1
|
Validation of the Bipolar Prodrome Symptom Interview and Scale-Abbreviated Prospective (BPSS-AP) in a clinical sample and healthy controls. J Affect Disord 2023; 324:463-468. [PMID: 36586622 DOI: 10.1016/j.jad.2022.12.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 11/16/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND After the existence of a bipolar disorder (BD) prodrome was established, the development of clinical rating instruments has become relevant that are sufficiently brief to be implemented in real-world clinical practice and that are designed to identify individuals at-risk for BD. This study aimed to validate a shorter version of the Bipolar Prodrome Symptom Interview and Scale (BPSS), the BPSS-Abbreviated Prospective (BPSS-AP), for use among clinical populations. METHODS Altogether, 104 adults, comprising individuals diagnosed with BD (n = 17, mania: n = 8, hypomania: n = 9), with major depressive disorder (MDD, n = 38, all currently depressed), and healthy controls (HCs, n = 49), underwent BPSS-AP interviews. The psychometric properties of the BPSS-AP were evaluated, including internal consistency, convergent validity, discriminant validity, and factor structure. RESULTS The median (IQR) age was 29 (23-38), 40 (23-55), and 25 (22-28) years, for the BD, MDD, and HC groups, respectively. The BPSS-AP showed excellent internal consistency (Cronbach's α = 0.95). Convergent validity between the BPSS-AP and Young Mania Rating Scale (YMRS) was high (r > 0.7). The BPSS-AP discriminated patients with BD from those with MDD (P < .001) and from HCs (P < .001). LIMITATIONS The study design precludes assessment of the predictive validity of the BPSS-AP. CONCLUSIONS This study found that the BPSS-AP, a more concise and feasible version of the semi-structured interview for identifying individuals at risk of developing BD, has satisfactory psychometric properties. There is room for further validation and application of the BPSS-AP in clinical settings to evaluate its utility in research and clinical care.
Collapse
|
2
|
Salazar de Pablo G, Moreno D, Gonzalez-Pinto A, Paya B, Castro-Fonieles J, Baeza I, Graell M, Arango C, Rapado-Castro M, Moreno C. Affective symptom dimensions in early-onset psychosis over time: a principal component factor analysis of the Young Mania Rating Scale and the Hamilton Depression Rating Scale. Eur Child Adolesc Psychiatry 2022; 31:1715-1728. [PMID: 34052909 DOI: 10.1007/s00787-021-01815-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 05/23/2021] [Indexed: 12/11/2022]
Abstract
Early-onset psychosis (EOP) is a complex disorder characterized by a wide range of symptoms, including affective symptoms. Our aim was to (1) examine the dimensional structure of affective symptoms in EOP, (2) evaluate the predominance of the clinical dimensions and (3) assess the progression of the clinical dimensions over a 2-year period. STROBE-compliant prospective principal component factor analysis of Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale-21 (HDRS-21) at baseline, 6-months, 1-year and 2-year follow-up. We included 108 EOP individuals (mean age = 15.5 ± 1.8 years, 68.5% male). The factor analysis produced a four-factor model including the following dimensions: mania, depression/anxiety, sleep and psychosis. It explained 47.4% of the total variance at baseline, 60.6% of the total variance at 6-months follow-up, 54.5% of the total variance at 1-year follow-up and 49.5% of the total variance at 2-year follow-up. According to the variance explained, the mania factor was predominant at baseline (17.4%), 6-month follow-up (23.5%) and 2-year follow-up (26.1%), while the depression/anxiety factor was predominant at 1-year follow-up (23.1%). The mania factor was the most stable; 58.3% items that appeared in this factor (with a load > 0.4) at any time point appeared in the same factor at ≥ 3/4 time points. Affective symptoms are frequent and persistent in EOP. Mania seems to be the most predominant and stable affective dimension. However, depression and anxiety may gain predominance with time. A comprehensive evaluation of the dimensional structure and the progression of affective symptoms may offer clinical and therapeutic advantages.
Collapse
Affiliation(s)
- Gonzalo Salazar de Pablo
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, C/Ibiza, 43, 28009, Madrid, Spain.,Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dolores Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, C/Ibiza, 43, 28009, Madrid, Spain
| | - Ana Gonzalez-Pinto
- Department of Psychiatry, Biomedical Research Networking Centre in Mental Health, BioAraba Research Institute, OSI Araba-University Hospital, University of the Basque Country (EHU/UPV), CIBERSAM, Vitoria, Spain
| | - Beatriz Paya
- Department of Child Psychiatry, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Josefina Castro-Fonieles
- Department of Child and Adolescent Psychiatry and Psychology, 2017SGR881, Neurosciences Institute, Hospital Clínic of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Inmaculada Baeza
- Department of Child and Adolescent Psychiatry and Psychology, 2017SGR881, Neurosciences Institute, Hospital Clínic of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Montserrat Graell
- Department of Child and Adolescent Psychiatry and Psychology, Hospital Infantil Universitario Niño Jesús, School of Medicine, Universidad Autónoma, Madrid, Spain
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, C/Ibiza, 43, 28009, Madrid, Spain
| | - Marta Rapado-Castro
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, C/Ibiza, 43, 28009, Madrid, Spain. .,Department of Psychiatry, Melbourne Neuropsychiatry Centre, The University of Melbourne and Melbourne Health, Victoria, Australia.
| | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, C/Ibiza, 43, 28009, Madrid, Spain
| |
Collapse
|
3
|
Girasek H, Nagy VA, Fekete S, Ungvari GS, Gazdag G. Prevalence and correlates of aggressive behavior in psychiatric inpatient populations. World J Psychiatry 2022; 12:1-23. [PMID: 35111577 PMCID: PMC8783168 DOI: 10.5498/wjp.v12.i1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/18/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest. One reason for this is that psychiatric patients are generally considered more likely to be aggressive, which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior. Predicting aggression in psychiatric wards is crucial, because aggressive behavior not only endangers the safety of both patients and staff, but it also extends the hospitalization times. Predictions of aggressive behavior also need careful attention to ensure effective treatment planning. This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes (dementia, psychoactive substance use, acute psychotic disorder, schizophrenia, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, personality disorders and intellectual disability). The prevalence of aggressive behavior and its underlying risk factors, such as sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior. Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed. Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.
Collapse
Affiliation(s)
- Hunor Girasek
- Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc South Pest Hospital, Budapest 1204, Hungary
| | - Vanda Adél Nagy
- Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc South Pest Hospital, Budapest 1204, Hungary
| | - Szabolcs Fekete
- Department of Psychiatry, National Institute of Forensic Psychiatry, Budapest 1108, Hungary
- School of PhD Studies, Semmelweis University, Budapest 1085, Hungary
| | - Gabor S Ungvari
- Division of Psychiatry, School of Medicine, University of Western Australia, Crawley 6009, Australia
- Section of Psychiatry, University of Notre Dame, Fremantle 6160, Australia
| | - Gábor Gazdag
- Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc South Pest Hospital, Budapest 1204, Hungary
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, Semmelweis University, Budapest 1083, Hungary
| |
Collapse
|
4
|
Edmiston EK, Fournier JC, Chase HW, Bertocci MA, Greenberg T, Aslam HA, Lockovich J, Graur S, Bebko G, Forbes EE, Stiffler R, Phillips ML. Assessing Relationships Among Impulsive Sensation Seeking, Reward Circuitry Activity, and Risk for Psychopathology: A Functional Magnetic Resonance Imaging Replication and Extension Study. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2020; 5:660-668. [PMID: 31862347 PMCID: PMC7202969 DOI: 10.1016/j.bpsc.2019.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND High trait impulsive sensation seeking (ISS), the tendency to engage in behavior without forethought and to seek out new or extreme experiences, is a transdiagnostic risk factor for externalizing and mood disorders, particularly bipolar disorder. We published a positive association between trait ISS and reward expectancy-related activity in the left ventrolateral prefrontal cortex (L vlPFC) and the ventral striatum. We aimed to replicate this finding and extend it by testing for mediation effects of ISS on relationships between reward expectancy-related activity and measures denoting hypomania. METHODS A transdiagnostic sample of 127 adults, 18 to 25 years of age, completed a card-guessing functional magnetic resonance imaging task as well as measures of ISS (inattention, motor impulsivity, fun seeking, positive and negative urgency) and the Moods Spectrum as a measure of hypomania. An original sample of 98 was included for confirmatory and mediation analyses. RESULTS We replicated a positive relationship between reward expectancy-related L vlPFC activity and negative urgency, an ISS component (β = .28, t = 2.44, p = .0169). We combined these data with the original sample, confirming this finding (β = .27, t = 2.41, p = .0184). Negative urgency statistically mediated the relationship between reward expectancy-related L vlPFC activity and Moods Spectrum factors associated with hypomania. No other associations between ISS measures and reward expectancy-related activity were replicated. CONCLUSIONS We replicated findings showing that reward expectancy-related L vlPFC activity is a biomarker for negative urgency, the tendency to react with frustration during distressing conditions. Negative urgency also statistically mediated the relationship between L vlPFC activity and measures indicative of hypomanic symptoms.
Collapse
Affiliation(s)
- E Kale Edmiston
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Jay C Fournier
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Henry W Chase
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michele A Bertocci
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Tsafrir Greenberg
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Haris A Aslam
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jeanette Lockovich
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Simona Graur
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Genna Bebko
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Erika E Forbes
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richelle Stiffler
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mary L Phillips
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
5
|
Work impairment in bipolar disorder patients – results from a two-year observational study (EMBLEM). Eur Psychiatry 2020; 25:338-44. [DOI: 10.1016/j.eurpsy.2010.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 11/19/2009] [Accepted: 01/10/2010] [Indexed: 11/19/2022] Open
Abstract
AbstractObjectivesTo explore factors associated with work impairment at 2 years following an acute episode.MethodsEuropean Mania in Bipolar disorder Longitudinal Evaluation of Medication (EMBLEM) is a prospective, observational study on the outcomes of patients with a manic/mixed episode. Work impairment was measured using a Longitudinal Interval Follow-up Evaluation (slice of LIFE) item and patients were categorised with either low or high work impairment at each observation. Baseline factors associated with work impairment at 2 years were assessed using multivariate modelling.ResultsAt baseline (n = 2289), 69% of patients had high work impairment. At 2 years (n = 1393), high impairment reduced to 41%. Modelling identified rapid cycling as the strongest disease-related factor associated with high work impairment at 2 years, although high work impairment at baseline had the strongest association overall. Lower levels of education, recent admissions, CGI-BP overall severity in the 12 months prior to baseline and CGI-BP mania at baseline all predicted higher work impairment. Living together in a relationship and independent housing were both significantly associated with having low work impairment at 2 years.ConclusionsWork impairment in bipolar disorder is maintained over long periods, and is strongly associated with relationship status, living conditions and various disease-related factors.
Collapse
|
6
|
Filgueiras A, Nunes A, Silveira L, de Assis da Silva R, da Silva R, Landeira-Fernandez J, Cheniaux E. Latent structure of the symptomatology of hospitalized patients with bipolar mania. Eur Psychiatry 2020; 29:431-6. [DOI: 10.1016/j.eurpsy.2014.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/30/2014] [Accepted: 02/09/2014] [Indexed: 10/25/2022] Open
Abstract
AbstractSeveral studies have attempted to understand the dimensions of psychiatric symptoms in manic episodes, but only a few have been able to model the latent structure of mania in bipolar disorder patients using confirmatory factor analysis. The objective of the present study was to search for the best model of the symptomatology of hospitalized manic patients. To achieve this goal, 117 manic inpatients during a manic crisis participated in this research. Exploratory factor analysis was conducted followed by confirmatory factor analysis using an exploratory factor analysis solution and three other theory-based models. The exploratory factor analysis results revealed a six-factor structure: depression, suicide, insomnia, mania, psychosis, and anxiety. This solution also presented the best fit to the data when tested with confirmatory factor analysis. A five-factor solution, without suicide as a separate dimension, appeared to be more theoretically suitable. Another important finding was that anxiety was an independent dimension in mania. Some hypotheses are discussed in light of contemporary theories, and future studies should investigate this aspect further.
