The many forms of bipolar disorder: a modern look at an old illness

Estimating the Prevalence of Serious Mental Illness and Dementia Diagnoses Among Medicare Beneficiaries in the Health and Retirement Study

OBJECTIVE

To estimate the prevalence of serious mental illness and dementia among Medicare beneficiaries in the Health and Retirement Study (HRS).

METHODS

This study utilizes HRS-linked Medicare claims data sets and inverse probability weighting to estimate overall and age-specific cumulative prevalence rates of dementia and serious mental illnesses among 18,740 Medicare beneficiaries. Two-way tabulations determine conditional probabilities of dementia diagnoses among beneficiaries diagnosed with specific mental illnesses, and binary logistic regressions determine conditional probabilities of dementia diagnoses among beneficiaries diagnosed with specific mental illnesses, controlling for covariates.

RESULTS

Weighted prevalence estimates for dementia, schizophrenia (SZP), bipolar disorder (BPD), and major depressive disorder (MDD) are similar to previous studies. Odds of dementia diagnosis are significantly greater for beneficiaries diagnosed with SZP, BPD, or MDD.

CONCLUSIONS

Co-occurring mental disabilities require further investigation, as in the near future increasing numbers of mentally ill older adults will need appropriate and affordable community-based services and supports.

Application of Proteomic Techniques for Improved Stratification and Treatment of Schizophrenia Patients

For major psychiatric disorders such as schizophrenia, there have been shortcomings in the translation of scientific findings into new treatments and this has led to diminished interest for large pharmaceutical companies. This chapter describes how incorporation of proteomic approaches into the clinical pipeline can lead to identification and implementation of biomarker tests for improved patient characterization, prediction of treatment response and monitoring treatment effects to help revitalize efforts in this important area. In addition, the construction of specific biomarker tests for disease prediction should smooth the progress of early intervention strategies which, in turn, may help to slow disease onset or progression. Finally, the development of purpose-built biomarker tests using lab-on-a-chip platforms with smartphone readouts will help to shift the diagnosis and treatment of this major psychiatric disorder into point-of-care settings for increased effectiveness and improved patient outcomes.

The Application of Multiplex Biomarker Techniques for Improved Stratification and Treatment of Schizophrenia Patients

In the case of major psychiatric disorders such as schizophrenia, shortcomings in the conversion of scientific discoveries into newer and safer treatment options has led to a loss of confidence and precipitated a crisis for large pharmaceutical companies. This chapter describes how incorporation of multiplex biomarker approaches into the clinical pipeline can lead to better patient characterization, delivery of novel treatment approaches and help to renew efforts in this important area. The development of specific biomarker test panels for disease prediction should facilitate early intervention strategies, which may help to slow disease development or progression. Furthermore, the development of such tests using lab-on-a-chip and smartphone platforms will help to shift diagnosis and treatment of this major disorder into a point-of-care setting for improved patient outcomes.

Maintaining Adherence Programme: evaluation of an innovative service model

Aims and method The Maintaining Adherence Programme (MAP) is a new model of care for patients with schizophrenia, schizoaffective disorder and bipolar affective disorder which aims to encourage adherence and prevent relapse. This evaluation, conducted by retrospective and prospective data collection (including patient questionnaires and staff interviews), aimed to describe MAP's impact on healthcare resource use, clinical measures and patient and staff satisfaction, following its implementation in a university National Health Service (NHS) foundation trust in England. We included 143 consenting patients who entered MAP before 31 March 2012. Results In-patient bed days and non-MAP NHS costs reduced significantly in the 18 months post-MAP entry. At 15-18 months post-MAP, Medication Adherence Rating Scale scores had improved significantly from baseline and there was a shift towards less severe clinician-rated disease categories. Based on patient surveys, 96% would recommend MAP to friends, and staff were also overwhelmingly positive about the service. Clinical implications MAP was associated with reduced cost of treatment, improvements in clinical outcomes and very high patient and staff satisfaction.

Misdiagnosis, duration of untreated illness (DUI) and outcome in bipolar patients with psychotic symptoms: A naturalistic study

BACKGROUND

A number of data show the negative role of duration of untreated illness (DUI) on outcome in mood disorders, but no investigation has been carried out about the impact of this variable in bipolar disorder (BD) with psychotic symptoms. Clinical experience shows that many bipolar patients with psychotic symptoms receive other diagnoses and often are chronically treated with first generation antipsychotics, with the effect to reduce duration of untreated psychosis/untreated episode with psychotic symptoms (DUP), but not DUI. Purpose of the study was to define the rate of misdiagnosis and the impact of DUP/DUI on outcome of bipolar patients with psychotic symptoms.

METHOD

Clinical information (DUP, DUI, first received diagnosis) about bipolar outpatients with psychotic symptoms (N=240) were extrapolated through a retrospective review of the clinical charts, Lombardy database and, if necessary, through clinical interviews with patients and their relatives. Outcome measures included psychiatric and substance abuse comorbidity, occupational status, Global Assessment of Functioning (GAF), number of hospitalizations and of suicidal attempts, number of depressive/manic recurrences. Patients were divided in two groups according to the DUP (1 year) and DUI (8 years) median, and the groups were compared through analyses of variance (ANOVAs) for continuous variables or χ(2) tests for dichotomous ones. Multivariate analysis of variance (MANOVA) with duration of illness as covariate was then performed to eliminate the effect of this variable. Finally, binary logistic regressions were performed considering age at onset, DUI, DUP as independent variables and outcome variables as dependent ones (presence of hospitalizations/suicidal attempts, GAF scores<50, occupational status).

