II disorders and the likely contribution of DSM-5 classification to their cleavage

Current diagnostic criteria define bipolar I (BP I) and bipolar II (BP II) disorders as distinct conditions, differing only slightly by clinical features. This review seeks to identify commonalities and differentiating features across the two sub-types, and emphasize that differences in causes and treatments are likely to be highly dependent on the diagnostic criteria used to define and differentiate the two conditions. We undertake a literature review of candidate clinical features that might be anticipated to vary or be shared across BP I and BP II disorders, and consider the impact of DSM definition on such applied findings. Studies respecting DSM-IV differentiation of BP I and BP II disorders have generated relatively few differences across the conditions, which may reflect definitional similarity or commonalities across the two conditions. As DSM-5 decision rules are similar to those used by DSM-IV to differentiate BP I and BP II disorders, we argue for application studies employing DSM-5 decisions to examine the differential impact of three features that weight BP I assignment (i.e. psychosis, hospitalization and/or impairment) and examine other sets of differentiating criteria.

Significant sleep disturbances in euthymic bipolar patients

OBJECTIVE

A growing amount of data suggests that sleep dysfunction is frequently observed in bipolar disorder (BD) patients even when they do not fulfill the criteria for major mood episodes. Thus, we performed a case-control study assessing sleep status in a group of euthymic BD patients and a group of health controls.

METHODS

A total of 209 subjects (104 health controls and 105 BD patients) were enrolled in the study. The Pittsburgh Sleep Quality Index (PSQI) was used for sleep assessment. Inclusion criteria for the BD group were a diagnosis of BD, following DSM-IV-TR criteria, according to the MINI-plus structured clinical interview. Euthymia was established as a score lower than 7 both in the Hamilton Depression Rating Scale (HDRS) and in the Young Mania Rating Scale (YMRS). Health controls were also interviewed using the MINI-plus and included in this study if they were free of any current or past DSM-IV-TR axis I psychiatric disorder as well the actual use of psychopharmacological medications.

RESULTS

While 21.2 % of the control group displayed poor sleep quality according to the global PSQI-BR score, 82.9 % of the euthymic BD patients had poor sleep quality (p=0.000). PSQI sleep duration subcomponent showed comparable results in the two groups (p=0.535), even though BD patients had significant disruptions in sleep latency (p=0.000) and sleep efficiency (p=0.000) subcomponents.

CONCLUSION

We were able to show that BD patients, even in euthymic phase, exhibit a significantly worse sleep quality as compared with health controls as assessed by PSQI total score and five of its seven subcomponents.

High-risk behaviour in hypomanic states

BACKGROUND

Risk-taking behaviours during hypomanic states are recognised, however the high-risk nature of some behaviours-including the potential for harm to both the individual and others-has not been detailed in the research literature. The current study examines risk-taking behaviours and their consequences (including their potential for impairment) in those with a bipolar II condition.

METHOD

Participants were recruited from the Sydney-based Black Dog Institute Depression Clinic. Diagnostic assignment of bipolar II disorder was based on clinician judgement and formal DSM-IV criteria. Participants completed a series of detailed questions assessing previous risk-taking behaviours during hypomanic states.

RESULTS

The sample comprised a total of 93 participants. Risk-taking behaviours during hypomania included spending significant amounts of money, excessive alcohol or drug use, dangerous driving and endangering sexual activities. Key consequences included interpersonal conflict, substantial financial burden and feelings of guilt, shame and remorse. Despite recognition of the risks and consequences associated with hypomanic behaviours, less than one-fifth of participants agreed that hypomania should be treated because of the associated risks.

LIMITATIONS

Study limitations included a cross-sectional design, reliance on self-report information, lack of controlling for current mood state, and comprised a tertiary referral sample that may be weighted to more severe cases. Findings may therefore not be generalisable and require replication.

CONCLUSIONS

Risk-taking behaviours during hypomania are common, and often linked with serious consequences. Whilst hypomania is often enjoyed and romanticised by patients-leading to ambivalence around treatment of such states-careful consideration of the impact of risk-taking behaviour is necessary, while the study raises the question as to what is 'impairment' in hypomania. Findings should advance clinical management by identifying those high-risk behaviours that would benefit from pre-emptive weighting in developing individual's wellbeing plans for managing the condition.

Clinical differences between unipolar and bipolar depression: interest of BDRS (Bipolar Depression Rating Scale)

OBJECTIVES

It is currently assumed that there are no important differences between the clinical presentations of unipolar and bipolar depression. Failure to distinguish bipolar from unipolar depression may lead to inappropriate treatment and poorer outcomes. We hereby compare unipolar and bipolar depressed subjects, in order to identify distinctive clinical specificities of bipolar depression.

