Mixed-state bipolar I and II depression: time to remission and clinical characteristics

Readmission and associated clinical factors among individuals admitted with bipolar affective disorder at a psychiatry facility in Uganda

BACKGROUND

Bipolar affective disorder (BAD) is a common severe mental health condition with a relapsing course that may include periods of hospital re-admissions. With recurrent relapses and admissions, the course, prognosis, and patient's overall quality of life can be affected negatively. This study aims to explore the rates and clinical factors associated with re-admission among individuals with BAD.

METHOD

This study used data from a retrospective chart review of all records of patients with BAD admitted in 2018 and followed up their hospital records for four years till 2021 at a large psychiatric unit in Uganda. Cox regression analysis was used to determine the clinical characteristics associated with readmission among patients diagnosed with BAD.

RESULTS

A total of 206 patients living with BAD were admitted in 2018 and followed up for four years. The average number of months to readmission was 9.4 (standard deviation = 8.6). The incidence of readmission was 23.8% (n = 49/206). Of those readmitted during the study period, 46.9% (n = 23/49) and 28.6% (n = 14/49) individuals were readmitted twice and three times or more, respectively. The readmission rate in the first 12 months following discharge was 69.4% (n = 34/49) at first readmission, 78.3% (n = 18/23) at second readmission, and 87.5% (n = 12/14) at third or more times. For the next 12 months, the readmission rate was 22.5% (n = 11/49) for the first, 21.7% (n = 5/23) for the second, and 7.1% (n = 1/14) for more than two readmissions. Between 25 and 36 months, the readmission rate was 4.1% (n = 2/49) for the first readmission and 7.1% (n = 1/14) for the third or more times. Between 37 and 48 months, the readmission rate was 4.1% (n = 2/49) for those readmitted the first time. Patients who presented with poor appetite and undressed in public before admission were at increased risk of being readmitted with time. However, the following symptoms/clinical presentations, were protective against having a readmission with time, increased number of days with symptoms before admission, mood lability, and high energy levels.

CONCLUSION

The incidence of readmission among individuals living with BAD is high, and readmission was associated with patients' symptoms presentation on previous admission. Future studies looking at BAD using a prospective design, standardized scales, and robust explanatory model are warranted to understand causal factors for hospital re-admission and inform management strategies.

Assessment Tool of Bipolar Disorder for Primary Health Care: The SAEBD

Mixed states are highly prevalent in patients with bipolar disorder and require comprehensive scales. Considering this, the current study aims to develop a measure to assess the full spectrum of clinical manifestations of bipolar disorder. A sample of 88 patients was evaluated; the Hamilton Depression Scale (HAM-D), Montgomery-Asberg Depression Scale (MADRS), and the Young Mania Rating Scale (YMRS) were applied, together with the preliminary version of the Scale for the Assessment of Episodes in Bipolar Disorder (SAEBD). After analyzing the appropriateness and statistical properties of the items, discriminant analysis and analysis of diagnostic capacity were performed. The discriminant functions correctly classified 100% of the cases in euthymia, predominant depressive symptoms or mixed symptoms, as well as 92.3% of the cases with predominant manic symptoms. Overall, the functions correctly classified 98.9% of the cases. The area under the curve (0.935) showed high capacity to discriminate between clinical and non-clinical cases (i.e., in euthymia). The SAEBD sensitivity was 0.95, specificity was 0.71, the Positive Predictive Value (PPV) was 0.88, the Negative Predictive Value (NPV) was 0.87, the Positive Likelihood Ratio (+LR) was 3.33, and the Negative Likelihood Ratio (−LR) was 0.07. In conclusion, the SAEBD is a promising scale that shows high reliability and validity, as well as diagnostic utility as a screening tool for use in diverse health care settings.