RESULTS

Most of patients (61.5%) received a first diagnosis different from BD with the most frequent DSM-diagnosis being delusional disorder (17.9%). Patients with longer DUP were not different in outcome measures with respect to patients with shorter DUP. Patients with a DUI >8 years presented higher number of hospitalizations (F=6.04, p=0.015), higher number of manic recurrences (F=5.25, p=0.023), higher number of depressive recurrences (F=7.13, p=0.008) and lower GAF scores (F=17.74, p<0.001). Statistical significance persisted for number of hospitalizations (p<0.001) and GAF scores (p=0.003) after MANOVA. Finally binary logistic regression showed that a longer DUI was predictive of GAF scores<50 (F=17.74, p<0.001).

DISCUSSION

More than half of bipolar patients with psychotic symptoms receive a different diagnosis at first contact with psychiatric services. DUI (but not DUP) is a predictor of outcome in bipolar patients with psychotic symptoms. This indicates that an early diagnosis and proper treatment with a mood stabilizer (or an atypical antipsychotic with mood stabilizing effects) may improve long-term outcome of these patients. In the light of the naturalistic design of the present paper, these results have to be considered as preliminary and have to be confirmed by prospective controlled studies.

The management of catatonia in bipolar disorder with stimulants

Catatonia, while not a rare occurrence in bipolar disorder, has not been widely discussed in the literature. We present a case of a married Caucasian male with a history of bipolar disorder, exhibiting catatonia and experiencing difficulty in day-to-day functioning. He demonstrated impairment in cognition and an inability to organize simple activities of daily life. After exhausting a number of options for medical management, including benzodiazepines, atypical antipsychotics, and amantadine, he only displayed significant clinical improvement with the addition of a stimulant, methylphenidate. In time, the patient saw a complete return to normal functioning. The use of stimulants for catatonia in bipolar disorder may be an interesting and effective option for treatment. While this is not the first time this treatment has been suggested, there is very little data in support of it; our case confirms the discoveries of previous case reports.

Cannabis use and mania symptoms: a systematic review and meta-analysis

BACKGROUND

Whilst cannabis use appears to be a causal risk factor for the development of schizophrenia-related psychosis, associations with mania remain relatively unknown. This review aimed to examine the impact of cannabis use on the incidence of manic symptoms and on their occurrence in those with pre-existing bipolar disorder.

METHODS

A systematic review of the scientific literature using the PRISMA guidelines. PsychINFO, Cochrane, Scopus, Embase and MEDLINE databases were searched for prospective studies.

RESULTS

Six articles met inclusion criteria. These sampled 2391 individuals who had experienced mania symptoms. The mean length of follow up was 3.9 years. Studies support an association between cannabis use and the exacerbation of manic symptoms in those with previously diagnosed bipolar disorder. Furthermore, a meta-analysis of two studies suggests that cannabis use is associated with an approximately 3-fold (Odds Ratio: 2.97; 95% CI: 1.80-4.90) increased risk for the new onset of manic symptoms.

LIMITATIONS

We were only able to identify a small number of studies of variable quality, thus our conclusions remain preliminary.

CONCLUSIONS

Our findings whilst tentative, suggest that cannabis use may worsen the occurrence of manic symptoms in those diagnosed with bipolar disorder, and may also act as a causal risk factor in the incidence of manic symptoms. This underscores the importance of discouraging cannabis use among youth and those with bipolar disorder to help prevent chronic psychiatric morbidity. More high quality prospective studies are required to fully elucidate how cannabis use may contribute to the development of mania over time.

The duration of undiagnosed bipolar disorder: effect on outcomes and treatment response

INTRODUCTION

There are commonly long delays between the onset of bipolar disorder (BP), seeking of treatment and acquiring a bipolar disorder diagnosis. Whether a longer duration of undiagnosed bipolar disorder (DUBP) leads to an inferior treatment response is unclear in the literature.

METHOD

We conducted two studies with independent samples of BP patients who had received a first-time diagnosis of BP - first investigating whether DUBP was related to clinical and social outcomes at the time of assessment (n=173) and, second, whether response to mood stabiliser medication was affected by DUBP when assessed three months following assessment and intervention (n=64).

RESULTS

Participants׳ mean DUBP was 18-20 years (from the onset of mood episodes). After controlling for age, a longer DUBP was associated with employment difficulties, whereas a shorter DUBP was associated with a history of engaging in self-harm behaviours, as well as a reduced likelihood of experiencing social costs as consequence of the mood disorder. The majority of study variables were statistically unrelated to DUBP. In a multivariate analysis, age was the only predictor variable to make a significant contribution to the DUBP (33%). Across the 3-month intervention period, participants improved significantly on all but one outcome measure. The participants׳ likelihood to improve, become worse or experience minimal/no change over the study period was not significantly related to the DUBP.

