High rate of unrecognized bipolar mixed states among destitute Hispanic adolescents referred for "major depressive disorder"

Not Only Mania or Depression: Mixed States/Mixed Features in Paediatric Bipolar Disorders

Background: early onset is frequent in Bipolar Disorders (BDs), and it is characterised by the occurrence of mixed states (or mixed features). In this systematic review, we aimed to confirm and extend these observations by providing the prevalence rates of mixed states/features and data on associated clinical, pharmacological and psychopathological features. Methods: following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched from inception to 9 February 2021 for all studies investigating mixed states/mixed features in paediatric BD. Data were independently extracted by multiple observers. The prevalence rates of mixed states/features for each study were calculated. Results: eleven studies were included in our review, involving a total patient population of 1365 individuals. Overall, of the patients with paediatric age BD, 55.2% had mixed states/features (95% CI 40.1–70.3). Children with mixed states/features presented with high rates of comorbidities, in particular, with Attention Deficit Hyperactivity Disorder (ADHD). Evidences regarding the psychopathology and treatment response of mixed states/features are currently insufficient. Conclusions: our findings suggested that mixed states/features are extremely frequent in children and adolescents with BD and are characterised by high levels of comorbidity. Future investigations should focus on the relationship between mixed states/features and psychopathological dimensions as well as on the response to pharmacological treatment.

Demographic and Clinical Characteristics, Including Subsyndromal Symptoms Across Bipolar-Spectrum Disorders in Adolescents

Objectives: Bipolar disorder (BD) is a debilitating illness that often starts at an early age. Prevention of first and subsequent mood episodes, which are usually preceded by a period characterized by subthreshold symptoms is important. We compared demographic and clinical characteristics including severity and duration of subsyndromal symptoms across adolescents with three different bipolar-spectrum disorders. Methods: Syndromal and subsyndromal psychopathology were assessed in adolescent inpatients (age = 12-18 years) with a clinical mood disorder diagnosis. Assessments included the validated Bipolar Prodrome Symptom Interview and Scale-Prospective (BPSS-P). We compared phenomenology across patients with a research consensus conference-confirmed DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnoses of BD-I, BD-not otherwise specified (NOS), or mood disorder (MD) NOS. Results: Seventy-six adolescents (age = 15.6 ± 1.4 years, females = 59.2%) were included (BD-I = 24; BD-NOS = 29; MD-NOS = 23) in this study. Median baseline global assessment of functioning scale score was 21 (interquartile range = 17-40; between-group p = 0.31). Comorbidity was frequent, and similar across groups, including disruptive behavior disorders (55.5%, p = 0.27), anxiety disorders (40.8%, p = 0.98), and personality disorder traits (25.0%, p = 0.21). Mania symptoms (most frequent: irritability = 93.4%, p = 0.82) and depressive symptoms (most frequent: depressed mood = 81.6%, p = 0.14) were common in all three BD-spectrum groups. Manic and depressive symptoms were more severe in both BD-I and BD-NOS versus MD-NOS (p < 0.0001). Median duration of subthreshold manic symptoms was shorter in MD-NOS versus BD-NOS (11.7 vs. 20.4 weeks, p = 0.002) and substantial in both groups. The most used psychotropics upon discharge were antipsychotics (65.8%; BD-I = 79.2%; BD-NOS = 62.1%; MD-NOS = 56.5%, p = 0.227), followed by mood stabilizers (43.4%; BD-I = 66.7%; BD-NOS = 31.0%; MD-NOS = 34.8%, p = 0.02) and antidepressants (19.7%; BD-I = 20.8%; BD-NOS = 10.3%; MD-NOS = 30.4%). Conclusions: Youth with BD-I, BD-NOS, and MD-NOS experience considerable symptomatology and are functionally impaired, with few differences observed in psychiatric comorbidity and clinical severity. Moreover, youth with BD-NOS and MD-NOS undergo a period with subthreshold manic symptoms, enabling identification and, possibly, preventive intervention of those at risk for developing BD or other affective episodes requiring hospitalization.

