Refining the evaluation of bipolar II: beyond the strict SCID-CV guidelines for hypomania

Is there a 'bipolar iceberg' in UK primary care psychological therapy services?

BACKGROUND

Improving Access to Psychological Therapies (IAPT) is a primary care therapy service commissioned by England's National Health Service (NHS) for people with unipolar depression and anxiety-related disorders. Its scope does not extend to 'severe mental illness', including bipolar disorders (BD), but evidence suggests there is a high BD prevalence in ostensibly unipolar major depressive disorder (uMDD) samples. This study aimed to indicate the prevalence and characteristics of people with BD in a naturalistic cohort of IAPT patients.

METHODS

371 participants were assessed before initiating therapy. Participants were categorised by indicated diagnoses: BD type-I (BD-I) or type-II (BD-II) as defined using a DSM diagnostic interview, bipolar spectrum (BSp, not meeting diagnostic criteria but exceeding BD screening thresholds), lifetime uMDD or other. Information about psychiatric history and co-morbidities was examined, along with symptoms before and after therapy.

RESULTS

368 patients provided sufficient data to enable classification. 10% of participants were grouped as having BD-I, 20% BD-II, 40% BSp, 25% uMDD and 5% other. BD and uMDD participants had similar demographic characteristics, but patients meeting criteria for BD-I/BD-II had more complex psychiatric presentations. All three 'bipolar' groups had particularly high rates of anxiety disorders. IAPT therapy receipt was comparable between groups, as was therapy response (F9704 = 1.113, p = 0.351).

CONCLUSIONS

Notwithstanding the possibility that bipolar diathesis was overestimated, findings illustrate a high prevalence of BD in groups of people notionally with uMDD or anxiety. As well as improving the detection of BD, further substantive investigation is required to establish whether individuals affected by BD should be eligible for primary care psychological intervention.

Korean Validation of the Short Version of the TEMPS-A (Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire) in Patients with Mood Disorders

BACKGROUND AND OBJECTIVES

The Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) is designed to assess affective temperaments. The short version of the TEMPS-A (TEMPS-A-SV) has been translated into various languages for use in research and clinical settings. However, no research has been conducted to validate the Korean version of the TEMPS-A-SV in patients with mood disorders. The goal of this study is to evaluate the reliability and validity of the TEMPS-A-SV in Korean mood disorder patients.

MATERIALS AND METHODS

In this cross-sectional retrospective study, a total of 715 patients (267 patients with major depressive disorder, 94 patients with bipolar disorder I, and 354 patients with bipolar disorder II) completed the Korean TEMPS-A-SV. Cronbach's alpha and McDonald's omega were used to assess the reliability. Exploratory factor analysis (EFA) was also performed. Spearman's correlation coefficient was used to examine associations between the five temperaments. The difference in five temperament scores between the gender or diagnosis groups was analyzed, and the correlation between five temperament scores and age was tested.

RESULTS

The Korean TEMPS-A-SV displayed good internal consistency (α = 0.65-0.88, ω = 0.66-0.9) and significant correlations between the subscales except one (the correlation between hyperthymic and anxious). Using EFA, a two-factor structure was produced: Factor I (cyclothymic, depressive, irritable, and anxious) and Factor II (hyperthymic). The cyclothymic temperament score differed by gender and the anxious temperament score was significantly correlated with age. All the temperaments, except for irritable temperament, showed significant differences between diagnosis groups.

CONCLUSIONS

Overall, the results show that the TEMPS-A-SV is a reliable and valid measurement that can be used for estimating Koreans' affective temperaments. However, more research is required on affective temperaments and associated characteristics in people with mood disorders.

Bipolar Depression: A Historical Perspective of the Current Concept, with a Focus on Future Research

The aim of this narrative review is to trace the origin of the concept of bipolar depression and to expose some of its limitations. Bipolar depression is a broad clinical construct including experiences ranging from traditional melancholic and psychotic episodes ascribed to "manic-depressive insanity," to another heterogeneous group of depressive episodes originally described in the context of binary models of unipolar depression (e.g., psychogenic depression, neurotic depression). None of the available empirical evidence suggests, however, that these subsets of "bipolar" depression are equivalent in terms of clinical course, disability, family aggregation, and response to treatment, among other relevant diagnostic validators. Therefore, the validity of the current concept of bipolar depression should be a matter of concern. Here, we discuss some of the potential limitations that this broad construct might entail in terms of pathophysiological, clinical, and therapeutic aspects. Finally, we propose a clinical research program for bipolar depression in order to delimit diagnostic entities based on empirical data, with subsequent validation by laboratory or neuroimaging biomarkers. This process will then aid in the development of more specific treatments.

Peripheral BDNF correlated with miRNA in BD-II patients

OBJECTIVES

We have identified the association between peripheral levels of candidate miRNAs (miR-7-5p, miR-142-3p, miR-221-5p, and miR-370-3p) for BD-II in previous study. Most of these miRNAs are associated with regulation of expression of peripheral brain derived neurotrophic factor (BDNF) levels. In order to clarify the underlying mechanism of BDNF and miRNAs in the pathogenesis of BD-II, it is of interest to investigate the relation between the peripheral levels of miR-7-5p, miR-142-3p, miR-221-5p, miR-370-3p with BDNF levels. Because the BDNF Val66Met polymorphism influence the secretion of BDNF, we further stratified the above correlations by this polymorphism.

METHODS

We have recruited 98 BD-II patients. Beside analyzing peripheral levels of miR-7-5p, miR-142-3p, miR-221-5p, miR-370-3p, and BDNF, the genetic distribution of the BDNF Val66Met polymorphism was also analyzed.

RESULTS

We found that the miR7-5p, miR221-5p, and miR370-3p significantly correlated with the BDNF levels for all patients. If stratified by the BDNF Val66Met polymorphism, the significant correlation between miR221-5p and miR370-3p with BDNF only remained in the Val/Met genotype. However, the correlation between miR7-5p and BDNF level is significant in all 3 genotypes.

CONCLUSION

Our result supported that these miRNAs may be involved in the pathomechanism of BD-II through relation with BDNF.

White matter integrity in young medication-naïve bipolar II depressed adults

It is unknown if young medication-naïve bipolar II (BPII) depressed patients have increased white matter (WM) disruptions. 27 each of young (average 23 years) and treatment-naïve BPII depressed, unipolar depressed (UD) patients and age–sex–education matched healthy controls (HC) underwent 3 T MRIs with diffusion tensor imaging. Diagnostic ratings included Structured Clinical Interview for DSM Disorders (SCID), Montgomery-Åsberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS) and Hamilton Anxiety Rating Scale (HAM-A). Patients were clinically depressed (MADRS-BPII: 26.15 [SD9.25], UD: 25.56 [5.24], p = 0.86). Compared to UD, BPII had increased family bipolarity (BPII 13.6% vs UD 2.5%, p = 0.01, φc = 0.28), hypomanic symptoms (YMRS-BPII: 4.22 [4.24], UD: 1.33 [2], p = 0.02, d = 0.87), lifetime number of depressive episodes (BPII: 2.37 [1.23], UD: 1.44 [0.75], p = 0.02, d = 0.91), lifetime and current-year number of episodes (lifetime BPII: 50.85 [95.47], UD: 1.7 [1.03]; current-year BPII: 9.93 [16.29], UD: 1.11 [0.32], ps = 0.04, ds = 0.73–0.77) and longer illness duration (BPII: 4.96 years [3.96], UD: 2.99 [3.33], p = 0.15, d = 0.54). BPII showed no increased WM disruptions vs UD or HC in any of the 15 a priori WM tracts. UD had lower right superior longitudinal fasciculus (SLF) (temporal) axial diffusivity (AD) (1.14 vs 1.17 (BPII), 1.16 (HC); F = 6.93, 95% CI of\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${F}_{B}$$\end{document}FB: 0.00073, 5.22, ηp² = 0.15). Principal component analysis followed by exploratory linear discriminant analysis showed that increased R-SLF (temporal) AD, YMRS and family bipolarity distinguished BPII from UD (81.5% sensitivity, 85.2% specificity) independent of episode number and frequency. Young, medication-naïve adults with BPII depression did not show the WM disruptions distinguishing more chronically ill BP patients from UD. These WM disruptions may therefore be partly attributable to illness chronicity. Longitudinal studies should examine the trajectory of WM changes in BPII and UD and predictive validity of these baseline clinical and imaging parameters.