LIMITATIONS

Self-reporting poses a risk to measurement precision. Being a naturalistic observation, no specific dose of medication was prescribed. The small sample of BP I patients provided insufficient statistical power to undertake meaningful separate analyses of the BP I and BP II participants.

CONCLUSION

Early detection and intervention remains important for helping to reduce morbidity and risks associated with untreated BP. However, the variation in DUBP was mostly a function of age and did not substantially affect clinical status at assessment, or lead to an inferior response to mood stabilising medication.

Lifetime mood spectrum symptoms among bipolar patients and healthy controls: a cross sectional study with the Mood Spectrum Self-Report questionnaire

BACKGROUND

The "spectrum" model has advantages for the conceptualization of mental disorders, representing a complementary approach to the currently available categorical systems. We carried out a study in order to assess lifetime mood symptoms among patients with bipolar disorder (BD) and healthy controls from a dimensional perspective.

METHODS

The Mood Spectrum Self-Report instrument (MOODS-SR) was administered to 101 bipolar patients (52 BD I, 32 BD II, and 17 BD NOS, 36 males/65 females, mean age+SD=36.10±13.34 years) and 38 healthy controls (16 males/22females, mean age+SD=35.18±13.70 years). The scores of the different MOOD-SR scales and subscales among patients and controls were compared using non-parametric tests (Mann-Whitney and Kruskal-Wallis).

RESULTS

Bipolar patients scored significantly higher than healthy controls on the total MOOD-SR scores (BD: mean±SD=98.65±22.17; HC: mean±SD=12.92±10.72; p<0.01) and all subdomains. Multiple comparisons revealed lower scores among controls when compared to each one of the subtypes of BD, also regarding the total scores and all subdomains (p<0.01). Comparisons across the different subtypes of BD revealed statistically significant higher scores among BD I patients when compared to BD II and BD NOS patients, only in regard to the total MOOD-SR scores (BD I: mean±SD=102.94±22.79; BD II: mean±SD=93.53±21.97; BD NOS: mean±SD= 94.88±18.68; p=0.03) and two subdomains: mood mania and energy mania.

CONCLUSIONS

These results, although preliminary, suggest that even though the MOODS-SR seems effective in distinguishing BD patients from HC, it is not as good in discriminating different subtypes of BD, especially in respect to lifetime depressive symptoms.

LIMITATIONS

Our sample size was small, and comprised by outpatients. The MOOD-SR measures only lifetime symptoms and does not take into account the progression of mood symptoms or the current mood state of patients.

Applications of blood-based protein biomarker strategies in the study of psychiatric disorders

Major psychiatric disorders such as schizophrenia, major depressive and bipolar disorders are severe, chronic and debilitating, and are associated with high disease burden and healthcare costs. Currently, diagnoses of these disorders rely on interview-based assessments of subjective self-reported symptoms. Early diagnosis is difficult, misdiagnosis is a frequent occurrence and there are no objective tests that aid in the prediction of individual responses to treatment. Consequently, validated biomarkers are urgently needed to help address these unmet clinical needs. Historically, psychiatric disorders are viewed as brain disorders and consequently only a few researchers have as yet evaluated systemic changes in psychiatric patients. However, promising research has begun to challenge this concept and there is an increasing awareness that disease-related changes can be traced in the peripheral system which may even be involved in the precipitation of disease onset and course. Converging evidence from molecular profiling analysis of blood serum/plasma have revealed robust molecular changes in psychiatric patients, suggesting that these disorders may be detectable in other systems of the body such as the circulating blood. In this review, we discuss the current clinical needs in psychiatry, highlight the importance of biomarkers in the field, and review a representative selection of biomarker studies to highlight opportunities for the implementation of personalized medicine approaches in the field of psychiatry. It is anticipated that the implementation of validated biomarker tests will not only improve the diagnosis and more effective treatment of psychiatric patients, but also improve prognosis and disease outcome.

Characteristics of bipolar symptoms in psychiatric patients: pattern of responses to the Korean version of the Mood Disorder Questionnaire

INTRODUCTION

Bipolar disorders are relatively frequent but easily misdiagnosed. The Korean version of the Mood Disorder Questionnaire (K-MDQ) is a screening instrument for bipolar disorders. The aim of this study was to establish the pattern of responses to the K-MDQ for several psychiatric disorders.

METHODS

The subjects for this study were 345 patients with bipolar disorders, schizophrenia, depressive disorders or anxiety disorders, as determined using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and 96 controls from five hospitals. The subjects completed the questionnaire by themselves.

RESULTS

The total K-MDQ score was higher in the bipolar disorder group than the other groups. Although the mean K-MDQ score differed significantly between the bipolar disorder group and the other groups, the distributions of total scores for the groups overlapped, and in particular with the schizophrenia group. The area under the receiver operating characteristics curve was relatively high for the bipolar disorder group and the other subjects, but it was less than 0.8 between the bipolar disorder group, and the schizophrenia and control groups.

