Current issues in the identification and management of bipolar spectrum disorders in 'special populations'

Old Age Bipolar Disorder-Epidemiology, Aetiology and Treatment

Data regarding older age bipolar disorder (OABD) are sparse. Two major groups are classified as patients with first occurrence of mania in old age, the so called “late onset” patients (LOBD), and the elder patients with a long-standing clinical history, the so called “early onset” patients (EOBD). The aim of the present literature review is to provide more information on specific issues concerning OABD, such as epidemiology, aetiology and treatments outcomes. We conducted a Medline literature search from 1970–2021 using the MeSH terms “bipolar disorder” and “aged” or “geriatric” or “elderly”. The additional literature was retrieved by examining cross references and by a hand search in textbooks. With sparse data on the treatment of OABD, current guidelines concluded that first-line treatment of OABD should be similar to that for working-age bipolar disorder, with specific attention to side effects, somatic comorbidities and specific risks of OABD. With constant monitoring and awareness of the possible toxic drug interactions, lithium is a safe drug for OABD patients, both in mania and maintenance. Lamotrigine and lurasidone could be considered in bipolar depression. Mood stabilizers, rather than second generation antipsychotics, are the treatment of choice for maintenance. If medication fails, electroconvulsive therapy is recommended for mania, mixed states and depression, and can also be offered for continuation and maintenance treatment. Preliminary results also support a role of psychotherapy and psychosocial interventions in old age BD. The recommended treatments for OABD include lithium and antiepileptics such as valproic acid and lamotrigine, and lurasidone for bipolar depression, although the evidence is still weak. Combined psychosocial and pharmacological treatments also appear to be a treatment of choice for OABD. More research is needed on the optimal pharmacological and psychosocial approaches to OABD, as well as their combination and ranking in an evidence-based therapy algorithm.

Feasibility randomised controlled trial of Recovery-focused Cognitive Behavioural Therapy for Older Adults with bipolar disorder (RfCBT-OA): study protocol

INTRODUCTION

Bipolar disorder is a severe and chronic mental health problem that persists into older adulthood. The number of people living with this condition is set to rise as the UK experiences a rapid ageing of its population. To date, there has been very little research or service development with respect to psychological therapies for this group of people.

METHODS AND ANALYSIS

A parallel two-arm randomised controlled trial comparing a 14-session, 6-month Recovery-focused Cognitive-Behavioural Therapy for Older Adults with bipolar disorder (RfCBT-OA) plus treatment as usual (TAU) versus TAU alone. Participants will be recruited in the North-West of England via primary and secondary mental health services and through self-referral. The primary objective of the study is to evaluate the feasibility and acceptability of RfCBT-OA; therefore, a formal power calculation is not appropriate. It has been estimated that randomising 25 participants per group will be sufficient to be able to reliably determine the primary feasibility outcomes (eg, recruitment and retention rates), in line with recommendations for sample sizes for feasibility/pilot trials. Participants in both arms will complete assessments at baseline and then every 3 months, over the 12-month follow-up period. We will gain an estimate of the likely effect size of RfCBT-OA on a range of clinical outcomes and estimate parameters needed to determine the appropriate sample size for a definitive, larger trial to evaluate the effectiveness and cost-effectiveness of RfCBT-OA. Data analysis is discussed further in the Analysis section in the main paper.

ETHICS AND DISSEMINATION

This protocol was approved by the UK National Health Service (NHS) Ethics Committee process (REC ref: 15/NW/0330). The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and local, participating NHS trusts.

TRIAL REGISTRATION NUMBER

ISRCTN13875321; Pre-results.