Collapse
|
7
|
Affective dimensions as a diagnostic tool for bipolar disorder in first psychotic episodes. Eur Psychiatry 2020; 29:424-30. [DOI: 10.1016/j.eurpsy.2013.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 07/24/2013] [Accepted: 07/27/2013] [Indexed: 11/23/2022] Open
Abstract
AbstractObjectiveTo examine the predictive diagnostic value of affective symptomatology in a first-episode psychosis (FEP) sample with 5 years’ follow-up.MethodAffective dimensions (depressive, manic, activation, dysphoric) were measured at baseline and 5 years in 112 FEP patients based on a factor structure analysis using the Young Mania Rating Scale and Hamilton Depression Rating Scale. Patients were classified as having a diagnosis of bipolar disorder at baseline (BDi), bipolar disorder at 5 years (BDf), or “other psychosis”. The ability of affective dimensions to discriminate between these diagnostic groups and to predict a bipolar disorder diagnosis was analysed.ResultsManic dimension score was higher in BDi vs. BDf, and both groups had higher manic and activation scores vs. “other psychosis”. Activation dimension predicted a bipolar diagnosis at 5 years (odds ratio = 1.383; 95% confidence interval, 1.205–1.587; P = 0.000), and showed high levels of sensitivity (86.2%), specificity (71.7%), positive (57.8%) and negative predictive value (90.5%). Absence of the manic dimension and presence of the depressive dimension were both significant predictors of an early misdiagnosis.ConclusionThe activation dimension is a diagnostic predictor for bipolar disorder in FEP. The manic dimension contributes to a bipolar diagnosis and its absence can lead to early misdiagnosis.
Collapse
|
8
|
Abstract
Mixed states are frequent clinical pictures in psychiatric practice but are not well described in nosologic systems. Debate exists as to defining mixed states. We review factor and cluster analytical studies and prominent clinical/conceptual models of mixed states. While mania involves standard manic symptoms and depression involves standard depressive symptoms, core additional features of the mixed state are, primarily, psychomotor activation and, secondarily, dysphoria. Those features are more pronounced in mixed mania than in mixed depression but are present in both.
Collapse
Affiliation(s)
- Sergio A Barroilhet
- Clínica Psiquiátrica Universitaria, Facultad Medicina Universidad de Chile, Santiago, Chile; Department of Psychiatry, Tufts University, School of Medicine, Tufts Medical Center, Pratt Building, 3rd Floor, 800 Washington Street, Box 1007, Boston, MA 02111, USA.
| | - S Nassir Ghaemi
- Department of Psychiatry, Tufts University, School of Medicine, Tufts Medical Center, Pratt Building, 3rd Floor, 800 Washington Street, Box 1007, Boston, MA 02111, USA; Department of Psychiatry, Harvard Medical School, Harvard University, Boston, MA, USA
| |
Collapse
|
9
|
Abstract
Background. Operational definitions of mania are based on expert consensus rather than empirical data. The aim of this study is to identify the key domains of mania, as well as the relevance of the different signs and symptoms of this clinical construct. Methods. A review of latent factor models studies in manic patients was performed. Before extraction, a harmonization of signs and symptoms of mania and depression was performed in order to reduce the variability between individual studies. Results. We identified 12 studies fulfilling the inclusion criteria and comprising 3039 subjects. Hyperactivity was the clinical item that most likely appeared in the first factor, usually covariating with other core features of mania, such as increased speech, thought disorder, and elevated mood. Depressive–anxious features and irritability–aggressive behavior constituted two other salient dimensions of mania. Altered sleep was frequently an isolated factor, while psychosis appeared related to grandiosity, lack of insight and poor judgment. Conclusions. Our results confirm the multidimensional nature of mania. Hyperactivity, increased speech, and thought disorder appear as core features of the clinical construct. The mood experience could be heterogeneous, depending on the co-occurrence of euphoric (elevated mood) and dysphoric (irritability and depressive mood) emotions of varying intensity. Results are also discussed regarding their relationship with other constitutive elements of bipolar disorder, such as mixed and depressive states.
Collapse
Affiliation(s)
- Diego J Martino
- Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, Ciudad Autónoma de Buenos Aires, Argentina.,National Council of Scientific and Technical Research (CONICET), Buenos Aires, Argentina
| | - Marina P Valerio
- National Council of Scientific and Technical Research (CONICET), Buenos Aires, Argentina.,Psychiatric Emergencies Hospital Torcuato de Alvear, Buenos Aires, Argentina
| | - Gordon Parker
- School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
| |
Collapse
|
10
|
Abstract
Our current conceptualisation of mixed states, defined as co-occurring manic and depressive symptoms, is unlikely to advance our knowledge or inform clinical practice. Episodes of mixed states can no longer be coded in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the 'mixed features specifier' fails to capture the most common mixed state presentations. This reflects a lack of understanding of both the importance of mixed states and their underlying pathophysiology. Indeed, research into the nature of mixed states is scarce and uninformative, and most clinical practice guidelines fail to provide advice regarding their management. In this paper, we proffer a reconceptualisation of mixed states that provides a framework for informing clinical practice and research. It is based on the ACE model, which deconstructs mood disorders into three domains of symptoms: activity, cognition, and emotion. Symptoms within each domain vary independently over time and in different directions (towards either excitation or inhibition). By deconstructing mood disorders into component domains, mixed states can be explained as the product of different domains varying 'out of sync'. In most cases, the aetiology of mixed states is unknown. Alongside such idiopathic mixed states, we describe three potential causes of mixed states that are important to consider when formulating management: transitions, ultradian cycling, and treatment-emergent affective switches. In addition to providing guidance on the identification of various kinds of mixed states, we discuss practical strategies for their management, including the monitoring of ACE domains and functioning, to inform the use of psychoeducation and lifestyle changes, psychotherapy, pharmacology, and electroconvulsive therapy.
Collapse
Affiliation(s)
- Gin S Malhi
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, 2000, Australia.
- Department of Academic Psychiatry, Northern Syndey Local Health District, St Leonards, NSW, 2065, Australia.
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.
| | - Kristina Fritz
- Department of Psychology, California State University, Northridge, CA, USA
| | - Preeya Elangovan
- Department of Academic Psychiatry, Northern Syndey Local Health District, St Leonards, NSW, 2065, Australia
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Lauren Irwin
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, 2000, Australia
- Department of Academic Psychiatry, Northern Syndey Local Health District, St Leonards, NSW, 2065, Australia
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| |
Collapse
|
11
|
O'Donnell C, Di Simplicio M, Brown R, Holmes EA, Burnett Heyes S. The role of mental imagery in mood amplification: An investigation across subclinical features of bipolar disorders. Cortex 2018; 105:104-117. [DOI: 10.1016/j.cortex.2017.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/16/2017] [Accepted: 08/09/2017] [Indexed: 02/03/2023]
|
12
|
Grunze H, Vieta E, Goodwin GM, Bowden C, Licht RW, Azorin JM, Yatham L, Mosolov S, Möller HJ, Kasper S. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Acute and long-term treatment of mixed states in bipolar disorder. World J Biol Psychiatry 2018; 19:2-58. [PMID: 29098925 DOI: 10.1080/15622975.2017.1384850] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Although clinically highly relevant, the recognition and treatment of bipolar mixed states has played only an underpart in recent guidelines. This WFSBP guideline has been developed to supply a systematic overview of all scientific evidence pertaining to the acute and long-term treatment of bipolar mixed states in adults. METHODS Material used for these guidelines is based on a systematic literature search using various data bases. Their scientific rigour was categorised into six levels of evidence (A-F), and different grades of recommendation to ensure practicability were assigned. We examined data pertaining to the acute treatment of manic and depressive symptoms in bipolar mixed patients, as well as data pertaining to the prevention of mixed recurrences after an index episode of any type, or recurrence of any type after a mixed index episode. RESULTS Manic symptoms in bipolar mixed states appeared responsive to treatment with several atypical antipsychotics, the best evidence resting with olanzapine. For depressive symptoms, addition of ziprasidone to treatment as usual may be beneficial; however, the evidence base is much more limited than for the treatment of manic symptoms. Besides olanzapine and quetiapine, valproate and lithium should also be considered for recurrence prevention. LIMITATIONS The concept of mixed states changed over time, and recently became much more comprehensive with the release of DSM-5. As a consequence, studies in bipolar mixed patients targeted slightly different bipolar subpopulations. In addition, trial designs in acute and maintenance treatment also advanced in recent years in response to regulatory demands. CONCLUSIONS Current treatment recommendations are still based on limited evidence, and there is a clear demand for confirmative studies adopting the DSM-5 specifier with mixed features concept.
Collapse
Affiliation(s)
- Heinz Grunze
- a Institute of Neuroscience , Newcastle University , Newcastle upon Tyne , UK
- b Paracelsus Medical University , Nuremberg , Germany
- c Zentrum für Psychiatrie Weinsberg , Klinikum am Weissenhof , Weinsberg , Germany
| | - Eduard Vieta
- d Bipolar Disorders Programme, Institute of Neuroscience , Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM , Barcelona , Catalonia , Spain
| | - Guy M Goodwin
- e Department of Psychiatry , University of Oxford, Warneford Hospital , Oxford , UK
| | - Charles Bowden
- f Dept. of Psychiatry , University of Texas Health Science Center , San Antonio , TX , USA
| | - Rasmus W Licht
- g Psychiatric Research Unit, Psychiatry , Aalborg University Hospital , Aalborg , Denmark
- h Clinical Department of Medicine , Aalborg University , Aalborg , Denmark
| | - Jean-Michel Azorin
- i Department of Psychiatry , Hospital Ste. Marguerite , Marseille , France
| | - Lakshmi Yatham
- j Department of Psychiatry , University of British Columbia , Vancouver , BC , Canada
| | - Sergey Mosolov
- k Department for Therapy of Mental Disorders , Moscow Research Institute of Psychiatry , Moscow , Russia
| | - Hans-Jürgen Möller
- l Department of Psychiatry and Psychotherapy , Ludwigs-Maximilian University , Munich , Germany
| | - Siegfried Kasper
- m Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | | |
Collapse
|
13
|
Johnson SL, Carver CS, Tharp JA. Suicidality in Bipolar Disorder: The Role of Emotion-Triggered Impulsivity. Suicide Life Threat Behav 2017; 47:177-192. [PMID: 27406282 PMCID: PMC5788807 DOI: 10.1111/sltb.12274] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/18/2016] [Indexed: 12/22/2022]
Abstract
A growing body of research suggests that impulsive responses to emotion more robustly predict suicidality than do other forms of impulsivity. This issue has not yet been examined within bipolar disorder, however. Participants diagnosed with bipolar I disorder (n = 133) and control participants (n = 110) diagnosed with no mood or psychotic disorder completed self-report measures of emotion-triggered impulsivity (Negative and Positive Urgency Scales) and interviews concerning lifetime suicidality. Analyses examined the effects of emotion-triggered impulsivity alone and in combination with gender, age of onset, depression severity, comorbid anxiety, comorbid substance use, and medication. A history of suicide ideation and attempts, as well as self-harm, were significantly more common in the bipolar disorder group compared with the control group. Impulsive responses to positive emotions related to suicide ideation, attempts, and self-harm within the bipolar group. Findings extend research on the importance of emotion-triggered impulsivity to a broad range of key outcomes within bipolar disorder. The discussion focuses on limitations and potential clinical implications.
