The duration of hypomania in bipolar-II disorder in private practice: methodology and validation

The AREDOC project and its implications for the definition and measurement of the bipolar disorders: A summary report

OBJECTIVES

Judging that the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria for defining mania/hypomania (and thus bipolar I/II disorders, respectively) would benefit from review, we formed an expert taskforce to derive modified criteria for consideration. The aim of this paper is to summarise the component stages and detail the final recommended criteria.

METHODS

We first sought taskforce members' views on the Diagnostic and Statistical Manual of Mental Disorders criteria and how they might be modified. Next, members recruited patients with a bipolar I or II disorder, and who were asked to judge new definitional options and complete a symptom checklist to determine the most differentiating items. The latter task was also completed by a small comparison group of unipolar depressed patients to determine the mood state items that best differentiate unipolar from bipolar subjects. Subsequent reports overviewed analyses arguing for bipolar I and II as being categorically distinct and generated empirically derived diagnostic criteria.

RESULTS

Alternatives to all the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria were generated. Modifications included recognising that impairment is not a necessary criterion, removing hospitalisation as automatically assigning bipolar I status, adding an irritable/angry symptom construct to the symptom list, deleting a mandatory duration period for manic/hypomanic episodes, and requiring a greater number of affirmed symptoms for a bipolar diagnosis to manage the risk of overdiagnosis. Granular symptom criteria were identified by analyses and constructed to assist clinician assessment. A potential bipolar screening measure was developed with analyses showing that it could clearly distinguish bipolar versus unipolar status, whether symptom items were assigned as having equal status or weighted by their quantified diagnostic contribution.

CONCLUSION

While requiring further validation, we suggest that the revised criteria overcome several current Diagnostic and Statistical Manual of Mental Disorders (5th ed.) limitations to defining and differentiating the two bipolar sub-types, while still respecting and preserving the Diagnostic and Statistical Manual of Mental Disorders template. It will be necessary to determine whether the bipolar screening measure has superiority to currently accepted measures.

A Longitudinal Study of the Association between the LEPR Polymorphism and Treatment Response in Patients with Bipolar Disorder

Patients with bipolar disorder (BD) exhibit individual variability in the treatment outcome, and genetic background could contribute to BD itself and the treatment outcome. Leptin levels significantly change in BD patients treated with valproate (VPA), but whether LEPR polymorphisms are associated with treatment response is still unknown. This longitudinal study aimed to investigate the associations between LEPR polymorphisms and VPA treatment response in BD patients who were drug naïve at their first diagnosis of BD. The single-nucleotide polymorphisms (SNPs) of LEPR (rs1137101, rs1137100, rs8179183, and rs12145690) were assayed, and the LEPR polymorphism frequencies of alleles and genotypes were not significantly different between the controls (n = 77) and BD patients (n = 130). In addition, after the 12-week course of VPA treatment in BD patients, the LEPR polymorphisms showed significant effects on changes in disease severity. Moreover, considering the effect of the LEPR haplotype, the frequency of the CAGG haplotype in BD patients was higher than that in the controls (9.3 vs. 2.9%, p = 0.016), and the LEPR CAGG haplotype was associated with a better treatment response than the other haplotypes in BD patients receiving VPA treatment. Therefore, LEPR polymorphisms might serve as mediators involved in the therapeutic action of VPA treatment.

Dextromethorphan Protect the Valproic Acid Induced Downregulation of Neutrophils in Patients with Bipolar Disorder

Objective

Valproic acid (VPA) is an anticonvulsant and commonly long term used as a mood stabilizer for patients with mood disorders. However its chronic effects on the hematological changes were noticed and need to be further evaluated. In this study, we evaluated, in Taiwanese Han Chinese patients with bipolar disorders (BD), the chronic effects of VPA or VPA plus dextromethorphan (DM) on the hematological molecules (white blood cell [WBCs], red blood cells [RBCs], hemoglobin, hematocrit, and platelets).

Methods

In a 12-week, randomized, double-blind study, we randomly assigned BD patients to one of three groups: VPA plus either placebo (VPA＋P, n = 57) or DM (30 mg/day, VPA＋DM30, n = 56) or 60 mg/day (VPA＋DM60, n = 53). The Young Mania Rating Scale and Hamilton Depression Rating Scale were used to evaluate symptom severity, and the hematological molecules were checked.

Results

Paired t test showed that the WBC, neutrophils, platelets and RBCs were significantly lowered after 12 weeks of VPA＋P or VPA＋DM30 treatment. VPA＋DM60 represented the protective effects in the WBCs, neutrophils, and RBCs but not in the platelets. We further calculated the changes of each hematological molecules after 12 weeks treatment. We found that combination use of DM60 significantly improved the decline in neutrophils induced by the long-term VPA treatment.

Conclusion

Hematological molecule levels were lower after long-term treatment with VPA. VPA＋DM60, which yielded the protective effect in hematological change, especially in the neutrophil counts. Thus, DM might be adjunct therapy for maintaining hematological molecules in VPA treatment.

Revising Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for the bipolar disorders: Phase I of the AREDOC project

OBJECTIVE

To derive new criteria sets for defining manic and hypomanic episodes (and thus for defining the bipolar I and II disorders), an international Task Force was assembled and termed AREDOC reflecting its role of Assessment, Revision and Evaluation of DSM and other Operational Criteria. This paper reports on the first phase of its deliberations and interim criteria recommendations.

METHOD

The first stage of the process consisted of reviewing Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and recent International Classification of Diseases criteria, identifying their limitations and generating modified criteria sets for further in-depth consideration. Task Force members responded to recommendations for modifying criteria and from these the most problematic issues were identified.

RESULTS

Principal issues focussed on by Task Force members were how best to differentiate mania and hypomania, how to judge 'impairment' (both in and of itself and allowing that functioning may sometimes improve during hypomanic episodes) and concern that rejecting some criteria (e.g. an imposed duration period) might risk false-positive diagnoses of the bipolar disorders.

CONCLUSION

This first-stage report summarises the clinical opinions of international experts in the diagnosis and management of the bipolar disorders, allowing readers to contemplate diagnostic parameters that may influence their clinical decisions. The findings meaningfully inform subsequent Task Force stages (involving a further commentary stage followed by an empirical study) that are expected to generate improved symptom criteria for diagnosing the bipolar I and II disorders with greater precision and to clarify whether they differ dimensionally or categorically.

Add-On Memantine Treatment for Bipolar II Disorder Comorbid with Alcohol Dependence: A 12-Week Follow-Up Study

BACKGROUND

Bipolar disorder (BD), especially BD-II, is frequently comorbid with alcohol dependence. Because BD-II and alcohol dependence are neurodegenerative disorders, agents with anti-inflammatory and neurotrophic effects might provide effective therapy. We investigated whether add-on memantine to regular valproic acid treatment ameliorated clinical symptoms, reduced alcohol use, and cytokine levels, and increased plasma brain-derived neurotrophic factor (BDNF) in BD-II patients with comorbid alcohol dependence.

METHODS

In a single-arm 12-week clinical trial, BD-II patients with comorbid alcohol dependence (n = 45) undergoing regular valproic acid treatments were given add-on memantine (5 mg/d). Symptom severity, alcohol use, cytokine (plasma tumor necrosis factor-α and C-reactive protein [CRP], transforming growth factor-β1 [TGF-β1], interleukin-8 [IL-8], IL-10), and plasma BDNF levels were regularly assessed.

RESULTS

Mean within-group decreases in Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) scores, alcohol use, CRP, BDNF, and IL-8 levels were significantly different from baseline after 12 weeks of treatment. We found no significant correlation between alcohol use levels and changes in HDRS or YMRS scores. The correlation between reduced alcohol use and reduced TGF-β1 level was significant (B = 0.003, p = 0.019).

CONCLUSIONS

BD-II comorbid with alcohol dependence might benefit from add-on memantine treatment, which significantly reduced clinical severity, alcohol use, and plasma cytokine levels, and increased BDNF levels.

Plasma oxytocin levels in major depressive and bipolar II disorders

Oxytocin may play a role in mood regulation. Research has shown the plasma oxytocin level of patients with bipolar I disorder (BD I) during a manic episode was significantly higher than that of BD I patients of other statuses, and also that of healthy subjects. However, whether or not a difference in the level of oxytocin exists between patients with major depressive disorder (MDD) and those with BD II is unclear. This study aimed to investigate the plasma oxytocin levels in MDD and BD II patients in a depressive episode. 119 healthy controls, 135 BD II patients, and 97 MDD patients were enrolled. All of the BD II and MDD patients were drug-naïve, with baseline depressive status 17-item Hamilton Depression Rating Scale scores >15. The plasma oxytocin level of the BD II patients was significantly higher than that of the MDD patients and controls at baseline. After treatment, the plasma oxytocin level of the BD II patients increased significantly; however, in the MDD group, the oxytocin level decreased slightly after treatment. Our findings suggested more significant plasma oxytocin dysregulation in the patients in the BD II group than in the MDD patients and controls, both before and after treatment.