Retrospective assessment of premorbid psychopathology and cognitive impairments in bipolar disorder

The present study investigated whether premorbid psychopathological and cognitive impairment symptoms could be retrospectively identified during the childhood and adolescence of those later diagnosed with bipolar disorder (BPD). The present sample consisted of 30 adults diagnosed with BPD, 30 of their significant-others, a group-matched control group of 30 adults (without any reported psychological or cognitive disorders), and 30 of their significant-others. The adults diagnosed with BPD and the control group completed a self-report form of the retrospective version of the Coolidge Personality and Neuropsychological Inventory (CPNI-R) as they were before the age of 16 years. The significant-others reported on the adults diagnosed with BPD or upon their controls. Initial two-factor analyses of variance revealed that on a comprehensive measure of psychopathology and of cognitive impairment, those diagnosed with BPD scored significantly higher than the control group on the self-report and the significant-other forms, with large effects sizes. Overall, the overarching research hypothesis was confirmed: adults diagnosed with BPD and their significant-others could report salient prodromes during their childhood or adolescence.

[Variables associated with disability in elderly bipolar patients on ambulatory treatment]

INTRODUCTION

Studies on adult bipolar patients have demonstrated a disability associated with the bipolar disorder, even in euthymic patients, but there is a lack of data in the elderly population.

MATERIAL AND METHOD

A cross-sectional, multicentre study on a consecutive sample of ambulatory bipolar patients (DSM-IV-TR criteria), aged 65 years or over. Retrospective and cross-sectional sociodemographic and clinical data were collected, as well as the Clinical Global Impression for Bipolar Modified scale (CGI-BP-M) and the level of disability using the World Health Organisation Disability Assessment Schedule (WHO/DAS). The disability was assessed globally and by areas. The presence of a moderate to maximum disability compared to a mild to no disability was considered a dependent variable.

RESULTS

A moderate to maximum global disability was present in 43.6% of the sample. By areas, occupational functioning was the area most frequently affected, and personal care the least affected. The only variables which were associated with disability were the presence of medical comorbidity (P = .01), increased age (P = .005) global clinical severity (P = .0001) and in the depressive pole (P = .03). There was no relationship between clinical subtype, duration of the disease, number of previous episodes, number of hospitalisations, or other clinical variables and the degree of disability.

CONCLUSIONS

These data underline the need to establish specific therapeutic strategies in the approach to depressive symptoms and medical comorbidity, with the aim of minimising the disability in elderly bipolar patients. Given the lack of current data, new studies are needed with larger samples and control groups.

Bipolar disorder: clinical perspectives and implications with cognitive dysfunction and dementia

Introduction. Cognitive dysfunction as a core feature in the course of bipolar affective disorder (BPD) is a current subject of debate and represents an important source of psychosocial and functional burden. Objectives. To stand out the connection and clinical implications between cognitive dysfunction, dementia, and BPD. Methods. A nonsystematic review of all English language PubMed articles published between 1995 and 2011 using the terms "bipolar disorder," "cognitive dysfunction," and "dementia". Discussion. As a manifestation of an affective trait or stage, both in the acute phases and in remission, the domains affected include attention, executive function, and verbal memory. The likely evolution or overlap with the behavioural symptoms of an organic dementia allows it to be considered as a dementia specific to BPD. This is named by some authors, as BPD type VI, but others consider it a form of frontotemporal dementia. It is still not known if this process is neurodevelopmental or neurodegenerative in nature, or both simultaneously. The assessment should consider the iatrogenic effects of medication, the affective symptoms, and a neurocognitive evaluation. Conclusion. More specific neuropsychological tests and functional imaging studies are needed and will assume an important role in the near future for diagnosis and treatment.

Are there developmentally limited forms of bipolar disorder?

Bipolar spectrum disorders have traditionally been thought to be chronic in course. However, recent epidemiologic research suggests that there may be developmentally limited forms of bipolar disorder. Two large, nationally representative studies reveal a strikingly high prevalence of bipolar disorders in emerging adulthood (5.5%-6.2% among 18-24-year-olds) that appear to resolve substantially during the latter half of the 3rd decade of life (3.1%-3.4% among 25-29-year-olds). Although ascertainment bias due to early mortality, institutionalization, incarceration, and homelessness may account for some of this reduction, the prevalence distribution suggests a high incidence in late adolescence and emerging adulthood that appears to resolve spontaneously in most cases. There were very few differences across age groups in symptom endorsement and comorbid diagnoses, suggesting that 18-24-year-olds that meet criteria for bipolar diagnoses experience clinically significant impairment and associated consequences of the disorder. More fine-grained longitudinal research is needed to determine whether developmentally limited forms of bipolar disorder exist and, if so, what markers might distinguish these forms of the disorder from more chronic courses.

