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Choi WJ, Woo YS, Choi WS, Lee J, Bahk WM. Defining "High Recurrence" of Depressive Episodes for Predicting Diagnostic Conversion from Major Depressive Disorder to Bipolar Disorder: A 5-year Retrospective Study. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2024; 22:364-369. [PMID: 38627083 PMCID: PMC11024704 DOI: 10.9758/cpn.24.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 04/21/2024]
Abstract
Objective This study determined the threshold for recurrent depressive episodes that predicted conversion from major depressive disorder (MDD) to bipolar disorder (BD). Methods We retrospectively reviewed the medical records of 296 patients diagnosed with MDD for a minimum of 5 years in two university hospitals. We examined their the Diagnostic and Statistical Manual of Mental Disorders, 5th edition diagnoses and detailed clinical information at the initial admission and yearly assessments after discharge to establish the threshold for recurrent depressive episodes indicating a risk of diagnostic conversion from MDD to BD. Optimal cut-offs were derived using receiver operating characteristic (ROC) curves. Results ROC curve analysis revealed that more than four recurrent depressive episodes was indicative of potential diagnostic conversion from MDD to BD (area under the curve, 0.604; sensitivity, 0.353; specificity, 0.855; positive predictive value, 0.421; negative predictive value, 0.816). Conclusion These findings suggest that the best predictor of conversion from MDD to BD is more than four recurrent depressive episodes. Our findings have the potential to enhance diagnostic accuracy and treatment efficiency. To validate our results, longitudinal prospective studies are necessary.
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Affiliation(s)
| | - Young Sup Woo
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won-Seok Choi
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jonghun Lee
- Department of Psychiatry, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Simonetti A, Luciano M, Sampogna G, Rocca BD, Mancuso E, De Fazio P, Di Nicola M, Di Lorenzo G, Pepe M, Sambataro F, Signorelli MS, Koukopoulos AE, Chiaie RD, Fiorillo A, Sani G. Effect of affective temperament on illness characteristics of subjects with bipolar disorder and major depressive disorder. J Affect Disord 2023; 334:227-237. [PMID: 37156280 DOI: 10.1016/j.jad.2023.04.130] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/18/2023] [Accepted: 04/29/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Affective temperaments represent the stable, biologically determined substrates of mood disorders. The relationship between affective temperaments and bipolar disorder (BD) or major depressive disorder (MDD) has been described. However, the strength of such relationship should be tested while considering other factors influencing the diagnosis of BD/MDD. Literature also lacks a comprehensive description of the interplay between affective temperament and characteristics of mood disorders. The aim of the present study is to address these issues. METHODS This is a multicentric observational study including 7 Italian university sites. Five-hundred-fifty-five euthymic subjects with BD/MDD were enrolled and further divided in those with hyperthymic (Hyper, N = 143), cyclothymic (Cyclo, N = 133), irritable (Irr, N = 49), dysthymic (Dysth, N = 155), and anxious (Anx N = 76) temperaments. Linear, binary, ordinal and logistic regressions were performed to assess the association between affective temperaments and i) diagnosis of BD/MDD; ii) characteristics of illness severity and course. RESULTS Hyper, Cyclo and Irr were more likely to be associated with BD, together with earlier age of onset and presence of a first-degree relative with BD. Anx and Dysth were more associated with MDD. Differences in association between affective temperaments and characteristics of BD/MDD were observed for hospital admissions, phase-related psychotic symptoms, length and type of depression, comorbidity and pharmacological intake. LIMITATIONS Small sample size, cross-sectional design, recall biases. CONCLUSION Specific affective temperaments were associated to certain characteristics of illness severity and course of BD or MDD. Evaluation of affective temperaments might help a deeper understanding of mood disorders.
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Affiliation(s)
- Alessio Simonetti
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Mario Luciano
- Department of Psychiatry, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Gaia Sampogna
- Department of Psychiatry, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Bianca Della Rocca
- Department of Psychiatry, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Emiliana Mancuso
- Department of Psychiatry, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Pasquale De Fazio
- Department of Health Sciences, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy
| | - Marco Di Nicola
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giorgio Di Lorenzo
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Maria Pepe
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Fabio Sambataro
- Department of Neuroscience, University of Padova, 35121 Padua, Italy
| | - Maria Salvina Signorelli
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | | | | | - Andrea Fiorillo
- Department of Psychiatry, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Gabriele Sani
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, 00168 Rome, Italy.
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Simonetti A, Bernardi E, Margoni S, Catinari A, Restaino A, Ieritano V, Palazzetti M, Mastrantonio F, Janiri D, Tosato M, Landi F, Sani G. Mixed Depression in the Post-COVID-19 Syndrome: Correlation between Excitatory Symptoms in Depression and Physical Burden after COVID-19. Brain Sci 2023; 13:brainsci13040688. [PMID: 37190653 DOI: 10.3390/brainsci13040688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023] Open
Abstract
The relationship between depression and post-COVID-19 disease syndrome (post-COVID-19 syndrome) is established. Nevertheless, few studies have investigated the association between post-COVID-19 syndrome and mixed depression, i.e., a specific sub-form of depression characterized by high level of excitatory symptoms. Aims of the present study are: (a) to compare the post-COVID-19 syndrome's burden in depressed and non-depressed patients, and (b) to investigate the correlation between post-COVID-19 syndrome's burden and the severity of mixed depression. One thousand and forty six (n = 1460) subjects with post-COVID-19 syndrome were assessed. Subjects were divided into those with (DEP) or without (CONT) depression. Sociodemographically, post-COVID-19 syndrome's symptoms number and type were compared. In DEP, association between levels of excitatory symptoms and the presence of post-COVID-19 syndrome's symptoms were additionally assessed. DEP showed greater percentages of family history of psychiatric disorders than CONT. DEP showed higher percentages of post-COVID-19 symptoms than CONT. A greater level of excitatory symptoms were associated to higher frequencies of post-COVID-19 syndrome' symptoms. Higher levels of post-COVID-19 syndrome's symptoms in DEP corroborate the evidence of a common pathway between these two syndromes. Presence of excitatory symptoms seem to additionally add a greater illness burden. Such findings might help clinicians choose the appropriate treatment for such states. More specifically, therapies aimed to treat excitatory symptoms, such as antipsychotics and mood stabilizers, might help reduce the illness burden in post-COVID-19 patients with mixed depression.
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Affiliation(s)
- Alessio Simonetti
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX 77030, USA
| | - Evelina Bernardi
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Stella Margoni
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonello Catinari
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio Restaino
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Valentina Ieritano
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Marta Palazzetti
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Federico Mastrantonio
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Delfina Janiri
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Matteo Tosato
- Department of Geriatrics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Geriatrics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Francesco Landi
- Department of Geriatrics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Geriatrics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Gabriele Sani
- Department of Neuroscience, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Neurosciences, Section of Psychiatry, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Koukopoulos AE, De Chiara L, Simonetti A, Kotzalidis GD, Janiri D, Manfredi G, Angeletti G, Sani G. The Koukopoulos mixed depression rating scale (KMDRS) and the assessment of mixed symptoms during the perinatal period. J Affect Disord 2021; 281:980-988. [PMID: 33039189 DOI: 10.1016/j.jad.2020.08.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/05/2020] [Accepted: 08/24/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Mixed symptoms in depression may underlie bipolar diathesis rather than unipolarity. Uncovering mixed depression (MxD) is crucial for appropriate management, especially in the perinatal period, as it may affect treatment planning and impact future child development. We used a scale specific for identifying MxD and tested its validity in pregnant and postpartum women with depression. METHODS Women developing a major depressive episode (MDE) during their perinatal period extending from pregnancy to one year postpartum from November-2012 through June-2019 were assessed with BPRS-18, EPDS, CGI-S, GAF, HAM-A, HAM-D, Koukopoulos' Mixed Depression Rating Scale (KMDRS), TEMPS, and YMRS. They were classified, based on KMDRS criteria, as with mixed (MxD) or without (nonMxD) mixed symptoms. We conducted ROC analysis and performed factor analysis of the KMDRS. RESULTS Of 45 included, MxD (N = 19) were biased towards diagnosis of bipolar disorder and nonMxD (N = 26) towards major depressive disorder. Other sociodemographic variables did not differ significantly between MxD and nonMxD. MxD scored higher on total YMRS, BPRS, and KMDRS, and on KMDRS-6 Subjective Feelings of Irritability and KMDRS-12 Suicidal Impulsiveness items. The KMDRS correlated in the entire sample, in MxD and nonMxD, with the YMRS and the BPRS, while correlating with the HAM-D in nonMxD only. The KMDRS showed acceptable AUC distribution, with a 68% sensitivity and 58% specificity. Best-fit was three-factor-structure, explaining 54.66% of cumulative variance. LIMITATIONS Small sample and cross-sectional design. CONCLUSIONS The KMDRS is fit for investigating MxD along with the YMRS and the BPRS in perinatal women with a MDE.