DISCUSSION

There are some distinguishing features of the K-MDQ pattern for each disorder, but their similarities were significant. This made it difficult to differentially diagnose the disorder using only the total K-MDQ score. The diagnostic power of the K-MDQ can only be improved in the clinical setting by utilizing reinforcing criteria to diagnose bipolar disorders. Clinicians should be cautious in their interpretation of the K-MDQ, and the use of additional data is essential.

Testes sanguíneos de biomarcadores para diagnóstico e tratamento de desordens mentais: foco em esquizofrenia

A descoberta e a aplicação clínica de biomarcadores para desordens mentais são confrontadas com muitos desafios. Em geral, os atuais métodos de descoberta e validação de biomarcadores não produziram os resultados que foram inicialmente aguardados depois da finalização do Projeto Genoma Humano. Isso se deve principalmente à falta de processos padronizados conectando a descoberta de marcadores com tecnologias para a validação e a tradução para uma plataforma que ofereça precisão e fácil uso em clínica. Como consequência, a maior parte dos psiquiatras e praticantes em geral são relutantes em aceitar que testes de biomarcadores pode suplementar ou substituir os métodos de diagnóstico utilizados baseados em entrevista. Apesar disso, agências regulatórias concordam agora que melhoras nos correntes métodos são essenciais. Além disso, essas agências estipularam que biomarcadores são importantes para o desenvolvimento de futuras drogas e iniciaram esforços no sentido de modernizar métodos e técnicas para suportar esses esforços. Aqui revisamos os desafios encontrados por essa tentativa do ponto de vista de psiquiatras, praticantes em geral, agências reguladoras e cientistas de biomarcadores. Também descrevemos o desenvolvimento de um novo teste sanguíneo molecular para esquizofrenia como um primeiro passo a esse objetivo.

Borderline personality disorder and bipolar affective disorder. Spectra or spectre? A review

OBJECTIVE

Bipolar affective disorder and borderline personality disorder have long been considered to have significant similarities and comorbidity. This review endeavours to clarify the similarities and differences between these disorders, with an effort to determine whether they reflect different forms of the same illness or separate illness clusters.

METHOD

The published literature relating to bipolar affective disorders, borderline personality disorders, and related areas of knowledge was reviewed using searches of several electronic databases (AMED, CINHAL, Embase, Ovid, ProQuest, MEDLINE, Web of Science, ScienceDirect) and published texts. These findings were combined with the personal clinical experience of the author, and information gathered from colleagues, to create a review of this topic.

RESULTS

Bipolar affective disorders and borderline personality disorders differ with respect to sense of self, disruption of relationships, family history of bipolar disorders, the benefits of medications, the extent of cognitive deficits, the form of affective dysregulation and mood cycling, the incidence of suicide and suicide attempts, the form of psychotic episodes, the incidence of early sexual abuse but not early trauma in general, the loss of brain substance, alterations in cortical activity, glucocorticoid receptor sensitivity, and mitochondrial dysfunction. They are similar with respect to non-specific features of affective dysregulation, the incidence of atypical depressive features, the incidence of self-mutilation, the incidence of transporter polymorphisms, possible genetic linkages, overall reduction in limbic modulation, reduction in the size of hippocampi and amygdala, and the incidence of sleep disruption.

CONCLUSIONS

This review concludes that bipolar affective disorders and borderline personality disorder are separate disorders, but have significant elements in common.

Disparities in diagnosis of bipolar disorder in individuals of African and European descent: a review

BACKGROUND

Over the past 3 decades, a wide range of studies in the United States and the United Kingdom has reported that white individuals are more likely to be diagnosed with bipolar and affective disorders, whereas black individuals appear to be at higher risk for schizophrenia spectrum diagnoses. Despite the pressing need for strategies aimed at eliminating racial and cultural disparities in diagnosis and treatment of bipolar disorder, no systematic review of the existing literature in this area has been done. This study draws together the disparate strands of information in a comprehensive overview of the research base in this area.

METHODS

An electronic literature search of the Medline and PsychINFO databases was conducted in October 2009, supplemented by a review of references in the identified articles, for a total of 51 articles included in this qualitative review.

RESULTS

Black patients have consistently been found to be more likely than white patients to be diagnosed with schizophrenia rather than bipolar disorder. Four factors were identified as potential contributors to racial disparities in diagnostic rates: clinical presentation and expression of symptoms, access to care, help-seeking behaviors, and clinician judgment.

CONCLUSION

Despite efforts to curtail the phenomenon, racial disparities in diagnosis of bipolar disorder persist. Racial and cultural elements may affect how patients manifest behaviors and symptoms and how these are interpreted and attributed by clinicians in the diagnostic process. As an appropriate diagnosis determines treatment options and is central to quality of care, incorrect diagnosis can potentially have a negative impact on treatment effectiveness and accuracy of prognosis.

Reliability and validity of the Chinese Version of the Mood Disorder Questionnaire

The purpose of this study was to examine the reliability, validity, sensitivity, and specificity of the Chinese Version of the Mood Disorder Questionnaire (MDQ-C). A total of 170 patients were administered the Mini International Neuropsychological Interview and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision as criterion standard by on-site psychiatrists. The Cronbach's alpha, test-retest reliability, and the content validity index of the MDQ-C were .83, .76, and .80, respectively. Factor analysis revealed that two factors, elevated mood overactivity and irritable behavior, explained 40.89% of the variance. On the basis of the sensitivity and specificity results, the optimal cutoff point was 6. The MDQ-C is an effective short and comprehensive tool with robust psychometric properties for diagnosis of bipolar disorders, specifically for patients with bipolar I.