Bipolar disorder in the elderly; different effects of age and of age of onset

BACKGROUND

Information about differences between younger and elderly patients with bipolar disorder and between elderly patients with early and late age of onset of illness is limited.

METHOD

The European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) study was a 2-year prospective, observational study in 3459 bipolar patients on the treatment and outcome of patients with an acute manic or mixed episode. Within this study, elderly patients (>60 years of age; n=475) were compared with younger patients (<50 years of age; n=2286), and within the elderly group, Late Onset Bipolar (LOB) patients (onset > or =50 years; n=141) were compared with Early Onset Bipolar (EOB) patients (<50 years; n=323).

RESULTS

In the year prior to enrollment, elderly patients, especially those with EOB, more frequently reported a rapid cycling course of illness, but fewer suicide attempts. At baseline, elderly patients more often used one psychotropic medication and demonstrated less severe manic and psychotic symptoms, but no difference in depressive symptomatology. However, prior to enrollment and during the acute phase of treatment, elderly patients more frequently received antidepressants. Atypical antipsychotics were given less frequently. Regarding 12-week outcomes, there was no difference between elderly and younger patients, although LOB elderly recovered faster, and were discharged sooner than EOB elderly patients.

LIMITATIONS

Information about somatic conditions was not systematically collected nor was information about concurrent use of non-psychiatric medication which might have given some indication of somatic comorbidity.

CONCLUSION

Elderly bipolar manic patients differ from younger bipolar manic patients regarding treatment but not treatment outcome. LOB elderly patients demonstrated a more favourable outcome. The use of medication and the occurrence of rapid cycling in EOB elderly patients warrant further study.

Prevalence and correlates of eating disorder co-morbidity in patients with bipolar disorder

This study was designed to document eating disorder symptoms in a well-defined sample of patients with bipolar disorder and to evaluate the relationship of current loss of control over eating (LOC) to demographic and clinical features hypothesized to characterize bipolar patients at risk for disordered eating. Eighty-one patients enrolled in the Bipolar Disorder Center for Pennsylvanians provided demographic information and completed the Structured Clinical Interview for DSM-IV Axis I Disorders. The Eating Disorder Examination was administered by independent clinicians to evaluate current and lifetime eating disorder symptomatology. Twenty-one percent of participants met DSM-IV criteria for a lifetime eating disorder, and 44% reported a history of LOC. Patients who endorsed weekly LOC during the past six months (n=18) were heavier, had more atypical depressive symptoms, and were more likely to have a lifetime substance use disorder compared to patients in the rest of the sample (n=63). These findings indicate that eating disorder symptoms are prevalent in patients with bipolar disorder and are associated with obesity and other psychiatric morbidity. Screening for eating disorders in bipolar patients is warranted, as intervention may minimize distress and improve treatment outcome.

The impact of co-morbid alcohol use disorder in bipolar patients

Alcohol use is highly prevalent in patients with bipolar disorder (BD) and is associated with significant mortality and morbidity. The detrimental effects of each condition are compounded by the presence of the other. The objective of this study was to examine the impact of alcohol abuse and of alcohol dependence in BD in a Brazilian sample, as indicated by clinical severity, functional impairment, and quality of life (QOL). A cross-sectional survey of 186 bipolar outpatients were interviewed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-4th Edition. The primary outcome measures were functioning, as indicated by the Global Assessment of Functioning Scale scores and QOL, as indicated by the World Health Organization Quality of Life Instrument. Secondary outcomes were clinical severity features. Alcohol abuse and dependence were associated with male gender, lower education, earlier age of onset, psychosis within first episode, depressive symptoms, and worse functioning. In addition, the presence of alcohol abuse or dependence was associated with remarkably high rates of suicide attempt. Our findings suggest that the co-occurrence of alcohol abuse/dependence with BD increases the risk for suicide attempt, which may reflect in part the greater severity of symptoms and impaired functioning. This subgroup of bipolar patients requires a treatment tailored to address both conditions.