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Affiliation(s)
- Alexia E Koukopoulos
- Azienda Ospedaliera Universitaria Policlinico Umberto I, Viale dell'Università 30, Rome 00185, Italy; Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy.
| | - Lavinia De Chiara
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy; Center for Prevention and Treatment of Women's Mental Health at Sant'Andrea Hospital of Rome, Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy
| | - Alessio Simonetti
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy; Department of Human Neurosciences, Sapienza University, Viale dell'Università 30, Rome 00185, Italy; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Georgios D Kotzalidis
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy; Center for Prevention and Treatment of Women's Mental Health at Sant'Andrea Hospital of Rome, Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy
| | - Delfina Janiri
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Department of Human Neurosciences, Sapienza University, Viale dell'Università 30, Rome 00185, Italy
| | - Giovanni Manfredi
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Center for Prevention and Treatment of Women's Mental Health at Sant'Andrea Hospital of Rome, Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy; UOC Psichiatria, Day Hospital, Azienda Ospedaliera-Universitaria Sant'Andrea, Via di Grottarossa 1035-1039, Rome 00189, Italy
| | - Gloria Angeletti
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy; Center for Prevention and Treatment of Women's Mental Health at Sant'Andrea Hospital of Rome, Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy
| | - Gabriele Sani
- Departmentof Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Rome 00168, Italy; Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
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Fiedorowicz JG, Persons JE, Assari S, Ostacher MJ, Goes FS, Nurnberger JI, Coryell WH. Moderators of the association between depressive, manic, and mixed mood symptoms and suicidal ideation and behavior: An analysis of the National Network of Depression Centers Mood Outcomes Program. J Affect Disord 2021; 281:623-630. [PMID: 33234283 PMCID: PMC7855874 DOI: 10.1016/j.jad.2020.11.101] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND It has not been established that suicide risk with mixed symptoms is any greater than the depressive component or if there is synergy between depressive and manic symptoms in conveying suicide risk. METHODS The National Network of Depression Centers Mood Outcomes Program collected data from measurement-based care for 17,179 visits from 6,105 unique individuals with clinically diagnosed mood disorders (998 bipolar disorder, 5,117 major depression). The Patient Health Questionaire-8 (PHQ-8) captured depressive symptoms and the Altman Self-Rating Mania scale (ASRM) measured hypomanic/manic symptoms. Generalized linear mixed models assessed associations between depressive symptoms, manic symptoms, and their interaction (to test for synergistic effects of mixed symptoms) on the primary outcome of suicidal ideation or behavior (secondarily suicidal behavior only) from the Columbia-Suicide Severity Rating Scale (C-SSRS). Moderation was assessed. RESULTS PHQ-8 scores were strongly associated with suicide-related outcomes across diagnoses. ASRM scores showed no association with suicidal ideation/behavior in bipolar disorder and an inverse association in major depression. There was no evidence of synergy between depressive and manic symptoms. There was no moderation by sex, race, or mood disorder polarity. Those over 55 years of age showed a protective effect of manic symptoms, which was lost when depressive symptoms were also present (mixed symptoms). DISCUSSION Mixed depressive and manic symptoms convey no excess risk of suicidal ideation or behavior beyond the risk conveyed by the depressive symptoms alone. Depressive symptoms are strongly linked to suicidal ideation and suicidal behavior and represent an important and potentially modifiable risk factor for suicide.
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Affiliation(s)
- Jess G. Fiedorowicz
- Department of Psychiatry, University of Ottawa, Department of Mental Health, The Ottawa Hospital Ottawa, ON, Canada
| | - Jane E. Persons
- Roy J. and Lucille A. Carver College of Medicine The University of Iowa, Iowa City, IA, USA
| | - Shervin Assari
- Department of Family Medicine Charles R, Drew University, Los Angeles, CA, USA.
| | - Michael J. Ostacher
- Bipolar Disorder & Depression Research Program VA Palo Alto Health System, Palo Alto, CA, USA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Fernando S. Goes
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, Baltimore, MD, USA
| | - John I. Nurnberger
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
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Benazzi F. Reviewing the diagnostic validity and utility of mixed depression (depressive mixed states). Eur Psychiatry 2020; 23:40-8. [PMID: 17764909 DOI: 10.1016/j.eurpsy.2007.07.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Revised: 07/15/2007] [Accepted: 07/15/2007] [Indexed: 12/01/2022] Open
Abstract
AbstractObjectiveTo review the diagnostic validity and utility of mixed depression, i.e. co-occurrence of depression and manic/hypomanic symptoms.MethodsPubMed search of all English-language papers published between January 1966 and December 2006 using and cross-listing key words: bipolar disorder, mixed states, criteria, utility, validation, gender, temperament, depression-mixed states, mixed depression, depressive mixed state/s, dysphoric hypomania, mixed hypomania, mixed/dysphoric mania, agitated depression, anxiety disorders, neuroimaging, pathophysiology, and genetics. A manual review of paper reference lists was also conducted.ResultsBy classic diagnostic validators, the diagnostic validity of categorically-defined mixed depression (i.e. at least 2–3 manic/hypomanic symptoms) is mainly supported by family history (the current strongest diagnostic validator). Its diagnostic utility is supported by treatment response (negative effects of antidepressants). A dimensionally-defined mixed depression is instead supported by a non-bi-modal distribution of its intradepression manic/hypomanic symptoms.DiscussionCategorically-defined mixed depression may have some diagnostic validity (family history is the current strongest validator). Its diagnostic utility seems supported by treatment response.
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Affiliation(s)
- Franco Benazzi
- Hecker Psychiatry Research Center, University of California at San Diego, San Diego, CA, USA.
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Koukopoulos AE, Angeletti G, Sani G, Janiri D, Manfredi G, Kotzalidis GD, De Chiara L. Perinatal Mixed Affective State: Wherefore Art Thou? Psychiatr Clin North Am 2020; 43:113-126. [PMID: 32008678 DOI: 10.1016/j.psc.2019.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Mixed states in patients with a perinatal mood episode is seldom encountered. Lack of appropriate assessment tools could be partly responsible for this observation. The authors conducted a selective review of studies dealing with the reporting of mixed symptoms in women during the perinatal period with the intention to quantify the phenomenon. In many instances of reported postpartum depression, either a first onset or an onset in the context of bipolar disorder, mixed states were identifiable. However, the strict application of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, mixed features specifier to these episodes risks misdiagnosis.
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Affiliation(s)
- Alexia Emilia Koukopoulos
- SPDC, Azienda Ospedaliera Universitaria Policlinico Umberto I, Sapienza School of Medicine and Dentistry, Rome, Italy; Centro Lucio Bini, Rome, Italy; Azienda Ospedaliera Sant'Andrea, UOC di Psichiatria, Via di Grottarossa 1035, CAP 00189, Rome 00185, Italy.
| | - Gloria Angeletti
- Centro Lucio Bini, Rome, Italy; Azienda Ospedaliera Sant'Andrea, UOC di Psichiatria, Via di Grottarossa 1035, CAP 00189, Rome 00185, Italy; NESMOS Department, Sapienza School of Medicine and Psychology, Sant'Andrea University Hospital, Rome, Italy
| | - Gabriele Sani
- Institute of Psychiatry, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Psychiatry, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Roma, Italy
| | - Delfina Janiri
- Centro Lucio Bini, Rome, Italy; Azienda Ospedaliera Sant'Andrea, UOC di Psichiatria, Via di Grottarossa 1035, CAP 00189, Rome 00185, Italy; NESMOS Department, Sapienza School of Medicine and Psychology, Sant'Andrea University Hospital, Rome, Italy
| | - Giovanni Manfredi
- Centro Lucio Bini, Rome, Italy; Azienda Ospedaliera Sant'Andrea, UOC di Psichiatria, Via di Grottarossa 1035, CAP 00189, Rome 00185, Italy; NESMOS Department, Sapienza School of Medicine and Psychology, Sant'Andrea University Hospital, Rome, Italy
| | - Georgios D Kotzalidis
- Centro Lucio Bini, Rome, Italy; Azienda Ospedaliera Sant'Andrea, UOC di Psichiatria, Via di Grottarossa 1035, CAP 00189, Rome 00185, Italy; NESMOS Department, Sapienza School of Medicine and Psychology, Sant'Andrea University Hospital, Rome, Italy
| | - Lavinia De Chiara
- Centro Lucio Bini, Rome, Italy; Azienda Ospedaliera Sant'Andrea, UOC di Psichiatria, Via di Grottarossa 1035, CAP 00189, Rome 00185, Italy; NESMOS Department, Sapienza School of Medicine and Psychology, Sant'Andrea University Hospital, Rome, Italy
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Sampogna G, Del Vecchio V, Giallonardo V, Luciano M, Fiorillo A. Diagnosis, Clinical Features, and Therapeutic Implications of Agitated Depression. Psychiatr Clin North Am 2020; 43:47-57. [PMID: 32008687 DOI: 10.1016/j.psc.2019.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Agitated "unipolar" depression is a clinical entity characterized by excitement together with depressed mood during the same episode. The clinical picture of agitated "unipolar" depression is characterized by a depressed and anxious mood with inner, psychic agitation, whereas motor agitation may or may not be present. Some investigators have conceptualized this disorder as a mixed affective state, laying on the bipolar disorder spectrum, but controversies still persist. The diagnosis of agitated "unipolar" depression has important prognostic and therapeutic implications, with many clinicians reporting difficulties to adequately diagnose and treat it.