[Exploring Early Maladaptative Schema (EMS) in adults with bipolar disorder: A systematic review of the scientific literature]

OBJECTIVES

Clinical heterogeneity during euthymic states is a crucial issue in bipolar disorders. Indeed, actual data are not sufficient to understand why some patients are unharmed by subthreshold symptoms and have functional impairments whereas others have a functional remission but have subthreshold symptoms. Based on the Ball model, cognitive and schematic vulnerability interact with genetic vulnerability and trigger affective symptoms with the intervention of stressful life events. Furthermore, according to this model, adjustment and adaptation to illness assessed by functional outcome and illness experience are associated with this cognitive and schematic vulnerability. So, theoretical arguments support that childhood adversity and temperamental deregulation characterize patients with bipolar disorders. Thus, the aim of this study is to systematically review studies of Early Maladaptive Schemas in bipolar disorder, to determine whether Early Maladaptive Schemas have specificity in bipolar disorder in comparison with other populations, and to identify which Early Maladaptive Schemas could be activated. The challenge of this review is to identify if the taking of early maladaptive schemas into account could allow us to better identify, understand and manage bipolar disorders.

METHODS

This systematic review was led according to the Preferred Reporting Items for Systematic review and Meta-Analysis statement on the electronic databases Cochrane, PsycArticles, Psychology and Behavioral Sciences Collection, PsycInfo, PubMed, ScienceDirect and Scopus with « early maladaptive schemas » AND « bipolar disorder » as keywords. Only studies meeting eligibility criteria concerning publication status, language, population and outcomes were included after several screenings on basis of title, abstract and full-text. Then, we carried out data extraction in accordance with criteria defined in principle (about characteristics of participants, objectives, materiel and methods, principle results and bias).

RESULTS

Among 39 records identified, a total of 10 studies met eligibility criteria for inclusion in this review. Synthesizing findings across the studies revealed three important topics. First, early maladaptive schemas appear as potential cognitive characteristics that clinicians have to investigate in clinical practice. Indeed, patients with bipolar disorders present greater activation of the early maladaptive schemas in comparison with people who have no disorder. This point supports the first part of Ball's theoretical model that considers schemas as a vulnerability to bipolarity. Secondly, early maladaptive schemas are relevant to distinguish bipolar disorders from unipolar depression and borderline personality disorder. A greater and a lower activation are respectively identified among bipolar disorders. Thirdly, supporting the second part of Ball's model, early maladaptive schemas play a key role in recovery regarding their impact on the course of bipolarity, in particular on suicidality and functional impairment. Finally, these dysfunctional schemas allow us to understand the clinical heterogeneity of bipolar disorder, and among others, about the type of bipolarity. These results have several implications, but there are some limits in this systematic review. First, no French study has been done. Then, reduced sample sizes in these studies increased the risk to conclude wrongly to an activation difference between groups. Furthermore, probably due to the variety of methods and populations, we could not identify an homogeneous pattern of early activated maladaptive schemas. Overall, scientific approaches used in these studies are based on statistical models using mean and standard deviation. These types of statistical analyses are the main limit because they cannot represent the heterogeneity of early maladaptive schemas profiles.

CONCLUSIONS

Schema theory proves to be a relevant approach in bipolar disorders, and early maladaptive schemas appear to be important to take into account in clinical practice. Nevertheless, in order to propose schemas therapy appropriately, it is necessary to specify if early maladaptive schemas are activated and to specify therapeutic indications because of clinical heterogeneity. Moreover, data do not yet allow us to understand the disparity of profiles during the inter-episode period. Indeed, a French research perspective is being considered that will prefer a person-oriented approach.

Type 2 diabetes, depressive symptoms and disability over a 15-year follow-up period in older Mexican Americans living in the southwestern United States

AIMS

To evaluate how depression and diabetes severity impact disability progression among Mexican Americans over a 15-year period.