Effect of memantine on C-reactive protein and lipid profiles in bipolar disorder

BACKGROUND

Balance in the immune system plays roles in bipolar disorder (BD) and its metabolic co-morbidities. Memantine is an NMDA receptor antagonist with anti-inflammatory effects. However, the effects of memantine adjunct treatment on metabolic status of BD are unclear.

METHODS

During the 12 weeks period, a total of 191 BD patients were enrolled and split into valproate (VPA) + placebo and VPA + memantine (5mg/day) arms. The fasting plasma levels of high-sensitivity C-reactive protein (CRP) and metabolic indices were assessed. BD patients were stratified according to their initial CRP level.

RESULTS

A cut-off value of initial CRP level of 2322ng/mL discriminated the waist circumference in these BD patients after 12-week VPA treatment. In the high CRP (> 2322ng/mL) group, patients in the VPA + memantine arm had a significantly decreased in their CRP (p= 0.009), total cholesterol (p= 0.002), LDL (p= 0.002) levels, BMI (p= 0.001), and waist circumference (p< 0.001), compared to those in the VPA + placebo arm. However, analysis of the low CRP group did not showed the effect.

LIMITATIONS

We recruited BD patients in depressed states and the sample size was relative small. The effects of the fixed dose of memantine on metabolic indices were 12-week follow up in BD patients treated with VPA.

CONCLUSIONS

BD patients with high initial CRP levels receiving memantine adjunct treatment have a reduced risk of inflammation and metabolic imbalance. Prospective studies are needed to confirm the long-term outcome for memantine adjunct therapy in BD patients.

FGF21 Is Associated with Metabolic Effects and Treatment Response in Depressed Bipolar II Disorder Patients Treated with Valproate

BACKGROUND

Patients with bipolar disorder are at high risk of metabolic disturbance after mood stabilizer treatment. However, the mediators linking the two conditions remain unknown. In this study, we investigated whether fibroblast growth factor-21 (FGF21) was associated with metabolic effects and treatment response in depressed bipolar disorder patients.

METHODS

We recruited 78 community-dwelling controls and 137 bipolar disorder patients; the latter were interviewed using the Chinese Version of the Modified Schedule of Affective Disorder and Schizophrenia-Life Time. Upon study entry, the bipolar disorder patients were all in a major depressive status, with 17-item Hamilton Depression Rating Scale (HDRS) scores >15. They received valproate (500-1000 mg daily) for 12 weeks, and fluoxetine 20 mg daily was permitted to treat depressive symptoms. Fasting plasma level of FGF21, lipid profiles, and body weight were collected at baseline and after 12 weeks of treatment.

RESULTS

At baseline, the demographic characteristics, FGF21 level, and metabolic indices did not differ significantly between the controls and bipolar disorder patients. After 12 weeks of treatment, the FGF21 level (167.7±122.0 to 207.1±162.3 pg/mL, P=.001), body weight and waist circumference had increased significantly (P<.001 and P=.028, respectively). Moreover, the change in FGF21 level was significantly correlated with the changes in HDRS score (r=0.393, P=.002), total cholesterol (r=-0.344, P=.008), and low-density lipoprotein (r=-0.347, P=.007).

CONCLUSIONS

The central and peripheral mediating effects of FGF21 on bipolar disorder depression treatment might be opposite. High peripheral FGF21 levels might link regulation of metabolic effect and resistance to treatment in bipolar disorder.

Effects of switching to aripiprazole from current atypical antipsychotics on subsyndromal symptoms and tolerability in patients with bipolar disorder

We evaluated the effectiveness of aripiprazole among bipolar patients who had switched to this medication as a result of difficulty maintaining on their prestudy atypical antipsychotics (AAPs) because of subsyndromal mood symptoms or intolerance. This study included 77 bipolar patients who were in syndromal remission with an AAP as monotherapy or with an AAP combined with a mood stabilizer(s) who needed to switch from their present AAP because of subsyndromal symptoms or intolerance. At 24 weeks after switching to aripiprazole, the remission rates on the Montgomery-Åsberg Depression Rating Scale (MADRS) and on both the MADRS and the Young Mania Rating Scale were increased significantly in the full sample and in the inefficacy subgroup. In the inefficacy subgroup, the MADRS score change was significant during the 24 weeks of study. Total cholesterol and prolactin decreased significantly after switching to aripiprazole. The proportion of patients who had abnormal values for central obesity and hypercholesterolemia decreased significantly from baseline to week 24. These findings suggest that a change from the current AAP to aripiprazole was associated with improvement in subsyndromal mood symptoms and several lipid/metabolic or safety profile parameters in patients with bipolar disorder with tolerability concerns or subsyndromal mood symptoms.

The Differential Levels of Inflammatory Cytokines and BDNF among Bipolar Spectrum Disorders

OBJECTIVE

Emerging evidence suggests that inflammation and neurodegeneration underlies bipolar disorder. To investigate biological markers of cytokines and brain-derived neurotrophic factor between bipolar I, bipolar II, and other specified bipolar disorder with short duration hypomania may support the association with inflammatory dysregulation and bipolar disorder and, more specifically, provide evidence for other specified bipolar disorder with short duration hypomania patients were similar to bipolar II disorder patients from a biological marker perspective.

METHODS

We enrolled patients with bipolar I disorder (n=234), bipolar II disorder (n=260), other specified bipolar disorder with short duration hypomania (n=243), and healthy controls (n=140). Their clinical symptoms were rated using the Hamilton Depression Rating Scale and Young Mania Rating Scale. Inflammatory cytokine (tumor necrosis factor-α, C-reactive protein, transforming growth factor-β1, and interleukin-8) and brain-derived neurotrophic factor levels were measured in each group. Multivariate analysis of covariance and linear regression controlled for possible confounders were used to compare cytokine and brain-derived neurotrophic factor levels among the groups.

RESULTS

Multivariate analysis of covariance adjusted for age and sex and a main effect of diagnosis was significant (P<.001). Three of the 5 measured biomarkers (tumor necrosis factor-α, transforming growth factor-β1, and interleukin-8) were significantly (P=.006, .01, and <.001) higher in all bipolar disorder patients than in controls. Moreover, covarying for multiple associated confounders showed that bipolar I disorder patients had significantly higher IL-8 levels than did bipolar II disorder and other specified bipolar disorder with short duration hypomania patients in multivariate analysis of covariance (P=.03) and linear regression (P=.02) analyses. Biomarkers differences between bipolar II disorder and other specified bipolar disorder with short duration hypomania patients were nonsignificant.

CONCLUSION

The immunological disturbance along the bipolar spectrum was most severe in bipolar I disorder patients. Other specified bipolar disorder with short duration hypomania patients and bipolar II disorder patients did not differ in these biological markers.

Comparing clinical responses and the biomarkers of BDNF and cytokines between subthreshold bipolar disorder and bipolar II disorder

Patients with subthreshold hypomania (SBP; subthreshold bipolar disorder) were indistinguishable from those with bipolar disorder (BP)-II on clinical bipolar validators, but their analyses lacked biological and pharmacological treatment data. Because inflammation and neuroprogression underlies BP, we hypothesized that cytokines and brain-derived neurotrophic factor (BDNF) are biomarkers for BP. We enrolled 41 drug-naïve patients with SBP and 48 with BP-II undergoing 12 weeks of pharmacological treatment (valproic acid, fluoxetine, risperidone, lorazepam). The Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) were used to evaluate clinical responses at baseline and at weeks 0, 1, 2, 4, 8, and 12. Inflammatory cytokines (tumour necrosis factor [TNF]-α, transforming growth factor [TGF]-β1, interleukin [IL]-6, IL-8 and IL-1β) and BDNF levels were also measured. Mixed models repeated measurement was used to examine the therapeutic effect and changes in BDNF and cytokine levels between the groups. HDRS and YMRS scores significantly (P < 0.001) declined in both groups, the SBP group had significantly lower levels of BDNF (P = 0.005) and TGF-β1 (P = 0.02). Patients with SBP and BP-II respond similarly to treatment, but SBP patients may have different neuroinflammation marker expression.