Collapse
Affiliation(s)
- Sheri L Johnson
- Department of Psychology, University of California, Berkeley, Berkeley, CA, USA
| | - Charles S Carver
- Department of Psychology, University of Miami, Coral Gables, FL, USA
| | - Jordan A Tharp
- Department of Psychology, University of California, Berkeley, Berkeley, CA, USA
| |
Collapse
|
14
|
Prognostic Value of Affective Symptoms in First-Admission Psychotic Patients. Int J Mol Sci 2016; 17:ijms17071039. [PMID: 27376266 PMCID: PMC4964415 DOI: 10.3390/ijms17071039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/22/2016] [Accepted: 06/24/2016] [Indexed: 01/09/2023] Open
Abstract
Background: Very little research has been conducted in patients with first-episode psychosis using a dimensional approach. Affective dimensional representations might be useful to predict the clinical course and treatment needs in such patients. Methods: Weincluded 112 patients with first-episode psychosis in a longitudinal-prospective study with a five-year follow-up (N = 82). Logistic analyses were performed to determine the predictive factors associated with depressive, manic, activation, and dysphoric dimensions. Results: High scores on the depressive dimension were associated with the best prognosis. On the other hand, high scores on the activation dimension and the manic dimension were associated with a poorer prognosis in terms of relapses. Only the dysphoric dimension was not associated with syndromic or functional prognosis. Conclusion: Ourresults suggest that the pattern of baseline affective symptoms helps to predict the course of psychotic illness. Therefore, the systematic assessment of affective symptoms would enable us to draw important conclusions regarding patients’ prognosis. Interventions for patients with high scores on manic or activation dimensions could be beneficial in decreasing relapses in first-episode psychosis.
Collapse
|
15
|
Shansis FM, Reche M, Capp E. Evaluating response to mood stabilizers in patients with mixed depression: A study of agreement between three different mania rating scales and a depression rating scale. J Affect Disord 2016; 197:1-7. [PMID: 26950019 DOI: 10.1016/j.jad.2016.02.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 02/18/2016] [Accepted: 02/26/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of the present study was to evaluate agreement between three pairs formed by one of three mania scales (Young Mania Rating Scale [YMRS], Bech-Rafaelsen Mania Scale [BRMS], or the Clinician-Administered Rating Scale for Mania [CARS-M]) and a single depression scale (21-item Hamilton Depression Rating Scale [21-HAM-D]) for evaluation of response to mood stabilizers in patients with mixed bipolar disorder. METHODS Between 2010 and 2014, 68 consecutive bipolar type I and II outpatients with mixed depression as per DSM-IV-TR and Cincinnati criteria were included in this 8-week open-label trial to randomly receive carbamazepine, lithium carbonate, or valproic acid as monotherapy. RESULTS Patterns of response (defined as a reduction of at least 50% in one of the mania scales and on the 21-HAM-D) were strikingly similar: 21-HAM-D+YMRS=22.1%, 21-HAM-D+BRMS=20.6%, and 21-HAM-D+CARS-M=23.5% (p<0.368). Assessment of agreement revealed very high kappa coefficients: 21-HAM-D+YMRS vs. 21-HAM-D+CARS-M, kappa=0.87; 21-HAM-D+YMRS vs. 21-HAM-D+BRMS, kappa=0.78; 21-HAM-D+CARS-M vs. 21-HAM-D+BRMS, kappa=0.91 (p<0.001). LIMITATIONS The decision to combine a depression rating scale with any one mania rating scale to assess treatment response in patients with mixed depression is questionable. CONCLUSIONS The present study suggests that any one of the three tested mania rating scales (YMRS, BRMS, and CARS-M) can be combined with the 21-HAM-D to assess treatment response in patients with mixed bipolar disorder. This should give clinicians an added measure of confidence in using this strategy until valid, and specific instruments are developed for assessment of mixed states.
Collapse
Affiliation(s)
- Flávio Milman Shansis
- Postgraduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), School of Medicine, Porto Alegre, RS, Brazil; Teaching and Research Program in Mood Disorders (PROPESTH), Hospital Psiquiátrico São Pedro, Porto Alegre, RS, Brazil.
| | - Mateus Reche
- Teaching and Research Program in Mood Disorders (PROPESTH), Hospital Psiquiátrico São Pedro, Porto Alegre, RS, Brazil; Postgraduate Program in Obstetrics and Gynecology, UFRGS, School of Medicine, Porto Alegre, RS, Brazil
| | - Edison Capp
- Postgraduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), School of Medicine, Porto Alegre, RS, Brazil; Postgraduate Program in Obstetrics and Gynecology, UFRGS, School of Medicine, Porto Alegre, RS, Brazil; Service of Obstetrics and Gynecology, Hospital de Clinicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil; Department of Obstetrics and Gynecology, UFRGS, School of Medicine, Porto Alegre, RS, Brazil; Department of Gynecological Endocrinology and Reproductive Medicine, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| |
Collapse
|
16
|
Tharp JA, Johnson SL, Sinclair S, Kumar S. Goals in bipolar I disorder: Big dreams predict more mania. MOTIVATION AND EMOTION 2015. [DOI: 10.1007/s11031-015-9519-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
17
|
Monahan PO, Stump T, Coryell WH, Harezlak J, Marcoulides GA, Liu H, Steeger CM, Mitchell PB, Wilcox HC, Hulvershorn LA, Glowinski AL, Iyer-Eimerbrink PA, McInnis M, Nurnberger JI. Confirmatory test of two factors and four subtypes of bipolar disorder based on lifetime psychiatric co-morbidity. Psychol Med 2015; 45:2181-2196. [PMID: 25823794 DOI: 10.1017/s0033291715000185] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The first aim was to use confirmatory factor analysis (CFA) to test a hypothesis that two factors (internalizing and externalizing) account for lifetime co-morbid DSM-IV diagnoses among adults with bipolar I (BPI) disorder. The second aim was to use confirmatory latent class analysis (CLCA) to test the hypothesis that four clinical subtypes are detectible: pure BPI; BPI plus internalizing disorders only; BPI plus externalizing disorders only; and BPI plus internalizing and externalizing disorders. METHOD A cohort of 699 multiplex BPI families was studied, ascertained and assessed (1998-2003) by the National Institute of Mental Health Genetics Initiative Bipolar Consortium: 1156 with BPI disorder (504 adult probands; 594 first-degree relatives; and 58 more distant relatives) and 563 first-degree relatives without BPI. Best-estimate consensus DSM-IV diagnoses were based on structured interviews, family history and medical records. MPLUS software was used for CFA and CLCA. RESULTS The two-factor CFA model fit the data very well, and could not be improved by adding or removing paths. The four-class CLCA model fit better than exploratory LCA models or post-hoc-modified CLCA models. The two factors and four classes were associated with distinctive clinical course and severity variables, adjusted for proband gender. Co-morbidity, especially more than one internalizing and/or externalizing disorder, was associated with a more severe and complicated course of illness. The four classes demonstrated significant familial aggregation, adjusted for gender and age of relatives. CONCLUSIONS The BPI two-factor and four-cluster hypotheses demonstrated substantial confirmatory support. These models may be useful for subtyping BPI disorders, predicting course of illness and refining the phenotype in genetic studies.
Collapse
Affiliation(s)
- P O Monahan
- Department of Biostatistics,Indiana University School of Medicine,Indianapolis,IN,USA
| | - T Stump
- Department of Biostatistics,Indiana University School of Medicine,Indianapolis,IN,USA
| | - W H Coryell
- Department of Psychiatry,Roy J. and Lucille A. Carver College of Medicine,University of Iowa,Iowa City,IA,USA
| | - J Harezlak
- Department of Biostatistics,Indiana University School of Medicine,Indianapolis,IN,USA
| | - G A Marcoulides
- Research Methods & Statistics Program,Graduate School of Education,University of California-Riverside,Riverside,CA,USA
| | - H Liu
- Department of Biostatistics,Indiana University School of Medicine,Indianapolis,IN,USA
| | - C M Steeger
- Department of Psychology,College of Arts and Letters,University of Notre Dame,Notre Dame,IN,USA
| | - P B Mitchell
- School of Psychiatry,University of New South Wales,Sydney,NSW,Australia
| | - H C Wilcox
- Department of Psychiatry and Behavioral Sciences,Johns Hopkins School of Medicine,Baltimore,MD,USA
| | - L A Hulvershorn
- Department of Psychiatry,Indiana University School of Medicine,Indianapolis,IN,USA
| | - A L Glowinski
- Department of Psychiatry,Washington University School of Medicine,St Louis,MO,USA
| | - P A Iyer-Eimerbrink
- Department of Psychiatry,Indiana University School of Medicine,Indianapolis,IN,USA
| | - M McInnis
- Department of Psychiatry,School of Medicine,University of Michigan,Ann Arbor,MI,USA
| | - J I Nurnberger
- Department of Psychiatry,Indiana University School of Medicine,Indianapolis,IN,USA
| |
Collapse
|
18
|
Ruggero CJ, Kotov R, Watson D, Kilmer JN, Perlman G, Liu K. Beyond a single index of mania symptoms: structure and validity of subdimensions. J Affect Disord 2014; 161:8-15. [PMID: 24751301 DOI: 10.1016/j.jad.2014.02.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 02/28/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND DSM-5 portrays mania as unitary despite evidence of distinct symptom clusters. Studies investigating the structure of mania have been inconsistent, in part because many relied on instruments not designed for this question. The present work used a clinical interview designed for structural analysis in order to identify and validate subdimensions specific to mania symptoms. METHODS Psychiatric outpatients (N=422) and undergraduates with a history of mental health treatment (N=306) were interviewed with a comprehensive measure of mood and anxiety that included 24 manic symptoms. Patients completed additional measures of symptoms and functioning, and a semi-structured diagnostic interview. RESULTS A 4-factor model of mania replicated across independent samples and was superior in fit to competing models, including the unidimensional model implied whenever researchers or clinicians use only a total score for mania. The factors were only moderately correlated, and three of the four ("Irritability" was the exception) showed a strong criterion, convergent and discriminant validity, suggesting they are specific to mania. Subdimensions showed distinct and meaningful associations with functioning. LIMITATIONS Symptoms of psychosis and depression are important features of manic episodes, but were not included in the present study since they lack specificity to mania. CONCLUSIONS Mania is multifaceted. At least three subdimensions specific to mania were identified ("Euphoric Activation," "Hyperactive Cognition" and "Reckless Overconfidence"). Use of subdimensions, in addition to overall mania severity, may enhance the ability of studies to detect meaningful biological correlates of bipolar disorder. Moreover, their different associations with functioning suggest assessing subdimensions has clinical utility as well.
Collapse
Affiliation(s)
- Camilo J Ruggero
- Department of Psychology, University of North Texas, 1155 Union Circle #311280, Denton, TX 76203, USA.
| | - Roman Kotov
- Department of Psychiatry and Behavioral Sciences, Stony Brook University, USA
| | - David Watson
- Department of Psychology, University of Notre Dame, USA
| | - Jared N Kilmer
- Department of Psychology, University of North Texas, 1155 Union Circle #311280, Denton, TX 76203, USA
| | - Greg Perlman
- Department of Psychiatry and Behavioral Sciences, Stony Brook University, USA
| | - Keke Liu
- Department of Psychology, University of North Texas, 1155 Union Circle #311280, Denton, TX 76203, USA
| |
Collapse
|
19
|
Pacchiarotti I, Nivoli AMA, Mazzarini L, Kotzalidis GD, Sani G, Koukopoulos A, Scott J, Strejilevich S, Sánchez-Moreno J, Murru A, Valentí M, Girardi P, Vieta E, Colom F. The symptom structure of bipolar acute episodes: in search for the mixing link. J Affect Disord 2013; 149:56-66. [PMID: 23394711 DOI: 10.1016/j.jad.2013.01.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 01/11/2013] [Accepted: 01/11/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The nature of mixed mood episodes is still a matter of controversy amongst experts. Currently, the approach to this syndrome is mainly categorical and very restrictive. The factor-structure of bipolar mood episodes has not been studied yet. We performed a dimensional analysis of the structure of bipolar episodes aimed at identifying a factor deconstructing mixed episodes; furthermore, we analyzed correlations of factors emerging from the factorial analysis of the Brief Psychiatric Rating Scale (BPRS) with Temperament Evaluation of Memphis-Pisa-Paris-San Diego (TEMPS-A) and predominant polarity. METHOD 187 consecutive bipolar I inpatients hospitalized for DSM-IV-TR acute mood episodes (depressive, manic or mixed) underwent a standardized assessment, including the 24-item Brief Psychiatric Rating Scale (BPRS 4.0), the 21-item Hamilton Depression Rating Scale (HDRS-21), the Young Mania Rating Scale (YMRS) and the TEMPS-A. Principal factor analysis was performed on BPRS-24 items. RESULTS This analysis revealed five factors corresponding to "psychosis", "euphoric mania", "mixity", "dysphoria" and "inhibited depression", capturing 71.89% of the rotated variance. The mixity factor was characterized by higher rates of suicidal ideation, more mixed episodes, higher frequencies of antidepressant (AD) use, depressive predominant polarity and anxious temperament. DISCUSSION The factor-structure of the BPRS in inpatients with bipolar I disorder with an acute episode of any type is pentafactorial; one factor identified is the mixity factor, which is independent from other factors and characterized by anxiety and motor hyperactivity and by the absence of motor retardation. Our results should prompt reconsideration of proposals for DSM-5 diagnostic criteria for the mixed features specifier. Limitations of the study include the relative small sample, the absence of drug-naïve patients and the use of rating scales no specific for mixed states.