A case series on the hypothesized connection between dementia and bipolar spectrum disorders: bipolar type VI?

BACKGROUND

The concept of bipolar spectrum disorders has opened therapeutic opportunities for patients with atypical and complex affective conditions. The literature has recently described several commonalities in pathophysiological processes of bipolar disorders and dementia. However, this connection has been insufficiently appreciated at the clinical level, in part because affective dysregulation in the elderly and, particularly in the dementia setting, is typically attributed either to secondary depressive states or otherwise relegated to a neurologically understandable behavioral complication resulting from cerebral disease.

METHODS

We selected a case series of 10 elderly patients with late-onset mood and related behavioral symptomatology and cognitive decline without past history of clear-cut bipolar disorder. Clinical features, temperament, cognition, family history and pharmacological response were assessed to identify prototypical patients to illustrate the complexities of the dementia-bipolar interface.

RESULTS

Mixed and depressive mood symptoms were most commonly observed and all patients had been premorbidly of hyperthymic, cyclothymic and/or irritable temperaments. Most patients had a family history of bipolar disorder or disorders related to the bipolar diathesis. Symptoms were often refractory to or aggravated by antidepressants and acetylcholinesterase inhibitors, whereas mood stabilizers and/or atypical antipsychotics were beneficial, promoting behavioral improvement in all treated patients and marked cognitive recovery in five.

LIMITATIONS

Case series with retrospective methodology.

CONCLUSION AND CLINICAL IMPLICATIONS

Patients with cognitive decline and frequent mood lability might be manifesting a late-onset bipolar spectrum disorder, which we posit as type VI. We further posit that dementia and/or other biopsychosocial challenges associated with aging might release latent bipolarity in such individuals. Antidepressants, even drugs targeting dementia, might aggravate the behavioral dysregulation in these patients. Evaluation of premorbid temperament and/or family history of bipolarity and related disorders might help in broadening the clinical and biological understanding of such patients, providing a rationale for better customized treatment along the lines of mood stabilization and avoidance of antidepressants.

Lithium therapy for unipolar and bipolar depression among the middle-aged and older adult patient subpopulation

Affective disorders are a major cause of morbidity and disability among middle-aged and older people. Thus, the prophylaxis of both unipolar depression and bipolar disorder in this patient subpopulation is an important task of psychiatrists and other physicians. Although lithium remains an effective prophylactic and treatment agent in younger individuals with bipolar disorder, its prophylactic efficacy and tolerability has not been thoroughly investigated among middle aged and older people with unipolar depression and bipolar disorder. Our study is based on a mirror-image design that compared the clinical course with lithium treatment and the clinical course prior to lithium treatment based on a retrospective chart review. We examined the results obtained with long-term lithium maintenance in a group of 60 middle-aged and older adult patients (age >60 years) with unipolar depression and bipolar disorder. More specifically, we analyzed changes of frequency, severity, and duration of depressive or manic relapses, rate and duration of hospitalizations and suicidal behavior (thoughts or attempts), and various assessments of outcome. A significant reduction was found on all indices during lithium therapy compared to before lithium treatment, attesting to the prophylactic efficacy of long-term lithium in unipolar depression and bipolar disorder. The range of side effects in our sample was similar to that found in other reports in this age group. The probability of relapse and recurrence in patients with bipolar disorder and with unipolar depression can be significantly decreased by lithium prophylaxis. Further investigation is mandated to confirm these findings under double-blind conditions.

Bipolar (spectrum) disorder and mood stabilization: standing at the crossroads?