The comparative short-term outcome of bipolar II disorder patients variably meeting or not meeting DSM-5 duration criteria following lamotrigine treatment

There is accruing clinical and empirical evidence supporting the efficacy of lamotrigine as a treatment for bipolar II disorder. However, the treatment response experienced by those with 'short duration' hypomania (or 'other specified' bipolar disorder) has been under-researched. We reviewed a clinical sample of 123 patients diagnosed with a bipolar II disorder three months following their initial assessment. A research interview evaluated treatment strategies implemented, depressive and hypomanic episode pattern and functional outcomes. Of patients who had achieved a minimum level of 75 mg of lamotrigine, n = 51 were assigned to the BP II disorder group (i.e., hypomanic episodes lasted four days or longer) and n = 28 to the short duration group (i.e., hypomanic episodes always lasted less than four days). There were no significant differences between the two groups at the three-month follow-up on self-report measures of changes in depressive and hypomanic episode pattern or functioning across six domains (i.e., intimate relationships, family relationships, friendships, work relationships, work performance, overall quality of life), and with the majority of patients reporting some level of improvement. Study limitations include being an observational, uncontrolled design with a relatively small sample size for detecting statistical differences. Nonetheless, lamotrigine appeared to be a suitable medication to be trialled in patients who alternate between depressive episodes and short periods of hypomania, (as for those with DSM-defined hypomanic episodes), and should prompt further investigation.

The Prevalence and Diagnostic Validity of Short-Duration Hypomanic Episodes and Major Depressive Episodes

Current diagnostic criteria for a hypomanic episode, as outlined in both the fourth and fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and DSM-5), require a minimum duration of four consecutive days of symptoms of mood elevation. The 4-day criterion for duration of hypomania has been challenged as arbitrary and lacking empirical support, with many arguing that shorter-duration hypomanic episodes are highly prevalent and that those experiencing these episodes are clinically more similar to patients with bipolar disorder than to those with unipolar major depressive disorder. We review the current evidence regarding the prevalence, diagnostic validity, and longitudinal illness correlates of shorter-duration hypomanic episodes and summarize the arguments for and against broadening the diagnostic criteria for hypomania to include shorter-duration variants. Accumulating findings suggest that patients with major depressive episodes and shorter-duration hypomanic episodes represent a complex clinical phenotype, perhaps best conceptualized as being on the continuum between those with unipolar depressive episodes alone and those with DSM-5-defined bipolar II disorder. Further investigation is warranted, ideally involving large prospective, controlled studies, to elucidate the diagnostic and treatment implications of depression with shorter-duration hypomanic episodes.

Therapeutic effects of add-on low-dose dextromethorphan plus valproic acid in bipolar disorder

Changes in inflammatory cytokines and dysfunction of the neurotrophic system are thought to be involved in the pathology of bipolar disorder (BP). We investigated whether inflammatory and neurotrophic factors were changed in BP. We also investigated whether treating BP with valproic acid (VPA) plus low-dose (30 or 60 mg/day) dextromethorphan (DM) is more effective than treating it with VPA only, and whether DM affects plasma cytokines and brain derived neurotrophic factor (BDNF) levels. In a 12-week, randomized, double-blind study, patients were randomly assigned to the VPA+DM30, VPA+DM60, or VPA+Placebo groups. The Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale (HDRS) were used to evaluate symptom severity, and ELISA to analyze plasma cytokine and BDNF levels. We recruited 309 patients with BP and 123 healthy controls. Before treatment, patients with BP had significantly higher plasma cytokine and lower plasma BDNF levels than did healthy controls. After treatment, HDRS and YMRS scores in each group showed significant improvement. Plasma cytokine levels tended to decline in all groups. Changes in plasma BDNF levels were significantly greater in the VPA+DM60 group than in the VPA+Placebo group.

CONCLUSION

patients with BP have a certain degree of systemic inflammation and BDNF dysfunction. Treatment with VPA plus DM (60 mg/day) provided patients with BP significantly more neurotrophic benefit than did VPA treatment alone.

Clinical course of the bipolar II disorder in a Japanese sample

BACKGROUND

The bipolar II disorder has been recognized a mental disorder distinctive from the bipolar I disorder, showing the stability of diagnosis in prospective studies. However, the characterization of the bipolar II disorder still remains under investigation.

METHODS

The present study was conducted on consecutively admitted bipolar II inpatients diagnosed by DSM-IV-TR to delineate the clinical features.

RESULTS

The types of initial mood disorders of the bipolar II inpatients were divided into four groups, i.e., major depressive episode (MDE), hypomanic episode (HME), and dysthymic and cyclothymic disorders. Seventy-one percent of all the patients belonged to the MDE group, a half of which underwent the first HME following the first MDE. The number of patients that exhibited the HME within one year after the first MDE was the highest in a widely distributed interval of years between the first MDE and the first HME. The cyclothymic disorder group was relatively young at the onset and was more prone to attempt suicide. Moreover, there might be a complex connection with other psychiatric disorders, such as anxiety disorders, in the longitudinal course of the bipolar disorder.

LIMITATION

The present study was carried out on a limited number of patients admitted to one hospital. The data are partly based on the retrospective information from the patients and their relatives. The generalization of the results requires further studies.

CONCLUSION

The bipolar II disorder could be divided into heterogeneous groups in the longitudinal course. Hence, paying attention to the heterogeneity in clinical practice and a study of the disorder are required.

The BDNF Val66Met polymorphism and plasma brain-derived neurotrophic factor levels in Han Chinese patients with bipolar disorder and schizophrenia

OBJECTIVE

Brain-derived neurotropic factor (BDNF) is widely distributed in the peripheral and central nervous systems. BDNF and its gene polymorphism may be important in synaptic plasticity and neuron survival, and may become a key target in the physiopathology of several mental illnesses. To elucidate the role of BDNF, we compared the plasma BDNF levels and the BDNF Val66Met gene variants effect in several mental disorders.

METHOD

We enrolled 644 participants: 177 patients with bipolar I disorder (BP-I), 190 with bipolar II disorder (BP-II), 151 with schizophrenia, and 126 healthy controls. Their plasma BDNF levels and BDNF Val66Met single nucleotide polymorphisms (SNP) were checked before pharmacological treatment.

RESULTS

Plasma levels of BDNF were significantly lower in patients with schizophrenia than in healthy controls and patients with bipolar disorder (F = 37.667, p<0.001); the distribution of the BDNF Val66Met SNP was not different between groups (χ(2) = 5.289, p = 0.507). Nor were plasma BDNF levels significantly different between Met/Met, Met/Val, and Val/Val carriers in each group, which indicated that the BDNF Val66Met SNP did not influence plasma BDNF levels in our participants. Plasma BDNF levels were, however, significantly negatively correlated with depression scores in patients with bipolar disorder and with negative symptoms in patients with schizophrenia.

CONCLUSION

We conclude that plasma BDNF profiles in different mental disorders are not affected by BDNF Val66Met gene variants, but by the process and progression of the illness itself.

Is the DSM-5 duration criterion valid for the definition of hypomania?

BACKGROUND

DSM-IV and DSM-5 impose a 4 day duration criterion for hypomanic episodes yet several studies have suggested that such an imposition may be invalid. We report a study involving a large sample pursuing the likely salience of the DSM duration criterion.

METHODS

We analyzed data on hypomanic symptoms provided by two bipolar screening measures - the Mood Disorders Questionnaire (MDQ) and the Mood Swings Questionnaire (MSQ) in a sample of 501 patients meeting DSM and other symptom criteria for a bipolar II disorder (BP II) and contrasted data for 186 meeting the DSM minimum duration of 4 days and 315 experiencing episodes lasting less than 4 days (i.e. 'standard' vs. 'brief' groups).

RESULTS

The brief group reported slightly less severe hypomanic episodes, but the two groups did not differ on a number of illness correlates including age of onset of depressive and of hypomanic episodes, or by rates of depressive and bipolar conditions in first-degree family members.

LIMITATIONS

The possibility of false positive BP II diagnoses, especially with brief hypomanic episodes, must be conceded while our examination of clinical symptoms was limited to two measures.

CONCLUSIONS

This study is consistent with previous studies suggesting that the DSM duration of 4 or more days for a diagnosis of a hypomanic episode is unnecessary to the clinical definition of a BP II disorder. Its preservation is likely to exclude a substantive number of those with a true BP II condition.

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.

Differentiation of bipolar I and II disorders by examining for differences in severity of manic/hypomanic symptoms and the presence or absence of psychosis during that phase

BACKGROUND

DSM-IV criteria for mania/hypomania overlap considerably. We sought to examine the utility of a model differentiating bipolar I and II disorders by weighting the presence or absence of psychosis during manic/hypomanic episodes as opposed to simply weighting symptom severity.