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Affiliation(s)
- Gaia Sampogna
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie, Naples 80138, Italy.
| | - Valeria Del Vecchio
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie, Naples 80138, Italy
| | - Vincenzo Giallonardo
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie, Naples 80138, Italy
| | - Mario Luciano
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie, Naples 80138, Italy
| | - Andrea Fiorillo
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie, Naples 80138, Italy
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Shahin I, Bonnin CDM, Saleh E, Helmy K, Youssef UM, Vieta E. Validity of the Shahin Mixed Depression Scale: A Self-Rated Instrument Designed to Measure the Non-DSM Mixed Features in Depression. Neuropsychiatr Dis Treat 2020; 16:2209-2219. [PMID: 33061391 PMCID: PMC7532079 DOI: 10.2147/ndt.s259996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 09/02/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The DSM5-defined mixed features in depression do not include psychomotor agitation, irritability or distractibility because they are considered overlapping symptoms. A growing number of modern psychiatrists have expressed dissatisfaction with this and proposed alternative sets of mixed symptoms that are much more common and clinically relevant. Among such alternative criteria were those proposed by Koukopoulos. He utilized the research diagnostic criteria of agitated depression (RDC-A) as a mixed depression subtype, and validated another form of mixed depression, the Koukopoulos criteria for mixed depression (K-DMX). PURPOSE This study provides psychometric validation for the first self-rated scale designed to measure the most common mixed symptoms in depression as proposed by Koukopoulos. PATIENTS AND METHODS We conducted a multicenter cross-sectional study of 170 patients with unipolar depression. They completed the Shahin Mixed Depression Scale (SMDS) and underwent expert interviews as a gold standard reference. SMDS' psychometric properties were assessed, including Cronbach's alpha, factor analysis, sensitivity, specificity, predictive value and accuracy. RESULTS We found significant association and agreement between mixity according to SMDS and the gold standard (K-DMX and RDC-A according to expert interview) with good internal consistency (Cronbach's alpha=0.87), high sensitivity (=91.4%), specificity (=98.0%), positive predictive value (=96.9%), negative predictive value (= 94.2%) and accuracy (=95.2%). Factor analysis identified one factor for psychomotor agitation and another for mixity without psychomotor agitation. CONCLUSION SMDS was a reliable and valid instrument for assessing the frequently encountered and clinically relevant mixed features in depression.
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Affiliation(s)
| | - Caterina Del Mar Bonnin
- Barcelona Bipolar Disorders and Depressive Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Elsayed Saleh
- Department of Psychiatry, Mansoura University, Mansoura, Egypt
| | - Khaled Helmy
- Training and Research Unit, New Nozha Hospital, Alexandria, Egypt.,Ciconia Recovery London (CRL), London, UK
| | - Usama M Youssef
- Department of Psychiatry, Zagazig University, Zagazig, Egypt
| | - Eduard Vieta
- Barcelona Bipolar Disorders and Depressive Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
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Serra F, Gordon-Smith K, Perry A, Fraser C, Di Florio A, Craddock N, Jones I, Jones L. Agitated depression in bipolar disorder. Bipolar Disord 2019; 21:547-555. [PMID: 31004555 DOI: 10.1111/bdi.12778] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES It has been suggested that agitated depression (AD) is a common, severe feature in bipolar disorder. We aimed to estimate the prevalence of AD and investigate whether presence of AD was associated with episodic and lifetime clinical features in a large well-characterized bipolar disorder sample. METHOD The prevalence of agitation, based on semi-structured interview and medical case-notes, in the most severe depressive episode was estimated in 2925 individuals with DSM-IV bipolar disorder recruited into the UK Bipolar Disorder Research Network. Predictors of agitation were ascertained using symptoms within the same episode and lifetime clinical features using multivariate models. RESULTS 32.3% (n = 946) experienced agitation during the worst depressive episode. Within the same episode, significant predictors of presence of agitation were: insomnia (OR 2.119, P < 0.001), poor concentration (OR 1.966, P = 0.027), decreased libido (OR 1.960, P < 0.001), suicidal ideation (OR 1.861, P < 0.001), slowed activity (OR 1.504, P = 0.001), and poor appetite (OR 1.297, P = 0.029). Over the lifetime illness course, co-morbid panic disorder (OR 2.000, P < 0.001), suicide attempt (OR 1.399, P = 0.007), and dysphoric mania (OR 1.354, P = 0.017) were significantly associated with AD. CONCLUSIONS Agitation accompanied bipolar depression in at least one-third of cases in our sample and was associated with concurrent somatic depressive symptoms, which are also common features of mixed manic states. Furthermore, AD in our sample was associated with lifetime experience of mixed mania, in addition to severe lifetime illness course including comorbid panic disorder and suicidal behavior. Our results have implications for the diagnosis and treatment of agitated features in bipolar depression.
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Affiliation(s)
| | | | - Amy Perry
- Psychological Medicine, University of Worcester, UK
| | | | | | - Nick Craddock
- National Centre of Mental Health, Cardiff University, UK
| | - Ian Jones
- National Centre of Mental Health, Cardiff University, UK
| | - Lisa Jones
- Psychological Medicine, University of Worcester, UK
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Brancati GE, Vieta E, Azorin JM, Angst J, Bowden CL, Mosolov S, Young AH, Perugi G. The role of overlapping excitatory symptoms in major depression: are they relevant for the diagnosis of mixed state? J Psychiatr Res 2019; 115:151-157. [PMID: 31132693 DOI: 10.1016/j.jpsychires.2019.05.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/11/2019] [Accepted: 05/13/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND DSM-5 and ICD-11 define mixed depression as the presence of non-overlapping symptoms of opposite polarity during a major depressive episode. However, such a definition has generated controversy. METHODS 2720 patients with major depression, enrolled in BRIDGE-II-MIX cross-sectional study, were subdivided in clusters using a k-medoids algorithm based on 32 clinical features. Clinical variables were compared among clusters. Stepwise logistic regression and random forest predictor importance estimates were used to identify which features best predicted cluster membership. Data-driven criteria were compared with DSM-5 mixed specifier and previously proposed research-based criteria (RBDC). RESULTS Two clusters were identified (MDE ± MX), mainly reflecting differences in current manic symptoms. As expected, MDE + MX showed higher rates of comorbidities and bipolar features, more previous depressive episodes and suicide attempts, shorter duration of current MDE and lower age at onset. Seven clinical features among the original 32 proved to be the best predictors of cluster membership. Derived criteria perfectly allocated subjects in clusters, requiring at least four features out of the following seven: irritability, emotional lability, psychomotor agitation, distractibility, mood reactivity, absence of reduced appetite, and absence of psychomotor retardation. RBDC showed a better performance than DSM-5 in identifying MDE + MX subjects. CONCLUSION Our results strongly suggest a predominant role for overlapping "manic" symptoms in defining mixed depressive states. Mixed depression is better identified by the presence of excitatory features shared with mania and atypical features rather than by non-overlapping manic symptoms.
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Affiliation(s)
- Giulio E Brancati
- University of Pisa, Pisa, Italy; Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Eduard Vieta
- Barcelona Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | | | - Jules Angst
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
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Lage RR, Santana CMT, Nardi AE, Cheniaux E. Mixed states and suicidal behavior: a systematic review. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2019; 41:191-200. [PMID: 31291413 DOI: 10.1590/2237-6089-2018-0042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 08/19/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The objective of this study was to identify whether mixed states in bipolar disorder (BD) are associated with more frequent suicidal behavior when compared to manic/hypomanic and depressive episodes. METHOD We performed a systematic search of the scientific literature on the subject using the PubMed, ISI Web Of Science, PsycINFO and SciELO databases. The terms chosen for the search were (bipolar) AND (suicid*) AND (mixed). We selected original studies comparing suicidal behavior of patients in mixed states and suicidal behavior of patients in other BD phases. RESULTS Sixteen papers fit the selection criteria. Twelve of the original 16 studies compared suicidal behavior in mixed states and pure mania, and the majority of these studies (n = 11) revealed that suicidal behavior was more frequent among individuals in mixed states. Five of the papers compared suicidal behavior between depressive and mixed phases of BD. One of these five papers reported more severe suicidal behavior in patients in mixed states and another described more frequent suicidal behavior in patients with pure depression. There were no significant statistical differences between groups in the remaining three of these five studies. CONCLUSION During acute BD episodes, suicidal behavior is more strongly associated with mixed states than with pure mania or hypomania. However, it was not possible to demonstrate that the association between suicidal behavior and mixed states is stronger than the association between suicidal behavior and depressive phases. The results hereby presented are worth considering in clinical practice to better evaluate suicide risk and to prevent suicide.
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Affiliation(s)
- Renata Reis Lage
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Cristina M T Santana
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Antonio Egidio Nardi
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Elie Cheniaux
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.,Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
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Shim IH, Bahk WM, Woo YS, Yoon BH. Pharmacological Treatment of Major Depressive Episodes with Mixed Features: A Systematic Review. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2018; 16:376-382. [PMID: 30466209 PMCID: PMC6245291 DOI: 10.9758/cpn.2018.16.4.376] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 03/12/2018] [Indexed: 01/10/2023]
Abstract
We reviewed clinical studies investigating the pharmacological treatment of major depressive episodes (MDEs) with mixed features diagnosed according to the dimensional criteria (more than two or three [hypo]manic symptoms+principle depressive symptoms). We systematically reviewed published randomized controlled trials on the pharmacological treatment of MDEs with mixed features associated with mood disorders, including major depressive disorder (MDD) and bipolar disorder (BD). We searched the PubMed, Cochrane Library, and ClinicalTrials.gov databases through December 2017 with the following key word combinations linked with the word OR: (a) mixed or mixed state, mixed features, DMX, mixed depression; (b) depressive, major depressive, MDE, MDD, bipolar, bipolar depression; and (c) antidepressant, antipsychotic, mood stabilizer, anticonvulsant, treatment, medication, algorithm, guideline, pharmacological. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We found few randomized trials on pharmacological treatments for MDEs with mixed features. Of the 36 articles assessed for eligibility, 11 investigated MDEs with mixed features in mood disorders: six assessed the efficacy of antipsychotic drugs (lurasidone and ziprasidone) in the acute phase of MDD with mixed features, although four of these were post hoc analyses based on large randomized controlled trials. Four studies compared antipsychotic drugs (olanzapine, lurasidone, and ziprasidone) with placebo, and one study assessed the efficacy of combination therapy (olanzapine+fluoxetine) in the acute phase of BD with mixed features. Pharmacological treatments for MDEs with mixed features have focused on antipsychotics, although evidence of their efficacy is lacking. Additional well-designed clinical trials are needed.