Collapse
Affiliation(s)
- Isabella Pacchiarotti
- Bipolar Disorders Programme, Institute of Clinical Neuroscience, Hospital Clínic, Universitat de Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalunya, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Lukasiewicz M, Gerard S, Besnard A, Falissard B, Perrin E, Sapin H, Tohen M, Reed C, Azorin JM. Young Mania Rating Scale: how to interpret the numbers? Determination of a severity threshold and of the minimal clinically significant difference in the EMBLEM cohort. Int J Methods Psychiatr Res 2013; 22:46-58. [PMID: 23526724 PMCID: PMC6878321 DOI: 10.1002/mpr.1379] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The aim of this analysis was to identify Young Mania Rating Scale (YMRS) meaningful benchmarks for clinicians (severity threshold, minimal clinically significant difference [MCSD]) using the Clinical Global Impressions Bipolar (CGI-BP) mania scale, to provide a clinical perspective to randomized clinical trials (RCTs) results. We used the cohort of patients with acute manic/mixed state of bipolar disorders (N = 3459) included in the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) study. A receiver-operating characteristic analysis was performed on randomly selected patients to determine the YMRS optimal severity threshold with CGI-BP mania score ≥ "Markedly ill" defining severity. The MCSD (clinically meaningful change in score relative to one point difference in CGI-BP mania for outcome measures) of YMRS, was assessed with a linear regression on baseline data. At baseline, YMRS mean score was 26.4 (±9.9), CGI-BP mania mean score was 4.8 (±1.0) and 61.7% of patients had a score ≥ 5. The optimal YMRS severity threshold of 25 (positive predictive value [PPV] = 83.0%; negative predictive value [NPV] = 66.0%) was determined. In this cohort, a YMRS score of 20 (typical cutoff for RCTs inclusion criteria) corresponds to a PPV of 74.6% and to a NPV of 77.6%, meaning that the majority of patients included would be classified as severely ill. The YMRS minimal clinically significant difference was 6.6 points.
Collapse
Affiliation(s)
- Michael Lukasiewicz
- AP-HP, Paul-Brousse Hospital, Department of Psychiatry and Addictology, Villejuif, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
M'Bailara K, Atzeni T, Colom F, Swendsen J, Gard S, Desage A, Henry C. Emotional hyperreactivity as a core dimension of manic and mixed states. Psychiatry Res 2012; 197:227-30. [PMID: 22414662 DOI: 10.1016/j.psychres.2011.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 08/30/2011] [Accepted: 12/01/2011] [Indexed: 11/16/2022]
Abstract
Despite its obvious importance in mood disorders, characterization of emotional reactivity has been neglected in bipolar disorders. Concerning manic states and the current classification, the main criterion is the presence of an elevated or expansive mood. In contrast to this characteristic and often prolonged mood state, emotional reactivity refers to a brief evoked response to salient emotional stimuli. The goal of this study was to assess the intensity of emotional responses triggered by viewing slides in bipolar patients with manic or mixed states. Our hypothesis was that all emotional responses are exacerbated, whatever the valence of the stimuli. We compared 33 patients with manic or mixed states with 33 matched euthymic patients and 33 healthy control subjects. Arousal and attribution of valence were assessed while subjects viewed slides taken from the International Affective Picture System (positive, neutral and negative slides). Patients with manic or mixed states reported a higher arousal when viewing all types of slides in comparison with the other groups. Concerning attribution of valence, patients with manic or mixed states assessed neutral slides as more pleasant. When bipolar patients with manic and mixed states are placed in front of positive, neutral and negative slides, the slides trigger a higher intensity of emotions, whatever the valence of the emotional stimuli. These results strengthen the importance of emotional hyperreactivity as a core dimension in manic and mixed states in bipolar disorder.
Collapse
Affiliation(s)
- Katia M'Bailara
- Laboratory of Psychology, University Bordeaux Segalen, Bordeaux, France.
| | | | | | | | | | | | | |
Collapse
|
22
|
Hong J, Reed C, Novick D, Haro JM, Aguado J. Clinical and economic consequences of medication non-adherence in the treatment of patients with a manic/mixed episode of bipolar disorder: results from the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) study. Psychiatry Res 2011; 190:110-4. [PMID: 21571375 DOI: 10.1016/j.psychres.2011.04.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 01/25/2011] [Accepted: 04/19/2011] [Indexed: 12/01/2022]
Abstract
The aim of the present study was to investigate clinical and economic consequences of medication non-adherence during 21-month follow-up in the treatment of bipolar disorder following a manic or mixed episode. Data were taken from the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM), which was a prospective, observational study on patient outcomes with a manic/mixed episode in Europe. Physician-rated adherence was dichotomized as adherence/non-adherence at each assessment. Cox proportional hazards models were employed to investigate the impact of non-adherence on remission, recovery, relapse, recurrence, hospitalization and suicide attempts. Costs of medication and resource use in adherent and non-adherent patients during follow-up were estimated with multivariate analyses. Of the 1341 patients analysed, 23.6% were rated non-adherent over 21 months. Non-adherence was significantly associated with decreased likelihood of achieving remission and recovery as well as increased risk of relapse and recurrence as well as hospitalization and suicide attempts. In addition, costs incurred by non-adherent patients during this period were significantly higher than those of adherent patients (£10231 vs £7379, p<0.05). This disparity mainly resulted from differences in inpatient costs (£4796 vs £2150, p<0.05). In conclusion, non-adherence in bipolar patients was associated with poorer long term clinical outcomes that have economic implications for health-care providers.
Collapse
Affiliation(s)
- Jihyung Hong
- Personal Social Services Research Unit, London School of Economics, London, UK.
| | | | | | | | | |
Collapse
|
23
|
Effectiveness of olanzapine monotherapy and olanzapine combination treatment in the long term following acute mania--results of a two year observational study in bipolar disorder (EMBLEM). J Affect Disord 2011; 131:320-9. [PMID: 21195486 DOI: 10.1016/j.jad.2010.11.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 11/30/2010] [Accepted: 11/30/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study compared the 2-year outcomes of patients with a manic/mixed episode of bipolar disorder taking olanzapine monotherapy or olanzapine in combination with other agents. METHODS EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) is a 2-year, prospective, observational study of clinical and functional outcomes of bipolar patients with an index manic/mixed episode. The study consisted of two phases: acute (12 weeks) and maintenance (follow-up over 2 years). The longitudinal outcome measure was the Clinical Global Impression-Bipolar Disorder scale. Cox regression models compared outcomes of both therapy groups using intention-to-treat and switching medication analysis. Treatment-emergent adverse events were also assessed. RESULTS 1076 patients were included in this analysis. 29% took olanzapine as monotherapy (n = 313) and 71% as combination (n = 763) at 12-weeks post-baseline (end of study acute phase). After adjusting for patient characteristics using switching medication analysis, only relapse rates differed (p = 0.01) in favour of monotherapy-treated patients. There was no significant difference in rates of improvement, remission, and recovery. Patients treated with combination therapy reported more tremor (OR 2.37, 95%CI 1.44-3.89) and polyuria (OR 3.08, 95%CI 1.45-6.54) treatment-emergent events than monotherapy, although weight change was greater in the monotherapy group. LIMITATIONS Unknown confounding and potential selection bias may differentially impact treatment outcomes. CONCLUSIONS EMBLEM patients benefitted from the selected therapy to a similar extent. Differences in patient characteristics between those prescribed monotherapy and combination therapy appear to be clinically relevant in the treatment decision. Physicians must balance the benefits and risks when determining appropriate treatment for individual patients.
Collapse
|
24
|
Bellivier F, Yon L, Luquiens A, Azorin JM, Bertsch J, Gerard S, Reed C, Lukasiewicz M. Suicidal attempts in bipolar disorder: results from an observational study (EMBLEM). Bipolar Disord 2011; 13:377-86. [PMID: 21843277 DOI: 10.1111/j.1399-5618.2011.00926.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare patients with and without a history of suicidal attempts in a large cohort of patients with bipolar disorder and to identify variables that are associated with suicidal behavior. METHODS European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) is a two-year, prospective, observational study that enrolled 3,684 adult patients with bipolar disorder and initiated or changed oral treatment for an acute manic/mixed episode. Of those, 2,416 patients were eligible for the two-year follow-up. Only baseline characteristics were studied in the present study, included sociodemographic data, psychiatric history and comorbidities, history of suicide attempts, history of substance use problems, compliance with treatment, inpatient admissions, and functional status. Symptom severity was assessed using the Clinical Global Impression-Bipolar Disorder (CGI-BP) scale, the Young Mania Rating Scale (YMRS), and the 5-item Hamilton Depression Rating Scale (HAMD-5). A logistic regression model identified baseline variables independently associated with a history of suicidal behavior. RESULTS Of the 2,219 patients who provided data on their lifetime history of suicide attempts, 663 (29.9%) had a history of suicidal behavior (at least one attempt). Baseline factors associated with a history of suicidal behavior included female gender, a history of alcohol abuse, a history of substance abuse, young age at first treatment for a mood episode, longer disease duration, greater depressive symptom severity (HAMD-5 total score), current benzodiazepine use, higher overall symptom severity (CGI-BP: mania and overall score), and poor compliance. CONCLUSIONS These factors may be considered as potential characteristics to identify subjects at risk for suicidal behavior throughout the course of bipolar disorder.
Collapse
Affiliation(s)
- Frank Bellivier
- INSERM, Unité 955, IMRB, Equipe de Psychiatrie Génétique, Créteil, France.
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Gender differences in outcomes of acute mania: a 12-month follow-up study. Arch Womens Ment Health 2011; 14:107-13. [PMID: 20957398 DOI: 10.1007/s00737-010-0185-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 09/09/2010] [Indexed: 10/18/2022]
Abstract
This study aimed to assess short-term (12 weeks) and long-term (12 months) gender differences in the outcomes of patients experiencing an episode of mania in the course of bipolar disorder. European Mania in Bipolar Longitudinal Evaluation of Medication was a 2-year, prospective, observational study of the outcomes of patients with a manic or mixed episode conducted in 14 European countries. Data were collected during the acute phase (12 weeks) and during a follow-up period (up to 12 months). Analyses were carried out in the subgroup of patients identified with a pure manic episode at baseline. Kaplan-Meier survival analysis estimated time to first occurrence of mania improvement, worsening, recovery and depressive episode, and Cox's proportional hazards models were used to analyse factors associated with these outcomes. Overall, 2,485 patients (46.6% men, 53.4% women) were included in the analysis. Frequency of substance abuse was higher in men than women. No significant gender differences were found in the severity of manic symptoms at baseline. There were no gender differences in assessment of mania improvement, worsening or recovery over 12 weeks, but more women than men showed mania improvement over 12 months (95.4% vs. 89.2%; p < 0.01). Significantly more women developed a depressive episode over 12 weeks (14.9% vs. 9.7%; p < 0.01) and over 12 months (27.7% vs. 21.5%; p < 0.001). In conclusion, the results show that there are small gender differences in the course of patients experiencing a pure manic episode. Women had a faster time to mania improvement and a higher risk of developing a depressive episode during the 12-month follow-up period.