Deconstructing major depressive episodes across unipolar and bipolar depression by severity and duration: a cross-diagnostic cluster analysis on a large, international, observational study

A cross-diagnostic, post-hoc analysis of the BRIDGE-II-MIX study was performed to investigate how unipolar and bipolar patients suffering from an acute major depressive episode (MDE) cluster according to severity and duration. Duration of index episode, Clinical Global Impression-Bipolar Version-Depression (CGI-BP-D) and Global Assessment of Functioning (GAF) were used as clustering variables. MANOVA and post-hoc ANOVAs examined between-group differences in clustering variables. A stepwise backward regression model explored the relationship with the 56 clinical-demographic variables available. Agglomerative hierarchical clustering with two clusters was shown as the best fit and separated the study population (n = 2314) into 65.73% (Cluster 1 (C1)) and 34.26% (Cluster 2 (C2)). MANOVA showed a significant main effect for cluster group (p < 0.001) but ANOVA revealed that significant between-group differences were restricted to CGI-BP-D (p < 0.001) and GAF (p < 0.001), showing greater severity in C2. Psychotic features and a minimum of three DSM-5 criteria for mixed features (DSM-5-3C) had the strongest association with C2, that with greater disease burden, while non-mixed depression in bipolar disorder (BD) type II had negative association. Mixed affect defined as DSM-5-3C associates with greater acute severity and overall impairment, independently of the diagnosis of bipolar or unipolar depression. In this study a pure, non-mixed depression in BD type II significantly associates with lesser burden of clinical and functional severity. The lack of association for less restrictive, researched-based definitions of mixed features underlines DSM-5-3C specificity. If confirmed in further prospective studies, these findings would warrant major revisions of treatment algorithms for both unipolar and bipolar depression.

Remission and recurrence in bipolar disorder: The data from health outcomes and patient evaluations in bipolar disorder (HOPE-BD) study

BACKGROUND

The HOPE-BD was a naturalistic study established to follow individuals in Canada seeking treatment for bipolar disorder (BD). The study aimed to examine the course of BD and describe how clinical and sociodemographic factors are associated with outcomes.

METHODS

Individuals with BD had their clinical data recorded at enrolment and were naturalistically treated. Participant were followed for up to four years, and visits occurred at least once every three months. We investigated the longitudinal outcomes with logistic, Cox, and quantile regressions.

RESULTS

Among the 354 participants, 57.3% had BD type I. Depression as first episode, younger ages at onset and older ages of the first professional help predicted longer delays in correct diagnosis. Among the symptomatic patients at baseline, the median time to remission was 10.9 months. Comorbid alcohol use disorder and the severity of baseline depressive symptoms predicted longer times to remission. Among the euthymic participants, the median time to recurrence was 14.5 months. History of anxiety disorder and younger ages at onset predicted shorter times to recurrence. Baseline depression scores predicted recurrence in euthymic patients.

LIMITATIONS

We did not investigate the predictors of each polarity. Our findings may not apply to individuals followed in non-specialised outpatient services.

CONCLUSION

Our study reinforces the necessity of early diagnosis and interventions, as well as the importance of treating depressive symptoms and comorbidities.

The prevalence and diagnostic classification of mixed features in patients with major depressive episodes: A multicenter study based on the DSM-5

OBJECTIVES

The purpose of this study was to evaluate the prevalence of mixed features using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and to examine how patients with mixed states would be classified using the DSM-5.

METHODS

In total, 12 hospitals participated in this study, and data on the demographic characteristics and clinical diagnoses of patients treated between October 2013 and September 2016 were obtained. We reviewed the data for opposite-polarity symptoms according to the DSM-5 criteria and the research-based diagnostic criteria.

RESULTS

Of the 859 patients included in the final analysis, the prevalence of mixed features in patients with major depressive episodes based on the DSM-5 remained low. Patients with major depressive disorder were more likely to be classified as experiencing anxious distress and/or a cluster-B personality disorder in mixed state patients not diagnosed with DSM-5 mixed features, whereas more mixed state patients with bipolar disorder were diagnosed with mixed features using the DSM-5.