The Co-Morbidity between Bipolar and Panic Disorder in Fibromyalgia Syndrome

About half of the patients with fibromyalgia (FM) had a lifetime major depression episode and one third had a panic disorder (PD). Because the co-morbidity between bipolar disorder (BD) and PD marks a specific subtype of BD we aimed to investigate if co-morbid BD/PD (comBD/PD) occurs more frequently than the single disorder in FM patients and evaluate the clinical significance and timing of this co-morbidity. Further, we explored the role of co-morbid subthreshold BD and PD. In 118 patients with FM, lifetime threshold and sub-threshold mood disorders and PD were diagnosed with Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR) Clinical Interview. Demographic and clinical variables were compared in co-morbid BD/PD (comBD/PD) and not co-morbid BD/PD (nocomBD/PD) subgroups. The co-morbidity BD/PD was seen in 46.6% of FM patients and in 68.6% when patients with minor bipolar (MinBD) and sub-threshold panic were included. These rates are higher than those of the general population and BD outpatients. There were no statistically significant differences between threshold and sub-threshold comBD/PD and nocom-BD/PD subgroups in demographic and clinical parameters. In the majority of patients (78.2%), the onset of comBD/PD preceded or was contemporary with FM. These findings support the hypothesis that comBD/PD is related to the development of FM in a subgroup of patients.

Assessing Relationships Among Impulsive Sensation Seeking, Reward Circuitry Activity, and Risk for Psychopathology: A Functional Magnetic Resonance Imaging Replication and Extension Study

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.

Does temperamental instability support a continuity between bipolar II disorder and major depressive disorder?

Background

The current categorical split of mood disorders in bipolar disorders and depressive disorders has recently been questioned. Two highly unstable personality features, i.e. the cyclothymic temperament (CT) and borderline personality disorder (BPD), have been found to be more common in bipolar II (BP-II) disorder than in major depressive disorder (MDD). According to Kraepelin, temperamental instability was the ‘foundation’ of his unitary view of mood disorders.

Study aim

The aim was to assess the distributions of the number of CT and borderline personality items between BP-II and MDD. Finding no bi-modal distribution (a ‘zone of rarity’) of these items would support a continuity between the two disorders.

Methods

Study setting: an outpatient psychiatry private practice. Interviewer: A senior clinical and mood disorder research psychiatrist. Patient population: A consecutive sample of 138 BP-II and 71 MDD remitted outpatients. Assessment instruments: The structured clinical interview for DSM-IV Axis I Disorders-Clinician Version (SCID-CV), the SCID-II Personality Questionnaire for self-assessing borderline personality traits (BPT) by patients, the TEMPS-A for self-assessing CT by patients. Interview methods: Patients were interviewed with the SCID-CV to diagnose BP-II and MDD, and then patients self-assessed the questions of the Personality Questionnaire relative to borderline personality, and the questions of the TEMPS-A relative to CT. As clinically significant distress or impairment of functioning is not assessed by the SCID-II Personality Questionnaire, a diagnosis of BPD could not be made, but BPT could be assessed (i.e. all BPD items but not the impairment criterion). The distribution of the number of CT and BPT items was studied by Kernel density estimate.

Results

CT and BPT items were significantly more common in BP-II versus MDD. The Kernel density estimate distributions of the number of CT and BPT items in the entire sample had a normal-like shape (i.e. no bi-modality).

Conclusions

The expected finding, on the basis of previous studies and of the present sample features, was a clustering of CT and BPT items on the BP-II side of the curves. Instead, no bi-modality was present in the distributions of the number of CT and BPT items in the entire sample, showing a normal-like shape. By using the bi-modality approach, a continuity between BP-II and MDD seems supported, questioning the current categorical splitting of BP-II and MDD based on classic diagnostic validators.

Lithium and valproate serum level fluctuations within the menstrual cycle: a systematic review

Some women affected by mood disorders experience mood instability during the premenstrual phase. Assuming that fluctuations in drug serum levels may contribute to the worsening of mood symptoms, we carried out a systematic review of available studies that investigated changes in lithium and valproate levels in relation to menstrual phases. We selected five studies; four of which assessed menstrual fluctuations in lithium serum levels and one in valproate levels. Study samples included women in their fertile age affected by bipolar disorder, epilepsy as well as healthy ones. Preliminary results showed a close relationship between cyclic premenstrual exacerbation of affective symptoms and a significant decrease in lithium levels during the luteal phase, despite stable oral doses, in bipolar women. In healthy women, lithium levels were influenced by neither menstrual cycle phases nor oral contraceptives use. Valproate serum levels in epileptic women showed a small, nonsignificant decline during the mid-luteal phase. Pharmacokinetic sex differences in adsorption, volume distribution, hepatic metabolism, and renal excretion of mood stabilizers have been supposed to partly explain such menstrual serum level fluctuations. A better understanding in this field could help to counteract the distress related to premenstrual phase, improving therapeutic management of mood disorders in women.

Genetic biomarkers for differential diagnosis of major depressive disorder and bipolar disorder: A systematic and critical review

Depressive symptoms are present in the depressive mood state of bipolar disorder (BPD) and major depression disorder (MDD). Often, in clinical practice, BPD patients are misdiagnosed with MDD. Therefore, genetic biomarkers could contribute to the improvement of differential diagnosis between BPD and MDD. This systematic and critical review aimed to find in literature reliable genetic biomarkers that may show differences between BPD and MDD. This systematic review followed the PRISMA-P method. The terms used to search PubMed, Scopus, PsycINFO, and Web of Science were depress*, bipolar, diagnos*, genetic*, biomark*. After applying the selection criteria, N = 27 studies were selected, being n = 9 about biomarkers for BPD; n = 15, about MDD; and n = 3 for distinguishing MDD from BPD. A total of N = 3086 subjects were assessed in the selected studies (n = 486 in BPD group; n = 1212 in MDD group; and n = 1388, healthy control group). The articles were dated up to June 2017. Of the N = 27 studies, n = 16 assessed gene, n = 1 miRNA, n = 2 lcnRNA and n = 3 protein expressions, n = 4 methylation, and n = 4 polymorphisms. Some studies applied more than one of these genetic analyses. To find reliable genetic biomarkers we have taken into account the methodological care during the studies development and their validity. The genetic biomarkers selected are related to genes that play a fundamental role in synaptic plasticity, neurogenesis, mood control, brain ageing, immune-inflammatory processes and mitochondrial respiratory chain. BDNF gene expression was one of the genetic biomarkers that highlighted because of its capacity of distinguishing BPD and MDD groups, and being adequately reproduced by more than one selected study.