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Affiliation(s)
- In Hee Shim
- Department of Psychiatry, Cancer Center, Dongnam Institute of Radiological & Medical Sciences, Busan, Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Sup Woo
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bo-Hyun Yoon
- Department of Psychiatry, Naju National Hospital, Naju, Korea
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Jones S, Riste L, Barrowclough C, Bartlett P, Clements C, Davies L, Holland F, Kapur N, Lobban F, Long R, Morriss R, Peters S, Roberts C, Camacho E, Gregg L, Ntais D. Reducing relapse and suicide in bipolar disorder: practical clinical approaches to identifying risk, reducing harm and engaging service users in planning and delivery of care – the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation and Suicidality) programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2018. [DOI: 10.3310/pgfar06060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundBipolar disorder (BD) costs £5.2B annually, largely as a result of incomplete recovery after inadequate treatment.ObjectivesA programme of linked studies to reduce relapse and suicide in BD.DesignThere were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users’ (SUs) and psychiatrists’ experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5).SettingParticipants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)].ParticipantsAged ≥ 18 years. In WS1–3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for theDiagnostic and Statistical Manual of Mental Disorders.InterventionsIn WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively.Main outcome measuresIn WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation.ResultsGroup PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio testp = 0.217). The interaction between the number of previous bipolar episodes (1–7 and 8–19, relative to 20+) and treatment arm was significant (χ2 = 6.80, degrees of freedom = 2;p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of £37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive–behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD:n = 72, 72% retention to follow-up; MI-CBT:n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans.LimitationsInferences for routine clinical practice from WS1 were limited by the absence of a ‘treatment as usual’ group.ConclusionThe programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support.Future workFuture work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated.Trial registrationCurrent Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steven Jones
- Spectrum Centre for Mental Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Lisa Riste
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | | | - Peter Bartlett
- School of Law and Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Caroline Clements
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Linda Davies
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Fiona Holland
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Nav Kapur
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
- Manchester Mental Health & Social Care NHS Trust, Manchester, UK
| | - Fiona Lobban
- Spectrum Centre for Mental Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Rita Long
- Spectrum Centre for Mental Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Richard Morriss
- Institute of Mental Health, University of Nottingham, Nottingham, UK
- Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Sarah Peters
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | - Chris Roberts
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Elizabeth Camacho
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Lynsey Gregg
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | - Dionysios Ntais
- Institute of Population Health, University of Manchester, Manchester, UK
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Perugi G, Cesari D, Vannucchi G, Maccariello G, Barbuti M, De Bartolomeis A, Fagiolini A, Maina G. The impact of affective temperaments on clinical and functional outcome of Bipolar I patients that initiated or changed pharmacological treatment for mania. Psychiatry Res 2018; 261:473-480. [PMID: 29360052 DOI: 10.1016/j.psychres.2018.01.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/03/2018] [Accepted: 01/15/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Affective temperaments have been shown to impact on the clinical manifestations and the course of bipolar disorder. We investigated their influence on clinical features and functional outcome of manic episode. METHOD In a naturalistic, multicenter, national study, a sample of 194 BD I patients that initated or changed pharmacological treatment for DSM-IV-TR manic episode underwent a comprehensive evaluation including briefTEMPS-M, CTQ, YMRS, MADRS, FAST, and CGI-BP. Factorial, correlation and comparative analyses were conducted on different temperamental subtypes. RESULTS Depressive, cyclothymic, irritable and anxious temperaments resulted significantly correlated with each other. On the contrary, hyperthymic temperament scores were not correlated with the other temperamental dimensions. The factorial analysis of the briefTEMPS-M sub-scales total scores allowed the extraction of two factors: the Cyclothymic-Depressive-Anxious (Cyclo-Dep-Anx) and the Hyperthymic. At final evaluation Dominant Cyclo-Dep-Anx patients reported higer scores in MADRS and in CTQ emotional neglect and abuse subscale scores than Dominant Hyperthymic patients. The latter showed a greater functional outcome than Cyclo-Dep-Anx patients. CONCLUSIONS Affective temperaments seem to influence the course of mania. Childhood emotional abuse and neglect were related to the cyclothymic disposition. Cyclothymic subjects showed more residual depressive symptoms and Hyperthymic temperament is associated with a better short-term functional outcome.
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Affiliation(s)
- G Perugi
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Italy.
| | - D Cesari
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Italy
| | - G Vannucchi
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Italy
| | - G Maccariello
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Italy
| | - M Barbuti
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Italy
| | - A De Bartolomeis
- Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, Section of Psychiatry, University Medical School of Naples Federico II, Italy
| | - A Fagiolini
- Department of Molecular Medicine, Psychiatry Division, University of Siena, Italy
| | - G Maina
- Department of Neurosciences, Polo Universitario San Luigi Gonzaga, University of Turin, Italy
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16
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Abstract
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.
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17
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Ferentinos P, Fountoulakis KN, Lewis CM, Porichi E, Dikeos D, Papageorgiou C, Douzenis A. Validating a two-dimensional bipolar spectrum model integrating DSM-5's mixed features specifier for Major Depressive Disorder. Compr Psychiatry 2017. [PMID: 28647613 DOI: 10.1016/j.comppsych.2017.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The literature on DSM-5's 'Major Depressive Disorder with lifetime mixed features' (MDD-MF) is limited. This study investigated MDD-MF's potential inclusion into a bipolar spectrum. METHODS We recruited 287 patients with Bipolar I disorder (BD-I), BD-II, MDD-MF or 'MDD without lifetime mixed features' (MDD-noMF); most (N=280) were stabilized for at least one year on medication. Sixteen validators (clinical features, psychiatric family history, temperament, stabilizing treatment) were compared across groups and subjected to trend analyses. Two discriminant function analyses (DFA; primary and secondary), excluding or including, respectively, treatment-related predictors, explored latent dimensions maximizing between-group discrimination; mahalanobis distances between group 'centroids' were calculated. RESULTS Eleven validators differed significantly across groups; nine varied monotonically along a bipolar diathesis gradient with significant linear trends; two peaked at MDD-MF and displayed significant quadratic trends. In the primary DFA, apart from a classic bipolarity dimension, correlating with hospitalizations, early age at onset, lifetime psychosis and lower anxious temperament scores, on which groups ranked along a bipolar propensity gradient, a second dimension was also significant, peaking at BD-II and MDD-MF (challenging the classic bipolar ranking), which correlated with lifetime psychiatric comorbidities, suicidality, lower lifetime psychosis rates, female gender, higher cyclothymic and lower depressive temperament scores; MDD-MF was equipoised amidst BD-II and MDD-noMF. After including treatment-related predictors (secondary DFA), discrimination improved overall but BD-II and MDD-MF were closest than any other pair, suggesting similar treatment patterns for these two groups at this naturalistic setting. CONCLUSIONS To our knowledge, this is the first time a two-dimensional bipolar spectrum based on classic external validators is proposed, fitting the data better than a unidimensional model. Additional predictors are warranted to improve BD-II/MDD-MF discrimination.
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Affiliation(s)
- Panagiotis Ferentinos
- 2nd Department of Psychiatry, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece; Institute of Psychiatry, Psychology & Neuroscience, Social, Genetic and Development Psychiatry Center, London, United Kingdom.
| | | | - Cathryn M Lewis
- Institute of Psychiatry, Psychology & Neuroscience, Social, Genetic and Development Psychiatry Center, London, United Kingdom.
| | - Evgenia Porichi
- 2nd Department of Psychiatry, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece.
| | - Dimitris Dikeos
- 1st Department of Psychiatry, National and Kapodistrian University of Athens, Eginition Hospital, Athens, Greece.
| | - Charalambos Papageorgiou
- 1st Department of Psychiatry, National and Kapodistrian University of Athens, Eginition Hospital, Athens, Greece.
| | - Athanassios Douzenis
- 2nd Department of Psychiatry, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece.
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Abstract
Mixed states address the relationships between episodes and the course of an illness, presenting significant clinical challenges. Recurrent affective disorders were described thousands of years ago as dimensional disturbances of the basic elements of behavior, combining the characteristics of what we would now consider manic and depressive episodes. It was recognized from the beginning that combinations of depressive and manic features are associated with a severe illness course, including increased suicide risk. Early descriptions of affective disorders formulated them as systemic illnesses, a concept supported by more recent data. Descriptions of affective disorders and their course, including mixed states, became more systematic during the 19th century. Structured criteria achieved importance with evidence that, in addition to early onset, frequent recurrence, and comorbid problems, mixed states had worse treatment outcomes than other episodes. In contrast to 2000 years of literature on recurrent affective episodes and mixed states, the unipolar-bipolar disorder distinction was formalized in the mid-20th century. Mixed-state criteria, initially developed for bipolar disorder, ranged from fully combined depression and mania to the DSM-5 criteria, no longer limited to bipolar disorder, of a primary depressive or manic episode with at least three symptoms of the other episode type. The challenges involved in understanding and identifying mixed states center largely on what drives them, including (1) their formulation as either categorical or dimensional constructs, (2) the specificity of their relationships to depressive or manic episodes, and (3) specificity for bipolar versus major depressive disorder. Their existence challenges the distinction between bipolar and major depressive disorders. The challenges involved in identifying the underlying physiological mechanisms go to the heart of these questions.