METHODS

A set of 632 patients with a so-assigned clinical bipolar I or II disorder diagnosis contributed to the principal analyses, and a subset of 210 was included in a comparative analyses of DSM-assigned diagnoses. We also examined the impact of duration of highs on symptom patterns and the extent to which depressive episodes were psychotic or non-psychotic melancholic in type.

RESULTS

There were no group differences for bipolar I and II patients (clinical or DSM groups) by age, gender, age of onset or age of formal bipolar diagnosis. Clinically assigned bipolar I patients returned higher severity scores than bipolar II patients on manic/hypomanic symptoms, but such differentiation was limited. Clinically-assigned bipolar I patients were more likely than bipolar II patients to be diagnosed with psychotic depression, and had lower rates of non-melancholic depression. Duration of highs had some impact on the phenomenology of highs, but not on the phenomenology of depression.

LIMITATIONS

We cannot establish the degree to which clinicians validly differentiated those with bipolar disorder, and accurately judged the lifetime presence of psychotic features and of depressive subtype differentiation.

CONCLUSIONS

Findings support the utility of an alternative model to DSM-IV in weighting the respective presence or absence of psychotic symptoms during highs in differentiating bipolar I and II disorders.

The use of Mood Disorder Questionnaire, Hypomania Checklist-32 and clinical predictors for screening previously unrecognised bipolar disorder in a general psychiatric setting

Bipolar disorder is often unrecognised and misdiagnosed in the general psychiatric setting. This study compared the psychometric properties of the Mood Disorder Questionnaire (MDQ) and the Hypomania Checklist-32 (HCL-32), examined the clinical predictors of bipolar disorder and determined the best approach for screening previously unrecognised bipolar disorder in a general psychiatric clinic. A random sample of 340 non-psychotic outpatients with no previous diagnosis of bipolar disorder completed the MDQ and HCL-32 during their scheduled clinic visits. Mood and alcohol/substance use disorders were reassessed using a telephone-based Structured Clinical Interview for DSM-IV. We found that the HCL-32 had better psychometric performance and discriminatory capacity than the MDQ. The HCL-32's internal consistency and 4-week test-retest reliability were higher. The area under the curve was also greater than that of the MDQ at various clustering and impairment criteria. The optimal cut-off of the MDQ was co-occurrence of four symptoms with omission of the impairment criterion; for the HCL-32, it was 11 affirmative responses. Multivariable logistic regression found that bipolar family history was associated with an increased risk of bipolar disorder (odds ratio=4.93). The study showed that simultaneous use of the HCL-32 and bipolar family history was the best approach for detecting previously unrecognised bipolar disorder.

Syndromal and subsyndromal illness status and five-year morbidity using criteria of the International Society for Bipolar Disorders compared to alternative criteria

BACKGROUND

Subsyndromal symptoms have been recognized as relevant in the course and outcome of bipolar disorder (BD) patients. Nevertheless, their definition and cutoff points on current depression and mania scales are uncertain. The recently defined International Society for Bipolar Disorders (ISBD) operational criteria for the assessment of the course and outcome of bipolar illness have never been tested until now.

METHODS

A naturalistic longitudinal follow-up study of up to 5 years included a cohort of 317 DSM-IV-TR BD outpatients. For the first time, we assessed the proportion of visits in different affective states using the ISBD criteria. Secondarily, we compared the results with those obtained applying other cutoff points.

RESULTS

Patients were symptomatic in 39.1% (95% CI 35.3-42.9) of the visits. Subsyndromal symptoms, primarily subsyndromal depression, were present in 15.9% of patients (95% CI 13.4-18.4). No significant differences were found between bipolar I patients and bipolar II patients. There were differences in the total percentage of visits in euthymia depending on the cutoff points (p < 0.05).

CONCLUSIONS

Applying ISBD criteria, bipolar patients have significant clinical morbidity and are often symptomatic, both with threshold symptoms and with subthreshold symptoms, especially with depression. The chosen cutoff points modify the apparent results.

LIMITATIONS

The cutoff points used have not been validated. Psychopharmacologic treatments were naturalistic.

Antidepressant treatment for acute bipolar depression: an update

While studies in the past have focused more on treatment of the manic phase of bipolar disorder (BD), recent findings demonstrate the depressive phase to be at least as debilitating. However, in contrast to unipolar depression, depression in bipolar patients exhibits a varying response to antidepressants, raising questions regarding their efficacy and tolerability. Methods. We conducted a MEDLINE and Cochrane Collaboration Library search for papers published between 2005 and 2011 on the subject of antidepressant treatment of bipolar depression. Sixty-eight articles were included in the present review. Results. While a few studies did advocate the use of antidepressants, most well-controlled studies failed to show a robust effect of antidepressants in bipolar depression, regardless of antidepressant class or bipolar subtype. There was no significant increase in the rate of manic/hypomanic switch, especially with concurrent use of mood stabilizers. Prescribing guidelines published in recent years rely more on atypical antipsychotics, especially quetiapine, as a first-line therapy. Conclusions. Antidepressants probably have no substantial role in acute bipolar depression. However, in light of conflicting results between studies, more well-designed trials are warranted.

Decreasing the minimum length criterion for an episode of hypomania: evaluation using self-reported data from patients with bipolar disorder

Brief hypomania lasting less than 4 days may impair functioning and help to detect bipolarity. This study analyzed brief hypomania that occurred in patients with bipolar disorder who were diagnosed according to the DSM-IV criteria. Daily self-reported mood ratings were obtained from 393 patients (247 bipolar I and 146 bipolar II) for 6 months (75,284 days of data, mean 191.6 days). Episodes of hypomania were calculated using a 4, 3, 2, and single day length criterion. Brief hypomania occurred frequently. With a decrease in the minimum criterion from 4 days to 2 days, there were almost twice as many patients with an episode of hypomania (102 vs. 190), and more than twice as many episodes (305 vs. 863). Single days of hypomania were experienced by 271 (69%) of the sample. With a 2-day episode length, 33% of all hypomania remained outside of an episode. There was no significant difference in the percent of hypomanic days outside of an episode between patients with bipolar I and II disorders. There were no significant differences in the demographic characteristics of patients who met the 4-day minimum as compared with those who only experienced episodes of hypomania using a shortened length criterion. Decreasing the minimum length criterion for an episode of hypomania will cause a large increase in the number of patients who experience an episode and in the aggregate number of episodes, but will not distinguish subgroups within a sample who meet the DSM-IV criteria for bipolar disorder. Frequency may be an important dimensional aspect of brief hypomania. Clinicians should regularly probe for brief hypomania.

The modified SCID Hypomania Module (SCID-Hba): a detailed systematic phenomenologic probing

Diagnosing past hypomania is a difficult task. Current structured interviews (e.g. CIDI, SCID) limit the ability to probe for hypomania. A modified SCID Hypomania Module was published by us (Benazzi and Akiskal, J Affect Disord 2003; Akiskal and Benazzi, J Clin Psychiatry 2005) in order to overcome the limitations of structured interviewing. Our papers outlined the framework of the modified SCID. In response to requests from many readers of this journal and other clinicians and investigators, we are hereby providing a more explicit step-by-step phenomenologic probing interview. DSM-IV criteria have to be met, but the probing for hypomania is very different from that of the SCID. All past hypomanic symptoms are assessed. No negative meaning is given to symptoms, as hypomania often improves functioning and it is seen by patients as a state of well being. The first step is probing for overactivity (increase in goal-directed activity), because observable behaviors are easier to remember by patients and key informants. There is no gold-standard for overactivity: each person becomes his/her own standard to 'measure' a clear-cut departure form the usual behavior. Questions, correspondingly, can change from patient to patient. The emotions associated with behavioral change are easier to be remembered than asking them first, as in the structured interviews. Structured interviews have mood change (elation, irritability) as stem question (corresponding to the criterion A of DSM-IV, which postulates that it must always be present). However, apart from a likely recall bias of past emotions, the description of mood change appears more or less negative in structured interviews (to increase specificity but by much reducing sensitivity, i.e. the false-negatives). Presenting mood change as simply having been more elated/irritable than usual can easily be interpreted as normal mood fluctuations, while presenting mood change as much more than usual could be understood as a severe mental disorder. Both ways are likely to lead to a negative response, moving the interviewers to unipolar disorders (the skip-out instruction). Our modified SCID is a fully semi-structured interview: many questions are asked about each symptom to make the question understandable according to each patient, and, very importantly, examples of the 'events' are systematically asked to check understanding and clinical relevance. Our interview follows DSM-IV criteria (apart from the minimum duration, 2 days versus DSM-IV 4 days), i.e. mood change must always been present, but our probing detects more hypomanic episodes than the SCID.