Bipolar features in major depressive disorder: Results from the Iranian mental health survey (IranMHS)

BACKGROUND

Past research suggests that individuals suffering from depressive disorders with bipolar features might have different clinical outcomes resembling bipolar disorders. The objectives of this study are to determine the prevalence of bipolar features among individuals meeting the criteria for 12-month major depressive disorder (MDD) in the Iranian population and to examine the demographic and clinical characteristics associated with these features.

METHODS

Data were drawn from the Iranian Mental Health Survey (IranMHS), a representative household survey of the Iranian population aged 15-64 years. The study sample consisted of all individuals with a 12-month MDD (n = 1014) ascertained by the Composite International Diagnostic Interview (CIDI 2.1) without a lifetime history of bipolar I or II disorders. Mood Disorder Questionnaire (MDQ) was used to screen for the lifetime history of bipolar features among participants with MDD.

RESULTS

Among participants meeting the 12-month MDD criteria, 22.1% (95% CI: 19.6-24.7) had a lifetime history of bipolar features. Compared with those without these features, participants with bipolar features had higher odds of endorsing suicidal ideations and suicide attempts, comorbid anxiety and substance use disorders, severe impairment, history of psychotic symptoms, some features of atypical depression and fewer depressive symptoms. Associations with comorbid anxiety disorders [Odds Ratio (OR) = 1.43; 95% confidence interval (CI): 1.00-2.03] and history of psychotic symptoms (OR = 2.63 95% CI: 1.81-3.81) persisted in multivariable models.

LIMITATION

Relying on self-reports of lifetime bipolar symptoms which is open to recall bias, and cross-sectional study design which limits interpretation of outcome and course of MDD are two major limitations of this study.

CONCLUSION

The presence of bipolar features is associated with a distinct demographic and clinical profile in MDD. Identifying these cases would enhance the homogeneity of the depressive disorder phenotype in general population surveys. Identifying MDD patients with these features has potential clinical implications.

Prospective: Is bipolar disorder being overdiagnosed?

OBJECTIVES

Many studies indicate that bipolar disorders are underdiagnosed. Yet from 2007 to 2008, a series of publications asserted that bipolar disorders were being overdiagnosed. This review examines the methods used in the studies that reported bipolar disorders were being overdiagnosed.

METHODS

A literature search for studies with original data related to overdiagnosis of bipolar disorders was performed.

RESULTS

Four studies were found indicating bipolar disorders were being overdiagnosed. The Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders (SCID) was used in the diagnostic process. The studies compared the clinical diagnosis of bipolar disorder to a single SCID interview without interviewing family or reviewing old records. The studies assumed the SCID diagnosis was correct.

CONCLUSIONS

Numerous concerns were found. The SCID frequently missed diagnosis of bipolar, the definitions of bipolar disorder are so narrow and conservative that the outcomes of the studies may have been predetermined. Ultimately, the studies compared the strength of a diagnosis made by a treating psychiatrist to a SCID diagnosis collected with virtually no information from the clinician. The assumption that the SCID diagnosis is always correct and the clinician is always wrong is unsupportable. The premise that bipolar disorders are being overdiagnosed is unsupported by reasonable science.

The relationship between body mass index and pain, disease activity, depression and anxiety in women with fibromyalgia

Background

Obesity is a possible factor which affects severity of symptoms and disease activity in fibromyalgia syndrome (FMS). The aim of our study was to determine the association between body mass index (BMI) and pain, tender point count (TPC), disease activity, anxiety and depression in patients with FMS.

Methods

This was a descriptive study. A total of 124 female FMS patients between 18 and 55 years of age were enrolled. FMS patients were evaluated with visual analog scale (VAS), fibromyalgia impact questionnaire (FIQ), Hamilton anxiety scale (HAM-A) and Hamilton depression scale (HAM-D). Patients were divided into three groups according to BMI levels: normal weight, overweight and obese. Normal weight was defined as BMI 18.5-24.9, overweight as BMI 25.0-29.9 and obesity as BMI ≥ 30. We assessed the BMI status and its association with symptom severity in patients with FMS.

Results

Significant differences were detected in VAS, TPC, FIQ and HAM-D among the groups (p < 0.05). There were no significant differences between the groups in HAM-A (p = 0.328). The highest scores were found in the obese group. Significant positive correlations were determined between BMI levels and VAS, TPC, FIQ and HAM-D (r = 0.277, p = 0.002; r = 0.384, p < 0.001; r = 0.292, p = 0.001; r = 0.357, p < 0.001).

Discussion

Obese female FMS patients had higher levels of pain, TPC, disease activity and depression. BMI was significantly and positively correlated with clinical manifestations of FMS. Therefore, FMS treatment programs should include weight loss strategies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cognitive Impairment In Treatment-Naïve Bipolar II and Unipolar Depression

Cognition dysfunction may reflect trait characteristics of bipolarity but cognitive effects of medications have confounded previous comparisons of cognitive function between bipolar II and unipolar depression, which are distinct clinical disorders with some overlaps. Therefore, we examined the executive function (WCST), attention, cognitive speed (TMT-A) and memory (CAVLT, WMS-Visual reproduction) of 20 treatment-naïve bipolar II patients (BPII), 35 treatment-naïve unipolar depressed (UD) patients, and 35 age/sex/education matched healthy controls. The subjects were young (aged 18–35), and had no history of psychosis or substance use, currently depressed and meeting either RDC criteria for Bipolar II Disorder or DSM-IV-TR criteria for Major Depressive Disorder. The patients were moderately depressed (MADRS) and anxious(HAM-A), on average within 3.44 years of illness onset. Sociodemographic data and IQ were similar between the groups. UD patients had significantly slower cognitive speed and cognitive flexibility (WCST perseverative error). BPII depressed patients showed relatively intact cognitive function. Verbal memory (CAVLT List A total) correlated with illness chronicity only in BPII depression, but not UD. In conclusion, young and treatment-naïve BPII depressed patients differed from unipolar depression by a relatively intact cognitive profile and a chronicity-cognitive correlation that suggested a stronger resemblance to Bipolar I Disorder than Unipolar Depression.

Hypomania in clinical practice

Recent work suggests that a broad clinical spectrum of bipolar disorder is more common than previously thought and that the disorder may affect up to 5% of the population. The correct definition and diagnosis of hypomania is central to the identification of bipolar disorder. In this review we focus on recent diagnostic and clinical advances relating to bipolar disorder, with particular reference to hypomanic states. We also highlight some of the controversies in this field and discuss ways in which clinicians might improve their detection of bipolar disorders.

Features of mood associated with high body weight in females with fibromyalgia

BACKGROUND

Fibromyalgia (FM) is a common syndrome whose main characteristic is chronic widespread musculoskeletal pain, the severity of which is frequently worsened by concomitant obesity. Major depression (MD), particularly as part of a bipolar spectrum disorder (BSD), is associated with both obesity and FM.

OBJECTIVE

To evaluate the relationship between lifetime MD, hypomanic symptoms and the body mass index (BMI) in patients with FM.