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Abstract
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mixed features specifier provides a less restrictive definition of mixed mood states, compared to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), including mood episodes that manifest with subthreshold symptoms of the opposite mood state. A limited number of studies have assessed the efficacy of treatments specifically for DSM-5-defined mixed features in mood disorders. As such, there is currently an inadequate amount of data to appropriately inform evidence-based treatment guidelines of DSM-5 defined mixed features. However, given the high prevalence and morbidity of mixed features, treatment recommendations based on the currently available evidence along with expert opinion may be of benefit. This article serves to provide these interim treatment recommendations while humbly acknowledging the limited amount of evidence currently available. Second-generation antipsychotics (SGAs) appear to have the greatest promise in the treatment of bipolar disorder (BD) with mixed features. Conventional mood stabilizing agents (ie, lithium and divalproex) may also be of benefit; however, they have been inadequately studied. In the treatment of major depressive disorder (MDD) with mixed features, the comparable efficacy of antidepressants versus other treatments, such as SGAs, remains unknown. As such, antidepressants remain first-line treatment of MDD with or without mixed features; however, there are significant safety concerns associated with antidepressant monotherapy when mixed features are present, which merits increased monitoring. Lurasidone is the only SGA monotherapy that has been shown to be efficacious specifically in the treatment of MDD with mixed features. Further research is needed to accurately determine the efficacy, safety, and tolerability of treatments specifically for mood episodes with mixed features to adequately inform future treatment guidelines.
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Abstract
The classical point of view-that major depressive episodes (MDEs), no matter what additional symptoms are present, should be treated first line with antidepressants-is now giving way to new a notion. The idea is that MDEs mixed with a few symptoms of mania/hypomania should be viewed very differently in terms of their natural history, clinical outcome, and treatment, and perhaps certain antipsychotics should be given as first-line treatment rather than antidepressant monotherapy.
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Abstract
During the past two decades, a number of studies have found that depressed patients frequently have manic symptoms intermixed with depressive symptoms. While the frequency of mixed syndromes are more common in bipolar than in unipolar depressives, mixed states are also common in patients with major depressive disorder. The admixture of symptoms may be evident when depressed patients present for treatment, or they may emerge during ongoing treatment. In some patients, treatment with antidepressant medication might precipitate the emergence of mixed states. It would therefore be useful to systematically inquire into the presence of manic/hypomanic symptoms in depressed patients. We can anticipate that increased attention will likely be given to mixed depression because of changes in the DSM-5. In the present article, I review instruments that have been utilized to assess the presence and severity of manic symptoms and therefore could be potentially used to identify the DSM-5 mixed-features specifier in depressed patients and to evaluate the course and outcome of treatment. In choosing which measure to use, clinicians and researchers should consider whether the measure assesses both depression and mania/hypomania, assesses all or only some of the DSM-5 criteria for the mixed-features specifier, or assesses manic/hypomanic symptoms that are not part of the DSM-5 definition. Feasibility, more so than reliability and validity, will likely determine whether these measures are incorporated into routine clinical practice.
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Abstract
A significant minority of people presenting with a major depressive episode (MDE) experience co-occurring subsyndromal hypo/manic symptoms. As this presentation may have important prognostic and treatment implications, the DSM-5 codified a new nosological entity, the "mixed features specifier," referring to individuals meeting threshold criteria for an MDE and subthreshold symptoms of (hypo)mania or to individuals with syndromal mania and subthreshold depressive symptoms. The mixed features specifier adds to a growing list of monikers that have been put forward to describe phenotypes characterized by the admixture of depressive and hypomanic symptoms (e.g., mixed depression, depression with mixed features, or depressive mixed states [DMX]). Current treatment guidelines, regulatory approvals, as well the current evidentiary base provide insufficient decision support to practitioners who provide care to individuals presenting with an MDE with mixed features. In addition, all existing psychotropic agents evaluated in mixed patients have largely been confined to patient populations meeting the DSM-IV definition of "mixed states" wherein the co-occurrence of threshold-level mania and threshold-level MDE was required. Toward the aim of assisting clinicians providing care to adults with MDE and mixed features, we have assembled a panel of experts on mood disorders to develop these guidelines on the recognition and treatment of mixed depression, based on the few studies that have focused specifically on DMX as well as decades of cumulated clinical experience.
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Kim H, Kim W, Citrome L, Akiskal HS, Goffin KC, Miller S, Holtzman JN, Hooshmand F, Wang PW, Hill SJ, Ketter TA. More inclusive bipolar mixed depression definition by permitting overlapping and non-overlapping mood elevation symptoms. Acta Psychiatr Scand 2016; 134:199-206. [PMID: 27137894 DOI: 10.1111/acps.12580] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this study was to assess the strengths and limitations of a mixed bipolar depression definition made more inclusive than that of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) by counting not only 'non-overlapping' mood elevation symptoms (NOMES) as in DSM-5, but also 'overlapping' mood elevation symptoms (OMES, psychomotor agitation, distractibility, and irritability). METHODS Among bipolar disorder (BD) out-patients assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, we assessed prevalence, demographics, and clinical correlates of mixed vs. pure depression, using more inclusive (≥3 NOMES/OMES) and less inclusive DSM-5 (≥3 NOMES) definitions. RESULTS Among 153 depressed BD, counting not only NOMES but also OMES yielded a three-fold higher mixed depression rate (22.9% vs. 7.2%) and important statistically significant clinical correlates for mixed compared to pure depression (more lifetime anxiety disorder comorbidity, more current irritability, and less current antidepressant use), which were not significant using the DSM-5 threshold. CONCLUSION To conclude, further studies with larger numbers of patients with DSM-5 bipolar mixed depression assessing strengths and limitations of more inclusive mixed depression definitions are warranted, including efforts to ascertain whether or not OMES should count toward mixed depression.
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Affiliation(s)
- H Kim
- Department of Psychiatry, Ilsan Paik Hospital, Inje University School of Medicine, Goyang, South Korea
| | - W Kim
- Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine, Seoul, South Korea
| | - L Citrome
- New York Medical College, Valhalla, NY, USA
| | - H S Akiskal
- International Mood Centre, University of California and Veterans Administration Hospital, San Diego, CA, USA
| | - K C Goffin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S Miller
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - J N Holtzman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - F Hooshmand
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - P W Wang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S J Hill
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - T A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Kim W, Kim H, Citrome L, Akiskal HS, Goffin KC, Miller S, Holtzman JN, Hooshmand F, Wang PW, Hill SJ, Ketter TA. More inclusive bipolar mixed depression definitions by requiring fewer non-overlapping mood elevation symptoms. Acta Psychiatr Scand 2016; 134:189-98. [PMID: 26989836 DOI: 10.1111/acps.12563] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Assess strengths and limitations of mixed bipolar depression definitions made more inclusive than that of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) by requiring fewer than three 'non-overlapping' mood elevation symptoms (NOMES). METHOD Among bipolar disorder (BD) out-patients assessed with Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, we assessed prevalence, demographics, and clinical correlates of mixed vs. pure depression, using less inclusive (≥3 NOMES, DSM-5), more inclusive (≥2 NOMES), and most inclusive (≥1 NOMES) definitions. RESULTS Among 153 depressed BD, compared to less inclusive DSM-5 threshold, our more and most inclusive thresholds, yielded approximately two- and five-fold higher mixed depression rates (7.2%, 15.0%, and 34.6% respectively), and important statistically significant clinical correlates for mixed compared to pure depression (e.g. more lifetime anxiety disorder comorbidity, more current irritability), which were not significant using the DSM-5 threshold. CONCLUSION Further studies assessing strengths and limitations of more inclusive mixed depression definitions are warranted, including assessing the extent to which enhanced statistical power vs. other factors contributes to more vs. less inclusive mixed bipolar depression thresholds having more statistically significant clinical correlates, and whether 'overlapping' mood elevation symptoms should be counted.
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Affiliation(s)
- W Kim
- Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine, Seoul, South Korea
| | - H Kim
- Department of Psychiatry, Ilsan Paik Hospital, Inje University School of Medicine, Goyang, South Korea
| | - L Citrome
- New York Medical College, Valhalla, NY, USA
| | - H S Akiskal
- International Mood Centre, University of California and Veterans Administration Hospital, San Diego, CA, USA
| | - K C Goffin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S Miller
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - J N Holtzman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - F Hooshmand
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - P W Wang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S J Hill
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - T A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Wang TY, Lee SY, Chen SL, Chung YL, Li CL, Chang YH, Wang LJ, Chen PS, Chen SH, Chu CH, Huang SY, Tzeng NS, Hsieh TH, Chiu YC, Lee IH, Chen KC, Yang YK, Hong JS, Lu RB. The Differential Levels of Inflammatory Cytokines and BDNF among Bipolar Spectrum Disorders. Int J Neuropsychopharmacol 2016; 19:pyw012. [PMID: 26865313 PMCID: PMC5006191 DOI: 10.1093/ijnp/pyw012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 02/03/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Emerging evidence suggests that inflammation and neurodegeneration underlies bipolar disorder. To investigate biological markers of cytokines and brain-derived neurotrophic factor between bipolar I, bipolar II, and other specified bipolar disorder with short duration hypomania may support the association with inflammatory dysregulation and bipolar disorder and, more specifically, provide evidence for other specified bipolar disorder with short duration hypomania patients were similar to bipolar II disorder patients from a biological marker perspective. METHODS We enrolled patients with bipolar I disorder (n=234), bipolar II disorder (n=260), other specified bipolar disorder with short duration hypomania (n=243), and healthy controls (n=140). Their clinical symptoms were rated using the Hamilton Depression Rating Scale and Young Mania Rating Scale. Inflammatory cytokine (tumor necrosis factor-α, C-reactive protein, transforming growth factor-β1, and interleukin-8) and brain-derived neurotrophic factor levels were measured in each group. Multivariate analysis of covariance and linear regression controlled for possible confounders were used to compare cytokine and brain-derived neurotrophic factor levels among the groups. RESULTS Multivariate analysis of covariance adjusted for age and sex and a main effect of diagnosis was significant (P<.001). Three of the 5 measured biomarkers (tumor necrosis factor-α, transforming growth factor-β1, and interleukin-8) were significantly (P=.006, .01, and <.001) higher in all bipolar disorder patients than in controls. Moreover, covarying for multiple associated confounders showed that bipolar I disorder patients had significantly higher IL-8 levels than did bipolar II disorder and other specified bipolar disorder with short duration hypomania patients in multivariate analysis of covariance (P=.03) and linear regression (P=.02) analyses. Biomarkers differences between bipolar II disorder and other specified bipolar disorder with short duration hypomania patients were nonsignificant. CONCLUSION The immunological disturbance along the bipolar spectrum was most severe in bipolar I disorder patients. Other specified bipolar disorder with short duration hypomania patients and bipolar II disorder patients did not differ in these biological markers.