CONCLUSIONS

The prevalence of mixed features did not increase significantly when the DSM-5 was used, and patients with mixed states were more likely to be classified as having anxious distress and/or a cluster-B personality disorder in addition to mixed features.

Pharmacological Treatment of Major Depressive Episodes with Mixed Features: A Systematic Review

We reviewed clinical studies investigating the pharmacological treatment of major depressive episodes (MDEs) with mixed features diagnosed according to the dimensional criteria (more than two or three [hypo]manic symptoms+principle depressive symptoms). We systematically reviewed published randomized controlled trials on the pharmacological treatment of MDEs with mixed features associated with mood disorders, including major depressive disorder (MDD) and bipolar disorder (BD). We searched the PubMed, Cochrane Library, and ClinicalTrials.gov databases through December 2017 with the following key word combinations linked with the word OR: (a) mixed or mixed state, mixed features, DMX, mixed depression; (b) depressive, major depressive, MDE, MDD, bipolar, bipolar depression; and (c) antidepressant, antipsychotic, mood stabilizer, anticonvulsant, treatment, medication, algorithm, guideline, pharmacological. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We found few randomized trials on pharmacological treatments for MDEs with mixed features. Of the 36 articles assessed for eligibility, 11 investigated MDEs with mixed features in mood disorders: six assessed the efficacy of antipsychotic drugs (lurasidone and ziprasidone) in the acute phase of MDD with mixed features, although four of these were post hoc analyses based on large randomized controlled trials. Four studies compared antipsychotic drugs (olanzapine, lurasidone, and ziprasidone) with placebo, and one study assessed the efficacy of combination therapy (olanzapine+fluoxetine) in the acute phase of BD with mixed features. Pharmacological treatments for MDEs with mixed features have focused on antipsychotics, although evidence of their efficacy is lacking. Additional well-designed clinical trials are needed.

Mixed symptoms in major depressive and bipolar disorders: A systematic review

BACKGROUND

The DSM-5 mixed features specifier for mood disorders encourages renewed interest in mixed states and led us to pool research findings regarding prevalence of mixed features in episodes of major depressive (MDD) and bipolar disorders (BD).

METHODS

We systematically searched to July 2017 for reports on mixed symptoms in depressive episodes of MDD and in depression and mania or hypomania in types I and II BD. For primary mood-states and diagnostic groups we compared rates of the presence of mixed symptoms: as defined by DSM-5 (≥3 features opposite to the dominant mood-polarity but not overlapping those of the primary disorder) or as having any ≥3 features of opposite polarity.

RESULTS

We identified 17 reports, from 13 world regions involving 19,198 participants meeting standard diagnostic criteria for an index major depressive or [hypo]manic episode. Prevalence of cases with ≥3 features of opposite polarity averaged 27.8% [CI: 27.2-28.5] overall, and differed significantly between BD and MDD disorders, ranking: BD-depressed (35.2% [33.8-36.5]) = BD-[hypo]manic (35.1% [32.9-37.3]) > MDD-depressed (23.8% [23.0-24.5]).

LIMITATIONS

Available findings were limited to mood disorders with mixed features by particular criteria, with few comparisons to other criteria or to their prognostic or therapeutic implications.

CONCLUSIONS

Prevalence of ≥3 features of opposite polarity ranked: depressive = [hypo]manic episodes of BD > depression in MDD.