METHOD

Of the 115 patients originally screened, 87 women with FM finally entered the study. Forty-nine patients (57%) had a lifetime diagnosis of MD, assessed by a structured clinical interview based on DSM-IV criteria, and four of them (4.6%) had a current MD episode. Lifetime hypomanic symptoms were measured by means of the self-rated Hypomania Checklist. According to the international criteria for BMI, FM patients were classified as under/normal-weight (61%), overweight (30%) and obese (9%).

RESULTS

62 patients (71.2%) with FM had a bipolar spectrum disorder (BSD). Thirty (48.3%) of them met criteria for bipolar II disorder, 32 (51,6%) for bipolar disorder NOS (18 FM patients with MD associated to sub-syndromal hypomanic syndrome and 14 with hypomanic syndrome without MD). No patient had a bipolar I disorder. Only one patient met the criteria for a major depressive disorder (MDD). There was no significant difference in mean BMI between the patients with and without a lifetime diagnosis of MD, but there was a positive association between the level of hypomanic symptoms and BMI values (p<0.009). When hypomania was considered categorically as hypomanic syndrome there was no significant effect on BMI.

CONCLUSIONS

Our finding adds to previous evidence indicating that hypomanic symptoms are a central feature of FM. In the case of the early identification of high-level hypomanic symptoms, body weight should be closely monitored in order to prevent obesity and its detrimental impact on females with FM.

Serum DHEA-S concentration correlates with clinical symptoms and neurocognitive function in patients with bipolar II disorder: A case-controlled study

OBJECTIVES

Dysregulation of the neuroendocrine system including dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEA-S), and pregnenolone may play a role in the pathophysiology of bipolar II disorder (BP-II). The aims of the current study are to determine (a) the differences in DHEA, DHEA-S and pregnenolone in patients with BP-II and controls; and (b) the correlation of levels of the above hormones, cognitive function, and clinical symptoms.

METHODS

Patients diagnosed with BP-II and healthy controls were recruited from psychiatric department. Blood samples were collected to measure the levels of DHEA, DHEA-S and pregnenolone in all participants, followed by assessment of cognitive function using the Brief Assessment of Cognition in Affective Disorders (BACA).

RESULTS

A total of 32 patients BP-II and 30 healthy control subjects were recruited. The BP-II group was found with significantly elder age, fewer years of education, and lower BACA composite scores compared to the healthy controls. The level of DHEA-S was significantly associated with performance in BACA when controlling for age, gender, years of education and having BP-II (P=0.018). The DHEA-S level was significantly correlated with mania score (r=-0.498, P=0.010).

CONCLUSION

Our findings support that serum level of DHEA-S may be a biomarker representing clinical manic symptoms and cognitive performance.

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

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

The DRD3 Ser9Gly Polymorphism Predicted Metabolic Change in Drug-Naive Patients With Bipolar II Disorder

Patients with bipolar II disorder (BDII) have a higher prevalence rate of metabolic disturbance. Whether BDII itself, in addition to its current standard treatment, is a risk factor for metabolic syndrome warrants additional study. The dopamine receptor D3 (DRD3) gene, one of the candidate genes for BDII, is also involved in the dopaminergic system. We investigated whether it is related to changes in the metabolic indices of patients with BDII given 12 weeks of standard treatment.Patients with a first diagnosis of BDII (n = 117) were recruited. Metabolic profiles (cholesterol, triglycerides, fasting serum glucose, body mass index) were measured at baseline and at 2, 8, and 12 weeks. The genotype of the DRD3 Ser9Gly polymorphism (rs6280) was determined. Multiple linear regressions with generalized estimating equation methods were used.Seventy-six (65.0%) patients completed the 12-week intervention. Significant differences in triglyceride change were associated with the DRD3 Ser9Gly genotype (P = 0.03). Patients with the Ser/Ser genotype had significantly smaller triglyceride increases and a lower risk of developing metabolic syndrome than did those with the Ser/Gly+Gly/Gly genotype. However, the associations between the DRD3 Ser9Gly polymorphism with changes in triglyceride level become nonsignificant after correcting for multiple comparisons.We conclude that the DRD3 Ser9Gly polymorphism is nominally associated with changes in triglycerides and metabolic syndrome after 12 weeks of standard BDII treatment.

A Case in the Bipolar Spectrum

It has been reported that the correct diagnosis and treatment are delayed when subsyndromal bipolar mood disorder symptoms are overlooked. Patients in this spectrum are reported to have a diminished level of functioning, and these patients fail to accept their diagnosis; therefore, there is a low level of treatment adherence. This case report focuses on the diagnosis and treatment of a patient in the bipolar spectrum.

Discriminating Between Bipolar Disorder and Major Depressive Disorder

Rates of misdiagnosis between major depressive disorder and bipolar disorder have been reported to be substantial, and the consequence of such misdiagnosis is likely to be a delay in achieving effective control of symptoms, in some cases spanning many years. Particularly in the midst of a depressive episode, or early in the illness course, it may be challenging to distinguish the 2 mood disorders purely on the basis of cross-sectional features. To date, no useful biological markers have been reliably shown to distinguish between bipolar disorder and major depressive disorder.

Prevalence and correlates of bipolar disorders in patients with eating disorders

BACKGROUND

To investigate the prevalence and correlates of bipolar disorders in patients with eating disorders (EDs), and to examine differences in effects between major depressive disorder and bipolar disorder on these patients.

METHODS

Sequential attendees were invited to participate in a two-phase survey for EDs at the general psychiatric outpatient clinics. Patients diagnosed with EDs (n=288) and controls of comparable age, sex, and educational level (n=81) were invited to receive structured interviews for psychiatric co-morbidities, suicide risks, and functional level. All participants also completed several self-administered questionnaires assessing general and eating-related pathology and impulsivity. Characteristics were compared between the control, ED-only, ED with major depressive disorder, and ED with bipolar disorder groups.

RESULTS

Patients with all ED subtypes had significantly higher rates of major depressive disorder (range, 41.3-66.7%) and bipolar disorder (range, 16.7-49.3%) than controls did. Compared to patients with only EDs, patients with comorbid bipolar disorder and those with comorbid major depressive disorder had significantly increased suicidality and functional impairments. Moreover, the group with comorbid bipolar disorder had increased risks of weight dysregulation, more impulsive behaviors, and higher rates of psychiatric comorbidities.

LIMITATIONS

Participants were selected in a tertiary center of a non-Western country and the sample size of individuals with bipolar disorder in some ED subtypes was small.

CONCLUSION

Bipolar disorders were common in patients with EDs. Careful differentiation between bipolar disorder and major depressive disorder in patients with EDs may help predict associated psychopathology and provide accurate treatment.

A potential interaction between COMT and MTHFR genetic variants in Han Chinese patients with bipolar II disorder

Bipolar II disorder (BP-II), characterized by recurrent dysregulation of mood, is a serious and chronic psychiatric illness. However, BP-II is commonly under-recognized, even in psychiatric settings. Because dopaminergic disturbance is thought to be involved in the development of bipolar disorder (BPD), it seems essential to investigate dopamine-related genes like the catechol-O-methyltransferase (COMT) gene, which are involved in dopamine metabolism, and the methylenetetrahydrofolate reductase (MTHFR) gene, which may affect COMT methylation and COMT function. The current study examined the association and interaction of the COMT Val158Met and MTHFR C677T variants with BP-II. Nine hundred seventy-eight participants were recruited: 531 with BP-II and 447 healthy controls. The genotypes of the COMT and MTHFR polymorphisms were determined using a polymerase chain reaction-restriction fragment length polymorphism analysis. Logistic regression analysis showed a significant interaction effect of the COMT Val158Met Val/Val genotype and the MTHFR C677T C/T + T/T genotype (P = 0.039) for the protective effect on the odds of developing BP-II. Our findings support preliminary evidence that the COMT and MTHFR genes interact in BP-II, and they imply the connection of both dopaminergic pathways and methylation pathways in the pathogenesis of BP-II.