Diagnosis and treatment of bipolar disorder has long been a neglected discipline. Recent years have shown an upsurge in bipolar research. When compared to major depressive disorder, bipolar research still remains limited and more expert based than evidence based. In bipolar diagnosis the focus is shifting from classic mania to bipolar depression and hypomania. There is a search for bipolar signatures in symptoms and course of major depressive episodes. The criteria for hypomania are softened, leading to a bipolar prevalence that now equals that of major depressive disorder. Anti-epileptics and atypical antipsychotics have joined lithium in the treatment of bipolar disorder. Fortunately, mood stabilization has become the core issue in bipolar disorder treatment. In contrast with recent trends in the diagnosis of bipolar disorder, treatment research remains more focused on classic mania than depression or hypomania. This leaves the clinician with the difficult task of diagnosing 'new bipolar patients' for whom no definite evidence-based treatment is available. An important efficacy-effectiveness gap further compromises the translation of the evidence base on bipolar disorder treatment into clinical practice. The recent upsurge of research on bipolar disorder is to be applauded, but further research is needed: for bipolar disorder in general, and for bipolar depression and the long-term treatment specifically. Given the complexity of the disorder and the many clinical uncertainties, effectiveness studies should be installed.

Eating disorders and illness burden in patients with bipolar spectrum disorders

OBJECTIVES

The objectives of the study were to evaluate the clinical significance of lifetime eating disorder comorbidity in a well-defined sample of patients with bipolar spectrum disorders and to describe cognitive correlates of disordered eating in this group.

METHOD

Twenty-six bipolar patients with a lifetime history of a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)-defined eating disorder (n = 17) or a clinically significant subthreshold eating disorder (n = 9) (ED group) were compared with 46 bipolar patients with no history of an eating disorder (no-ED group) on demographic and clinical characteristics at study presentation, history of bipolar illness, and other psychiatric comorbidity. Measures included the Structured Clinical Interview for the DSM-IV Axis I Disorders, the Clinical Global Impression-Severity Scale-Bipolar Version (CGI-S-BP), and the Eating Disorder Examination. Height and weight were recorded to calculate body mass index.

RESULTS

Patients in the ED group were heavier and were rated as more symptomatic on the CGI-S-BP than were patients in the no-ED group. The ED group also had a higher number of lifetime depressive episodes and greater psychiatric comorbidity, excluding eating and mood disorders. Finally, after controlling for body mass index and CGI-S-BP rating, patients in the ED group had significantly higher Eating Disorder Examination Restraint, Eating Concern, Shape Concern, Weight Concern, and Global scores than did patients in the no-ED group.

CONCLUSIONS

These findings highlight the need for a renewed emphasis on the evaluation and management of weight and eating in the mood disorders. In particular, this research suggests that eating disorder comorbidity may be a marker for increased symptom load and illness burden in bipolar disorder.

Anxiety disorders among patients with co-occurring bipolar and substance use disorders

Bipolar and substance use disorders are known to co-occur frequently, but limited attention has been paid to anxiety disorders that may accompany this dual diagnosis. Therefore, we examined the prevalence and nature of anxiety disorders among treatment-seeking patients diagnosed with current bipolar and substance use disorders, and investigated the association between anxiety disorders and substance use. Among 90 participants diagnosed with bipolar disorder I (n = 75, 78%) or II (n = 15, 22%), 43 (48%) had a lifetime anxiety disorder, with post-traumatic stress disorder (PTSD) occurring most frequently (n = 21, 23%). We found that those with PTSD, but not with the other anxiety disorders assessed, began using drugs at an earlier age and had more lifetime substance use disorders, particularly cocaine and amphetamine use disorders, than those without PTSD. Further examination revealed that (1) most participants with PTSD were women, (2) sexual abuse was the most frequently reported index trauma, and (3) the mean age of the earliest index trauma occurred before the mean age of initiation of drug use. Our findings point to the importance of further investigating the ramifications of a trauma history among those who are dually diagnosed with bipolar and substance use disorders.