METHODS

We used seven waves of the Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE). Primary disability outcomes included the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales. Explanatory variables included time since diagnosis with diabetes (no type 2 diabetes, 1-10, 11-20, 21+), an indicator of disease severity, and depression. Longitudinal generalized estimating equation models were used to estimate the relationship between time since diabetes diagnosis, depressive symptoms and ADL and IADL disability progression over a 15-year time period.

RESULTS

Years since diabetes diagnosis was associated with more rapid ADL and IADL disability progression compared to those without type 2 diabetes. Depression accelerated the disabling process in participants who were diagnosed with diabetes 11years or more years ago.

CONCLUSIONS

Longer duration of diabetes and greater symptoms of depression increase vulnerability for disability among older Mexican American adults.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Features preceding diagnosis of bipolar versus major depressive disorders

BACKGROUND

Better and earlier predictive differentiation of bipolar (BD) vs. unipolar major depressive disorder (UD) diagnoses should improve long-term clinical planning.

METHODS

We reviewed randomly selected clinical records of 334 adults diagnosed with DSM-IV-TR BD-I (n=109), BD-II (n=106), and UD (n=119) and compared features preceding major affective episodes or diagnoses, using bivariate, multivariate, and Bayesian methods.

RESULTS

We identified antecedents selectively associated with later BD vs. UD in 52.6% vs. 31.1% of subjects in childhood, starting at age 7.4 years, and 60.0% vs. 32.8% in adolescence, with far more features in BD than UD cases (10.3 vs. 4.64/100 person-years; p<0.001). In multivariate modeling, BD-selective factors were: younger at first clinical event > male sex > family BD-history > cyclothymic or hyperthymic temperament > antecedents/person-year. Nonaffective (anxiety, eating, or substance-use) disorders preceded BD vs. UD in 41.4% vs. 28.6% of subjects (p=0.02). By ROC analysis, differential prediction of BD vs. UD was optimal with any ≥ 3 factors/person.

LIMITATIONS

The validity and timing of antecedent events and factors identified retrospectively from clinical records could not be verified independently, but information was recorded systematically and consistently by a single mood-disorder expert prior to diagnosis, and extracted by two independent observers.

COMMENT

Early clinical features distinguished later BD from UD, often by years. Such prediction should improve treatment-planning and limit risk of mood-switching.

Aripiprazole in pediatric psychosis and bipolar disorder: a clinical review

BACKGROUND

Aripiprazole is an atypical antipsychotic with unique pharmacological properties, used for a variety of indications, including psychotic and mood disorders in youth. Existing literature was reviewed to summarize experience with this agent in that population.

METHODS

A review of relevant literature using the key words aripiprazole, children, pediatric, all child, schizophrenia, bipolar disorder, and atypical antipsychotics was conducted.

RESULTS

A total of 140 articles and book chapters were identified, of which 7 reported double-blind controlled trials with aripiprazole, 5 were meta-analyses of pooled data, 11 were open label trials, 10 were chart reviews, and 17 were case reports or case series.

LIMITATIONS

Although every effort was made to locate all available data, some information from posters or researchers was not available. Publication bias tends to report positive outcomes with a treatment, while negative studies are less likely to be reported. Most trials are of short duration.

CONCLUSIONS

Treatment with aripiprazole is associated with significant reduction of the Positive and Negative Symptom Scale (PANSS) scores in youth with schizophrenia, and reductions in items in the negative symptom scores at higher doses (30 mg/day). Significant reductions in the Young Mania Rating Scale (YMRS) have been demonstrated in youth with bipolar disorder. In mixed populations, reductions in the Clinical Global Impressions Scale (CGI-S) have also been demonstrated when compared with treatment with placebo. Head-to-head comparisons are fewer in number, and overall aripiprazole compares favorably with other atypical antipsychotics (ATAs) in the populations studied. Treatment with aripiprazole is reported to have a lower incidence of weight gain, and less elevation of prolactin. At higher doses, it appears more likely to result in extrapyramidal symptoms (EPS) and tremor.