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Affiliation(s)
- Tzu-Yun Wang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Sheng-Yu Lee
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Shiou-Lan Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Yi-Lun Chung
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Chia-Ling Li
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Yun-Hsuan Chang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Liang-Jen Wang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Po See Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Shih-Heng Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Chun-Hsien Chu
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - San-Yuan Huang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Nian-Sheng Tzeng
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Tsai-Hsin Hsieh
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Yen-Chu Chiu
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - I Hui Lee
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Kao-Chin Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Yen Kuang Yang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Jau-Shyong Hong
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.)
| | - Ru-Band Lu
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan (Drs T.-Y.W., S.-Y.L., S.-L.C., Ms Y.-L.C. Drs C.-L.L.,Y.-H.C., and P.S.C. , Ms T.-H.H., Drs I.H.L., K.-C.C., Y.K.Y., and R.-B.L.); Institute of Behavioral Medicine (Drs Y.K.Y. and R.-B.L.), and Institute of Allied Health Sciences (Dr Y.-H.C. and R.-B.L.), College of Medicine, and Addiction Research Center (Drs P.S.C., I.H.L, K.C.C., Y.K.Y., and R.-B.L.), National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Dr S.-Y.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University(KMU), Lipid Science and Aging Research Center, KMU, Kaohsiung, Taiwan (Dr S.-L.C.); Department of Psychiatry, Tri-Service General Hospital, School of Medicine, and Student Counseling Center (Dr N.-S.T.), National Defense Medical Center, Taipei, Taiwan (Dr S.-Y.H.); Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (Dr L.-J.W.); Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan (Dr Y.K.Y.); Center for Neuropsychiatric Research, National Health Research Institutes, Miaoli, Taiwan (Dr R.-B.L.); Neurobiology Laboratory, NIH/NIEHS, Research Triangle Park, NC (Drs S.-H.C. and J.-S.H.); Deprtment of Psychology, Asia University, Taichung, Taiwan (Dr Y.-H.C.); Institute of Molecular Medicine (Dr C.-H.C.) , and Institute of Basic Medical Sciences (Ms Y.-L.C.), College of Medicine, National Cheng Kung University, Tainan, Taiwan ; Department of Biomedical Science and Environmental Biology, School of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan (Ms Y.-C.C.).
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Comparing clinical responses and the biomarkers of BDNF and cytokines between subthreshold bipolar disorder and bipolar II disorder. Sci Rep 2016; 6:27431. [PMID: 27270858 PMCID: PMC4895208 DOI: 10.1038/srep27431] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/10/2016] [Indexed: 11/08/2022] Open
Abstract
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.
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Chang HA, Chang CC, Kuo TBJ, Huang SY. Distinguishing bipolar II depression from unipolar major depressive disorder: Differences in heart rate variability. World J Biol Psychiatry 2016; 16:351-60. [PMID: 25800950 DOI: 10.3109/15622975.2015.1017606] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Bipolar II (BPII) depression is commonly misdiagnosed as unipolar depression (UD); however, an objective and reliable tool to differentiate between these disorders is lacking. Whether cardiac autonomic function can be used as a biomarker to distinguish BPII from UD is unknown. METHODS We recruited 116 and 591 physically healthy patients with BPII depression and UD, respectively, and 421 healthy volunteers aged 20-65 years. Interviewer and self-reported measures of depression/anxiety severity were obtained. Cardiac autonomic function was evaluated by heart rate variability (HRV) and frequency-domain indices of HRV. RESULTS Patients with BPII depression exhibited significantly lower mean R-R intervals, variance (total HRV), low frequency (LF)-HRV, and high frequency (HF)-HRV but higher LF/HF ratio compared to those with UD. The significant differences remained after adjusting for age. Compared to the controls, the patients with BPII depression showed cardiac sympathetic excitation with reciprocal vagal impairment, whereas the UD patients showed only vagal impairment. Depression severity independently contributed to decreased HRV and vagal tone in both the patients with BPII depression and UD, but increased sympathetic tone only in those with BPII depression. CONCLUSIONS HRV may aid in the differential diagnosis of BPII depression and UD as an adjunct to diagnostic interviews.
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Affiliation(s)
- Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center , Taipei , Taiwan
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Perugi G, Angst J, Azorin JM, Bowden CL, Caciagli A, Mosolov S, Vieta E, Young AH. Relationships between mixed features and borderline personality disorder in 2811 patients with major depressive episode. Acta Psychiatr Scand 2016; 133:133-143. [PMID: 26073759 DOI: 10.1111/acps.12457] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study focused on the relationship between mixed depression and borderline personality disorder (BPD). METHOD The sample comprised 2811 patients with a major depressive episode (MDE). Clinical characteristics were compared in patients with (BPD+) and without (BPD-) comorbid BPD and in BPD+ with (MXS+) and without (MXS-) mixed features according to DSM-5 criteria. RESULTS A total of 187 patients (6.7%) met the criteria for BPD. A DSM-IV-TR diagnosis of bipolar disorder (BD) was significantly more frequent in patients with BPD+ than in patients with BPD. Patients with BPD+ were significantly younger and reported lower age at onset than BPD-. Patients with BPD+ also showed more hypomania/mania in first-degree relatives in comparison with patients with BPD-, as well as more psychiatric comorbidity, mixed features, atypical features, suicide attempts, prior mood episodes and antidepressant-induced hypo/manic switches. Mixed features according to DSM-5 criteria were observed in 52 (27.8%) BPD+. In comparison with MXS-, MXS+ were significantly younger at age of onset and at prior mood episode and had experienced more mood episodes and hypo/manic switches with antidepressant treatments. CONCLUSION Major depressive episode patients with comorbid BPD reported a high prevalence of mixed features and BD. The presence of DSM-5 mixed features in MDE patients with BPD may be associated with complex course and reduced treatment response.
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Affiliation(s)
| | - J Angst
- Psychiatrische Universitätsklinik, Zürich, Switzerland
| | - J-M Azorin
- Hôpital Sainte-Marguerite, Marseille, France
| | - C L Bowden
- University of Texas Health Center, San Antonio, TX, USA
| | | | - S Mosolov
- Moscow Research Institute of Psychiatry, Moscow, Russia
| | - E Vieta
- Hospital Clinic at the University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
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Sani G, Napoletano F, Vöhringer PA, Sullivan M, Simonetti A, Koukopoulos A, Danese E, Girardi P, Ghaemi N. Mixed depression: clinical features and predictors of its onset associated with antidepressant use. PSYCHOTHERAPY AND PSYCHOSOMATICS 2015; 83:213-21. [PMID: 24970376 DOI: 10.1159/000358808] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 01/16/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mixed depression (MxD) is narrowly defined in the DSM-IV and somewhat broader in the DSM-5, although both exclude psychomotor agitation as a diagnostic criterion. This article proposes a clinical description for defining MxD, which emphasizes psychomotor excitation. METHODS Two hundred and nineteen consecutive outpatients were diagnosed with an MxD episode using criteria proposed by Koukopoulos et al. [Acta Psychiatr Scand 2007;115(suppl 433):50-57]; we here report their clinical features and antidepressant-related effects. RESULTS The most frequent MxD symptoms were: psychic agitation or inner tension (97%), absence of retardation (82%), dramatic description of suffering or weeping spells (53%), talkativeness (49%), and racing or crowded thoughts (48%). MxD was associated with antidepressants in 50.7% of patients, with similar frequency for tricyclic antidepressants (45%) versus selective serotonin reuptake inhibitors (38.5%). Positive predictors of antidepressant-associated MxD were bipolar disorder type II diagnosis, higher index depression severity, and higher age at index episode. Antipsychotic or no treatment was protective against antidepressant-associated MxD. CONCLUSIONS MxD, defined as depression with excitatory symptoms, can be clinically identified, is common, occurs in both unipolar depression and bipolar disorder, and is frequently associated with antidepressant use. If replicated, this view of MxD could be considered a valid alternative to the DSM-5 criteria for depression with mixed features.