Challenges of introducing new biomarker products for neuropsychiatric disorders into the market

There are many challenges associated with the discovery and development of serum-based biomarkers for psychiatric disorders such as schizophrenia. Here, we review these challenges from the point of view of psychiatrists, general practitioners, the regulatory agencies, and biomarker scientists. There is a general opinion in psychiatric medicine that improvements over the current subjective tests are essential. Despite this, there is a reluctance to accept that peripheral molecules can do the job any better. In addition, psychiatrists find it difficult to accept that peripheral molecules, such as those found in blood, can reflect what is happening in the brain. However, the regulatory health authorities now consider biomarkers as important for the future of drug development and have called for efforts to modernize methods, tools, and techniques for the purpose of developing more efficient and safer drugs. We also describe here the development of the first ever molecular blood test for schizophrenia, and its reception in the market place, as a case in point.

Distinguishing affective depersonalization from anhedonia in major depression and bipolar disorder

BACKGROUND

Affective depersonalization has received limited attention in the literature, although its conceptualization may have implications in terms of identification of clinical endophenotypes of mood disorders. Thus, this study aims to test the hypothesis that anhedonia and affective depersonalization represent 2 distinct psychopathological dimensions and to investigate their clinical correlates in patients with major depressive disorder (MDD) and bipolar disorder (BD).

METHODS

Using a data pool of 258 patients with mood and anxiety disorders, an item response theory-based factor analysis approach was carried out on 16 items derived from 2 clinical instruments developed in the Spectrum Project (the Structured Clinical Interview for Mood Spectrum and the Structured Clinical Interview for Derealization-Depersonalization Spectrum). Clinical correlates of these psychometrically derived dimensions were subsequently investigated in patients with BD or MDD.

RESULTS

Using an item response theory-based factor analysis, a 2-factor solution was identified, accounting overall for the 47.0% of the variance. Patients with BD showed statistically significant higher affective depersonalization factor scores than those with MDD (Z = 2.215, P = .027), whereas there was no between-groups difference in anhedonia scores (Z = 0.825 P = .411). In patients with BD, age of onset of the disease correlated with affective depersonalization factor scores (rho = -0.330, P = .001) but not with anhedonia factor scores (rho = -0.097, P = .361).

CONCLUSIONS

Affective depersonalization and anhedonia seem to be 2 distinct psychopathological dimensions, although closely related, bearing the opportunity to identify patients with a specific profile for a better clinical and neurobiological definition.

Bipolar disorder in the Bulgarian Gypsies: genetic heterogeneity in a young founder population

We report the results of follow-up analyses of 12 genomic regions showing evidence of linkage in a genome-wide scan (GWS) of Gypsy families with bipolar affective disorder (BPAD). The Gypsies are a young founder population comprising multiple genetically differentiated sub-isolates with strong founder effect and limited genetic diversity. The BPAD families belong to a single sub-isolate and are connected by numerous inter-marriages, resulting in a super-pedigree with 181 members. We aimed to re-assess the positive GWS findings and search for evidence of a founder susceptibility allele after the addition of newly recruited subjects, some changes in diagnostic assignment, and the use of denser genetic maps. Linkage analysis was conducted with SimWalk2, accommodating the full complexity of pedigree structure and using a conservative narrow phenotype definition (BPAD only). Six regions were rejected, while 1p36, 13q31, 17p11, 17q21, 6q24, and 4q31 produced nominally significant results in both the individual families and the super-pedigree. Haplotypes were reconstructed and joint tests for linkage and association were done for the most promising regions. No common ancestral haplotype was identified by sequencing a strong positional and functional candidate gene (GRM1) and additional STR genotyping in the top GWS region, 6q24. The best supported region was a 12 cM interval on 4q31, also implicated in previous studies, where we obtained significant results in the super-pedigree using both SimWalk2 (P = 0.004) and joint Pseudomarker analysis of linkage and linkage disequilibrium (P = 0.000056). The size of the region and the characteristics of the Gypsy population make it suitable for LD mapping.

The misdiagnosis of bipolar disorder as a psychotic disorder: some of its causes and their influence on therapy

OBJECTIVES

Looking at chart records bipolar disorder is often misdiagnosed as a psychotic disorder but no study has ever systematically looked into the reasons. One reason for misdiagnoses could be that clinicians use heuristics like the prototype approach in routine practice instead of strictly adhering to the diagnostic criteria. Using an experimental approach we investigated if the use of heuristics can explain when a diagnosis of psychotic disorder is given instead of bipolar disorder. We systematically varied information about the presence or absence of specific symptoms, i.e. hallucinations and decreased need for sleep during a manic episode.

METHODS

Experimentally varied case vignettes were randomly sent to psychiatrists in Southern Germany. The four versions of the case vignette all described the same person in a manic state and differed only in two aspects: the presence or absence of auditory hallucinations and of decreased need for sleep. The psychiatrists were asked to make a diagnosis, to rate their confidence in their diagnosis, and to recommend treatments.