Collapse
|
26
|
Houston JP, Gatz JL, Degenhardt EK, Jamal HH. Symptoms predicting remission after divalproex augmentation with olanzapine in partially nonresponsive patients experiencing mixed bipolar I episode: a post-hoc analysis of a randomized controlled study. BMC Res Notes 2010; 3:276. [PMID: 21044339 PMCID: PMC2987872 DOI: 10.1186/1756-0500-3-276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 11/02/2010] [Indexed: 11/17/2022] Open
Abstract
Background Rating scale items in a 6-week clinical trial of olanzapine versus placebo augmentation in patients with mixed bipolar disorder partially nonresponsive to ≥14 days of divalproex monotherapy were analyzed to characterize symptom patterns that could predict remission. At baseline, the two treatment groups were similar. Findings Factor analysis with Varimax rotation was performed post hoc on baseline items of the 21-Item Hamilton Depression Rating Scale (HDRS-21) and Young Mania Rating Scale (YMRS). Backwards-elimination logistic regression ascertained factors predictive of protocol-defined endpoint remission (HDRS-21 score ≤ 8 and YMRS score ≤ 12) with subsequent determination of optimally predictive factor score cutoffs. Factors for Psychomotor activity (YMRS items for elevated mood, increased motor activity, and increased speech and HDRS-21 agitation item) and Guilt/Suicidality (HDRS-21 items for guilt and suicidality) significantly predicted endpoint remission in the divalproex+olanzapine group. No factor predicted remission in the divalproex+placebo group. Patients in the divalproex+olanzapine group with high pre-augmentation psychomotor activity (scores ≥10) were more likely to remit compared to those with lower psychomotor activity (odds ratio [OR] = 3.09, 95% confidence interval [CI] = 1.22-7.79), and patients with marginally high Guilt/Suicidality (scores ≥2) were less likely to remit than those with lower scores (OR = 0.37, 95% CI = 0.13-1.03). Remission rates for divalproex+placebo vs. divalproex+olanzapine patients with high psychomotor activity scores were 22% vs. 45% (p = 0.08) and 33% vs. 48% (p = 0.29) for patients with low Guilt/Suicidality scores. Conclusions Patients who were partially nonresponsive to divalproex treatment with remaining high vs. low psychomotor activity levels or minimal vs. greater guilt/suicidality symptoms were more likely to remit with olanzapine augmentation. Trial Registration ClinicalTrials.gov; http://clinicaltrials.gov/ct2/show/NCT00402324?term=NCT00402324&rank=1, Identifier: NCT00402324
Collapse
Affiliation(s)
- John P Houston
- US Medical Neuroscience, Lilly USA, LLC; Drop Code 4133, Indianapolis, IN 46285 USA.
| | | | | | | |
Collapse
|
27
|
Comparison of olanzapine and risperidone in the EMBLEM Study: translation of randomized controlled trial findings into clinical practice. Int Clin Psychopharmacol 2010; 25:257-63. [PMID: 20531011 DOI: 10.1097/yic.0b013e32833b8fe4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Data from the EMBLEM Study, a 2-year, prospective, observational study of health outcomes associated with acute treatment of patients experiencing a manic/mixed episode of bipolar disorder, was used to compare the effectiveness of olanzapine monotherapy versus risperidone monotherapy, and to investigate whether the treatment effects were similar to those reported in a 3-week, randomized controlled trial assessing the same treatments. Symptom severity measures included the Young Mania Rating Scale (YMRS), the 5-item Hamilton Depression Rating Scale, and the Clinical Global Impression-Bipolar Disorder Scale. A total of 245 EMBLEM inpatients were analyzed with YMRS >or=20: olanzapine (n=209), risperidone (n=36). Both the treatment groups had similar improvements in YMRS from baseline to 6 weeks, but there was a significantly greater improvement in 5-item Hamilton Depression Rating Scale in the olanzapine group. There was a similar improvement in Clinical Global Impression-Bipolar Disorder Scale in both the groups and the occurrence of treatment-emergent adverse events and weight gain did not differ between the treatment groups. The EMBLEM results partly support those of the randomized controlled trial, which suggests olanzapine and risperidone have similar improvements in mania but that olanzapine monotherapy may be more effective than risperidone monotherapy in the treatment of depressive symptoms associated with mania. Limitations include differences in study design, patient population, and length of follow-up.
Collapse
|
28
|
Aspiazu S, Mosquera F, Ibañez B, Vega P, Barbeito S, López P, Ruiz de Azúa S, Ugarte A, Vieta E, González-Pinto A. Manic and depressive symptoms and insight in first episode psychosis. Psychiatry Res 2010; 178:480-6. [PMID: 20471100 DOI: 10.1016/j.psychres.2010.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 10/27/2009] [Accepted: 03/15/2010] [Indexed: 10/19/2022]
Abstract
Insight impairment is common early in the course of psychosis. Most studies have focused on the relationship between insight and depression, although manic symptoms are also frequent in psychoses. The main aim of this study was to examine the relationship between insight dimensions and manic and depressive symptoms in first-episode psychosis. A group of inpatients in their first psychotic episodes (n=124) were evaluated using the Scale to Assess Unawareness of Mental Disorder, Young Mania Rating Scale and Hamilton Depression Rating Scale. To study the effect of clinical, manic and depressive symptoms on insight, awareness of mental disorder, awareness of the achieved effects of medication, and awareness of the social consequences of having a mental disorder were modelled using ordinal logistic regression techniques. Results showed that greater awareness of mental disorder was significantly related to higher age at first episode together with higher scores for negative and depressive symptoms. The opposite was found to be true in presentations with a higher severity of disease and manic symptoms. The model fitting unawareness of the achieved effects of medication identified the same significant variables, except in the case of negative symptoms. Finally, the model assessing the social consequences of having a mental disorder showed unawareness to be greater when manic symptoms and disease severity were high.
Collapse
Affiliation(s)
- Saioa Aspiazu
- Santiago Apóstol Hospital, Stanley Institute International Mood-Disorders Research Center, 03-RC-003, Centro de Investigación Biomédica en Red de Salud Mental (CIBER-sam), EHU/UPV, Vitoria, Spain
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Azorin JM, Luquiens A, Aubrun E, Reed C, Gasquet I, Lukasiewicz M. Modalités de prise en charge de l’accès maniaque ou mixte aigu et évolution à trois mois. Encephale 2010; 36:226-35. [DOI: 10.1016/j.encep.2009.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 05/14/2009] [Indexed: 11/29/2022]
|
30
|
Principal domains of behavioral psychopathology identified by the Bipolar Inventory of Signs and Symptoms Scale (BISS). Psychiatry Res 2010; 175:221-6. [PMID: 20022384 DOI: 10.1016/j.psychres.2009.04.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Revised: 02/20/2009] [Accepted: 04/23/2009] [Indexed: 11/21/2022]
Abstract
Current symptom rating scales and diagnostic categories for bipolar disorder (BD) do not provide dimensional profiles of the types of behavior disturbed in this complex disorder. To overcome these limitations we identified the principal domains of behavioral symptomatology in bipolar individuals, including all mood states, and used a more comprehensive rating scale for BD: the Bipolar Inventory of Signs and Symptoms Scale (BISS). A total of 246 patients with BD (196 with BD type I, and 50 with BD type II) were interviewed using the BISS. Exploratory factor analysis was performed on the BISS results using the maximum likelihood factor extraction method, followed by oblique rotation of the extracted factor loadings. We determined the strength of relationships between factor scores using the Pearson correlation coefficient. The following five factors were extracted: mania, depression, irritability, anxiety and psychosis. Anxiety was significantly correlated with depression and irritability. The mania factor score was only weakly associated with the other four factors. The domains of the BISS capture both the historical categories of depression and mania, plus irritability, psychosis, and an additional principal domain, anxiety. Despite the common occurrence of anxiety in BD, it has not been identified in most prior factor analyses, in part due to limited coverage of anxiety symptoms in the source scales.
Collapse
|
31
|
Abstract
OBJECTIVE The purpose of the present study was to identify the factor structure of manic symptoms as assessed by the Scale for Manic States (SMS). METHOD The pattern of symptoms in a group of 225 adults with an ICD-10-DCR diagnosis of manic episode was studied. A factor analysis was conducted of the broad range of psychiatric symptoms covered by SMS. A principal component analysis followed by oblimin rotation was performed. RESULTS Six eigenvalues were greater than unity and parallel analysis indicated four factors. After observing the scree plot a five-factor solution seemed appropriate. Nevertheless, a six-factor solution was chosen that described the data appropriately and was clinically relevant. The six factors (psychosis, irritability aggression, dysphoria, accelerated thought stream, hedonia, and hyperactivity) captured 59.29% of the total variance. CONCLUSION A six-factor solution explains the clinical dimensions of mania in the present sample and dysphoria appeared as a separate factor.
Collapse
|
32
|
Predictors of switching from mania to depression in a large observational study across Europe (EMBLEM). J Affect Disord 2009; 118:118-23. [PMID: 19269690 DOI: 10.1016/j.jad.2009.02.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 02/12/2009] [Accepted: 02/12/2009] [Indexed: 11/23/2022]
Abstract
BACKGROUND The risk of switching from mania to depression in bipolar disorder has been poorly studied. Large observational studies may be useful in identifying variables that predict switch to depression after mania and provide data on medication use and outcomes in "real world" patients. METHOD EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) is a 2-year, prospective, observational study of patients with a manic/mixed episode. Symptom severity measures included Clinical Global Impression-Bipolar Disorder scale (CGI-BP), Young Mania Rating Scale (YMRS) and 5-item Hamilton Depression Rating Scale. Switching was defined using CGI-BP mania and depression such that patients changed from manic and not depressed to depressed but not manic over two consecutive observations within the first 12 weeks of follow-up. Cox proportional hazards models identified baseline variables independently associated with switch to depression. RESULTS Of 2390 patients who participated in the maintenance phase (i.e. up to 24 months), 120 (5.0%) switched to depression within the first 12 weeks. Factors associated with greater switching to depression include previous depressive episodes, substance abuse, greater CGI-BP overall severity and benzodiazepine use. Factors associated with lower switching rates were greater CGI-BP depression, lower YMRS severity and atypical antipsychotic use. LIMITATIONS The definition of switching biased against patients with mixed episodes being likely to switch. CONCLUSIONS Strictly defined, switch to depression from mania occurs in a small proportion of bipolar patients. Clinical history, illness severity, co-morbidities and treatment patterns are associated with switching to depression. Atypical antipsychotics may protect against switch to depression.
Collapse
|
33
|
Validity and reliability of the Hamilton depression rating scale (5 items) for manic and mixed bipolar disorders. J Nerv Ment Dis 2009; 197:682-6. [PMID: 19752648 DOI: 10.1097/nmd.0b013e3181b3b3a0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Depressive symptoms during mania have prognostic value in bipolar disorder. For depressive symptoms, it has been proposed that shorter scales should be cost-effective and practical. To determine the usefulness of 5-item Hamilton Depression Rating Scale (HAMD-5) in manic and mixed bipolar disorder, we used a four-week follow-up prospective, observational study. Convergent and discriminant validity, internal consistency, and reliability were analyzed and compared with HAMD-21, HAMD-5, and HAMD-21 cut-off points were calculated versus CGI-BP. A total of 173 manic and mixed patients were evaluated. HAMD-5 showed appropriate convergent validity, discriminant validity, internal consistency, and test-retest reliability. Discriminant validity was higher for HAMD-5 than HAMD-21. Best cut-off point of remission was: HAMD-21 < or =5 and HAMD-5 < or =1. HAMD-5 presents appropriate validity and reliability estimates. It is comparable to HAMD-21 and focuses more specifically on depressive symptoms.