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Affiliation(s)
- Gabriele Sani
- NESMOS Department (Neuroscience, Mental Health, and Sensory Organs), Sapienza University, School of Medicine and Psychology, Sant'Andrea Hospital, Rome, Italy
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30
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Prieto ML, Youngstrom EA, Ozerdem A, Altinbas K, Quiroz D, Aydemir O, Yalin N, Geske JR, Feeder SE, Angst J, Frye MA. Different patterns of manic/hypomanic symptoms in depression: A pilot modification of the hypomania checklist-32 to assess mixed depression. J Affect Disord 2015; 172:355-60. [PMID: 25451437 DOI: 10.1016/j.jad.2014.09.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 09/30/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are no self-report scales that assess manic/hypomanic symptoms in patients with depression. The aim of this study was to explore the use of a modified screening instrument for bipolar disorder to assess current manic/hypomanic symptoms in patients with a depressive episode. METHODS The study sample consisted of 188 patients with Structured Clinical Interview for DSM-IV-TR disorders (SCID) confirmed bipolar or major depressive disorder. We modified the Hypomania Checklist-32 (mHCL-32) to assess current instead of lifetime symptoms. An Exploratory Factor Analysis (EFA) was conducted to identify clusters of mHCL-32 items that were endorsed concurrently. A Latent Class Analysis (LCA) was carried out to identify groups of patients with similar mHCL-32 item endorsement patterns. RESULTS The EFA identified 3 factors: factor #1 ("elation-disinhibition-increased goal directed activity"), factor #2 ("risk-taking-impulsivity-substance use") and factor #3 (distractibility-irritability). The LCA yielded 3 classes (2 showing manic/hypomanic features). While class #1 patients endorsed more items related to disinhibition and racing thoughts, class #2 patients recognized more items associated with irritability and substance use. LIMITATIONS Lack of an adequate gold standard measure of mixed depression to compare to, the cross-sectional design and the lack of a validation sample. CONCLUSIONS The mHCL-32 scale allowed a comprehensive and convergent delineation of hypomanic/manic symptoms in depression. Further validation of these findings is needed.
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Affiliation(s)
- Miguel L Prieto
- Universidad de los Andes, Facultad de Medicina, Departamento de Psiquiatría, Santiago, Chile; Mayo Clinic Depression Center, Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Eric A Youngstrom
- Department of Psychology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Aysegul Ozerdem
- Department of Psychiatry, Dokuz Eylul University, Izmir, Turkey; Department of Neuroscience, Dokuz Eylul University, Izmir, Turkey
| | - Kursat Altinbas
- Department of Psychiatry, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | | | - Omer Aydemir
- Department of Psychiatry, Celal Bayar University, Manisa, Turkey
| | - Nefize Yalin
- Department of Psychology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer R Geske
- Mayo Clinic Depression Center, Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Scott E Feeder
- Mayo Clinic Depression Center, Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Jules Angst
- Zürich University Psychiatric Hospital, Zurich, Switzerland
| | - Mark A Frye
- Mayo Clinic Depression Center, Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA.
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Zimmerman M, Chelminski I, Young D, Dalrymple K, Martinez JH. A clinically useful self-report measure of the DSM-5 mixed features specifier of major depressive disorder. J Affect Disord 2014; 168:357-62. [PMID: 25103631 DOI: 10.1016/j.jad.2014.07.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 07/08/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND To acknowledge the clinical significance of manic features in depressed patients, DSM-5 included criteria for a mixed features specifier for major depressive disorder (MDD). In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we modified our previously published depression scale to include a subscale assessing the DSM-5 mixed features specifier. METHODS More than 1100 psychiatric outpatients with MDD or bipolar disorder completed the Clinically Useful Depression Outcome Scale (CUDOS) supplemented with questions for the DSM-5 mixed features specifier (CUDOS-M). To examine discriminant and convergent validity the patients were rated on clinician severity indices of depression, anxiety, agitation, and irritability. Discriminant and convergent validity was further examined in a subset of patients who completed other self-report symptom severity scales. Test-retest reliability was examined in a subset who completed the CUDOS-M twice. We compared CUDOS-M scores in patients with MDD, bipolar depression, and hypomania. RESULTS The CUDOS-M subscale had high internal consistency and test-retest reliability, was more highly correlated with another self-report measure of mania than with measures of depression, anxiety, substance use problems, eating disorders, and anger, and was more highly correlated with clinician severity ratings of agitation and irritability than anxiety and depression. CUDOS-M scores were significantly higher in hypomanic patients than depressed patients, and patients with bipolar depression than patients with MDD. LIMITATIONS The study was cross-sectional, thus we did not examine whether the CUDOS-M detects emerging mixed symptoms when depressed patients are followed over time. Also, while we examined the correlation between the CUDOS-M and clinician ratings of agitation and irritability, we did not examine the association with a clinician measure of manic symptomatology such as the Young Mania Rating Scale CONCLUSIONS In the present study of a large sample of psychiatric outpatients, the CUDOS-M was a reliable and valid measure of the DSM-5 mixed features specifier for MDD.
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Affiliation(s)
- Mark Zimmerman
- Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, RI, United States.
| | - Iwona Chelminski
- Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, RI, United States
| | - Diane Young
- Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, RI, United States
| | - Kristy Dalrymple
- Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, RI, United States
| | - Jennifer H Martinez
- Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, RI, United States
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Abstract
The DSM-5 definition of mixed features "specifier" of manic, hypomanic and major depressive episodes captures sub-syndromal non-overlapping symptoms of the opposite pole, experienced in bipolar (I, II, and not otherwise specified) and major depressive disorders. This combinatory model seems to be more appropriate for less severe forms of mixed state, in which mood symptoms are prominent and clearly identifiable. Sub-syndromal depressive symptoms have been frequently reported to co-occur during mania. Similarly, manic or hypomanic symptoms during depression resulted common, dimensionally distributed, and recurrent. The presence of mixed features has been associated with a worse clinical course and high rates of comorbidities including anxiety, personality, alcohol and substance use disorders and head trauma or other neurological problems. Finally, mixed states represent a major therapeutic challenge, especially when you consider that these forms tend to have a less favorable response to drug treatments and require a more complex approach than non-mixed forms.
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Affiliation(s)
- Giulio Perugi
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy,
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Benarous X, Guedj MJ, Braitman A, Gallois E, Lana P. [The link between aggressive behavior and depression in adolescence. A cross-sectional study conducted in the psychiatric emergency unit at the Sainte-Anne hospital]. Encephale 2014; 40:439-46. [PMID: 25127898 DOI: 10.1016/j.encep.2014.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 02/07/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The link between depression and aggressive behavior in adults has been found in many studies. In adolescents, this relationship is still controversial. Several studies point out that irritability is a key symptom in adolescent depressed. Few studies have analyzed precisely the kind of aggressive behavior. This study sets out to assess the relationship between aggressive behavior and depressive affects in adolescents. We also pay attention in this population to hopelessness feelings, anxiety, global functioning and the type of aggressive behavior. METHOD This is a descriptive and observational cross-sectional study. Data was collected from 49 successive adolescents admitted for a 24-hour evaluation in the emergency department of the Sainte-Anne psychiatric hospital. The inclusion period was from February to April 2012, with age limits between 15 and 18. For each patient, the clinician completed with the parents or other caregivers the Modified Overt Aggressive Scale (MOAS) searching for existence of aggressive behavior in the week prior to the consultation. The population was divided into two groups: P- group when the MOAS score was < 3 and the P+ group when the MOAS score was ≥ 3. The Global Assessment of Functioning Scale and Adolescent Depression Rating Scale for clinicians (ADRSc) were also completed. Each patient completed the self-report Buss-Perry Aggression Questionnaire (QA), the Beck Hopelessness scale and the Adolescent Depression Rating Scale for patients (ADRSp). RESULTS Forty-nine adolescents with a median age of 16 years and 4 months participated. The first reason for consultation was depressive symptoms, followed by disruptive behavior. The analysis was conducted on 39 questionnaires. The demographic profile of the two groups was similar. We did not find any significant difference between the groups P+ and P- on ADRSc scores and secondary criteria. However, we found higher scores in the QA in the more depressed patient, especially a higher hostility score in this sample. In the subgroup analysis: as expected self-aggressive behavior was associated with a higher depression score, more hospitalization and a poor global functioning score. Surprisingly, the patients who showed physical aggression against others had a better prognosis and lower depression scores. DISCUSSION The study did not conclude on the link between aggressive behavior and depression in this population. The adolescent hostility appears more characteristic of depression compared to other dimensions of aggressivity (anger, verbal aggression, physical aggression) in adolescents. Physical aggression against others appeared not only less typical in depression but was also associated with a better global functioning. Clinicians should pay particular attention to the kind of aggressive behavior in clinical evaluations of adolescents in an emergency context.
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Affiliation(s)
- X Benarous
- Centre psychiatrique d'orientation et d'accueil, hôpital Sainte-Anne, Assistance publique-Hôpitaux de Paris, 1, rue Cabanis, 75014 Paris, France; Service de psychiatrie de l'enfant et de l'adolescent, hôpital Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - M J Guedj
- Centre psychiatrique d'orientation et d'accueil, hôpital Sainte-Anne, Assistance publique-Hôpitaux de Paris, 1, rue Cabanis, 75014 Paris, France
| | - A Braitman
- Centre psychiatrique d'orientation et d'accueil, hôpital Sainte-Anne, Assistance publique-Hôpitaux de Paris, 1, rue Cabanis, 75014 Paris, France
| | - E Gallois
- Centre psychiatrique d'orientation et d'accueil, hôpital Sainte-Anne, Assistance publique-Hôpitaux de Paris, 1, rue Cabanis, 75014 Paris, France
| | - P Lana
- Centre psychiatrique d'orientation et d'accueil, hôpital Sainte-Anne, Assistance publique-Hôpitaux de Paris, 1, rue Cabanis, 75014 Paris, France
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Marwaha S, He Z, Broome M, Singh SP, Scott J, Eyden J, Wolke D. How is affective instability defined and measured? A systematic review. Psychol Med 2014; 44:1793-1808. [PMID: 24074230 DOI: 10.1017/s0033291713002407] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Affective instability (AI) is poorly defined but considered clinically important. The aim of this study was to examine definitions and measures of AI employed in clinical populations. METHOD This study was a systematic review using the PRISMA guidelines. MEDLINE, Embase, PsycINFO, PsycArticles and Web of Science databases were searched. Also five journals were hand searched. Primary empirical studies involving randomized controlled trials (RCTs), non-RCTs, controlled before and after, and observational investigations were included. Studies were selected, data extracted and quality appraised. A narrative synthesis was completed. RESULTS A total of 11 443 abstracts were screened and 37 studies selected for final analysis on the basis that they provided a definition and measure of AI. Numbers of definitions for each of the terms employed in included studies were: AI (n = 7), affective lability (n = 6), affective dysregulation (n = 1), emotional dysregulation (n = 4), emotion regulation (n = 2), emotional lability (n = 1), mood instability (n = 2), mood lability (n = 1) and mood swings (n = 1); however, these concepts showed considerable overlap in features. A total of 24 distinct measures were identified that could be categorized as primarily measuring one of four facets of AI (oscillation, intensity, ability to regulate and affect change triggered by environment) or as measuring general emotional regulation. CONCLUSIONS A clearer definition of AI is required. We propose AI be defined as 'rapid oscillations of intense affect, with a difficulty in regulating these oscillations or their behavioural consequences'. No single measure comprehensively assesses AI and a combination of current measures is required for assessment. A new short measure of AI that is reliable and validated against external criteria is needed.