RESULTS

Almost half of the 142 psychiatrists (45%) did not diagnose bipolar disorder. Mentioning hallucinations decreased the likelihood of diagnosing bipolar disorder. The information about decreased need for sleep only affected the diagnosis significantly, if schizoaffective disorder was considered a bipolar disorder.

CONCLUSIONS

Our results suggest that clinicians indeed use heuristics when making diagnostic decisions instead of strictly adhering to diagnostic criteria. More research is needed to better understand diagnostic decision making, especially under real life settings, and this might also be of interest when revising diagnostic manuals such as DSM.

The structure of lifetime manic-hypomanic spectrum

BACKGROUND

The observation that bipolar disorders frequently go unrecognized has prompted the development of screening instruments designed to improve the identification of bipolarity in clinical and non-clinical samples. Starting from a lifetime approach, researchers of the Spectrum Project developed the Mood Spectrum Self-Report (MOODS-SR) that assesses threshold-level manifestations of unipolar and bipolar mood psychopathology, but also atypical symptoms, behavioral traits and temperamental features. The aim of the present study is to examine the structure of mania/hypomania using 68 items of the MOODS-SR that explore cognitive, mood and energy/activity features associated with mania/hypomania.

METHODS

A data pool of 617 patients with bipolar disorders, recruited at Pittsburgh and Pisa, Italy was used for this purpose. Classical exploratory factor analysis, based on a tetrachoric matrix, was carried out on the 68 items, followed by an Item Response Theory (IRT)-based factor analytic approach.

RESULTS

Nine factors were initially identified, that include Psychomotor Activation, Creativity, Mixed Instability, Sociability/Extraversion, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Inflated Self-esteem, Euphoria, Wastefulness/Recklessness, and account overall for 56.4% of the variance of items. In a subsequent IRT-based bi-factor analysis, only five of them (Psychomotor Activation, Mixed Instability, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Euphoria) were retained.

CONCLUSIONS

Our data confirm the central role of Psychomotor Activation in mania/hypomania and support the definitions of pure manic (Psychomotor Activation and Euphoria) and mixed manic (Mixed Instability and Mixed Irritability) components, bearing the opportunity to identify patients with specific profiles for a better clinical and neurobiological definition.

On the prevalence of bipolar disorder in epilepsy

Although mood disorders represent a frequent psychiatric comorbidity in epilepsy, data on bipolar disorder (BD) are still limited, and the role of possible specific confounding variables (seizures and antiepileptic drug therapy) has never been considered. Data for 143 adult outpatients with epilepsy assessed with the Mini International Neuropsychiatric Interview Plus Version 5.0.0 using the Epilepsy Addendum for Psychiatric Assessment, the Mood Disorder Questionnaire, and the Interictal Dysphoric Disorder Inventory revealed that 11.8% had the Diagnostic and Statistical Manual of Mental Disorders-based diagnosis of BD, only 1.4% of whom could be considered as having "pure" BD, because in all other cases BD symptoms were related to phenotype copies of BD such as interictal dysphoric disorder of epilepsy, postictal manic or hypomanic states, and preictal dysphoria.

Disorders of thought are severe mood disorders: the selective attention defect in mania challenges the Kraepelinian dichotomy a review

Kraepelin said severe mental illness was due to 2 diseases subsequently characterized as disorders of thought vs disorders of mood, ie, the Kraepelinian dichotomy. Schizophrenia, traditionally considered the disorder of thought, has been defined by the presence of hallucinations, delusions, catatonia, and disorganization. Tangentiality, derailment, loose associations, and thought blocking are typically considered pathognomonic of schizophrenia. By contrast, the mood disorders have been characterized only as disorders of the emotions, though both depression and mania, when severe, are now recognized to include the same psychotic features traditionally considered diagnostic of schizophrenia. This article addresses disordered thinking in mania in order to clarify the relationship between schizophrenia and psychotic mood disorders. Normally, the brain's selective attention mechanism filters and prioritizes incoming stimuli by excluding from consciousness extraneous, low-priority stimuli and grading the importance of more relevant data. Because this "filter/prioritizer" becomes defective in mania, tangential stimuli are processed without appropriate prioritization. Observed as distractibility, this symptom is an index of the breakdown in selective attention and the severity of mania, accounting for the signs and symptoms of psychotic thinking. The zone of rarity between schizophrenia and psychotic mood disorders is blurred because severe disorders of mood are also disorders of thought. This relationship calls into question the tenet that schizophrenia is a disease separate from psychotic mood disorders. Patients whose case histories are discussed herein gave their written informed consent to participate in this institutional human subjects committee-approved protocol.

Hospitalization risks in the treatment of bipolar disorder: comparison of antipsychotic medications

OBJECTIVES

This study compared the relative risk for hospitalization of patients with bipolar and manic disorders receiving atypical and typical antipsychotics.

METHODS

This retrospective study was based on administrative claims data extracted from the PharMetrics database during 1999 through 2003. Comparisons were made among atypical antipsychotics (risperidone, olanzapine, quetiapine or ziprasidone), as well as between each of these versus a combined group of the leading typical antipsychotics. Relative risk for hospitalization was estimated with Cox proportional regression, which adjusted for differences in patient characteristics.