Collapse
|
34
|
Okasha TA, Kucukalić A, Nasr AAA, Zelman M, Karamustafalioğlu O, Sir A, Harrison G, Treuer T. Longer-term treatment of patients with bipolar disorder: a 9-month observational study in Central and Eastern Europe, the Middle East and Africa. Curr Med Res Opin 2009; 25:1889-900. [PMID: 19538106 DOI: 10.1185/03007990903070270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the longer-term outcomes of pharmacological treatment of patients with a diagnosis of bipolar affective disorder currently suffering a manic or hypomanic episode prescribed olanzapine or non-olanzapine medication in naturalistic, clinical practice settings in Bosnia-Herzegovina, Slovakia, Slovenia, Turkey, Saudi Arabia and Egypt. RESEARCH DESIGN AND METHODS Prospective, observational, non-interventional study conducted over 9 months. Inpatients or outpatients who initiated or changed oral bipolar mania medication were grouped into (1) those prescribed olanzapine at baseline (n = 569) and (2) those not prescribed olanzapine (n = 325). MAIN OUTCOME MEASURE(S) The change from baseline in the Clinical Global Impression Severity scale for bipolar disorder (CGI-BP-S), the rates of symptomatic response and remission (based on CGI-BP-S) and the frequency and nature of treatment-emergent adverse events. Analyses included (1) linear or logistic regression, with adjustment for confounders, based on the last observation carried forward and (2) weighted repeated measures models that adjusted for treatment switching and patient drop-out. RESULTS When results were adjusted for treatment switching and patient drop-out, patients prescribed olanzapine had significantly better CGI-BP-S scores (mean difference = -0.24; 95% confidence interval [CI] -0.33, -0.16; p < 0.001) and significantly greater odds of treatment response (odds ratio [OR] = 1.86; 95% CI 1.31, 2.65; p < 0.001) and symptom remission (OR = 1.65; 95% CI 1.18-2.32; p = 0.003) than those not prescribed olanzapine. The frequency of most adverse events decreased in both groups. Patients prescribed olanzapine had significantly greater weight gain from baseline (mean increase = 2.66 kg; 95% CI 2.35, 2.98) compared with those not prescribed olanzapine (mean increase = 1.85 kg; 95% CI 1.51, 2.19; p < 0.001). CONCLUSIONS Inclusion of olanzapine is of benefit for pharmacological treatment of patients with bipolar disorder. However, the favourable outcomes observed cannot be directly attributed to olanzapine alone because of the high prevalence of polypharmacy in the patient population.
Collapse
Affiliation(s)
- Tarek A Okasha
- Institute of Psychiatry, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Reed C, Novick D, Gonzalez-Pinto A, Bertsch J, Haro JM. Observational study designs for bipolar disorder - what can they tell us about treatment in acute mania? Prog Neuropsychopharmacol Biol Psychiatry 2009; 33:715-21. [PMID: 19345251 DOI: 10.1016/j.pnpbp.2009.03.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 03/17/2009] [Accepted: 03/17/2009] [Indexed: 11/17/2022]
Abstract
Randomised controlled trials may have generalisability limitations when applied to the complex treatment of patients with bipolar disorder. Observational study designs can inform us about the diversity of bipolar disorder treatment in naturalistic settings. The aim of this paper was to describe the treatments prescribed for acute mania in a large prospective observational study of bipolar disorder. Patients with a manic/mixed episode were enrolled in EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) if they initiated or changed oral medication with antipsychotics, lithium and/or anticonvulsants. The use of monotherapy or combination therapy for treatment of acute mania, concomitant medications and rate of treatment switching during the 12-week acute treatment phase were assessed. Of the 3459 patients, 36% were treated with one drug and 64% with combination therapy. 55% of patients initiating combination therapy started on an atypical antipsychotic plus lithium or an anticonvulsant. Patients prescribed combination therapy at baseline were more clinically severe, were more often treated as inpatients and had more manic episodes in the previous year compared with the monotherapy group. Treatment switching occurred in 54.4% of patients over the 12-week acute phase. Many patients were taking at least one concomitant medication at baseline (69.4%) and week 12 (50.5%). The results of this observational study show that treatment for mania is complex with multiple combinations of treatment and frequent switching during an acute episode.
Collapse
Affiliation(s)
- Catherine Reed
- Lilly Research Centre, Erl Wood Manor, Sunninghill Road, Windlesham, GU20 6PH, UK.
| | | | | | | | | |
Collapse
|
36
|
Azorin JM, Aubrun E, Bertsch J, Reed C, Gerard S, Lukasiewicz M. Mixed states vs. pure mania in the French sample of the EMBLEM study: results at baseline and 24 months--European mania in bipolar longitudinal evaluation of medication. BMC Psychiatry 2009; 9:33. [PMID: 19500417 PMCID: PMC2701946 DOI: 10.1186/1471-244x-9-33] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 06/07/2009] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND To describe the clinical course and treatment patterns over 24 months of patients experiencing an acute manic/mixed episode within the standard course of care. METHODS EMBLEM was a 2-year European prospective, observational study on outcomes of patients experiencing a manic/mixed episode. Adults with bipolar disorder were enrolled within the standard course of care as in/outpatients if they initiated or changed oral medication for treatment of acute mania. After completing 12 weeks of acute phase, patients were assessed every 3-6 months during the maintenance phase. We present the 24 month results, with subgroup analysis for mixed states (MS) and pure mania (PM). These subgroup analyses are driven by the high proportion of antidepressants prescribed in this cohort. RESULTS In France, 771 patients were eligible for the maintenance phase. 69% of patients completed the follow up over 24 months. The mean age was 45.5 years (sd = 13.6) with 57% of women. 504 (66%) patients were experiencing a PM and 262 (34%) a MS at baseline. The main significant differences in MS vs. PM at baseline were: a higher rate of women, and in the previous 12 months, a higher frequency of episodes (manic/mixed and depressive), more suicide attempts, more rapid cycling, fewer social activities and more work impairment. Over the 24 months of follow-up the MS group had a significantly lower recovery than PM (36% vs. 46%, p = 0.006). Overall, 42% of all patients were started on monotherapy and 58% on combination therapy; of those 35% and 30% respectively remained on their initial medication throughout the 24 months. At baseline, 36% were treated with an antidepressant, this proportion remains high throughout the follow-up period, with a significantly higher rate for MS vs. PM at 24 months (55% vs. 27%, p < 0.001). CONCLUSION In this large sample, MS occur frequently (34%), they are more severe at baseline and have a worse functional prognosis than PM. Although antidepressants are not recommended in MS and PM, they were frequently prescribed at baseline and are maintained during the 24 months of follow-up.
Collapse
Affiliation(s)
| | - Elodie Aubrun
- Neurosciences Medical department, Eli Lilly and company, Suresnes, France
| | - Jordan Bertsch
- Fundacio Sant Joan de Déu, Serveis de Salut Mental, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Catherine Reed
- European Health Outcomes, Eli Lilly and company, Windlesham, UK
| | - Stephanie Gerard
- Neurosciences Medical department, Eli Lilly and company, Suresnes, France
| | | |
Collapse
|
37
|
Characterization of affective domains within the nonaffective psychotic disorders. Schizophr Res 2009; 111:61-9. [PMID: 19321311 DOI: 10.1016/j.schres.2009.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 02/26/2009] [Accepted: 03/04/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To characterize the affective dimensions of psychopathology in patients with a nonaffective psychosis and to examine their validity against a number of external variables. METHODS Five-hundred and thirty-five patients with a lifetime DSM-IV diagnosis of nonaffective psychosis were assessed during the index episode for 22 affective symptoms. These symptoms were factor analyzed and the resulting factor scores were examined for associations with a number of risk factors, illness characteristics, index episode psychopathology and outcome variables. RESULTS One-hundred and fifty-six patients (29.1%) met the criteria for a mood disorder during the index episode. Factor analysis of affective symptoms resulted in six factors (mania, core depression, anxiety, retarded depression, dysphoria and lability/mixed) explaining 56% of the variance. Regressions of clinical variables on the six factor scores (p < 0.01 after Bonferroni correction) revealed that mania was related to familial loading to bipolar disorder, shorter duration of the index episode and severity of disorganization symptoms; simple depression was related to suicidal behavior; anxiety was related to psychosocial stressors and reality-distortion symptoms; retarded depression was related to familial loading to major depression, poor premorbid adjustment and negative symptoms; dysphoria was related to violent behavior; lastly, the lability/mixed factor was related to better global functioning, shorter duration of the index episode, better response to treatment and episode polymorphism. CONCLUSIONS These results extend the phenomenology of nonaffective psychoses beyond the existing literature to include six affective domains. The validity of each domain is supported by their differential association pattern with illness-related variables.
Collapse
|
38
|
Van Riel WG, Vieta E, Martinez-Aran A, Haro JM, Bertsch J, Reed C, Van Os J, For The Emblem Advisory Board. Chronic mania revisited: factors associated with treatment non-response during prospective follow-up of a large European cohort (EMBLEM). World J Biol Psychiatry 2009; 9:313-20. [PMID: 18949649 DOI: 10.1080/15622970701805491] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To describe the course and outcome of patients with prospectively defined chronic mania and to identify predictors of treatment non-response. METHOD EMBLEM is a 2-year prospective, observational study of bipolar disorder treatment outcomes conducted in 14 European countries. Patients with a manic/mixed episode were assessed and prospectively followed for 1 year. Clinical scales (Clinical Global Impressions-Bipolar Disorder (CGI-BP) overall, mania, and depression; Young Mania Rating Scale (YMRS); and five-item Hamilton Depression Rating Scale (HAM-D-5)) and medication taken were systemically recorded. Treatment adherence and outcome measures were also captured. Chronic mania (non-response) was defined as not achieving more than one point improvement on CGI-BP mania scale during up to 12-month follow-up. The analysis was conducted with 3373 patients who had at least two CGI-BP mania ratings available. RESULTS A total of 15% of patients fulfilled criteria for chronic mania. Compared to those who responded to treatment, chronic mania was associated with lower severity of mania symptoms at baseline (OR = 0.44, 95% CI 0.37-0.52), shorter duration of current episode before treatment start (OR = 0.71, 95% CI 0.52-0.96), more delusions/hallucinations at baseline (OR = 1.12, 95% CI 1.03-1.22), less socially active (OR = 0.52, 95% CI 0.39-0.70) and greater occupational impairment (OR = 1.54, 95% CI 1.01-2.35) by multivariate statistical analysis. CONCLUSIONS Rather than severity or duration of manic symptoms, factors associated with chronicity in mania are the presence of psychotic symptoms and issues related to social and occupational functioning.
Collapse
Affiliation(s)
- Willemijn G Van Riel
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona IDIBAPS, CIBER-SAM, Barcelona, Spain
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Cassano G, Mula M, Rucci P, Miniati M, Frank E, Kupfer D, Oppo A, Calugi S, Maggi L, Gibbons R, Fagiolini A. The structure of lifetime manic-hypomanic spectrum. J Affect Disord 2009; 112:59-70. [PMID: 18541309 PMCID: PMC3387675 DOI: 10.1016/j.jad.2008.04.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 04/23/2008] [Accepted: 04/23/2008] [Indexed: 12/17/2022]
Abstract
BACKGROUND The observation that bipolar disorders frequently go unrecognized has prompted the development of screening instruments designed to improve the identification of bipolarity in clinical and non-clinical samples. Starting from a lifetime approach, researchers of the Spectrum Project developed the Mood Spectrum Self-Report (MOODS-SR) that assesses threshold-level manifestations of unipolar and bipolar mood psychopathology, but also atypical symptoms, behavioral traits and temperamental features. The aim of the present study is to examine the structure of mania/hypomania using 68 items of the MOODS-SR that explore cognitive, mood and energy/activity features associated with mania/hypomania. METHODS A data pool of 617 patients with bipolar disorders, recruited at Pittsburgh and Pisa, Italy was used for this purpose. Classical exploratory factor analysis, based on a tetrachoric matrix, was carried out on the 68 items, followed by an Item Response Theory (IRT)-based factor analytic approach. RESULTS Nine factors were initially identified, that include Psychomotor Activation, Creativity, Mixed Instability, Sociability/Extraversion, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Inflated Self-esteem, Euphoria, Wastefulness/Recklessness, and account overall for 56.4% of the variance of items. In a subsequent IRT-based bi-factor analysis, only five of them (Psychomotor Activation, Mixed Instability, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Euphoria) were retained. CONCLUSIONS Our data confirm the central role of Psychomotor Activation in mania/hypomania and support the definitions of pure manic (Psychomotor Activation and Euphoria) and mixed manic (Mixed Instability and Mixed Irritability) components, bearing the opportunity to identify patients with specific profiles for a better clinical and neurobiological definition.