Neuropsychological performance of patients with soft bipolar spectrum disorders

OBJECTIVES

There is much evidence that shows that a substantial number of individuals with DSM-IV-defined unipolar depression (UP) manifest hypomanic sub-syndrome and bipolar diathesis. Other definitions have conceptualized the term soft bipolar spectrum (SBP) for these individuals. Little is known about the cognitive profiles of individuals with SBP. We hypothesized that they are representative of individuals with bipolar II disorder and are different from that of 'strict' UP.

METHODS

Consecutive referrals suffering major depressive episodes were categorically assigned to groups of either bipolar I disorder (n = 98), bipolar II disorder (n = 138), or UP (n = 300). Based on the SBP criteria by Akiskal and Pinto (17), patients with UP were subdivided into 81 SBP and 219 strict UP. We administered self- and clinician-administered scales to evaluate affective temperaments, and neuropsychological tests to assess seven cognitive domains.

RESULTS

Patients with SBP performed significantly better than strict UP patients in the domains of processing speed (p = 0.002), visual-spatial memory (p = 0.017), and verbal working memory (p = 0.017). Compared to patients with bipolar I disorder, patients with SBP were significantly better in set shifting (p < 0.001) and visual-spatial memory (p = 0.042). Patients with SBP performed similarly to patients with bipolar II disorder in all of the cognitive domains tested (p > 0.05). There was a group × cognitive domain interaction effect between bipolar I disorder, bipolar II disorder, SBP, and strict UP groups [Pillai's F = 2.231, df = (18,1437), p = 0.002].

CONCLUSIONS

Our data suggest that patients with SBP differ from patients with UP not only in external validators (e.g., family history of bipolar disorder) and hypomanic symptoms, but also in neuropsychological performance and that the profiles of cognitive functioning were different across bipolar I disorder and 'bipolar II spectrum' that subsumes bipolar II disorder and SBP.

Correlation of plasma brain-derived neurotrophic factor and metabolic profiles in drug-naïve patients with bipolar II disorder after a twelve-week pharmacological intervention

OBJECTIVE

Brain-derived neurotrophic factor (BDNF) is thought to be involved in the pathophysiology of bipolar disorder (BD) and metabolic syndrome. We investigated the correlation between plasma BDNF with mood symptoms and metabolic indices in patients with BD-II over a 12-week pharmacological intervention.

METHOD

Drug-naïve patients with BD-II (n=117) were recruited. Metabolic profiles [cholesterol, triglyceride, HbA1C, fasting serum glucose, body mass index (BMI)] and plasma BDNF wtrun "tblautotrun "tblsctrun "tbl_contere measured at baseline and 2, 8, and 12 weeks after beginning medication. To adjust within-subject dependence over repeated assessments, multiple linear regressions with generalized estimating equation methods were used.

RESULTS

Seventy-six (65.0%) patients completed the intervention. Plasma BDNF levels were significantly associated with BMI (P=9.6E-5), low-density lipoprotein (P=0.034) and total (P=0.001) cholesterol, but not with the Hamilton Depression Rating Scale-17 and Young Mania Rating Scale scores over the 12-week treatment.

CONCLUSION

We found initial evidence of a positive correlation between plasma BDNF levels and BMI, low-density lipoprotein and total cholesterol in drug-naïve patients with BD-II. The specific function of BDNF in regulating and maintaining peripheral metabolic health requires additional investigation.

Comorbid bipolar disorder and borderline personality disorder and substance use disorder

Bipolar disorder (BD) and borderline personality disorder (BPD) are disabling and life-threatening conditions. Both disorders share relevant comorbidities, particularly the risk of having a lifetime substance use disorder (SUD). We tested the hypothesis that patients with both BD type I (BDI) or II (BDII) and BPD would have a higher rate of SUD than would patients with either disorder alone. A total of 3651 psychiatric patients were evaluated with semistructured diagnostic interviews for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, axis I and II disorders. A total of 63 patients were diagnosed with both BD and BPD, and these patients were significantly more likely to have a SUD compared with BDII patients without BPD (76% vs. 50%, χ = 9.69, p < 0.01). There were no differences when comparing the comorbid group with BPD patients without BD (76% vs. 71%, χ = 0.519, p = 0.4). The present study shows the importance of taking both BPD and BD into consideration insofar as the co-occurrence of the disorders increased the risk of having a SUD especially when compared with BDII alone.

The Hypomania Checklist (HCL) - systematic review of its properties to screen for bipolar disorders

OBJECTIVE

Bipolar disorders (BDs) are often not recognised with potentially drastic consequences for the individuals and their families. In clinical practice self-reports can be used to screen to enhance recognition. We therefore present a systematic review of the screening properties for the Hypomania Checklist (HCL-32).

METHODS

A systematic literature search was conducted to identify all relevant studies looking at the screening properties of the HCL-32 in adults.

RESULTS

Out of 196 papers 21 papers reported data on 22 independent samples. We narratively reviewed these studies. Weighted estimated Sensitivity was 80% regardless of whether a BD diagnosis was compared to unipolar depression or any other non-bipolar diagnosis. Specificity indicated that the HCL-32 was better when comparing BD to unipolar depression (65.3%) than to any other diagnostic category (57.3%). Fewer studies provided estimates for predictive powers, leading to less reliable overall estimates for these indicators.

CONCLUSIONS

Despite some limitations, using the HCL-32 as a first screening in patients seeking help for depression can be recommended, but should never be used on its own for diagnosing. Future research should examine whether screening properties can be improved by developing an algorithm incorporating the negative consequences reported for different areas in the HCL-32.

The effects of add-on low-dose memantine on cytokine levels in bipolar II depression: a 12-week double-blind, randomized controlled trial

Memantine, a noncompetitive N-methyl-d-aspartate receptor antagonist with a mood-stabilizing effect, and an association between bipolar disorder and proinflammatory cytokine levels have been reported. Whether adding-on memantine would reduce cytokine levels and is more effective than valproic acid (VPA) alone in bipolar II disorder was investigated. A randomized, double-blind, controlled, 12-week study was conducted. Patients undergoing regular VPA treatments were randomly assigned to a group: VPA + memantine (5 mg/d) (n = 106) or VPA + placebo (n = 108). The Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) were used to evaluate clinical response. Symptom severity, plasma tumor necrosis factor α (TNF-α), interleukin 6 (IL-6), IL-8, and IL-1 levels were examined during weeks 0, 1, 2, 4, 8, and 12. To adjust within-subject dependence over repeated assessments, multiple linear regressions with generalized estimating equation methods were used to examine the therapeutic effect. Tumor necrosis factor α levels were significantly lower in the VPA + memantine group than in the VPA + placebo group (P = 0.013). Posttreatment HDRS and YMRS scores decreased significantly in both groups, but not significant, nor was the other between-group cytokine level difference pretreatment and posttreatment. The HDRS score changes were significantly associated with IL-6 (P = 0.012) and IL-1 (P = 0.005) level changes and changes in YMRS score changes with TNF-α (P = 0.005) level changes. Treating bipolar II depression with VPA + memantine may improve the plasma TNF-α level. However, adding-on memantine may not improve clinical symptoms or cytokine levels other than TNF-α. Clinical symptoms may be correlated with certain cytokines.