RESULTS

Risperidone and olanzapine demonstrated higher risks for hospitalization than quetiapine [hazard ratio (HR) 1.19, p < 0.05 for both], translating into higher annual mental health inpatient charges of $260 per patient. Risperidone and olanzapine also showed higher estimated risks than ziprasidone, which approached the p < 0.05 threshold. Differences between each of the atypicals and the combined typicals were not significant. Patients with putative rapid cycling had a threefold greater risk for hospitalization than other patients with bipolar disorder. In these patients, comparisons among atypical antipsychotics showed that risperidone had a significantly higher hospitalization risk than olanzapine (HR 3.31, p < 0.05), resulting in higher annual mental health inpatient charges of $4,930 per patient.

CONCLUSIONS

In the treatment of bipolar and manic disorders, risperidone and olanzapine were associated with a higher risk for hospitalization than quetiapine, and possibly ziprasidone. In the treatment of putative rapid cyclers, olanzapine was associated with a lower risk for hospitalization than risperidone.

Developing core sets for persons with bipolar disorder based on the International Classification of Functioning, Disability and Health

INTRODUCTION

Functioning is increasingly being taken into account when assessing the impact of bipolar disorder (BD) on the individual, as well as the effectiveness of treatments. With the International Classification of Functioning, Disability and Health (ICF), we can now rely on a globally agreed-upon framework and system for classifying the typical spectrum of problems in functioning, given the environmental context in which subjects live. ICF Core Sets are subgroups of ICF items selected to capture those aspects of functioning that are most likely to be affected by specific disorders. Within a given disorder, both Brief and Comprehensive Core Sets can be established to serve specific purposes.

OBJECTIVE

The aim of this paper is to outline the development process of the ICF Core Sets for BD.

METHODS

The final definition of ICF Core Sets for BD will be determined at an ICF Core-Sets Consensus Conference, which will integrate evidence from preliminary studies, namely (a) semi-structured interviews with people with BD in different countries, (b) a Delphi exercise with international experts participating and (c) a cross-sectional study.

CONCLUSION

ICF Core Sets are being designed with the goal of providing useful standards for research, clinical practice and teaching. We believe that these ICF Core Sets for BD will stimulate research leading to improved understanding of functioning, disability and health in BD. Such research, we hope, will lead to interventions and accommodations to improve restoration and maintenance of functioning and minimise disability among people with BD throughout the world.

Valproate and copper accelerate TRH-like peptide synthesis in male rat pancreas and reproductive tissues

Treatment with valproate (Valp) facilitates the synthesis of TRH-like peptides (pGlu-X-Pro-NH(2)) in rat brain where "X" can be any amino acid residue. Because high levels of TRH-like peptides occur in the pancreas and pGlu-Glu-Pro-NH(2) (Glu-TRH) has been shown to be a fertilization promoting peptide, we hypothesized that these peptides mediate some of the metabolic and reproductive side effects of Valp. Male WKY rats were treated with Valp acutely (AC), chronically (CHR) or chronically followed by a 2 day withdrawal (WD). AC, CHR and WD treatments significantly altered TRH and/or TRH-like peptide levels in pancreas and reproductive tissues. Glu-TRH was the predominant TRH-like peptide in epididymis, consistent with its fertilization promoting activity. Glu-TRH levels in the epididymis increased 3-fold with AC Valp. Phe-TRH, the most abundant TRH-like peptide in the pancreas, increased 4-fold with AC Valp. Phe-TRH inhibits both basal and TRH-stimulated insulin release. Large dense core vesicles (LDCV's) contain a copper-dependent enzyme responsible for the post-translational processing of precursors of TRH and TRH-like peptides. Copper (500 microM) increased the in vitro C-terminal amidation of TRH-like peptides by 8- and 4-fold during 24 degrees C incubation of homogenates of pancreas and testis, respectively. Valp (7 microM) accelerated 3-fold the processing of TRH and TRH-like peptide precursors in pancreatic LDCV's incubated at 24 degrees C. We conclude that copper, an essential cofactor for TRH and TRH-like peptide biosynthesis that is chelated by Valp, mediates some of the metabolic and reproductive effects of Valp treatment via acceleration of intravesicular synthesis and altered release of these peptides.

Cannabis use and expression of mania in the general population

BACKGROUND

Cannabis use is common in patients with bipolar disorder, however little is known about cannabis as a risk factor for mania. In order to investigate the association between exposure to cannabis and subsequent development of manic symptoms whilst controlling for psychotic symptoms, a longitudinal population-based study was carried out.

METHODS

4815 individuals aged 18 to 64 years were interviewed using the Composite International Diagnostic Interview at baseline, 1 year follow up and 3 year follow up, including assessment of substance use, manic symptoms and psychotic symptoms.