Collapse
Affiliation(s)
- G.B. Cassano
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy,Corresponding author. Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa, via Roma 67-56100 Pisa, Italy. Tel.: +39 050 835419; fax: +39 050 21581. (G.B. Cassano)
| | - M Mula
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy
| | - P Rucci
- Department of Psychiatry, University of Pittsburgh School of Medicine, United States
| | - M Miniati
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy
| | - E Frank
- Department of Psychiatry, University of Pittsburgh School of Medicine, United States
| | - D.J. Kupfer
- Department of Psychiatry, University of Pittsburgh School of Medicine, United States
| | - A Oppo
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy
| | - S Calugi
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy
| | - L Maggi
- Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, School of Medicine, University of Pisa, Italy
| | - R Gibbons
- Center for Health Statistics, University of Illinois at Chicago, United States
| | - A Fagiolini
- Department of Psychiatry, University of Pittsburgh School of Medicine, United States
| |
Collapse
|
40
|
Cruz N, Vieta E, Comes M, Haro JM, Reed C, Bertsch J. Rapid-cycling bipolar I disorder: course and treatment outcome of a large sample across Europe. J Psychiatr Res 2008; 42:1068-75. [PMID: 18262204 DOI: 10.1016/j.jpsychires.2007.12.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 12/14/2007] [Accepted: 12/17/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate the baseline characteristics and follow-up outcomes of rapid-cycling (RC) bipolar I patients in a large, prospective, observational study. METHODS EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) is a long-term prospective observational study of in- and outpatients with an acute mania/mixed episode conducted in 14 European countries. Demographic and clinical variables were collected at baseline, including the presence or absence of DSM-IV rapid-cycling during the past year. Outcome measures included the 5-item Hamilton Depression Rating Scale (HAMD-5) and Young Mania Rating Scale (YMRS) over 12 weeks, as well as the Clinical Global Impressions-Bipolar Disorder Scale (CGI-BP overall, mania and depression) over 12 months. RESULTS Of 3684 patients enrolled, 3089 patients provided reliable data to qualify for either RC (N=535, 17.3%) or non-RC (NRC, N=2554), according to DSM-IV. RC prevalence varied across countries (p<0.001). Baseline and 12 week outcomes on the YMRS and HAMD-5, 12 month ratings on the CGI-BP subscales and work impairment at 12 months were significantly different (p<0.001) between groups, being worse in RC. RC patients were more likely to receive antidepressants and lamotrigine (p<0.001). Using logistic regression, RC was associated to country (p<0.001), female sex (p=0.029), outpatients (p=0.035), more history of attempted suicide (p<0.001) and alcohol abuse (p<0.001). CONCLUSIONS The EMBLEM results suggest that in naturalistic settings, patients with mania and RC differ from NRC in socio-demographic characteristics, treatment prescriptions and clinical outcome measures with a consistently worse occupational outcome and comorbidities. RC represents a longitudinally severe form of bipolar disorder, with poorly evidence-based diagnostic and therapeutic tools.
Collapse
Affiliation(s)
- N Cruz
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBER-SAM, Barcelona, Spain
| | | | | | | | | | | | | |
Collapse
|
41
|
Staton D. The impairment of pediatric bipolar sleep: hypotheses regarding a core defect and phenotype-specific sleep disturbances. J Affect Disord 2008; 108:199-206. [PMID: 18001840 DOI: 10.1016/j.jad.2007.10.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 10/09/2007] [Accepted: 10/10/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND The nature of the sleep disturbances associated with different phenotypes of pediatric bipolar disorder is unknown. Most manic children exhibit delayed sleep onset, but only a minority display decreased need for sleep. The DSM-IV manic sleep criterion is inadequate. METHOD All published studies of the sleep characteristics of bipolar children and adolescents are reviewed. Relevant studies of pediatric unipolar depressed subjects, circadian variation of bipolar and sleep variables, and circadian neurobiology are also reviewed. This information forms the basis of hypotheses regarding the core defect of pediatric bipolar sleep and phenotype-specific sleep disturbances of bipolar children and adolescents. LIMITATIONS The extant research literature is extremely limited. Interpretation of bipolar sleep is confounded by day-to-day variation of bipolar symptoms and sleep parameters, the presence of comorbid conditions, and environmental and psychosocial factors. CONCLUSIONS The core defect of pediatric bipolar sleep is hypothesized to be a significant delay of the circadian sleep-wake cycle, a form of the delayed sleep-phase syndrome. Children and adolescents with part-day manic cycles and chronic mixed conditions typically will manifest delayed sleep onset, but not decreased need for sleep. Pediatric individuals with days-long manic cycles or chronic mania typically will manifest decreased need for sleep, produced by interaction between the sleep-onset phase delay and bedtime and early morning manic psychomotor acceleration. The sleep-onset phase delay, when expressed, is hypothesized to be a trait marker of bipolar spectrum illness. Revision of the DSM-IV manic sleep criterion is necessary.
Collapse
Affiliation(s)
- Dennis Staton
- Lakeland Mental Health Center, 1010 32nd Avenue South, Moorhead, Minnesota 56560, United States.
| |
Collapse
|
42
|
van Rossum I, Haro JM, Tenback D, Boomsma M, Goetz I, Vieta E, van Os J. Stability and treatment outcome of distinct classes of mania. Eur Psychiatry 2008; 23:360-7. [PMID: 18434101 DOI: 10.1016/j.eurpsy.2008.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Revised: 02/26/2008] [Accepted: 02/27/2008] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Psychopathological heterogeneity in manic syndromes may in part reflect underlying latent classes with characteristic outcome patterns. Differential treatment course and outcome after 12 weeks of treatment were examined for three distinct classes of patients with acute mania in bipolar disorder. SUBJECTS AND METHODS Three thousand four hundred and twenty-five patients with acute mania were divided into three distinct mania classes: 'Typical', 'Psychotic' and 'Dual' (i.e. comorbid substance use) mania. Persistence of class differences and social outcomes were examined, using multilevel regression analyses and odds ratios. RESULTS The three classes showed substantial stability post-baseline in the pattern of associations with class-characteristic variables. Psychotic and Dual mania predicted poorer outcome in terms of psychosis comorbidity and overall bipolar and mania severity, while Dual mania additionally predicted poorer outcome of alcohol and substance abuse. Worse social outcomes were observed for both Dual and Psychotic mania. CONCLUSION The identified distinct classes are stable and associated with differential treatment outcome. Overall, Dual and Psychotic mania show less favourable outcomes compared to Typical mania. These findings additionally give rise to concern on the generalisability of randomized clinical trials RCTs.
Collapse
Affiliation(s)
- Inge van Rossum
- Medical Department, Eli Lilly Nederland, Grootslag 1-5, Houten, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Vieta E, Panicali F, Goetz I, Reed C, Comes M, Tohen M. Olanzapine monotherapy and olanzapine combination therapy in the treatment of mania: 12-week results from the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) observational study. J Affect Disord 2008; 106:63-72. [PMID: 17582508 DOI: 10.1016/j.jad.2007.05.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Revised: 05/11/2007] [Accepted: 05/13/2007] [Indexed: 12/19/2022]
Abstract
BACKGROUND To evaluate the 12-week outcomes (effectiveness, tolerability, and patterns of medication use) of olanzapine (either in antimanic monotherapy or in combination with other antipsychotics, anticonvulsants, and/or lithium) in patients with bipolar mania or mixed mania. METHOD EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) is a 24-month prospective observational study of in- and outpatients with acute mania/mixed mania conducted in 14 European countries. Primary outcome measures included Clinical Global Impressions-Bipolar Disorder scale (overall, mania, and depression); 5-item Hamilton Depression Rating Scale; and Young Mania Rating Scale. Tolerability measures included a questionnaire to assess patients' symptomatic complaints. RESULTS Overall, 2004 patients received olanzapine (olanzapine monotherapy, n=673; olanzapine combination, n=1331). Concomitant therapy with antidepressants and/or anxiolytics was possible in both groups. The countries significantly differed in the use of olanzapine monotherapy versus olanzapine combination (p<.0001). Baseline-to-endpoint changes on the CGI-BP subscales, YMRS, and HAMD-5 were significant within both treatment groups (p<.0001). Olanzapine monotherapy was generally better tolerated than olanzapine combination, particularly with regard to sedation (12% vs 17%; p<.001), tremor (2% vs 5%; p<.001), and akathisia (3% vs 6%; p<.001). DISCUSSION The acute-phase EMBLEM results suggest that in naturalistic settings, olanzapine (both as monotherapy and combination) may be effective in treating patients with bipolar mania. The use of olanzapine monotherapy or combination varies significantly across countries, but combination is generally the rule, rather than the exception.
Collapse
Affiliation(s)
- Eduard Vieta
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona IDIBAPS, Barcelona, Spain.
| | | | | | | | | | | |
Collapse
|
44
|
Staton D, Volness LJ, Beatty WW. Diagnosis and classification of pediatric bipolar disorder. J Affect Disord 2008; 105:205-12. [PMID: 17604120 DOI: 10.1016/j.jad.2007.05.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2006] [Revised: 05/07/2007] [Accepted: 05/15/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND Many children and adolescents with apparent bipolar disorder cannot be meaningfully diagnosed using the DSM-IV. The variety of pediatric bipolar phenotypes observed in clinical practice remains unclarified. METHOD 130 consecutively evaluated bipolar children and adolescents were assessed using semistructured clinical interviews and operational criteria that abandoned adherence to the DSM-IV cardinal symptom, duration of symptom persistence, and episodicity requirements. RESULTS 97.6% of the total sample manifested either all three, or two of the three symptoms elation, grandiosity, and racing thoughts, when manic. 96.9% of the total sample exhibited five or more of the eight DSM-IV criterion symptoms when manic. 52.3% of the subjects manifested ultradian cycling; 22.3% manifested chronic mania or chronic simultaneous manic mixed conditions. Only 21.5% could be classified within the Leibenluft et al. [Leibenluft, E., Charney, D.S., Towbin, K.E., Bhangoo, R.K., Pine, D.S., 2003. Defining clinical phenotypes of juvenile mania. Am. J. Psychiatry 160, 430-437.] system. Problematic distractibility-inattention was present in 89.9% and recurrent rage attacks in 48.5% of the total sample. Older subjects exhibited significantly more depressive symptoms, and nonsignificantly greater prevalences of major depression, severe depression, and ultradian cycling than did younger subjects. The number of depressive symptoms was significantly correlated with ultradian cycling. LIMITATIONS This study relied upon retrospective as well as current reports of symptoms. The study results cannot be generalized to community samples. CONCLUSIONS We propose two testable hypotheses: (1) that the recurrent, or chronic, simultaneous presence of any two of the symptoms elation, grandiosity, and racing thoughts and a total of five DSM-IV manic symptoms (without specific cardinal symptom, duration, or episodicity requirements) will identify nearly all clinic-referred bipolar children and adolescents; and (2) that a comprehensive classification of pediatric bipolar phenotypes based upon pattern of manic symptom episodicity or chronicity and degree of depression will identify subtypes of pediatric bipolar disorder that have greater correspondence with treatment response than do those of the DSM-IV classification. Problematic distractibility-inattention and explosive irritability-rage are highly prevalent; their presences should be specified when indicated.