A community survey of the twelve-month prevalence and correlates of bipolar spectrum disorder in Hong Kong

BACKGROUND

Recent community and clinical epidemiological studies have indicated that bipolar spectrum disorder (BSD) is a common illness. No community-based epidemiological study of BSD has been conducted in Chinese and other Asian populations.

METHOD

A random sample of 3016 Chinese adults underwent a telephone-based community survey that examined their twelve-month prevalences of BSD, sociodemographic characteristics, level of distress, and role impairment using the Sheehan Disability Scale. Bipolar I disorder (BP-I) and bipolar II disorder (BP-II) were based on DSM-IV criteria. Soft bipolar II disorder (Soft BP-II) fulfilled the DSM-IV criteria of major depressive episode and hypomanic episode except that the hypomanic/manic symptoms lasted two to three days.

RESULTS

The lifetime prevalences of manic episode, hypomanic episode, and soft hypomanic episode were 2.2%, 2.2%, and 10.7% respectively. The twelve-month prevalences of BP-I, BP-II, and Soft BP-II were 1.4%, 0.5%, and 1.8%, respectively. Respondents with BSD were more likely to be female, younger, and single than those without. Impairment and distress associated with depressive symptoms were similar across the three groups of bipolar disorders, but those associated with manic/hypomanic symptoms were more severe among respondents with BP-I than BP-II and Soft BP-II. The number of manic/hypomanic symptoms and depressive symptoms did not differ across the three bipolar groups.

LIMITATION

Structured interview questions based on core DSM-IV mood symptoms might under-estimate hypomania. Detailed sociodemographic information was not available.

CONCLUSION

BSD was common among Chinese people in Hong Kong and exhibited an epidemiological profile comparable to that of western societies.

A prediction rule for diagnosing hypomania

BACKGROUND

Missing the diagnosis of past hypomania, and thus of bipolar II disorder, is common. Study aim was to find a 'prediction rule' for facilitating the diagnosis of past hypomania.

METHODS

In an outpatient psychiatry private practice (non-tertiary care), a consecutive sample of 275 bipolar II disorder (BP-II) remitted patients, and consecutive, independent, sample of 138 major depressive disorder (MDD) remitted patients, had been interviewed for different study goals during follow-up visits by a senior bipolar-trained psychiatrist. Using the Structured Clinical Interview for DSM-IV, modified and validated by Benazzi and Akiskal [Benazzi F (2007). Lancet 369: 935-945] to improve the probing for past hypomania, patients had been questioned about the most common symptoms and duration of recent threshold and subthreshold hypomanic episodes. The sample was retrospective in nature. A prediction rule was tested. This is a score resulting from the sum of the weighted scores of each hypomanic symptom which was an independent predictor of hypomania. Its cutoff score for discriminating hypomania was based on the highest figure of correctly classified hypomanias and on the most balanced combination of sensitivity and specificity. A second, independent sample of 138 BP-II and 71 MDD remitted outpatients was tested to replicate the findings.

RESULTS

By univariate logistic regression, hypomanic symptoms distinguishing BP-II and MDD included 'increase in goal-directed activity' (overactivity) (OR=28.3), 'elevated mood' (OR=14.9), 'increased talkativeness' (OR=9.2), 'inflated self-esteem', 'decreased need for sleep', 'excessive risky activities', and 'irritable mood'. By multivariable logistic regression, the independent predictors of hypomania resulted 'increase in goal-directed activity' (OR=14.9, weighted score=15), 'elevated mood' (OR=7.5, weighted score=7), 'increased talkativeness' (OR=3.6, weighted score=4); 'irritable mood', 'inflated self-esteem', 'decreased need for sleep', and 'excessive risky activities' had ORs between 2.04 and 2.39, with a weighted score=2. The prediction rule showed that the cutpoint score > or = 21 had the highest figure of correctly classified hypomanias (88%, ROC area=0.94), showing the most balanced combination of sensitivity (87%) and specificity (89%). This prediction rule, tested on the second sample, found that the same cutoff score > or =21 correctly classified the highest figure of hypomanias (94%, ROC area=0.97), showing the most balanced combination of sensitivity (93%) and specificity (95%). To cross this cutoff score, overactivity was always required (as the sum of the scores of elevated mood and of the other symptoms did not reach this cutoff). However, scores 10 to 20 correctly classified only slightly lower figures of hypomanias.

CONCLUSIONS

A prediction rule for hypomania was tested. The scores of overactivity plus at least some hypomanic symptom (among elevated mood, irritability, inflated self-esteem, less sleep, talkativeness, excessive risky activities) correctly classified 88% of hypomanias. Instead, elevated mood without overactivity, plus even all the other symptoms, did not reach the best figure of correctly classified. However, lower cutoff scores, up to 10, classified slightly lower figures of hypomanias, but with less balanced combinations of sensitivity and specificity. These findings may have diagnostic utility, because BP-II versus MDD is likely to be a more severe disorder. This prediction rule, if replicated and fine-tuned in different settings, may help clinicians better probing past hypomania, thus reducing the common misdiagnosis of BP-II as MDD.

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

BACKGROUND

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

STUDY AIM

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

METHODS

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

RESULTS

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

DISCUSSION

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

Defining mixed depression

BACKGROUND

Mixed depression, i.e. a major depressive episode plus co-occurring manic/hypomanic symptoms, has recently become the focus of research. However, it is still unclear if its definition should be based on specific manic symptoms or on a number/score of manic symptoms. Different definitions may have different diagnostic utility, such as treatment impacts.

STUDY AIM

Study aim was to test which definition of mixed depression was more supported, by using, as diagnostic validator, early age at onset on the basis of previous studies supporting its bipolar nature.

METHODS

Consecutive 336 Bipolar II Disorder (BP-II), and 224 Major Depressive Disorder (MDD) outpatients were cross-sectionally assessed for major depressive episode (MDE) and concurrent DSM-IV hypomanic symptoms when presenting for treatment of depression, by a mood disorder specialist psychiatrist using the Structured Clinical Interview for DSM-IV as modified by Akiskal and Benazzi (J Clin Psychiatry, 2005) and the Hypomania Interview Guide (HIG), in a private practice. Mixed depression was defined as co-occurrence of MDE and hypomanic symptoms. Early age at onset (EO) below 21 years was used as diagnostic validator.

RESULTS

Multivariable logistic regression of EO versus all within-MDE hypomanic symptoms, controlled for BP-II, showed that no specific symptom was independently associated with EO. By ROC analysis versus EO, the best combination of sensitivity and specificity, and the highest figure of correctly classified, were shown by a cutoff number >=3 symptoms, and by a cutoff HIG score >=8. Both cutoffs had similar strength of association with EO. Mixed depression defined by >=3 within-MDE hypomanic symptoms (A), or by a HIG score >=8 (B), were more frequent in EO group versus LO group (A: 70.5% versus 49.8%; B: 60.7% versus 40.9%; p<0.001), and in BP-II versus MDD (A: 72.3% versus 39.7%; p<0.001; positive predictive value for BP-II=73.1%; B: 63.9% versus 29.0%; p<0.001; positive predictive value for BP-II=76.7%).

DISCUSSION

Findings could support the diagnostic validity of a definition of mixed depression based on a cutoff number/score of within-depression hypomanic symptoms versus one based on specific symptoms, complementing and supporting previous studies using bipolar family history as validator. Diagnosing mixed depression has treatment impacts, such as careful use of antidepressants added to mood stabilising agents or no use of antidepressants, as recently shown by large naturalistic and controlled studies.

A relationship between bipolar II disorder and borderline personality disorder?

BACKGROUND

The relationship between DSM-IV-TR borderline personality disorder (BPD) and bipolar disorders, especially bipolar II disorder (BP-II), is still unclear. Many recent reviews on this topic have come to opposite or different conclusions.

STUDY AIM

The aim was to test the association between hypomania symptoms and BPD traits, as hypomania is the defining feature of BP-II in DSM-IV-TR.

METHODS

During follow-up visits in a private practice, consecutive 138 remitted BP-II outpatients were re-diagnosed by a mood disorder specialist psychiatrist, using the Structured Clinical Interview for DSM-IV (as modified by Benazzi and Akiskal for better probing hypomania). Soon after, patients self-assessed (blind to interviewer) the SCID-II Personality Questionnaire for BPD. Associations and confounding were tested by logistic regression, between each criteria symptom of hypomania (apart from "racing thoughts" and "distractibility", not assessed as probing focused mainly on behavioral, observable signs), and the entire set of BPD traits. Multivariate regression was also used to jointly regress the entire set of hypomanic symptoms on the entire set of BPD traits.