The use of 15-point hypomanic checklist in differentiating bipolar I and bipolar II disorder from major depressive disorder

OBJECTIVES

Individuals with bipolar disorder (BP) are often misdiagnosed with major depressive disorder (MDD). In this study, we developed a Chinese version of 15-point hypomania scale (HCL-15) in order to determine its sensitivity and specificity in the diagnosis of BP and BP-II in particular.

METHODS

A total of 623 individuals suffering a major depressive episode (MDE) were systematically interviewed with both Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Patient Edition, and HCL-15. A cutoff score of 8 or more in HCL-15 was suggested for BP.

RESULTS

Of the 623 depressed patients, 115 (18.5%) actually required a diagnosis of BP-I, and another 159 (25.5%) could be more appropriately diagnosed with BP-II, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. The sensitivity of 15-HCL in detection of BP-II was 0.78 and 0.46 for BP-I; the specificity was 0.9 and 0.69, respectively. The specificity of HCL-15 for BP versus MDD was as high as 0.93. Approximately 60%-80% of all questions in the HCL-15 questionnaire revealed positive responses from patients, while items 11 and 12, measuring the consumption of alcohol, coffee and cigarettes, demonstrated a low positive response rate.

CONCLUSIONS

The HCL-15 assessment scale was fairly sensitive and highly specific for a BP-II diagnosis but not for a BP-I diagnosis. Some items in the HCL-15 symptom list need to be further modified to better fit Chinese culture and customs. The HCL-15 scale could be a useful tool in clinical practice for screening individuals with BP-II in order to avoid a misdiagnosis of MDD.

Genotype variant associated with add-on memantine in bipolar II disorder

Memantine is a non-competitive N-methyl-d-asparate (NMDA) receptor antagonist with a mood-stabilizing effect. We investigated whether using valproic acid (VPA) plus add-on memantine to treat bipolar II disorder (BP-II) is more effective than using VPA alone (VPA + Pbo). We also evaluated, in BP-II patients, the association between the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism with treatment response to VPA + add-on memantine and to VPA + Pbo. In this randomized, double-blind, controlled 12 wk study, BP-II patients undergoing regular VPA treatments were randomly assigned to a group: VPA + Memantine (5 mg/day) (n = 115) or VPA + Pbo (n = 117). The Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) were used to evaluate clinical response during week 0, 1, 2, 4, 8 and 12. The genotypes of the BDNF Val66Met polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis. To adjust within-subject dependence over repeated assessments, multiple linear regression with generalized estimating equation methods was used to analyze the effects of the BDNF Val66Met polymorphism on the clinical performance of memantine. Both groups showed significantly decreased YMRS and HDRS scores after 12 wk of treatment; the differences between groups were non-significant. When stratified by the BDNF Val66Met genotypes, significantly greater decreases in HDRS scores were found in the VPA + memantine group in patients with the Val Met genotype (p = 0.004). We conclude that the BDNF Val66Met polymorphism influenced responses to add-on memantine by decreasing depressive symptoms in patients with BP-II.

Subjective experience of thought overactivation in mood disorders: beyond racing and crowded thoughts

BACKGROUND

Racing thoughts, crowded thoughts and flight of ideas are frequent symptoms in mood disorders, but the underlying subjective experience of overactivation of thought processes remains poorly documented.

METHODS

Qualitative analysis of audiotaped interviews explored subjective experience of thought overactivation in patients with mood disorders (sample 1, n = 45). Quantitative analysis considered the properties of a newly developed rating scale in sample 1, in an additional sample of patients with mood disorders (sample 2, n = 37) and in healthy subjects (sample 3, n = 38).

RESULTS

Qualitative analysis of individual interviews revealed that 5 conceptual categories characterized thought overactivation: sequential thought flow, overstimulation, competition for resource allocation, unexpected/unexplained onset, and association with mood and emotions. A principal component analysis of the initial 16-item rating scale indicated that a single component explained 55.9% of the variance, with major and exclusive contributions from 9 items, which were retained in the final 9-item Subjective Thought Overactivation Questionnaire (STOQ; Cronbach's α = 0.95). Total score correlated significantly with activation, depression and perceived conflict subscales of the Internal State Scale (ISS; rs = 0.57-0.66, p < 0.001). It was associated with decreased well-being (ISS; rs = -0.48, p = 0.001) and increased state anxiety (State-Trait Anxiety Inventory; rs = 0.60, p < 0.001). The STOQ score was significantly higher in patients than in healthy subjects. It allowed distinguishing between ISS mood states, with the highest median score in mixed states.

LIMITATIONS

Sample size, representativeness, possible bias in qualitative analysis, and quality of expert consensus.

CONCLUSIONS

Qualitative analysis of clinical interviews, together with a new short rating scale, contributed to a documentation of subjective thought overactivation, an important but often undetected feature in mood disorders.

Add-on memantine to valproate treatment increased HDL-C in bipolar II disorder

Memantine is a noncompetitive NMDA receptor antagonist. As an augmenting agent, it has an antidepressant-like and mood-stabilizing effect. Memantine also reduces binge eating episodes and weight. We investigated whether memantine added on to valproate (VPA) is more effective than VPA alone for treating BP-II depression and improving the patient's metabolic profile. This was a randomized, double-blind, controlled study. BP-II patients undergoing regular VPA treatments were randomly assigned to one of two groups: VPA plus either add-on [1] memantine (5 mg/day) (n = 62) or [2] placebo (n = 73) for 12 weeks. The Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale (HDRS) were used to evaluate clinical response. Height, weight, fasting serum glucose, fasting total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides were followed regularly. Multiple linear regressions with generalized estimating equation methods were used to analyze the effects of memantine on clinical performance. There were no significant differences in pre- and post-treatment YMRS and HDRS scores between the VPA + memantine and VPA + placebo groups. Although there were no significant differences in the pre- and post-treatment values of most metabolic indices between the two groups, there was a significant increase of HDL-C (p = 0.009) in the VPA + memantine group compared with the VPA + placebo group. This increase remained significant even after controlling for body mass index (BMI) (p = 0.020). We conclude that add-on memantine plus VPA treatment of BP-II depression increases the blood level of HDL-C even in the absence of change in affective symptoms.

TRIAL REGISTRATION

NCT01188148 (https://register.clinicaltrials.gov/), Trial date was from 1st August, 2008 to 31st July, 2012 in National Cheng Kung University and Tri-Service General Hospital.