Collapse
Affiliation(s)
- Dennis Staton
- Lakeland Mental Health Center, 1010 32nd Avenue South, Moorhead, Minnesota 56560, United States.
| | | | | |
Collapse
|
45
|
Bertschy G, Gervasoni N, Favre S, Liberek C, Ragama-Pardos E, Aubry JM, Gex-Fabry M, Dayer A. Frequency of dysphoria and mixed states. Psychopathology 2008; 41:187-93. [PMID: 18337629 DOI: 10.1159/000120987] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 07/03/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mixed states are a complex entity in the field of mood disorders. Dysphoria has been advocated as an important clinical dimension of mixed states. The objective of this work is to study the frequency of dysphoria within a population of patients with DSM-IV major depressive and/or manic episodes and to determine if it may help establish diagnostic criteria for subthreshold cases of depressive or manic mixed states. SAMPLING AND METHODS A total of 165 patients were assessed using the Mini International Neuropsychiatric Interview complemented by a section defining dysphoria as a constellation of 3 among 4 symptoms (inner tension, irritability, aggressive behavior and hostility). RESULTS When classifying patients according to the number of symptoms of the opposite polarity, changes in the frequency of dysphoria revealed a clear contrast between the 2 opposite manic and depressive poles and the full mixed state (DSM-IV definition). The frequency of dysphoria was 17.5% in pure depression, 22.7% in pure mania and 73.3% in full mixed state. Two threshold effects were identified: (1) the frequency of dysphoria increased from 17.5 to 61.1% (p = 0.002) when the number of manic symptoms in DSM-IV depressed patients increased from 0 to 1, and (2) dysphoria increased from 14.3 to 69.2% (p = 0.057) when the number of depressive symptoms increased from 2 to 3 in DSM-IV manic patients. CONCLUSION Dysphoria is strongly but not necessarily associated with mixed states. When used as a clinical marker for mixed states, dysphoria confirms the modern delimitations of sub-threshold mixed states by specifying the required number of symptoms of the opposite polarity (which could be lower for depressive mixed states than for manic mixed states). The study has limitations related to the inclusion of patients who are not drug-free, to the definition of dysphoria and to the sample size.
Collapse
Affiliation(s)
- G Bertschy
- Division of Adult Psychiatry, Department of Psychiatry, University Hospitals of Geneva, Geneva, Switzerland.
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Bertschy G, Gervasoni N, Favre S, Liberek C, Ragama-Pardos E, Aubry JM, Gex-Fabry M, Dayer A. Phenomenology of mixed states: a principal component analysis study. Bipolar Disord 2007; 9:907-12. [PMID: 18076542 DOI: 10.1111/j.1399-5618.2007.00462.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To contribute to the definition of external and internal limits of mixed states and study the place of dysphoric symptoms in the psychopathology of mixed states. METHODS One hundred and sixty-five inpatients with major mood episodes were diagnosed as presenting with either pure depression, mixed depression (depression plus at least three manic symptoms), full mixed state (full depression and full mania), mixed mania (mania plus at least three depressive symptoms) or pure mania, using an adapted version of the Mini International Neuropsychiatric Interview (DSM-IV version). They were evaluated using a 33-item inventory of depressive, manic and mixed affective signs and symptoms. RESULTS Principal component analysis without rotation yielded three components that together explained 43.6% of the variance. The first component (24.3% of the variance) contrasted typical depressive symptoms with typical euphoric, manic symptoms. The second component, labeled 'dysphoria', (13.8%) had strong positive loadings for irritability, distressing sensitivity to light and noise, impulsivity and inner tension. The third component (5.5%) included symptoms of insomnia. Median scores for the first component significantly decreased from the pure depression group to the pure mania group. For the dysphoria component, scores were highest among patients with full mixed states and decreased towards both patients with pure depression and those with pure mania. CONCLUSIONS Principal component analysis revealed that dysphoria represents an important dimension of mixed states.
Collapse
Affiliation(s)
- G Bertschy
- Division of Adult Psychiatry, Department of Psychiatry, University Hospitals of Geneva, Geneva, Switzerland.
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
The presence of depressive symptomatology during acute mania has been termed mixed mania, dysphoric mania, depressive mania or mixed bipolar disorder. Highly prevalent, mixed mania occurs in at least 30% of bipolar patients. Correct diagnosis is a major challenge. The DSM diagnostic criteria, the most widely adopted clinical convention, require a complete manic and complete depressive syndrome co-occurring for at least 1 week. However, recent alternative categorical and dimensional studies of manic phenomenology have shown that there are certain depressive symptoms or constellations that have special clinical importance when describing mixed states, such as depressed mood and anxiety symptomatology that do not overlap with manic symptoms. Patients with mixed mania are over-represented in the subgroup with severe and treatment-resistant symptoms. The course and prognosis of mixed mania are worse than that of pure manic forms in the medium and long term, with higher recurrence rates, higher frequency of co-morbid substance abuse and greater risk of suicidal ideation and attempts. Moreover, mixed manic episodes are usually associated with increased depression during follow-up, greater risk of rapid cycling course and higher prevalence of physical co-morbidities, principally related to thyroid function. All these factors are very relevant to selection of treatment. There are three crucial steps in the treatment of mixed mania--making the correct diagnosis, starting treatment early, and considering not only the acute state but also maintenance treatment and the patient's long-term outcome. Although challenging, acute mixed episodes are treatable. To date there have been no controlled studies devoted exclusively to treatment of mixed mania, and the only controlled data available therefore derive from sub-analyses of randomised clinical trials. Both short-term and maintenance treatments of patients with mixed mania require experience and usually involve the combination of different treatments. As a general rule, there is some consensus about discontinuing antidepressants during mixed mania. Olanzapine, aripiprazole or valproate semisodium (divalproex sodium) are first-line drugs for mild episodes; severe episodes of mixed mania usually require treatment with a combination of valproate semisodium or lithium plus an antipsychotic, preferably an atypical agent. Carbamazepine is also useful for the treatment of mixed mania. High-dose medications are sometimes needed to control the episode, and time to remission is usually longer than in pure mania. Importantly, patients with mixed manic episodes have more adverse events of psychopharmacological treatment. In some cases, electroconvulsive therapy is required.
Collapse
Affiliation(s)
- Ana González-Pinto
- Stanley International Mood Disorders Research Center, Hospital Santiago Apóstol, University of the Basque Country, Vitoria, Spain.
| | | | | | | |
Collapse
|
48
|
Myint AM, Kim YK, Verkerk R, Park SH, Scharpé S, Steinbusch HWM, Leonard BE. Tryptophan breakdown pathway in bipolar mania. J Affect Disord 2007; 102:65-72. [PMID: 17270276 DOI: 10.1016/j.jad.2006.12.008] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2006] [Revised: 12/06/2006] [Accepted: 12/08/2006] [Indexed: 02/04/2023]
Abstract
The upregulation of the initiating step of the kynurenine pathway was demonstrated in postmortem anterior cingulated cortex from individuals with schizophrenia and bipolar disorder. However, the tryptophan and kynurenine metabolism in bipolar mania patients especially in drug naïve state has not been clearly explored. This study explored the plasma tryptophan and its competing amino acids, kynurenine, kynurenic acid and 3-hydroxyanthranillic acid and their association with psychopathological scores in 39 drug naïve and drug-free bipolar manic patients in comparison with 80 healthy controls. When age and gender were controlled in multivariate analysis, bipolar manic patients have significantly lower tryptophan index than normal controls (f=9.779, p=0.004). The mean plasma tryptophan concentration and mean tryptophan index were reduced and mean tryptophan breakdown index was increased significantly after a 6-week treatment. The reduction in plasma tryptophan and reduction in tryptophan index showed significant negative correlation with reduction in YMRS score (r=-0.577, p=0.019 and r=-0.520, p=0.039 respectively). The reduction in YMRS also showed positive correlation with both plasma tryptophan concentration and tryptophan index both at the time of admission (r=0.464, p=0.019 and r=0.4, p=0.047 respectively) and discharged (r=0.529, p=0.035 and r=0.607, p=0.013 respectively). The reduction in BPRS score also showed positive correlation with tryptophan index at the time of discharge (r=0.406, p=0.044). These findings indicated the involvement of bi-directional tryptophan metabolism and kynurenine pathway in pathophysiology and response to medication in bipolar mania.
Collapse
Affiliation(s)
- Aye Mu Myint
- Department of Psychiatry and Neuropsychology, University of Maastricht, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
49
|
van Os J, van Rossum I, Boomsma M, Vieta E, Goetz I, Reed C, Haro JM. The social, psychopathological and consumer context of rate of symptom improvement in acute mania. Soc Psychiatry Psychiatr Epidemiol 2007; 42:631-8. [PMID: 17598062 DOI: 10.1007/s00127-007-0215-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Accepted: 05/29/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Knowledge of moderators of symptom improvement over time in acute mania improves predictability of individual patient outcomes. This study attempted to identify such moderators of the rate of symptom improvement. METHODS In 3459 patients with high levels of mania in whom a change in psychotropic treatment was initiated and who were assessed six times over three months, clinical and social moderators of the rate of response were examined. Additionally, moderators of symptom improvement in individuals with high baseline levels of comorbid depression (n = 815) and psychosis (n = 1849) were identified. RESULTS Within three months, mania symptoms were reduced by 52%, psychotic symptoms by 56% and depressive symptoms by 36%. High levels of baseline depression, greater illness severity in the past year, lower age of onset and rapid cycling reduced the rate of mania symptom improvement by 5-15%. Social variables indicating disadvantage similarly had negative contributions (5%-14%). Several reasons for change of medication involving patient choice, patient compliance, side effects and lack of effectiveness impacted negatively (reductions of 10%, 6%, 14% and 9% respectively). For the psychosis dimension, both low mania scores (22% reduction) and high depression scores (14% reduction) at baseline impacted negatively, whereas rate of reduction in depression was not conditional on baseline psychopathology. CONCLUSIONS The rate of symptom improvement in acute mania is to a large extent conditional on the context as provided by the social, psychopathological and consumer environment. Understanding the context of treatment response offers valuable insights into treatment approaches aimed at moderation of traditional pharmacological interventions.
Collapse
Affiliation(s)
- Jim van Os
- Dept. of Psychiatry and Neuropsychology, Maastricht University, European Graduate School of Neuroscience, PO Box 616, 6200, MD, Maastricht, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
50
|
Bellantuono C, Barraco A, Rossi A, Goetz I. The management of bipolar mania: a national survey of baseline data from the EMBLEM study in Italy. BMC Psychiatry 2007; 7:33. [PMID: 17640381 PMCID: PMC1940252 DOI: 10.1186/1471-244x-7-33] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Accepted: 07/19/2007] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Although a number of studies have assessed the management of mania in routine clinical practice, no studies have so far evaluated the short- and long-term management and outcome of patients affected by bipolar mania in different European countries. The objective of the study is to present, in the context of a large multicenter survey (EMBLEM study), an overview of the baseline data on the acute management of a representative sample of manic bipolar patients treated in the Italian psychiatric hospital and community settings. EMBLEM is a 2-year observational longitudinal study that evaluates across 14 European countries the patterns of the drug prescribed in patients with bipolar mania, their socio-demographic and clinical features and the outcomes of the treatment. METHODS The study consists of a 12-week acute phase and a < or = 24-month maintenance phase. Bipolar patients were included into the study as in- or out-patients, if they initiated or changed, according to the decision of their psychiatrist, oral antipsychotics, anticonvulsants and/or lithium for the treatment of an episode of mania. Data concerning socio-demographic characteristics, psychiatric and medical history, severity of mania, prescribed medications, functional status and quality of life were collected at baseline and during the follow-up period. RESULTS In Italy, 563 patients were recruited in 56 sites: 376 were outpatients and 187 inpatients. The mean age was 45.8 years. The mean CGI-BP was 4.4 (+/- 0.9) for overall score and mania, 1.9 (+/- 1.2) for depression and 2.6 (+/- 1.6) for hallucinations/delusions. The YMRS showed that 14.4% had a total score < 12, 25.1% > or = 12 and < 20, and 60.5% > or = 20. At entry, 75 patients (13.7%) were treatment-naïve, 186 (34.1%) were receiving a monotherapy (of which haloperidol [24.2%], valproate [16.7%] and lithium [14.5%] were the most frequently prescribed) while 285 (52.2%) a combined therapy (of which 8.0% were represented by haloperidol/lithium combinations). After a switch to an oral medication, 137 patients (24.8%) were prescribed a monotherapy while the rest (415, 75.2%) received a combination of drugs. CONCLUSION Data collected at baseline in the Italian cohort of the EMBLEM study represent a relevant source of information to start addressing the short and long-term therapeutic strategies for improving the clinical as well as the socio-economic outcomes of patients affected by bipolar mania. Although it's not an epidemiological investigation and has some limitations, the results show several interesting findings as a relatively late age of onset of bipolar disorder, a low rate of past suicide attempts, a low lifetime rate of alcohol abuse and drug addiction.
Collapse
Affiliation(s)
- Cesario Bellantuono
- Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Italy
| | | | | | | |
Collapse
|