Bipolar disorder in older adult inpatients

The literature on bipolar disorder in older adults is very limited, in spite of the fact that the elderly are a growing population in the United States. This retrospective record review study evaluated clinical characteristics and hospital-based resource use patterns among 48 older adults with bipolar disorder, and compared groups with early-onset (EOS) versus late-onset (LOS) bipolar disorder. The mean age of the group was 67.3 years, with no difference in age between EOS and LOS categories. Late onset illness was identified in 29.2% of the group (N = 14). Compared with individuals with EOS, individuals with LOS were 2.8 times more likely to be female. Both groups had extensive medical comorbidity (mean of 3.7 comorbid medical conditions), substantial hospital usage (mean length of stay, 14.8 days) and polypharmacy usage. Bipolar disorder with onset after age 50 is not uncommon among older adults hospitalized on a geropsychiatric unit. Clinical characteristics may differ between individuals with early-onset and late-onset bipolar illness, and resource utilization may be extensive in both groups.

Recognizing Women’s Common Mental Health Problems: The Earthquake Assessment Model

Women's reproductive events may coincide with the onset of a mood or anxiety disorder or the exacerbation of a previously existing one due to the interconnection of neurotransmitters, stress, and reproductive hormones. The women's health nurse plays a critical role in the identification of mood and anxiety disorders during a woman's life span. This article provides nurses with a mental health assessment model, describes the common mood and anxiety disorders, and discusses simple management and referral strategies.

Searching for behavioral indicators of bipolar II in patients presenting with major depressive episodes: the "red sign," the "rule of three" and other biographic signs of temperamental extravagance, activation and hypomania

BACKGROUND

Since 1977, the work of the author has shown the primacy of behavioral activation, flamboyance, and extravagance in detecting hypomania, the historical hallmark of cyclothymic and the broader spectrum of bipolar II (BP-II) disorders. In other words, the soft spectrum is more likely to declare itself in behavioral rather than mood disturbances. The obligatory search for elation and related mood changes a la DSM-IV (and its interview form, the SCID) during the clinical interview is often doomed to failure, thereby "condemning" the patient to a unipolar diagnosis, and hence to sequential and often tragic failures with antidepressants or combinations thereof.

METHODS

To characterize behavioral signs of good specificity, though individually of low sensitivity for BP-II in patents presenting with major depression, the author undertook a chart review of over 1000 depressive patients he had examined extending over a period of nearly three decades. The Mood Clinic Data Questionnaire (MCDQ) used in the author's Memphis mood clinic permitted systematization of unstructured observations. BP-II had been independently confirmed by hypomania of > or =2 days and/or cyclothymia over the course of the index illness (both of which were validated by family history for bipolarity in earlier research in our clinic).

RESULTS

Triads of behavior or traits in the patients' biographical history-as well as in the biologic kin-involving polyglottism, eminence, creative achievement, professional instability, multiple substance/alcohol use, multiple comorbidity (axis I and axis II), multiple marriages, a broad repertoire of sexual behavior (including brief interludes of homosexuality), impulse control disorders, as well as ornamentation and flamboyance (with red and other bright colors dominating) were specific for BP-II. Temperamentally, many of these individuals thrive on activity-they are indeed "activity junkies."

LIMITATION

The reported findings pertain primarily to the differential diagnosis between BP-II and unipolar depression. Replication of the approach espoused herein will require quantification of the operational definitions of the observed phenomenology.

CONCLUSION

The findings, which make sense in an evolutionary model of the advantage that "dilute" bipolar traits confer to human biography and erotic life, suggest that such behavioral traits can be useful provisionally in assigning a depressive episode to the realm of the bipolar II spectrum. Overall, the perspective espoused in this paper indicates that temperamental excesses and, more generally, a biographical approach, represent a more coherent approach than hypomanic episodes in the diagnosis of BP-II patients. Finally, such a diagnostic approach underscores the importance of incorporating evolutionary considerations and principles in understanding the origin of affective disorders.

Recorded psychiatric comorbidity with bipolar disorder--a Finnish hospital discharge register study

Bipolar disorder is frequently connected to other psychiatric disorders. On the basis of The National Hospital Discharge Register in Finland, we studied the recorded prevalence of psychiatric comorbidity among bipolar inpatients by clinicians, and the factors that were associated with it. Of the 2687 hospital stays in 1998, 82% had no other recorded psychiatric diagnosis except an episode of bipolar disorder. Psychiatric comorbidity was recorded in 18% of hospital stays, of which 20% had two comorbid psychiatric diagnoses. Substance-related disorders (11%) were the most commonly recorded comorbid disorders. Personality disorders were recorded in 6%, and anxiety disorder in 1% of the hospital stays. These figures should be considered far below the expected ones. Recorded comorbidity was associated with the type of episode. Comorbidity in bipolar disorder in psychiatric hospitals in Finland seems to go greatly undetected and may have a deteriorating impact on the course of the illness.