METHODS

Two independent samples of depressed patients (unipolar and bipolar) were recruited, with 55 patients in one sample, and 49 in the other. In both samples, unipolar and bipolar patients were compared on a broad range of parameters, including sociodemographic characteristics, comorbidities, Montgomery and Asberg Depression Scale (MADRS; assessing depression severity), CORE (assessing psychomotor disturbance) and Bipolar Depression Rating Scale (assessing specific bipolar depression symptoms).

RESULTS

Results were similar in both samples. MADRS scores were similar in bipolar and unipolar subjects (median score 33 vs 34; p=0.74). On the CORE, there was a trend to higher scores among the bipolar subjects. BDRS scores were higher in bipolar than in unipolar subjects (median score 33 vs 27; p<0.001). The difference was particularly marked on the "mixed" subscale of the BDRS. We tested the ability of the mixed subscale of the BDRS to distinguish bipolar from unipolar depression, using different cut off points: a cut off point of 3 can predict bipolar depression, with a sensibility of 62% and a specificity of 82%.

CONCLUSIONS

Presence of mixed symptoms during a depressive episode is in favour of bipolar depression. The BDRS scale should be integrated in a probabilistic approach to distinguish bipolar from unipolar 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.

A predictive model for diagnosing bipolar disorder based on the clinical characteristics of major depressive episodes in Chinese population

BACKGROUND

A correct timely diagnosis of bipolar depression remains a big challenge for clinicians. This study aimed to develop a clinical characteristic based model to predict the diagnosis of bipolar disorder among patients with current major depressive episodes.

METHODS

A prospective study was carried out on 344 patients with current major depressive episodes, with 268 completing 1-year follow-up. Data were collected through structured interviews. Univariate binary logistic regression was conducted to select potential predictive variables among 19 initial variables, and then multivariate binary logistic regression was performed to analyze the combination of risk factors and build a predictive model. Receiver operating characteristic (ROC) curve was plotted.

RESULTS

Of 19 initial variables, 13 variables were preliminarily selected, and then forward stepwise exercise produced a final model consisting of 6 variables: age at first onset, maximum duration of depressive episodes, somatalgia, hypersomnia, diurnal variation of mood, irritability. The correct prediction rate of this model was 78% (95%CI: 75%-86%) and the area under the ROC curve was 0.85 (95%CI: 0.80-0.90). The cut-off point for age at first onset was 28.5 years old, while the cut-off point for maximum duration of depressive episode was 7.5 months.

LIMITATIONS

The limitations of this study include small sample size, relatively short follow-up period and lack of treatment information.

CONCLUSION

Our predictive models based on six clinical characteristics of major depressive episodes prove to be robust and can help differentiate bipolar depression from unipolar depression.

Differences between bipolar I and bipolar II disorders in clinical features, comorbidity, and family history

BACKGROUND

The present study was designed to investigate whether bipolar II disorder (BP-II) has different characteristics from bipolar I disorder (BP-I), not only in manic severity but also in clinical features, prior course, comorbidity, and family history, sufficiently enough to provide its nosological separation from BP-I.

METHODS

Comprehensive clinical evaluation was performed based on information available from ordinary clinical settings. Seventy-one BP-I and 34 BP-II patients were assessed using the Diagnostic Interview for Genetic Studies, Korean version. Psychiatric assessment for first-degree relatives (n=374) of the probands was performed using the modified version of the Family History-Research Diagnostic Criteria.

RESULTS

The frequency of depressive episodes was higher in BP-II (p=0.009) compared to BP-I. Further, seasonality (p=0.035) and rapid-cycling course (p=0.062) were more common in BP-II. Regarding manic expression, 'elated mood' was predominant in BP-II whereas 'elated mood' and 'irritable mood' were equally prevalent in BP-I. With regard to depressive symptoms, psychomotor agitation, guilty feeling, and suicidal ideation were more frequently observed in BP-II. BP-II patients exhibited a higher trend of lifetime co-occurrence of an axis I diagnosis (p=0.09), and a significantly higher incidence of phobia and eating disorder. The overall occurrence rate of psychiatric illness in first-degree relatives was 15.4% in BP-I and 26.5% in BP-II (p=0.01). Major depression (p=0.005) and substance-related disorder (p=0.051) were more prevalent in relatives of BP-II probands.

CONCLUSION

Distinctive characteristics of BP-II were identified in the current study and could be adopted to facilitate the differential diagnosis of BP-I and BP-II in ordinary clinical settings.