Treatment of mixed features in bipolar disorder

Mood episodes with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)-defined mixed features are highly prevalent in bipolar disorder (BD), affecting ~40% of patients during the course of illness. Mixed states are associated with poorer clinical outcomes, greater treatment resistance, higher rates of comorbidity, more frequent mood episodes, and increased rates of suicide. The objectives of the current review are to identify, summarize, and synthesize studies assessing the efficacy of treatments specifically for BD I and II mood episodes (ie, including manic, hypomanic, and major depressive episodes) with DSM-5-defined mixed features. Two randomized controlled trials (RCTs) and 6 post-hoc analyses were identified, all of which assessed the efficacy of second-generation antipsychotics (SGAs) for the acute treatment of BD mood episodes with mixed features. Results from these studies provide preliminary support for SGAs as efficacious treatments for both mania with mixed features and bipolar depression with mixed features. However, there are inadequate data to definitively support or refute the clinical use of specific agents. Conventional mood stabilizing agents (eg, lithium and divalproex) have yet to have been adequately studied in DSM-5-defined mixed features. Further study is required to assess the efficacy, safety, and tolerability of treatments specifically for BD mood episodes with mixed features.

Treatment recommendations for DSM-5-defined mixed features

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mixed features specifier provides a less restrictive definition of mixed mood states, compared to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), including mood episodes that manifest with subthreshold symptoms of the opposite mood state. A limited number of studies have assessed the efficacy of treatments specifically for DSM-5-defined mixed features in mood disorders. As such, there is currently an inadequate amount of data to appropriately inform evidence-based treatment guidelines of DSM-5 defined mixed features. However, given the high prevalence and morbidity of mixed features, treatment recommendations based on the currently available evidence along with expert opinion may be of benefit. This article serves to provide these interim treatment recommendations while humbly acknowledging the limited amount of evidence currently available. Second-generation antipsychotics (SGAs) appear to have the greatest promise in the treatment of bipolar disorder (BD) with mixed features. Conventional mood stabilizing agents (ie, lithium and divalproex) may also be of benefit; however, they have been inadequately studied. In the treatment of major depressive disorder (MDD) with mixed features, the comparable efficacy of antidepressants versus other treatments, such as SGAs, remains unknown. As such, antidepressants remain first-line treatment of MDD with or without mixed features; however, there are significant safety concerns associated with antidepressant monotherapy when mixed features are present, which merits increased monitoring. Lurasidone is the only SGA monotherapy that has been shown to be efficacious specifically in the treatment of MDD with mixed features. Further research is needed to accurately determine the efficacy, safety, and tolerability of treatments specifically for mood episodes with mixed features to adequately inform future treatment guidelines.

More inclusive bipolar mixed depression definition by permitting overlapping and non-overlapping mood elevation symptoms

OBJECTIVE

The objective of this study was to assess the strengths and limitations of a mixed bipolar depression definition made more inclusive than that of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) by counting not only 'non-overlapping' mood elevation symptoms (NOMES) as in DSM-5, but also 'overlapping' mood elevation symptoms (OMES, psychomotor agitation, distractibility, and irritability).

METHODS

Among bipolar disorder (BD) out-patients assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, we assessed prevalence, demographics, and clinical correlates of mixed vs. pure depression, using more inclusive (≥3 NOMES/OMES) and less inclusive DSM-5 (≥3 NOMES) definitions.

RESULTS

Among 153 depressed BD, counting not only NOMES but also OMES yielded a three-fold higher mixed depression rate (22.9% vs. 7.2%) and important statistically significant clinical correlates for mixed compared to pure depression (more lifetime anxiety disorder comorbidity, more current irritability, and less current antidepressant use), which were not significant using the DSM-5 threshold.

CONCLUSION

To conclude, further studies with larger numbers of patients with DSM-5 bipolar mixed depression assessing strengths and limitations of more inclusive mixed depression definitions are warranted, including efforts to ascertain whether or not OMES should count toward mixed depression.

More inclusive bipolar mixed depression definitions by requiring fewer non-overlapping mood elevation symptoms

OBJECTIVE

Assess strengths and limitations of mixed bipolar depression definitions made more inclusive than that of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) by requiring fewer than three 'non-overlapping' mood elevation symptoms (NOMES).

METHOD

Among bipolar disorder (BD) out-patients assessed with Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, we assessed prevalence, demographics, and clinical correlates of mixed vs. pure depression, using less inclusive (≥3 NOMES, DSM-5), more inclusive (≥2 NOMES), and most inclusive (≥1 NOMES) definitions.