Bipolar disorder in older adults: a critical review

OBJECTIVES

The goal of this article is to provide a comprehensive critical review of studies reporting the prevalence, features, age of onset, course, comorbidity, and neuropsychology of, as well as service utilization, in bipolar disorder in older age.

METHODS

We searched the Medline, Pubmed, and PsycINFO databases using combinations of the keywords 'Bipolar', 'Manic/a', 'Manic Depression', 'Elderly', and 'Older'. We included English-language reports presenting quantitative data on the prevalence and/or any descriptive information about adults with bipolar disorder over age 50. Findings from similar studies were pooled when possible. A total of 61 studies met our broad criteria.

RESULTS

Common methodological problems in the published studies included small sample sizes, retrospective chart review, lack of standardized measures, overemphasis on inpatients, and dearth of longitudinal data. Strong evidence indicates that bipolar disorder becomes less common with age, accounts for 8-10% of late life psychiatric admissions, is associated with neurologic factors in late-onset groups, and is a heterogeneous life-long illness. Weak or inconsistent evidence was found for a higher prevalence of mixed episodes in older adults, a lower treatment response, and the association with lower family history in late-onset groups. Minimal information is available on bipolar depression in late life.

CONCLUSIONS

Bipolar disorder in old age is a growing public health problem. Greater research on bipolar disorder in older people will assist in enhancing services to this group as well as inform research on bipolar disorder across the life span.

Mood swings in patients with anxiety disorders compared with normal controls

BACKGROUND

About 70-80% of patients with anxiety syndromes suffer from depression. Mood variability including hypomania, cyclothymia and hyperthymia have been described in 40-50% of patients with depression. There is an emerging literature that such variability could also characterize anxiety disorders. The aim of this study was to visually document and quantify mood variability in patients with anxiety disorders.

METHODS

Twenty patients with anxiety disorders and 22 normal control subjects completed two visual analogue scales (VAS) on depressed mood and high mood, twice per day for 14 days. The Beck Depression Inventory and the Altman Self-Rating Mood Scale were used for concurrent validity.

RESULTS

On the VAS, patients showed higher levels of depressed and high moods, and greater mood variability than the controls. Variability of depressed and high moods was highly correlated.

LIMITATIONS

This was a relatively small sample from a single center. Patients were selected by convenience and were under treatment. The control subjects were not interviewed.

CONCLUSIONS

Subsyndromal mood variability in patients with anxiety disorders can be visually depicted and quantified. The mood variability of patients with anxiety disorders who also complain of mood swings is greater than the mood fluctuations described by normal subjects.

Clinical characteristics and length of hospital stay among older adults with bipolar disorder, schizophrenia or schizoaffective disorder, depression, and dementia

Although many older adults with serious psychiatric illnesses share common concerns, such as medical comorbidity, personal loss, greater propensity for adverse medication effects, and greater dependence on others for basic needs such as transportation, individualized treatment needs must be differentiated by underlying psychiatric disorders. This retrospective study evaluated clinical characteristics and resource use among 137 older adults with bipolar disorder, schizophrenia or schizoaffective disorder, depression, and dementia who were discharged from an urban, academic medical center's inpatient geropsychiatric unit. The authors found women to be significantly overrepresented among individuals with schizophrenia or schizoaffective disorder compared to those with bipolar disorder, depression, and dementia (P=.034). Among those with bipolar disorder, anticonvulsant medications were predominantly used as mood stabilizers, with only the rare use of lithium. Individuals with schizophrenia or schizoaffective disorder were the youngest group of patients; individuals with dementia were the oldest group (P<.001). This shows significant differences in clinical characteristics among hospitalized older adults with serious mental illnesses. Additional studies are needed on outcomes of serious chronic psychiatric illnesses in later life to optimize care environments for older adult psychiatric patients.