Inflammation's Association with Metabolic Profiles before and after a Twelve-Week Clinical Trial in Drug-Naïve Patients with Bipolar II Disorder

Inflammation is thought to be involved in the pathophysiology of bipolar disorder (BP) and metabolic syndrome. Prior studies evaluated the association between metabolic profiles and cytokines only during certain mood states instead of their changes during treatment. We enrolled drug-naïve patients with BP-II and investigated the correlation between changes in mood symptoms and metabolic indices with changes in plasma cytokine levels after 12 weeks of pharmacological treatment. Drug-naïve patients (n = 117) diagnosed with BP-II according to DSM-IV criteria were recruited. Metabolic profiles (cholesterol, triglyceride, HbA1C, fasting serum glucose, body mass index (BMI) and plasma cytokines (TNF-α, CRP, IL-6, and TGF-β) were measured at baseline and 2, 8, and 12 weeks post-treatment. To adjust within-subject dependence over repeated assessments, multiple linear regressions with generalized estimating equation methods were used. Seventy-six (65.0%) patients completed the intervention. Changes in plasma CRP were significantly associated with changes in BMI (P = 1.7E-7) and triglyceride (P = 0.005) levels. Changes in plasma TGF-β1 were significantly associated with changes in BMI (P = 8.2E-6), cholesterol (P = 0.004), and triglyceride (P = 0.006) levels. However, changes in plasma TNF-α and IL-6 were not associated with changes in any of the metabolic indices. Changes in Hamilton Depression Rating Scale scores were significantly associated with changes in IL-6 (P = 0.003) levels; changes in Young Mania Rating Scale scores were significantly associated with changes in CRP (P = 0.006) and TNF-α (P = 0.039) levels. Plasma CRP and TGF-β1 levels were positively correlated with several metabolic indices in BP-II after 12 weeks of pharmacological intervention. We also hypothesize that clinical symptoms are correlated with certain cytokines. These new findings might be important evidence that inflammation is the pathophysiology of clinical symptoms and metabolic disturbance in BP-II.

Trial Registration

ClinicalTrials.gov NCT01188148.

The relationship between childhood parental loss and metabolic syndrome in obese subjects

The increasing global trend of obesity is a fundamental contributor to the growing prevalence of metabolic syndrome, a cluster of medical abnormalities including impaired glucose and lipid metabolism, obesity and hypertension. Results from animal and human investigations have shown that early life stress can result in weight gain and metabolic changes. Our aim is to investigate whether a particular type of an early adverse event, i.e. parental loss during childhood, is associated with the development of metabolic syndrome in severely obese subjects. One hundred thirty-five consecutive obese patients who were seeking bariatric surgery were assessed for metabolic syndrome according to the Adult Treatment Panel (ATP) III criteria. Information regarding the experience of parental separation or bereavement before the age of 17 was collected with the use of a semi-structured interview. In our population, 31.1% of the subjects met the criteria for metabolic syndrome. No significant differences in demographic factors, health habits or psychiatric diagnosis were found between patients with and without coexisting metabolic syndrome. After adjusting for age and gender, multivariate logistic regression analysis revealed that both childhood loss of a parent and a body mass index (BMI) value greater than 50 were significant predictors of metabolic syndrome. This study provides preliminary evidence linking childhood parental loss to risk factors for the development of metabolic syndrome.

Cross validation with the mood disorder questionnaire (MDQ) of an instrument for the detection of hypomania in Brazil: The 32 item hypomania symptom check-list, first Revision (HCI-32-R1)

BACKGROUND

Bipolar disorders are frequently diagnosed and treated as unipolar depression initially and accurate diagnosis is often delayed by 8 to 10years. It has been demonstrated that the bipolar spectrum disorders are associated with notable disability and that the current diagnostic gold standard, the Structured Clinical Interview for DSM-IV (SCID) is not sufficiently sensitive to the diagnosis of hypomania or subthreshold manic states. There is a need for better and simpler ways to identify these conditions.

METHODS

Hirschfeld et al. (2000) developed and tested a self-report scale for bipolar disorder: the Mood Disorder Questionnaire (MDQ). Recently, another scale has been developed by Angst to assess hypomanic symptoms and to increase the detection of suspected and of manifest, but undertreated, cases of bipolar disorders. In this Brazilian study, 200 patients with the putative diagnosis of "depression" were interviewed using the Structured Clinical Interview for DSM-IV, Axis I Disorders - Clinician Version (SCID-CV; First et al., 1997), as modified by Benazzi and Akiskal (2003) to increase the sensitivity to BP II disorders. Before the interview patients were screened by both HCI-32-R(1) and MDQ and asked to complete them.

RESULTS

The HCI-32-R(1) showed a sensitivity of 79.8% and a specificity of 60.5% for the cut-off of 14. A sensitivity of 68.1% and a specificity of 63% were obtained for the Mood Disorder Questionnaire for the cut-off of 7.

LIMITATIONS

Although not showing a good specificity, the MDQ seems to be a useful instrument for the screening phase, in which it is important that "cases" are recognized. The HCI-32-R(1) does not distinguish between BP I and BP II disorders. The sample size of patients should be increased in further studies.

CONCLUSIONS

The HCI-32-R(1) demonstrated two main factors identified as "active-elated" hypomania and "risk-taking/irritable" hypomania and showed to be a sensitive instrument for hypomanic symptoms. It is a simple and easy-to-use tool for the self-assessment of hypomanic symptoms and may be a valuable supplement to the clinician's interview. The Mood Disorder Questionnaire is a useful screening instrument for bipolar I, bipolar II disorders and other manifestations of bipolar spectrum. As such, this scale might increase the detection of under-treated cases of bipolar disorders. Further studies are needed to verify the accuracy of these tools in non-psychiatric settings and in the general population.

COMT and BDNF interacted in bipolar II disorder not comorbid with anxiety disorder

Bipolar disorder (BP), especially bipolar II disorder (BP-II), is highly comorbid with anxiety disorder (AD). Monoaminergic dysfunction has been implicated in the pathogenesis of BP, it may be important to investigate genes such as the catechol-O-methyltransferase (COMT), involved in monoamine metabolism and brain-derived neurotrophic factor (BDNF) genes, modulating the monoamine system. We therefore examined the association of the COMT Val158Met and BDNF Val66Met polymorphisms with BP-II with and without comorbidity of AD, and possible interactions between these genes. Seven hundred and seventy-one participants were recruited: 314 with bipolar-II without AD, 117 with bipolar-II with AD, and 340 healthy controls. The genotypes of the COMT and BDNF polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis. Logistic regression analysis showed a significant effect of the COMT and the BDNF polymorphisms, and a significant interaction effect for the Val/Val genotypes of the BDNF Val66Met polymorphism and the COMsT Val158Met Val/Met and Met/Met genotypes (P=0.007, 0.048) discriminated between BP-II without AD patients and controls. Our findings provide initial evidence that the COMT and BDNF genes interact in bipolar-II without AD. Our findings suggest the involvement of dopaminergic pathway in the pathogenesis of bipolar-II.

Brazilian Portuguese validation of Mood Disorder Questionnaire

BACKGROUND

The Mood Disorder Questionnaire (MDQ) is a screening instrument for bipolar spectrum disorders already validated in many languages.

METHODS

Patients from 2 psychiatric outpatient facilities were diagnosed with bipolar disorder (BD) type I and II and major depression according to the mood module of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID), Axis I Disorders--Clinician Version. In addition, a control group of healthy subjects was selected. The diagnostic interviews were used as the gold standard against which to investigate the performance of the MDQ. The MDQ was administered to 153 subjects, distributed among 4 groups. We analyzed the test reliability and discriminative capacity of the MDQ for the detection of patients with BD.