RESULTS

Use of cannabis at baseline increased the risk for manic symptoms during follow-up (adjusted OR 2.70, 95% CI: 1.54, 4.75), adjusted for age, sex, educational level, ethnicity, single marital status, neuroticism, use of other drugs, use of alcohol, depressive symptoms and manic symptoms at baseline. The association between cannabis use and mania was independent of the prevalence and the incidence of psychotic symptoms. There was no evidence for reverse causality, as manic symptoms at baseline did not predict the onset of cannabis use during follow-up (OR = 0.35, 95% CI: 0.03, 3.49).

LIMITATIONS

As 3 years is a relative short period of follow-up, long-term effects of cannabis use on mania outcomes could not be detected.

CONCLUSION

The results suggest that cannabis use may affect population expression of manic symptoms (and subsequent risk to develop bipolar disorder [Regeer, E.J., Krabbendam, L., R, DE Graaf, Ten Have, M., Nolen, W.A., Van Os, J., 2006. A prospective study of the transition rates of subthreshold (hypo)mania and depression in the general population. Psychol Med, 1-9.]). These findings may not be due to the emergence of psychotic symptoms or the effects of self-medication.

Symptomatic and functional outcome 12 months after a first episode of psychotic mania: barriers to recovery in a catchment area sample

OBJECTIVE

Recent studies have shown that outcome in mania is worse than previously thought. Such studies have been conducted in selected samples with restrictive measures of outcome. We aimed to explore outcome and its predictors in a catchment area sample of first-episode psychotic mania of DSM-III-R bipolar I disorder.

METHODS

Prospective 6 and 12 months follow-up was conducted with 87 DSM-III-R first-episode psychotic mania patients admitted to Early Psychosis Prevention and Intervention Centre between 1989 and 1997. Syndromic and symptomatic outcome were determined with the Brief Psychiatric Rating Scale; functional outcome with the Quality of Life Scale and Premorbid Adjustment Scale subitems.

RESULTS

Symptomatic outcome was assessed in 67 patients at 6 months and 61 patients at 12 months, and functional outcome in 56 patients at 6 months and 49 patients at 12 months. Logistic regressions were conducted on 46 and 43 patients, respectively, to explore predictors of outcome. While 90% of patients achieved syndromic recovery at 6 and 12 months, 40% had not recovered symptomatically at 6 and 12 months, still presenting with anxiety or depression. A total of 66% of patients at 6 months and 61% of patients at 12 months failed to return to previous level of functioning. Age at intake, family history of affective disorder, illicit drug use and functional recovery at 6 months predicted functional outcome at 12 months.

CONCLUSIONS

This study confirms poor symptomatic and functional outcome after first-episode psychotic mania. It suggests possible usefulness of early intervention strategies in bipolar disorders and need for developing specific interventions addressing anxiety, depression and substance abuse comorbidity.

A review of the possible relevance of inositol and the phosphatidylinositol second messenger system (PI-cycle) to psychiatric disorders--focus on magnetic resonance spectroscopy (MRS) studies

Myo-inositol is an important part of the phosphatidylinositol second messenger system (PI-cycle). Abnormalities in nerve cell myo-inositol levels and/or PI-cycle regulation has been suggested as being involved in the pathophysiology and/or treatment of many psychiatric disorders including bipolar disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder, eating disorders and schizophrenia. This review examines the metabolism and biochemical importance of myo-inositol and the PI-cycle. It relates this to the current in vivo evidence for myo-inositol and PI-cycle involvement in these psychiatric disorders, particularly focusing upon the magnetic resonance spectroscopy (MRS) findings in patient studies to date. From this review it is concluded that while the evidence suggests probable relevance to the pathophysiology and/or treatment of bipolar disorder, there is much less support for a significant role for the PI-cycle or myo-inositol in any other psychiatric disorder. More definitive investigation is required before PI-cycle dysfunction can be considered specific to bipolar disorder.

Bipolar disorders: special diagnostic and treatment considerations in women

Bipolar disorder in women presents special diagnostic and treatment challenges to the clinician. The presentation of female bipolar may resemble depressive disorders, comorbid Axis I disorders, Axis II personality disorders, behavioral dysregulation, or general medical disorders; thus, it is critically important for clinicians to assess for a history of hypomania or mania when determining diagnosis in any woman presenting with psychological symptoms. Several gender differences may exist in the epidemiology and symptomatology of bipolar disorder, and each must be kept in mind during assessment. Rapid cycling and mixed states have been associated with female gender and may present diagnostic challenges as each often presents as major depression. Symptoms of postpartum psychosis tend to differ from the symptoms typically seen in bipolar mania; therefore, if postpartum psychosis is actually a manifestation of bipolar disorder, accurate diagnosis depends upon a knowledge of these differences. Special treatment considerations for bipolar disorder in women involve interactions between the illness and the female reproductive cycle. A risk of fetal malformation exists when some mood-stabilizing agents are used during conception and/or during the first trimester of pregnancy. Neurobehavioral teratogenicity and neonatal toxicity is also possible. Careful treatment management is necessary to reduce the risks to the fetus/infant and to effectively manage bipolar disorder in the mother. In treating women with bipolar disorder, clinicians should discuss the issue of pregnancy and associated risks of treatment versus no treatment with every patient of reproductive age. Further studies are needed on gestational timing and exposure to mood-stabilizing agents, especially newer agents recently approved or currently being considered for the treatment of bipolar disorder.