Avanços no diagnóstico do transtorno do humor bipolar

Atualmente, vemos transformações no diagnóstico do Transtorno de Humor Bipolar (THB). A prática clínica exige conhecimento mais detalhado da correlação THB - outras doenças psiquiátricas. Nessa revisão não-sistemática, foram abordados aspectos diagnósticos do THB: a) histórico, b) Espectro Bipolar, c) Depressão Atípica (DeA) e Disforia Histeróide, d) Estados Mistos, e) relação THB-Transtornos de Ansiedade, f) relação com o diagnóstico de Transtorno de Personalidade Borderline (TPB), g) contraponto ao conceito de espectro bipolar. A doença é conhecida desde a Grécia Antiga. Os estudos baseados nas publicações de Hagop Akiskal expandem o diagnóstico para além dos critérios usualmente utilizados, criando o conceito de espectro bipolar. A alta prevalência de comorbidade entre THB e Transtornos de Ansiedade corroboram que ambos compartilham o mesmo substrato neurobiológico. O debate demonstra que não há consenso, expondo a fragilidade dos nossos métodos diagnósticos. Entretanto, a revisão mostra a utilidade de sempre considerar o THB como diagnóstico diferencial.

Aging-related issues in bipolar disorder: a health services perspective

Among the elderly, bipolar disorder is a significant public health problem, often leading to functional impairment and substantial use of health care resources. There has been a growing awareness regarding the manifestations of bipolar disorder among older adults owing to both changes in national demographics and developing sophistication in the treatment of bipolar illness. Bipolar disorder accounts for 5% to 19% of mood disorder presentations in the elderly, although a clear picture of the exact prevalence of bipolar disorder among older adults in the community is still lacking. Data from treatment centers give a somewhat unreliable picture of the true prevalence and manifestations of bipolar disorder in the general population as elderly patients tend to underuse mental health systems, under-report psychiatric symptoms, and are often treated in nonhospital/clinic settings, such as nursing homes. Factors of particular relevance in late-life bipolar disorder include age of onset, symptom presentation/recognition, secondary mania, psychiatric and medical comorbidity, and response to treatment. Future mental health services research must further explore these issues to optimize care for older adults with bipolar disorder.

Treatment of bipolar disorder in older adults

BACKGROUND

It has been reported that 10% of all patients with bipolar disorder develop their illness after the age of 50, with bipolar disorder accounting for 5-19% of mood disorder presentations in the elderly. There has been a growing awareness regarding the manifestation of bipolar disorder among older adults due to both changes in national demographics, and developing sophistication in the treatment of bipolar illness. A persistent problem in our understanding of management of late life bipolar disorder is the paucity of research and rigorous published studies on the psychopharmacology of this condition.

OBJECTIVE

This paper reviews medication treatments, non-medication biological therapies, and psychosocial interventions for bipolar disorder in late life with a particular emphasis on age related modifiers of treatment.

METHODS

Findings are based upon review of the current literature.

RESULTS

There are multiple, significant gaps in our knowledge of bipolar disorder in late life which have important implications in the optimum treatment of elderly individuals with bipolar illness.

CONCLUSION

There are a number of areas of needed future research in late life bipolar disorder.

The "softer" end of the bipolar spectrum

The prevalence and diversity of bipolar disorder may be under appreciated. Recent data suggest that when clinicians look beyond strict DSM-IV criteria for bipolar disorder, we find that as many as 5%-7% of the general public may suffer from some form of "bipolar spectrum disorder." At the same time, the comorbidity between bipolar disorder and other psychiatric conditions may create understandable confusion in diagnosis and treatment. Recognition of bipolar depression and the "soft end" of the bipolar spectrum demands not only the identification of the hallmarks of bipolarity, but a heightened awareness of the problems of missed diagnosis and inappropriate treatment. By attending to some key historical and clinical clues, the psychiatrist is more likely to detect bipolar spectrum disorder and provide appropriate treatment for it.