Classification of bipolar disorder in psychiatric hospital. A prospective cohort study

BACKGROUND

This study has explored the classification of bipolar disorder in psychiatric hospital. A review of the literature reveals that there is a need for studies using stringent methodological approaches.

METHODS

480 first-time admitted patients to psychiatric hospital were found eligible and 271 of these gave written informed consent. The study sample was comprised of 250 patients (52%) with hospital diagnoses. For the study, expert diagnoses were given on the basis of a structured diagnostic interview (M.I.N.I.PLUS) and retrospective review of patient records.

RESULTS

Agreement between the expert's and the clinicians' diagnoses was estimated using Cohen's kappa statistics. 76% of the primary diagnoses given by the expert were in the affective spectrum. Agreement concerning these disorders was moderate (kappa ranging from 0.41 to 0.47). Of 58 patients with bipolar disorder, only 17 received this diagnosis in the clinic. Almost all patients with a current manic episode were classified as currently manic by the clinicians. Forty percent diagnosed as bipolar by the expert, received a diagnosis of unipolar depression by the clinician. Fifteen patients (26%) were not given a diagnosis of affective disorder at all.

CONCLUSIONS

Our results indicate a considerable misclassification of bipolar disorder in psychiatric hospital, mainly in patients currently depressed. The importance of correctly diagnosing bipolar disorder should be emphasized both for clinical, administrative and research purposes. The findings questions the validity of psychiatric case registers. There are potential benefits in structuring the diagnostic process better in the clinic.

Prevalence and risk factors associated with suicide ideation and attempts in korean college students

OBJECTIVE

Suicide is a leading cause of death in college age students. Identification of the associated risk factors has important implications for how to prevent and respond to this population; however, few studies have been performed on this topic in this age group. The purpose of this study was to evaluate the prevalence and risk factors associated with suicide ideation and attempts in college students.

METHODS

Three hundred sixty-eight college students participated in this cross-sectional observational study. The recent (over two weeks) suicide ideation and lifetime suicide attempts were defined according to Moscicki's suicide behavior index. Sociodemographic variables were assessed and psychopathology measured using the Beck Depression Inventory, the Bipolar Spectrum Diagnostic Scale and the Alcohol Use Disorders Identification Test. A hierarchical multiple logistic regression analysis was used to identify the significant risk factors related to suicide ideation and attempts.

RESULTS

The two-week prevalence of suicidal ideation was 9.8%, and the lifetime prevalence of suicide attempts was 3.3%. The univariate analysis showed that students who had more severe depression (p<0.001), a higher probability for bipolar disorder (p<0.001) and decrement of academic achievement (p<0.005) were more likely to have suicide ideation. Those with factors such as severe depression (p<0.05), a higher probability of bipolar disorder (p<0.001), a low socioeconomic status (p<0.001), who lived alone (p<0.01), and were female (p<0.05) had a higher risk for suicide attempts. The most important predictors of suicide ideation, by the logistic regression analysis, were depression, probability for bipolar disorder and academic achievement, and the risks identified for suicide attempts were socioeconomic status and probability of bipolar disorder.

CONCLUSION

Suicide ideation and attempts were common in college students. The results of this study suggest that early identification and management of mood disorders and other sociodemographic risk factors may have implications for intervention and prevention.

Bipolar pharmacotherapy and suicidal behavior Part 2. The impact of antidepressants

Antidepressant-induced mania and cycle acceleration is a potential risk in bipolar patients. Another serious risk of antidepressants, that of increasing suicidal behavior, has been identified in some affectively ill populations. However, there is a dearth of knowledge about the effects of antidepressants on suicidal behavior specifically in bipolar patients.