Lay theories of bipolar disorder: the causes, manifestations and cures for perceived bipolar disorder

This study aimed to investigate lay theories of the cause and treatment of bipolar disorder, and the recognition of its symptoms. This questionnaire-based study included vignette descriptions of mental disorders and 70 items relating to bipolar disorder. It was completed by 173 participants. Bipolar disorder was recognized less than depression but at the same rate as schizophrenia. Contrary to previous research, analysis showed that lay beliefs of the causes of bipolar disorder generally concur with scientific academic theories. Drug treatment was favoured as a cure rather than psychotherapy. Theories of cause and treatment were logically correlated. Overall, the results suggest that lay people have reasonably informed beliefs about the causes and treatments of bipolar disorder, however recognition of the symptoms is poor.

Phenomenology of racing and crowded thoughts in mood disorders: a theoretical reappraisal

BACKGROUND

Racing thoughts is a frequent symptom in mood disorders, particularly mixed depressive states. This paper aims to summarize our current knowledge about its phenomenology and frequency in the spectrum of mood disorders, and to offer a new theoretical framework.

METHODS

We made a selective review of original and review papers in Medline and PsychInfo database using the keywords "racing thoughts", "crowded thoughts" and "depressive mixed state" in conjunction with "mood disorders".

RESULTS

In the context of a hypomanic state, "racing thoughts" may appear as a result from an excessive production of thoughts, moving quickly from one to the other, and generating a sense of fluidity and pleasantness. In the context of depression, "racing thoughts" are phenomenologically different and better described as "crowded thoughts": they are not only characterized by too many thoughts occurring at the same time in the field of consciousness, but perceived as unpleasant and induce the feeling that ideas are difficult to catch. DISCUSSION AND CLINICAL RELEVANCE: We suggest that crowded thoughts might result from the mixture of a hypomanic component, with an accelerated production of new thoughts (constituting the main source of this symptom in hypomania), and a depressive component, with a deficit of inhibition of previous thoughts (hence making thoughts crowded rather than truly racing). This distinction could help better identify crowded thoughts, and consequently depressive mixed states, which has important implications for therapeutic management. It might also help to further disentangle the psychobiological processes which contribute to the complexity of mood disorders.

Sleep Disturbance in Bipolar Disorder Across the Lifespan

The aim of this article is to highlight the importance of the sleep-wake cycle in children, adolescents, and adults with bipolar disorder. After reviewing the evidence that has accrued to date on the nature and severity of the sleep disturbance experienced, we document the importance of sleep for quality of life, risk for relapse, affective functioning, cognitive functioning, health (sleep disturbance is implicated in obesity, poor diet, and inadequate exercise), impulsivity, and risk taking. We argue that sleep may be critically important in the complex multifactorial cause of interepisode dysfunction, adverse health outcomes, and relapse. An agenda for future research is presented that includes improving the quality of sleep measures and controlling for the impact of bipolar medications.

Resting energy expenditure in manic episode

OBJECTIVE

We aimed to assess the resting energy expenditure in bipolar I disorder, manic episode patients.

METHOD

Forty-two bipolar I disorder, manic episode patients that were treated in the inpatient psychiatry clinic of Trakya University Hospital and had met the necessary study criteria were included along with 27 controls. DSM-IV criteria and the Bech-Rafaelsen Mania Rating Scale were used to evaluate patients' diagnosis and severity of the manic episodes. The indirect calorimetry device was used to measure resting energy expenditure values.

RESULTS

Resting energy expenditure values of manic patients were found to be higher than those of the controls. Controls showed significant correlations between body mass index and resting energy expenditure, but manic patients did not exhibit similar correlations. There was also no relation between Bech-Rafaelsen Mania Rating Scale scores and resting energy expenditure values in manic patients.

CONCLUSIONS

We found significantly increased resting energy expenditure values in bipolar I disorder, manic episode patients. These findings suggest a possible clinical use of resting energy expenditure for evaluation of bipolar I disorder manic episode and also suggest resting energy expenditure as a possible biological marker.

Decision making in bipolar disorder: a cognitive modeling approach

A formal modeling approach was used to characterize decision-making processes in bipolar disorder. Decision making was examined in 28 bipolar patients (14 acute and 14 remitted) and 25 controls using the Iowa Gambling Task (Bechara et al., 1994), a decision-making task used for assessing cognitive impulsivity. To disentangle motivational and cognitive aspects of decision-making processes, we applied a formal cognitive model to the performance on the Iowa Gambling Task. The model has three parameters: The relative impact of rewards and punishments on evaluations, the impact of recent and past payoffs, and the degree of choice consistency. The results indicated that acute bipolar patients were characterized by low choice consistency, or a tendency to make erratic choices. Low choice consistency improved the prediction of acute bipolar disorder beyond that provided by cognitive functioning and self-report measures of personality and temperament.