RESULTS

Mean (SD) age was 39.0 (9.8) years, females were 76.3%. Frequency of BPD traits ranged between 17% and 66% (e.g. impulsivity trait 41%, affective instability trait 63%), mean (SD) number of traits was 4.2 (2.3). The most common episodic hypomanic symptoms were elevated mood (91%) and overactivity (93%); frequency of excessive risky, impulsive activities (impulsivity) was 62%. By logistic regression the only significant association was between the episodic impulsivity of hypomania and the trait impulsivity of BPD. Multivariate regression of the entire set of hypomanic symptoms jointly regressed on the entire set of BPD traits was not statistically significant.

DISCUSSION

The core feature of BP-II, i.e. hypomania, does not seem to have a close relationship with BDP traits in the study setting, partly running against a strong association between BPD and BP-II and a bipolar spectrum nature of BPD.

How best to identify a bipolar-related subtype among major depressive patients without spontaneous hypomania: superiority of age at onset criterion over recurrence and polarity?

BACKGROUND

History of high depressive recurrence (without history of mania/hypomania) has been proposed as a mood subtype close to bipolar disorders. Herein we test whether this is the best approach to this question.

METHODS

We systematically evaluated consecutive 224 Major Depressive (MDD) and 336 Bipolar II Disorders (BP-II) outpatients in a private practice, by the SCID for DSM-IV (modified for better probing hypomania by Akiskal and Benazzi [Akiskal, H.S., Benazzi, F., 2005. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J. Clin. Psychiatry 66, 914-921]). We conducted univariate and multivariate analyses on such putative bipolar validators as early age at onset of first major depressive episode (before 21 years), high recurrence, family history for bipolar disorders, and depressive mixed states (mixed depression, i.e. depression plus concurrent hypomanic symptoms), in order to identify an MDD subgroup close to BP-II.

RESULTS

All bipolar validators were independent predictors of BP-II. Early onset was the only variable which identified an MDD subgroup significantly associated with all bipolar validators. This MDD subgroup was similar to BP-II on age at onset and bipolar family history, and had a high frequency of mixed depression. A dose-response relationship was found between number of bipolar validators present in MDD, and bipolar family history loading among MDD relatives.

LIMITATIONS

Study limited to outpatients.

CONCLUSIONS

From among the bipolar validators, early age at onset of first major depression (<21 years) was superior to high recurrence (>4 depressive episodes) in identifying an MDD subgroup close to BP-II, which might be subsumed under the broad bipolar spectrum. Implications of unipolar-bipolar boundaries and genetic investigations are discussed.

Validation of the Chinese version of the hypomania checklist (HCL-32) as an instrument for detecting hypo(mania) in patients with mood disorders

BACKGROUND

Bipolar disorder (BP) has been consistently under-recognized and erroneously diagnosed as major depression. The resulting inappropriate or delayed treatment is associated with elevated risk of (hypo)mania or cycling. The recognition of (hypo)manic episodes is essential for the correct diagnosis of BP. The Hypomania CheckList (HCL-32) is developed to increase the detection of suspected or manifest but mistreated BP cases. We aimed to determine the accuracy and validity of the Chinese version of the HCL-32 in an adult psychiatric setting. We also compared the results with prior studies carried out in a comparable sample.

METHODS

Patients suffering from mood disorders completed the HCL-32 before being interviewed with the Schedule for Affective Disorder and Schizophrenia-Lifetime (SADS-L) to make DSM-IV diagnosis. The 4-day duration criterion for hypomania was replaced by a 2-day cut-off for BPII. The internal consistency and discriminatory capacity of the HCL-32 were analyzed.

RESULTS

Results indicated high internal consistency of the Chinese version of the HCL-32. The dual factor structure was confirmed. A score of 14 or more on the HCL-32 total scale distinguished between BP and MDD yielding a sensitivity of 82% and a specificity of 67%. This scale also distinguished between BPI and BPII with a sensitivity of 64% and a specificity of 73% for the cut-off score of 21.

LIMITATIONS

The sample size of MDD patients needs to be increased.

CONCLUSIONS

The Chinese HCL-32 is a useful screening tool for BP in a psychiatric setting. Its performance is also comparable to that reported in previous studies.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A tetrachoric factor analysis validation of mixed depression

BACKGROUND

Mixed depression, i.e. a Major Depressive Episode plus co-occurring manic/hypomanic symptoms, has recently become the focus of research. However, its diagnostic validity and bipolar nature are still not firmly supported. A bipolar nature could have significant treatment impacts.

STUDY AIM

The aim was to psychometrically validate the concept of, and the bipolar nature, of mixed depression, by using (for the first time) tetrachoric factor analysis of its hypomanic symptoms.

METHODS

Consecutive 441 Bipolar II Disorder (BP-II), and 289 Major Depressive Disorder (MDD) outpatients were cross-sectionally assessed for Major Depressive Episode (MDE) and concurrent hypomanic symptoms (as binary variables) when presenting for treatment of depression, by a mood disorder specialist psychiatrist (FB), using the Structured Clinical Interview for DSM-IV (as modified by [Akiskal HS, Benazzi F. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J Clin Psychiatry 2005; 66: 914-921.]) in a private practice. Consecutive 275 remitted BP-II were also assessed for past hypomania. Mixed depression was defined as co-occurrence of MDE and 3 or more, usually subthreshold, hypomanic symptoms.

RESULTS

In multivariable logistic regression, BP-II independent predictor variables were young onset age, MDE recurrences, mixed depression, and bipolar family history. Factor analysis of past hypomania symptoms found three factors: an "irritable mental overactivity" factor, an "elevated mood" factor, and a "motor overactivity" factor. Factor analysis of intradepression hypomanic symptoms in BP-II, and in MDD, found two similar mental and motor overactivity factors. Multivariate regression of the intradepression hypomanic factors versus bipolar validators, such as bipolar family history and young onset age, found significant associations.

DISCUSSION

Findings could support the diagnostic validity, and the bipolar nature, of mixed depression, on the basis of the close similarities found between the factor structure of inter-depression hypomania and intra-depression hypomanic symptoms. Impacts on treatment of a bipolar nature of mixed depression may be significant (e.g. more use of mood stabilising agents, less/no use of antidepressants).

Testing predictors of bipolar-II disorder with a 2-day minimum duration of hypomania

The study's aim was to find if features often reported to distinguish bipolar and depressive disorders could predict bipolar-II disorder (BP-II). Consecutive major depressive episode (MDE) outpatients, including 284 with BP-II and 196 with major depressive disorder (MDD), were interviewed with the Structured Clinical Interview for DSM-IV, Hypomania Interview Guide, and Family History Screen, in a private practice. The minimum duration of past hypomania was 2 days. Mixed depression was defined as an MDE plus three or more intradepressive, non-euphoric hypomanic symptoms. BP-II predictors were early onset (<20 years), many recurrences (>4 MDEs), bipolar family history, mixed depression, and atypical depressions. Bipolar family history had the highest positive predictive value (PPV) (80.8%) but low sample frequency (32.7%); early onset had high PPV (75.2%) and a sample frequency of 37.0%; many recurrences had the highest frequency (70.4%) but the lowest PPV (66.5%). Combinations of three or more predictors had high PPV (79.0%) and a sample frequency of 46.6%. Predictors and combinations of predictors may correctly identify 75% to 80% of BP-II, reducing the misdiagnosis of BP-II as MDD (by prompting careful probing for hypomania history), and improving treatment of depression (as antidepressants alone may worsen BP-II course). As PPV is related to disease prevalence, findings need to be replicated in different settings.