METHODS

Retrospective chart review of 405 veterans with bipolar disorder followed for a mean of three years, with month by month systematic assessment of current pharmacotherapy and suicide completion, attempt or hospitalization for suicidality. Chi-squared comparison of (log) rates of suicidal events during mood stabilizer monotherapy, antidepressant monotherapy, and combination of mood stabilizer and antidepressant.

RESULTS

Suicidal behavior event rates (per 100 patient years) were greatest during treatment with antidepressant monotherapy (25.92), least during mood stabilizer monotherapy (3.48), and intermediate during mood stabilizer + antidepressant combination treatment (9.75). These differences were statistically significant.

LIMITATIONS

In a clinical setting, antidepressants may have been prescribed because patients were deemed at greater risk of suicidality.

CONCLUSIONS

During treatment with antidepressants (even when coupled with mood stabilizers), patients with bipolar disorder have significantly higher rates of non-lethal suicidal behavior compared to those on mood stabilizers without antidepressants, and thus require careful monitoring.

Post-traumatic stress disorder among adolescents with bipolar disorder and its relationship to suicidality

OBJECTIVES

The aims of this cross-sectional pilot study were to ascertain the rates of post-traumatic stress disorder (PTSD) among adolescents with bipolar disorder (BPD) and major depressive disorder (MDD) relative to a comparison group comprised of non-affectively ill patients, and to determine whether PTSD is related to suicidal ideation and attempts. The impetus for the study was born of clinical impressions derived in the course of routine clinical practice.

METHODS

Patients were screened by a single interviewer for BPD, MDD and PTSD, panic disorder, obsessive-compulsive disorder (OCD) and social phobia using the apposite modules from the Structured Clinical Interview for DSM-IV (SCID) and histories of suicidal ideation and attempts. The data were subjected to analysis using a logistic regression model.

RESULTS

The database included 34 patients with BPD, 79 with MDD and 26 with a non-affective disorder. The risk for PTSD for a patient with BPD significantly exceeded that for a patient with MDD [odds ratio (OR) = 4.9, 95% confidence interval (CI) = 1.9-12.2, p = 0.001]. Patients with PTSD had an insignificantly increased risk for suicidal ideation (OR = 2.8, 95% CI = 0.9-8.9, p = 0.069), and a 4.5-fold significantly increased risk of having had a suicide attempt (OR = 4.5, 95% CI = 1.7-11.7, p = 0.002). The relationship between PTSD and suicide attempts remained significant even after controlling for the confounding effects of concurrent panic disorder, OCD and social phobia (OR = 3.4, 95% CI = 1.1-10.0, p = 0.023).

CONCLUSIONS

Patients with BPD have a greater risk for PTSD than those with MDD. Post-traumatic stress disorder is significantly related to history of suicide attempts.

Bipolar disorder: causes, contexts, and treatments

Bipolar disorder is a chronic and often devastating illness that may go undiagnosed because of its complex and diverse presentation. Clinicians can provide psychological treatments, in conjunction with pharmacotherapy, that can reduce the frequency, severity, and duration of manic and depressive episodes. Because bipolar disorder is characterized by high degrees of comorbidity and high rates of medical complications, the clinician will frequently need to implement other treatments targeted to comorbid conditions, such as panic, generalized anxiety, substance abuse, and personality disorders. This article introduces the issue of Journal of Clinical Psychology: In Session devoted to the treatment of bipolar disorder. We describe the cognitive styles and personal vulnerabilities that pose greater risk for bipolar disorder. Three evidence-based psychological treatments (interpersonal social rhythm therapy, family-focused treatment, and cognitive-behavioral therapy) and current pharmacological treatments are examined and illustrated. Finally, we review the effectiveness and practice implications of a variety of treatments for this severe and underresearched disorder.