RESULTS

Among 153 depressed BD, compared to less inclusive DSM-5 threshold, our more and most inclusive thresholds, yielded approximately two- and five-fold higher mixed depression rates (7.2%, 15.0%, and 34.6% respectively), and important statistically significant clinical correlates for mixed compared to pure depression (e.g. more lifetime anxiety disorder comorbidity, more current irritability), which were not significant using the DSM-5 threshold.

CONCLUSION

Further studies assessing strengths and limitations of more inclusive mixed depression definitions are warranted, including assessing the extent to which enhanced statistical power vs. other factors contributes to more vs. less inclusive mixed bipolar depression thresholds having more statistically significant clinical correlates, and whether 'overlapping' mood elevation symptoms should be counted.

Assessment and management of agitation in psychiatry: Expert consensus

BACKGROUND

Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions.

METHODS

An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items.

RESULTS

Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic.

CONCLUSIONS

Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.

Diagnosis, Epidemiology and Management of Mixed States in Bipolar Disorder

Approximately 40% of patients with bipolar disorder experience mixed episodes, defined as a manic state with depressive features, or manic symptoms in a patient with bipolar depression. Compared with bipolar patients without mixed features, patients with bipolar mixed states generally have more severe symptomatology, more lifetime episodes of illness, worse clinical outcomes and higher rates of comorbidities, and thus present a significant clinical challenge. Most clinical trials have investigated second-generation neuroleptic monotherapy, monotherapy with anticonvulsants or lithium, combination therapy, and electroconvulsive therapy (ECT). Neuroleptic drugs are often used alone or in combination with anticonvulsants or lithium for preventive treatment, and ECT is an effective treatment for mixed manic episodes in situations where medication fails or cannot be used. Common antidepressants have been shown to worsen mania symptoms during mixed episodes without necessarily improving depressive symptoms; thus, they are not recommended during mixed episodes. A greater understanding of pathophysiological processes in bipolar disorder is now required to provide a more accurate diagnosis and new personalised treatment approaches. Targeted, specific treatments developed through a greater understanding of bipolar disorder pathophysiology, capable of affecting the underlying disease processes, could well prove to be more effective, faster acting, and better tolerated than existing therapies, therefore providing better outcomes for individuals affected by bipolar disorder. Until such time as targeted agents are available, second-generation neuroleptics are emerging as the treatment of choice in the management of mixed states in bipolar disorder.

Prevalence rates and clinical implications of bipolar disorder "with mixed features" as defined by DSM-5

BACKGROUND

We investigated the increase in the prevalence of bipolar disorder with mixed features following the replacement of DSM-IV-TR criteria with DSM-5 criteria. Additionally, we examined the clinical implications of the use of "with mixed features" as a specifier with bipolar disorder.

METHOD

We retrospectively reviewed medical charts from 2003 to 2013. A total of 331 patients diagnosed with bipolar disorder using the DSM-IV TR were enrolled and categorized into four groups: manic/hypomanic with mixed features, manic/hypomanic without mixed features, depressed with mixed features, and depressed without mixed features. These classifications were made in accordance with the DSM-5 definition of bipolar disorder "with mixed features." Changes in the prevalence, demographic and clinical characteristics were compared among the groups.

RESULTS

The prevalence rates of mixed features were significantly different when using the DSM-5 criteria vs. the DSM-IV-TR criteria. Patients with mixed features had a younger age of onset, younger age at hospitalization, more frequent hospitalizations for mixed episodes, and greater suicide risk compared with patients without mixed features.

LIMITATIONS

Retrospective study may have resulted in under diagnosis of mixed states.

CONCLUSIONS

An approximately three-fold greater risk for mixed features was observed in patients with bipolar disorder when using the DSM-5 criteria than when using the DSM-IV-TR criteria. The additional patients may represent patients with sub-syndromal mixed features and could indicate that patients with mixed features are underdiagnosed.