Bipolar II disorder : epidemiology, diagnosis and management

Bipolar II disorder (BP-II) is defined, by DSM-IV, as recurrent episodes of depression and hypomania. Hypomania, according to DSM-IV, requires elevated (euphoric) and/or irritable mood, plus at least three of the following symptoms (four if mood is only irritable): grandiosity, decreased need for sleep, increased talking, racing thoughts, distractibility, overactivity (an increase in goal-directed activity), psychomotor agitation and excessive involvement in risky activities. This observable change in functioning should not be severe enough to cause marked impairment of social or occupational functioning, or to require hospitalisation. The distinction between BP-II and bipolar I disorder (BP-I) is not clearcut. The symptoms of mania (defining BP-I) and hypomania (defining BP-II) are the same, apart from the presence of psychosis in mania, and the distinction is based on the presence of marked impairment associated with mania, i.e. mania is more severe and may require hospitalisation. This is an unclear boundary that can lead to misclassification; however, the fact that hypomania often increases functioning makes the distinction between mania and hypomania clearer. BP-II depression can be syndromal and subsyndromal, and it is the prominent feature of BP-II. It is often a mixed depression, i.e. it has concurrent, usually subsyndromal, hypomanic symptoms. It is the depression that usually leads the patient to seek treatment.DSM-IV bipolar disorders (BP-I, BP-II, cyclothymic disorder and bipolar disorder not otherwise classified, which includes very rapid cycling and recurrent hypomania) are now considered to be part of the 'bipolar spectrum'. This is not included in DSM-IV, but is thought to also include antidepressant/substance-associated hypomania, cyclothymic temperament (a trait of highly unstable mood, thinking and behaviour), unipolar mixed depression and highly recurrent unipolar depression.BP-II is underdiagnosed in clinical practice, and its pharmacological treatment is understudied. Underdiagnosis is demonstrated by recent epidemiological studies. While, in DSM-IV, BP-II is reported to have a lifetime community prevalence of 0.5%, epidemiological studies have instead found that it has a lifetime community prevalence (including the bipolar spectrum) of around 5%. In depressed outpatients, one in two may have BP-II. The recent increased diagnosing of BP-II in research settings is related to several factors, including the introduction of the use of semi-structured interviews by trained research clinicians, a relaxation of diagnostic criteria such that the minimum duration of hypomania is now less than the 4 days stipulated by DSM-IV, and a probing for a history of hypomania focused more on overactivity (increased goal-directed activity) than on mood change (although this is still required for a diagnosis of hypomania). Guidelines on the treatment of BP-II are mainly consensus based and tend to follow those for the treatment of BP-I, because there have been few controlled studies of the treatment of BP-II. The current, limited evidence supports the following lines of treatment for BP-II. Hypomania is likely to respond to the same agents useful for mania, i.e. mood-stabilising agents such as lithium and valproate, and the second-generation antipsychotics (i.e. olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole). Hypomania should be treated even if associated with overfunctioning, because a depression often soon follows hypomania (the hypomania-depression cycle). For the treatment of acute BP-II depression, two controlled studies of quetiapine have not found clearcut positive effects. Naturalistic studies, although open to several biases, have found antidepressants in acute BP-II depression to be as effective as in unipolar depression; however, one recent large controlled study (mainly in patients with BP-I) has found antidepressants to be no more effective than placebo. Results from naturalistic studies and clinical observations on mixed depression, while in need of replication in controlled studies, indicate that antidepressants may worsen the concurrent intradepression hypomanic symptoms. The only preventive treatment for both depression and hypomania that is supported by several, albeit older, controlled studies is lithium. Lamotrigine has shown some efficacy in delaying depression recurrences, but there have also been several negative unpublished studies of the drug in this indication.

Impulsivity in bipolar-II disorder: trait, state, or both?

BACKGROUND

In bipolar-II (BP-II) disorder impulsivity (defined as excessive risky activities by DSM-IV-TR) is one of the symptoms of hypomania. It is unclear if impulsivity is also a trait in BP-II.

STUDY AIM

The aim was to test if impulsivity was also a trait in BP-II.

METHODS

Consecutive 136 remitted BP-II outpatients (assessed when presenting for depression by a mood disorder specialist psychiatrist using the Structured Clinical Interview for DSM-IV), self-assessed trait impulsivity during follow-ups, using the Personality Questionnaire of the Structured Clinical Interview for DSM-IV Axis II Disorders, in a private practice. Trait mood swings were also self-assessed, using the TEMPS-A. A trait nature of impulsivity in BP-II could be supported by finding (1) a relatively high frequency, (2) association between trait impulsivity and symptoms of past hypomania, especially impulsivity, (3) dose-response relationship between number of past hypomania symptoms and trait impulsivity, and (4) association between trait impulsivity and trait mood swings (a trait feature of BP-II).

RESULTS

Trait impulsivity was present in 41.1% of BP-II. BP-II with, versus BP-II without, trait impulsivity had significantly more males, trait mood swings, past hypomania symptoms (irritable mood, talkativeness, increased goal-directed activity), and excessive risky activities (i.e. state impulsivity), corresponding to an irritable risky overactivity. Past state impulsivity and trait impulsivity were significantly associated. Number of past hypomania symptoms and trait impulsivity were significantly correlated. A dose-response relationship was found between number of past hypomania symptoms and trait impulsivity.

DISCUSSION

Findings suggest that trait impulsivity may be a feature of BP-II. Limitation of self-assessment of personality traits should be taken into account. Findings may have treatment impacts, as the combination of trait impulsivity and mood swings may facilitate relapses and mixed states, which mood stabilising agents could prevent/delay.

Delineation of the clinical picture of Dysphoric/Mixed Hypomania

BACKGROUND

While Mixed Depression (i.e. depression plus subthreshold concurrent manic/hypomanic symptoms) has recently seen a wave of studies, little is known about Dysphoric/Mixed Hypomania (i.e. combination of syndromal hypomania and depression) compared to Bipolar I Disorder Mixed State (i.e. combination of syndromal mania and depression).

STUDY AIM

To delineate the clinical picture of Dysphoric/Mixed Hypomania.

METHODS

Consecutive 441 Bipolar II Disorder (BP-II) Major Depressive Episode (MDE) outpatients were cross-sectionally assessed for depression and concurrent hypomanic symptoms when presenting for treatment of depression, by a mood disorder specialist psychiatrist (FB), using the Structured Clinical Interview for DSM-IV, in a private practice. Consecutive 275 remitted BP-II were also assessed for the clinical picture of past (recalled) Hypomania. Dysphoric Hypomania was defined as the co-occurrence of DSM-IV irritable mood Hypomania and MDE.

RESULTS

Frequency of Dysphoric Hypomania was 17.0%, and it was 66.4% for Mixed Depression. Irritable mood, always present by definition in Dysphoric Hypomania, was present in 65.9% of recalled Hypomania and elevated mood in 81.4%. Dysphoric Hypomania had significantly more racing/crowded thoughts, and much less increased goal-directed activity. Functioning was always impaired in Dysphoric Hypomania (by definition), while it was improved in most recalled Hypomanias. Factor structure was different: recalled Hypomania had three factors ('elevated mood', 'irritability and racing/crowded thoughts', 'goal-directed and risky overactivity'), Dysphoric Hypomania had five factors ('depressive vegetative symptoms', 'low mood and psychomotor agitation', 'risky activities', 'loss of interest', 'racing/crowded thoughts and suicidality').

DISCUSSION

Dysphoric Hypomania was uncommon among depressed outpatients (while Mixed Depression was common). Its clinical picture was closer to depression than to hypomania. If it were seen as a simple depression, antidepressants could be used alone (i.e. not protected by mood stabilising agents), risking the worsening of intra-depression irritable hypomania (which was related to suicidality). Systematic assessment of intra-depression hypomanic symptoms is supported.

Bipolar disorder--focus on bipolar II disorder and mixed depression

Bipolar II disorder (recurrent depressive and hypomanic episodes) and related disorders (united in the bipolar spectrum) are understudied, despite a prevalence of about 5% in the community and about 50% in depressed outpatients. The apparent increase in prevalence of the bipolar spectrum is related to several changes in diagnostic criteria, including improved probing for history of hypomania (focused more on overactivity than on mood change), lower minimum duration of hypomania, and inclusion of unipolar depressions with bipolar signs (eg, family history of bipolar disorder, mixed depression). Prevalence of mixed depression, a combination of depression and manic or hypomanic symptoms, is high in patients with bipolar disorders. Controlled studies are needed to investigate treatment of mixed depression; antidepressants can worsen manic and hypomanic symptoms, and mood stabilising agents might be necessary.

Challenging the unipolar-bipolar division: does mixed depression bridge the gap?

BACKGROUND

Mixed states, i.e., opposite polarity symptoms in the same mood episode, question the categorical splitting of mood disorders in bipolar disorders and unipolar depressive disorders, and may support a continuum between these disorders. Study aim was to find if there were a continuum between hypomania (defining BP-II) and depression (defining MDD), by testing mixed depression as a 'bridge' linking these two disorders. A correlation between intradepressive hypomanic symptoms and depressive symptoms could support such a continuum, but other explanations of a correlation are possible.

METHODS

Consecutive 389 BP-II and 261 MDD major depressive episode (MDE) outpatients were interviewed, cross-sectionally, with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide (to assess intradepressive hypomanic symptoms) and the Family History Screen, by a mood disorders specialist psychiatrist in a private practice. Patients presented voluntarily for treatment of depression when interviewed drug-free and had many subsequent follow-ups after treatment start. Mixed depression (depressive mixed state) was defined as the combination of MDE (depression) and three or more DSM-IV intradepressive hypomanic symptoms (elevated mood and increased self-esteem were always absent by definition), a definition validated by Akiskal and Benazzi.