Subjective well-being and 'male depression' in male adolescents

BACKGROUND

The concept of male depression is based on the hypothesis that typical symptoms of depression in men often seem to be masked by non-typical male distress symptoms not considered in common depression inventories. Although there is a large amount of clinical evidence, scientific evidence is still lacking. The study aims at further validating the concept of male depression, by obtaining information on symptoms reported by males, and analyzing the dimensional structure of the Gotland Scale of Male Depression [Rutz, W., 1999. Improvement of care for people suffering from depression: The need for comprehensive education. International Clinical Psychopharmacology 14, 27-33.].

METHODS

A community sample of male adolescents aged 18 (n=1004) was asked to complete the WHO-5 Well-being Index [Bech, P., 1998. Quality of life in the psychiatric patient. London: Mosby-Wolfe.] and the Gotland Scale of Male Depression [Rutz, W., 1999. Improvement of care for people suffering from depression: The need for comprehensive education. International Clinical Psychopharmacology 14, 27-33.]. Principal component analysis with promax rotation was calculated to analyze the dimensional structure of the Gotland Scale. Cluster center analyses were used to classify the sample according to the symptoms' characteristics.

RESULTS

General well-being was rather reduced, and 22% of the respondents were seen to be at risk of male depression. There was no evidence for the hypothesis that young males tend to mask their depressive symptoms with distress symptoms. Depressive and male distress symptoms appeared to be mixed in a dominant factor, while male distress symptoms constitute an additional minor factor. A cluster of 38% of those at risk for depression could be identified who reported significantly elevated male distress symptoms. Irritability turned out to be the single item of the Gotland Scale with the highest item-total correlation.

LIMITATIONS

Risk of depression was not assessed by an additional depression scale or evaluated by a clinical rating.

CONCLUSIONS

Male distress symptoms should be considered when diagnosing depression in men. Further research is needed with respect to comorbidity and differential diagnoses, which should also include bipolar depression.

Dose-response relationship between number of comorbid anxiety disorders in adolescent bipolar/unipolar disorders, and psychosis, suicidality, substance abuse and familiality

OBJECTIVES

To ascertain rates of panic, obsessive-compulsive (OCD) and social phobic disorders among adolescents with bipolar disorder (BP), unipolar major depressive disorder (MDD) and psychiatric comparison patients, to assess their relationships to suicidality, psychosis, comorbidity patterns and familiality.

METHODS

The first author (SCD) interviewed 313 Latino adolescents using a structured interview based on the SCID. Family history was ascertained by live interview or interview by proxy. Patients were classified as BP, MDD, or non-affectively ill comparison controls (CC). Data regarding suicidality and psychosis were collected. Regression analysis was used to test associations and control for confounding effects. Positive likelihood ratios were used to measure the dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness.

RESULTS

Of the total sample, 36.7% were BP, 44.7% MDD and 18.5% CC. In BP vs. MDD the odds of panic disorder were 4.4, of OCD 5.1, and of social phobia 3.3. MDD, in turn, were more likely to have these disorders than CC. BP (but not MDD) with panic disorder and social phobia, were more likely to have suicidal ideation; among the anxiety disorders, only social phobia was associated with having greater odds of suicide attempts. Among BP and MDD, patients with all three anxiety disorders were more likely to be psychotic. Presence of any mood disorder among first-degree relatives substantially increased the odds of having panic disorder and social phobia. The presence of one comorbid anxiety disorder increased the odds of having another. Finally, there were dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness.

LIMITATIONS

Single interviewer using the SCID; cross sectional exploratory study.

CONCLUSIONS

BP adolescents have a greater anxiety disorder burden than their MDD counterparts. The results are compatible with the hypothesis that heavy familial-genetic loading for affective illness in juveniles is associated with bipolarity, cumulative anxiety disorder comorbidity, suicidality and psychosis. These observations are in line with pioneering psychopathologic observation in the early 1900s by two French psychiatrists, Gilbert Ballet and Pierre Kahn, who saw common ground between what until then had been considered the distinct categories of the neuroses and cyclothymic (circular) psychoses. This perspective has much in common with current complex genetic models of anxious diatheses in bipolar disorder.