RESULTS

Based on the SCID, Axis I Disorders--Clinician Version, 52 subjects (33.3%) presented a bipolar spectrum disorder (type I, II, or not otherwise specified), 48 (32.4%) were diagnosed as having unipolar depressive disorder, whereas 54 (35.3%) were unaffected by any type of psychiatric disorder (had no psychiatric disorder according to SCID results). The sensitivity for bipolar disorder was 0.72 (bipolar I disorder, 0.81; bipolar II disorder, 0.58; and bipolar disorder not otherwise specified, 0.69), with specificity of 0.95. The Brazilian Portuguese MDQ demonstrated adequate internal consistency (Cronbach α = .87).

LIMITATIONS

Recruiting patients attending tertiary services may inflate the performance of the MDQ.

CONCLUSIONS

The performance of the Brazilian Portuguese MDQ is comparable with other language validations. In a psychiatric outpatient sample, the Brazilian Portuguese MDQ proves to be a feasible and reliable screening instrument.

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

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

Subthreshold bipolarity: diagnostic issues and challenges

BACKGROUND

Research suggests that current diagnostic criteria for bipolar disorders may fail to include milder, but clinically significant, bipolar syndromes and that a substantial percentage of these conditions are diagnosed, by default, as unipolar major depression. Accordingly, a number of researchers have argued for the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to better account for subsyndromal hypomanic presentations.

METHODS

The present paper is a critical review of research on subthreshold bipolarity, and an assessment of some of the challenges that researchers and clinicians might face if the DSM-5 were designed to systematically document subsyndromal hypomanic presentations.

RESULTS

Individuals with major depressive disorder (MDD) who display subsyndromal hypomanic features, not concurrent with a major depressive episode, have a more severe course compared to individuals with MDD and no hypomanic features, and more closely resemble individuals with bipolar disorder on a number of clinical validators.

CONCLUSION

There are clinical and scientific reasons for systematically documenting subsyndromal hypomanic presentations in the assessment and diagnosis of mood disorders. However, these benefits are balanced with important challenges, including (i) the difficulty in reliably identifying subsyndromal hypomanic presentations, (ii) operationalizing subthreshold bipolarity, (iii) differentiating subthreshold bipolarity from borderline personality disorder, (iv) the risk of over-diagnosing bipolar spectrum disorders, and (v) uncertainties about optimal interventions for subthreshold bipolarity.

Childhood parental loss and bipolar spectrum in obese bariatric surgery candidates

BACKGROUND

Early adverse experiences such as sexual, verbal, or physical abuse and parental neglect have been associated with a higher risk of weight or eating problems in adulthood, and death or prolonged separation from parents during childhood has been implicated as a correlate of adult psychiatric disorders that are widely represented in obese subjects seeking bariatric surgery.

OBJECTIVE

The aim of this study was to examine the rate of childhood parental loss in obese bariatric surgery candidates and explore its association with a psychiatric diagnosis and clinical and weight/eating-related characteristics.

METHODS

The current and lifetime psychiatric diagnoses of 120 consecutive bariatric patients undergoing pre-surgical psychiatric consultation were assessed using a modified version of the Structured Clinical Interview for DSM-IV (SCID-CV), and information relating to parental death or separation before the age of 17 years was collected using a semi-structured interview. The rate of childhood parental loss was compared with that of an always slender population sharing the same psychiatric diagnosis.

RESULTS

91.7% of the obese subjects were diagnosed as having a bipolar spectrum disorder. Overall, 28% of the patients reported a childhood parental death or separation. Early parental loss was not equally distributed in the different diagnostic subgroups, being more frequent in those with bipolar II disorders; the always slender subjects with bipolar II disorders showed a lower rate of early parental loss.

CONCLUSIONS

The study findings confirm the association between obesity and bipolar disorders and suggest that early parental loss may play a role in the development of obesity in bipolar II subjects.

The comorbidity of anxiety disorders in bipolar I and bipolar II patients among Turkish population

High rates of anxiety disorders have been reported in bipolar disorders. The study aimed to investigate prevalence of anxiety disorders in remitted bipolar subjects and their influence on the illness severity. Bipolar subjects with anxiety disorders were younger, had earlier age at onset of illness, and were overrepresented by female subjects and those with earlier onset illness compared to those without anxiety disorder. The study demonstrated that (1) anxiety disorders are highly prevalent in bipolar subjects, (2) individual anxiety disorders, particularly SP and PD seem to have an effect on illness severity, (3) bipolar subjects with comorbid anxiety tend to have a poorer course and are less responsive to treatment, and (4) anxiety tends to be associated with an earlier age at onset of bipolar disorder (BPD) and results in a more complicated and severe disease course.

Reliability and validity of a Chinese version of the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF-C)

AIM AND OBJECTIVES

To examine the psychometric properties of the Chinese version of the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF-C) for use in Chinese-speaking countries.

BACKGROUND

The assessment of fatigue is a challenging task for most researchers because culture may influence perceptions of meaning of fatigue. The lack of examination of the psychometric properties of the fatigue measures across studies limits the scientific rigour for generating additional research on the concept of 'fatigue.'

DESIGN

A cross-sectional study.

METHODS

The study recruited 107 cancer inpatients from two medical centres in Taiwan. The MFSI-SF-C was examined using a two step process: (1) Translation and back-translation of the instrument; and (2) Examination of internal consistency reliability, test-retest reliability, content validity and construct validity.

RESULTS

The results showed that the Cronbach's α of MFSI-SF-C total scale and subscales ranged between 0·83-0·92. The content validity index was 0·93. The difference between the fatigue of cancer patients and the comparison group of healthy people in the community was significant. The results demonstrated good convergent validity when comparing fatigue with depression and quality of life. Factor analysis confirmed the four dimensions of fatigue: physical, emotional, mental and vigour. It showed moderate intercorrelation between subscales and high factor loadings also helped to clarify the psychometric meaning.

CONCLUSIONS

The reliability and validity information presented in this article support the use of the Chinese version of the MFSI-SF as a research instrument for measuring fatigue in Chinese populations. This study also provides evidence that the MFSI-SF possesses robust psychometric properties.

RELEVANCE TO CLINICAL PRACTICE

The MFSI-SF-C is an effective and comprehensive tool for measuring fatigue in Chinese patients with cancer.

Management of Bipolar II Disorder

Bipolar II disorder (BP II) disorder was recognized as a distinct subtype in the DSM-IV classification. DSM-IV criteria for BP II require the presence or history of one or more major depressive episode, plus at least one hypomanic episode, which, by definition, must last for at least 4 days. Various studies found distinct patterns of symptoms and familial inheritance for BP II disorder. BP II is commonly underdiagnosed or misdiagnosed. Making an early and accurate diagnosis of BP II is utmost importance in the management of BP II disorder. The clinician should have this diagnosis in mind when he is facing a patient presenting with mood problems, particularly unipolar depression. Quetiapine and lamotrigine are the only agents with demonstrated efficacy in double-blind RCT. Although the evidence for the use of lithium in long-term therapy is largely based on observational studies, the many years of close follow-up, comparatively larger subject numbers, and 'harder' clinically meaningful with bipolar disorder outcomes measures, enhance our confidence in its role in treating BP II. With respect to short-term treatment, there is some limited support for the use of risperidone and olanzepine in hypomania and for fluoxetine, venlafaxine and valproate in treating depression. The current clinical debate over whether one should use antidepressants as monotherapy or in combination with a mood stabilizer when treating BP II depression is not yet settled. There is a need for large, well-designed RCTs to cast more definitive light on how best to manage patients with BP II disorder.