RESULTS

BP-II, versus MDD, had significantly lower age at onset, more recurrences, atypical and mixed depressions, bipolar family history, MDE symptoms and intradepressive hypomanic symptoms. Mixed depression was present in 64.5% of BP-II and in 32.1% of MDD (p=0.000). There was a significant correlation between number of MDE symptoms and number of intradepressive hypomanic symptoms. A dose-response relationship between frequency of mixed depression and number of MDE symptoms was also found.

CONCLUSIONS

Differences on classic diagnostic validators could support a division between BP-II and MDD. Presence of intradepressive hypomanic symptoms by itself, and correlation between intradepressive hypomanic symptoms and depressive symptoms could instead support a continuum. Other explanations of such a correlation are possible. Depending on the method used, a BP-II-MDD continuum could be supported or not.

Mixed depression and the dimensional view of mood disorders

BACKGROUND

Mixed depression (MxD), i.e. depression plus cooccurring noneuphoric manic/hypomanic symptoms, questions the current categorical dividing of mood disorders into bipolar disorders and depressive disorders, and supports a dimensional approach. The study aim was to test a dimensional approach to mood disorders by looking for a progressive grading of age at onset and bipolar family history loading between bipolar II disorder (BP-II) and major depressive disorder (MDD).

METHODS

Consecutive 389 BP-II and 261 MDD major depressive episode outpatients were interviewed (off psychoactive drugs) with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide (to assess intradepressive noneuphoric hypomanic symptoms), and the Family History Screen, by a mood disorder specialist psychiatrist in a private practice. BP-II and MDD MxD and non-MxD were compared on age at onset and bipolar family history loading (the diagnostic validators). A dose-response was tested between the number of intradepressive hypomanic symptoms and bipolar family history loading, and a correlation was tested between the number of intradepressive hypomanic symptoms and age at onset.

RESULTS

MxD was present in 64.5% of BP-II and in 32.1% of MDD. There were significant differences in classic diagnostic validators (onset age, bipolar family history). The comparisons between BP-II and MDD MxD and non-MxD on age at onset and bipolar family history found a clear and significant grading in age at onset from BP-II MxD to MDD non-MxD (a progressive increase), and a clear and significant grading in bipolar family history loading from BP-II MxD to MDD non-MxD (a progressive decrease). A dose-response relationship was found between the number of intradepressive hypomanic symptoms and bipolar family history loading. The area under the ROC curve was small. A significant correlation was found between the number of intradepressive hypomanic symptoms and age at onset.

CONCLUSIONS

The presence of MxD in a significant proportion of MDD, the progressive grading of age at onset and bipolar family history from BP-II MxD to MDD non-MxD, the dose-response relationship between intradepressive hypomanic symptoms and bipolar family history loading, and the correlation between intradepressive hypomanic symptoms and age at onset could support a dimensional approach to mood disorders (BP-II and MDD). On the other hand, the significant differences on classic diagnostic validators could support a categorical distinction. A mixed approach (dimensional and categorical) to mood disorders could be supported.

Validity of the assessment of bipolar spectrum disorders in the WHO CIDI 3.0

OBJECTIVE

Although growing interest exists in the bipolar spectrum, fully structured diagnostic interviews might not accurately assess bipolar spectrum disorders. A validity study was carried out for diagnoses of threshold and sub-threshold bipolar disorders (BPD) based on the WHO Composite International Diagnostic Interview (CIDI) in the National Comorbidity Survey Replication (NCS-R). CIDI BPD screening scales were also evaluated.

METHOD

The NCS-R is a nationally representative US household population survey (n=9282 using CIDI to assess DSM-IV disorders. CIDI diagnoses were evaluated in blinded clinical reappraisal interviews using the non-patient version of the Structured Clinical Interview for DSM-IV (SCID).

RESULTS

Excellent CIDI-SCID concordance was found for lifetime BP-I (AUC=.99 kappa=.88, PPV=.79, NPV=1.0), either BP-II or sub-threshold BPD (AUC=.96, kappa=.88, PPV=.85, NPV=.99), and overall bipolar spectrum disorders (i.e., BP-I/II or sub-threshold BPD; AUC=.99, kappa=.94, PPV=.88, NPV=1.0). Concordance was lower for BP-II (AUC=.83, kappa=.50, PPV=.41, NPV=.99) and sub-threshold BPD (AUC=.73, kappa=.51, PPV=.58, NPV=.99). The CIDI was unbiased compared to the SCID, yielding a lifetime bipolar spectrum disorders prevalence estimate of 4.4%. Brief CIDI-based screening scales detected 67-96% of true cases with positive predictive value of 31-52%.

LIMITATION

CIDI prevalence estimates are still probably conservative, though, but might be improved with future CIDI revisions based on new methodological studies with a clinical assessment more sensitive than the SCID to sub-threshold BPD.

CONCLUSIONS

Bipolar spectrum disorders are much more prevalent than previously realized. The CIDI is capable of generating conservative diagnoses of both threshold and sub-threshold BPD. Short CIDI-based scales are useful screens for BPD.

Challenging DSM-IV criteria for hypomania: diagnosing based on number of no-priority symptoms

BACKGROUND

DSM-IV definition of hypomania of bipolar-II disorder (BP-II), which includes elevated/irritable mood change as core feature (i.e., it must always be present), is not based on sound evidence.

STUDY AIM

Following classic descriptions of hypomania, was to test if hypomania could be diagnosed on the basis of its number (9) of DSM-IV symptoms, setting no-priority symptom.

METHODS

Consecutive 422 depression-remitted outpatients were re-interviewed by a mood specialist psychiatrist using the Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version [a semi-structured interview modified by Benazzi and Akiskal (J Affect Disord, 2003; J Clin Psychiatry, 2005) to improve the probing for BP-II] in a private practice. History of episodes of subthreshold (i.e., 2 or more symptoms) and threshold (i.e., meeting DSM-IV criteria of elevated mood plus at least 3 symptoms, or irritable mood plus at least 4) hypomania, lasting at least 2 days, and which were the most common symptoms during the episodes, were systematically assessed.

RESULTS

Bipolar-II disorder (BP-II) patients (according to DSM-IV criteria, apart from hypomania duration) were 260, and major depressive disorder (MDD) patients were 162. Mood change was present in all BP-II by definition. The most common symptoms were overactivity, which was present in almost all BP-II, followed by elevated mood and racing thoughts. ROC analysis of the number of hypomanic symptoms predicting BP-II found that a cut point of 5 or more symptoms over 9 had the best combination of sensitivity (90%) and specificity (84%), and the highest figure of correctly classified (87%) BP-II. History of episodes of 5 or more hypomanic symptoms was met by almost all BP-II.

LIMITATIONS

Single interviewer.

CONCLUSIONS

Following classic descriptions of hypomania, not setting any priority among the three basic domains of hypomania (mood, thinking, behavior), results suggest that a cutoff number of 5 symptoms over 9 (of those listed by DSM-IV) could be used to diagnose hypomania of BP-II. Diagnosing hypomania by counting a checklist of symptoms should make it easier to diagnose BP-II, and should reduce the current high misdiagnosis of BP-II as MDD, significantly impacting the treatment of depression.

Self-reported data from patients with bipolar disorder: impact on minimum episode length for hypomania

OBJECTIVE

Some investigators have suggested decreasing the minimum hypomania episode length criterion from 4 days, as in the DSM-IV, to 2 days. Using daily self-reported mood ratings, we studied the impact of changing the length requirement on the number of hypomanic episodes in patients with bipolar disorder.

METHOD

203 patients (135 bipolar I and 68 bipolar II by DSM-IV criteria) recorded mood daily using ChronoRecord software (30,348 total days, mean 150 days). Episodes of hypomania and days of hypomania outside of episodes were determined.

RESULTS

Decreasing the minimum duration criterion for an episode of hypomania from 4 to 2 days doubled the mean percent of days in a hypomanic episode for each patient (4% to 8%), doubled the number of patients with a hypomanic episode (44 to 96) and increased the number of hypomanic episodes for all patients about three-fold (129 to 404). With a minimum episode length of 4 days, bipolar I patients were more likely to report hypomania outside episodes than bipolar II patients (p=0.010), but with a length of 2 or 3 days there was no significant difference in the distribution of hypomania outside of episodes by diagnosis. With a 2-day length, about one-third (36%) of hypomania remained outside of an episode.

LIMITATIONS

Self-reported data, computer access, relatively short length, fewer bipolar II than bipolar I patients.

CONCLUSION

As the minimum length for an episode of hypomania decreases, there was a large increase in both the number of episodes and number of patients with episodes. One-day hypomania outside of episodes occurs frequently in both bipolar I and bipolar II disorder.