Validation of the Mood Disorder Questionnaire for screening for bipolar disorder in a UK sample

BACKGROUND

The Mood Disorder Questionnaire (MDQ) was designed as a screening questionnaire for bipolar disorder. Previous research has raised questions about the suitability of the MDQ structure for screening for bipolar II disorder. This study investigated the optimal sensitivity and specificity cut-off thresholds for the MDQ in bipolar I and bipolar II patients in a UK sample.

METHODS

The MDQ was administered to patients before attending a tertiary mood disorders clinic. Diagnostic interviews were used to determine DSM-IV diagnoses and these were used as the gold standard against which to investigate the performance of the MDQ.

RESULTS

54 patients with bipolar spectrum disorder and 73 patients with unipolar depressive disorder completed the MDQ. With the original scoring criteria (symptoms and supplementary questions) the sensitivity for bipolar disorder was 0.76 (bipolar I disorder 0.83, bipolar II disorder 0.67) with specificity 0.86. The optimal cut-off score in the current sample was a score of 9 or more endorsed symptoms without applying the supplementary questions (sensitivity of 0.90 and 0.88 for bipolar I and bipolar II groups respectively with a specificity of 0.90).

LIMITATIONS

The sample was drawn from a tertiary mood disorders clinic.

CONCLUSIONS

The MDQ appears to be a useful screening tool for bipolar spectrum disorder in UK psychiatric practice with sensitivity for bipolar II disorder improved by dropping the supplementary sections. Further investigation of the optimal cut-off scores of the MDQ is needed to determine its utility in non-specialist and community based samples.

Antidepressant monotherapy in pre-bipolar depression; predictive value and inherent risk

OBJECTIVE

To identify specific treatment-emergent symptoms in response to antidepressant therapy in depression preceding bipolar disorder.

METHODS

Retrospective chart review of response to antidepressants in "pre-bipolar" depression, compared to a matched unipolar sample.

RESULTS

Family history of completed suicide (p=0.0003) and bipolar disorder (p=0.004) were more common in the pre-bipolar subgroup. Earlier age of onset of diagnosed depression (p=0.005) as well as even earlier episodes of untreated retrospectively diagnosed major depression (p<0.0001) were associated with a future bipolar course. The pre-bipolar group was less likely to respond to antidepressant treatment (p=0.009). Treatment-emergent "mixed" symptoms (two or more symptoms of DSM IV mania, mood lability, irritability/rage with co-existing depression) and in particular, "serious symptoms" (treatment emergent or increased agitation, rage or suicidality) occurred more commonly in the bipolar group. The two variables that best accounted for the between-group differences in logistic regression, were early age at first symptoms of depression and treatment-emergent agitation.

CONCLUSIONS

Family history of completed suicide and/or bipolar disorder, early onset of depressive symptoms as well as treatment-emergent "mixed" symptoms are common in depression preceding the diagnosis of bipolar disorder.

Comparison of short-term venlafaxine versus lithium monotherapy for bipolar II major depressive episode: a randomized open-label study

OBJECTIVE

Practice guidelines for the initial treatment of bipolar II (BP II) major depressive episode (MDE) recommend mood stabilizer (MS) monotherapy or combined MS plus antidepressant drug (AD) therapy. We hypothesized that initial AD monotherapy would be superior to MS monotherapy for BP II MDE with a low hypomanic switch rate.

METHODS

Bipolar II MDE patients were randomized to a 12-week open-label treatment with either venlafaxine monotherapy (n = 43) or lithium carbonate monotherapy (n = 40). The primary outcome measure was the 28-item Hamilton Depression Rating Scale (HAM-D 28). The secondary outcome measures included the Young Mania Rating Scale (YMRS), clinical global impressions severity and change ratings, and the proportion of patients classified as responder (with > or = 50% reduction in baseline HAM-D score) or as remitter (final HAM-D score, < or = 8).

RESULTS

Thirty-four venlafaxine-treated patients (79.1%) and 15 lithium-treated patients (37.5%) completed the trial (P < 0.0005). Venlafaxine monotherapy produced a greater reduction in HAM-D 28 scores, with a difference in change of -6.57 points (95% confidence interval, -11.97 to -1.18) (P = 0.017) between treatment conditions. There was a greater proportion of venlafaxine-treated (vs lithium-treated) patients classified either as treatment responder (58.1% vs 20.0%; P < 0.0005) or as treatment remitter (44.2% vs 7.5%; P < 0.0005) for the HAM-D 28 scores. There was no significant increase in mean YMRS scores over time in the venlafaxine (vs lithium) treatment condition, and no significant increase in mean YMRS scores at any study visit compared with baseline for either treatment.

CONCLUSIONS

Results from this study suggest that AD monotherapy with venlafaxine may be an effective initial therapy for BP II MDE with a low hypomanic switch rate.