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Affiliation(s)
- S Marwaha
- Division of Mental Health and Wellbeing, Warwick Medical School,University of Warwick,Coventry,UK
| | - Z He
- Division of Mental Health and Wellbeing, Warwick Medical School,University of Warwick,Coventry,UK
| | - M Broome
- Division of Mental Health and Wellbeing, Warwick Medical School,University of Warwick,Coventry,UK
| | - S P Singh
- Division of Mental Health and Wellbeing, Warwick Medical School,University of Warwick,Coventry,UK
| | - J Scott
- Academic Psychiatry, Institute of Neuroscience,Newcastle University,Newcastle upon Tyne,UK
| | - J Eyden
- Department of Psychology,University of Warwick,Coventry,UK
| | - D Wolke
- Division of Mental Health and Wellbeing, Warwick Medical School,University of Warwick,Coventry,UK
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Perugi G, Medda P, Swann AC, Reis J, Rizzato S, Mauri M. Phenomenological subtypes of severe bipolar mixed states: a factor analytic study. Compr Psychiatry 2014; 55:799-806. [PMID: 24582325 DOI: 10.1016/j.comppsych.2014.01.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 01/15/2014] [Accepted: 01/21/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The correct identification of bipolar mixed states (MS) has important implications for clinical practice. The aim of the study was to define the multidimensional psychopathological structure of severe MS. To our knowledge, no factor analytical studies including only patients with MS, have been conducted before. METHODS In the first week of hospitalization, we evaluated by HAM-D-17, YMRS, BPRS and CGI, 202 Bipolar I inpatients with MS according to DSM-IV criteria referred for an ECT trial. A Principal-component analysis followed by Varimax rotation was performed on the 24-item BPRS. The relationships among different symptomatological subtypes and other clinical characteristics were explored. RESULTS Six interpretable factors were extracted: Psychotic-positive symptoms, Mania, Disorientation-Unusual Motor Behaviour, Depression, Negative Symptoms and Anxiety. On the basis of the highest z-scores, we found 6 "dominant" BPRS factor groups, that were statistically distinct and without significant overlap in the main symptomatological presentation. Only 29 (14.4%) of our patients could be described as "Dominant Manic" and 48 (23.8%) as "Dominant Depressive"; most importantly 125 (61.9%) were neither predominately-manic nor predominately-depressive. Variables including age, number of previous episodes, suicidal behavior and HAM-D and YMRS scores significantly differentiated the subtypes. CONCLUSION At least in the most severe forms, MS appears to represent more than the superposition of affective symptoms of opposite polarity. Anxiety, perplexity, psychotic experiences, motor disturbances and grossly disorganized behavior seem to arise from protracted intra-episodic instability and presence of a drive state influencing the mood state and the emotional resonance.
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Affiliation(s)
- Giulio Perugi
- Clinica Psichiatrica, Dipartmento di Medicina Sperimentale, University of Pisa, Pisa, Italy.
| | - Pierpaolo Medda
- Clinica Psichiatrica, Dipartmento di Medicina Sperimentale, University of Pisa, Pisa, Italy
| | - Alan C Swann
- Department of Psychiatry, The University of Texas Health Science Center, Houston, TX, USA
| | - Joao Reis
- Serviço de Psiquiatria e Saúde Mental, Hospital de Santa Maria - CHLN, Lisboa, Portugal - Faculdade de Medicina de Lisboa, Universidade de Lisboa
| | - Salvatore Rizzato
- Clinica Psichiatrica, Dipartmento di Medicina Sperimentale, University of Pisa, Pisa, Italy
| | - Mauro Mauri
- Clinica Psichiatrica, Dipartmento di Medicina Sperimentale, University of Pisa, Pisa, Italy
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Panic attacks and suicidality in bipolar patients. MIDDLE EAST CURRENT PSYCHIATRY 2014. [DOI: 10.1097/01.xme.0000446388.97341.3a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Koukopoulos A, Sani G. DSM-5 criteria for depression with mixed features: a farewell to mixed depression. Acta Psychiatr Scand 2014; 129:4-16. [PMID: 23600771 DOI: 10.1111/acps.12140] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2013] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To review the DSM-5 proposed criteria for mixed depression in light of robust and consistent historical and scientific evidence. METHOD An extensive historical search, a systematic review of the papers used by DSM-5 as reference papers, and a PubMed search were performed. RESULTS As Hippocrates, depressive mixed states have been described as conditions of intense psychic suffering, consisting of depressed mood, inner tension, restlessness, and aimless psychomotor agitation. In DSM-5, new criteria are proposed for a mixed features specifier, as part of depression either in major depressive disorder (MDD) or bipolar disorder. Those criteria require, as diagnostically specific, manic/hypomanic symptoms that are the least common kinds of symptoms that actually arise in depressive mixed states. The DSM-5 proposal is based, almost entirely, on a speculative wish to avoid 'overlapping' manic and depressive symptoms. Mixed states are, in fact, nothing but overlapping manic and depressive symptoms. CONCLUSION In this article, we review the psychopathology and research on mixed depressive states, and try to demonstrate that the DSM-5 proposal has weak scientific basis and does not identify a large number of mixed depressive states. This may be harmful because of the different treatment required by these conditions.
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Leão IAT, Del Porto JA. 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). J Affect Disord 2012; 140:215-21. [PMID: 22284020 DOI: 10.1016/j.jad.2011.12.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 11/27/2011] [Accepted: 12/14/2011] [Indexed: 11/19/2022]
Abstract
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.
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Mazza M, Mandelli L, Zaninotto L, Di Nicola M, Martinotti G, Harnic D, Bruschi A, Catalano V, Tedeschi D, Colombo R, Bria P, Serretti A, Janiri L. Bipolar disorder: "pure" versus mixed depression over a 1-year follow-up. Int J Psychiatry Clin Pract 2012; 16:113-20. [PMID: 22296514 DOI: 10.3109/13651501.2011.633171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To compare two samples of Bipolar (BD) patients presenting "pure" (D) and mixed (Mx) depression to assess any difference in terms of clinical outcome, social functioning and quality of life during a 1-year follow-up. METHODS A total of 114 depressed outpatients (HDRS > 13) were included. "Pure" depressed (D, n = 76) were divided from "mixed" depressed (Mx, n = 38) by the number of concomitant manic symptoms. All patients were evaluated by the Hamilton Depression Rating Scale (HDRS), the Hamilton Anxiety Rating Scale (HARS), the Young Mania Rating Scale (YMRS), the Global Assessment of Functioning (GAF), the Social Adjustment Self-reported Scale (SASS) and the Quality of Life Scale (QoL), at baseline and after 1, 3, 6 and 12 months of treatment. RESULTS Mx patients were significantly younger at the onset of BD. Manic features persisted significantly higher in Mx than in D patients all over the follow-up period. Axis I comorbidities had a negative impact on the course of social functioning over the medium term period, while Mx patients showed a faster improvement in social adjustment than "pure" depressed patients. CONCLUSIONS Mixed features may persist relatively stable throughout a depressive episode, having a negative impact over clinical and functional outcome, but not on social adjustment.
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Affiliation(s)
- Marianna Mazza
- Department of Neurosciences, Institute of Psychiatry and Psychology, Bipolar Disorders Unit, Catholic University of Sacred Heart, Rome, Italy
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Perugi G, Toni C, Maremmani I, Tusini G, Ramacciotti S, Madia A, Fornaro M, Akiskal HS. The influence of affective temperaments and psychopathological traits on the definition of bipolar disorder subtypes: a study on bipolar I Italian national sample. J Affect Disord 2012; 136:e41-e49. [PMID: 20129674 DOI: 10.1016/j.jad.2009.12.027] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 12/15/2009] [Accepted: 12/29/2009] [Indexed: 01/13/2023]
Abstract
UNLABELLED Affective temperament and psychopathological traits such as separation anxiety (SA) and interpersonal sensitivity (IPS) are supposed to impact on the clinical manifestation and on the course of Bipolar Disorder (BD); in the present study we investigated their influence on the definition of BD subtypes. METHOD : Among 106 BD-I patients with DSM-IV depressive, manic or mixed episode included in a multi-centric Italian study and treated according to the routine clinical practice, 89 (84.0%) were in remission after a follow-up period ranging from 3 to 6 months (Clinical Global Impression-BP [CGI-BP] <2). Remitting patients underwent a comprehensive evaluation including self-report questionnaires such as the Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A) scale, Separation Anxiety Symptom Inventory (SASI), Interpersonal Sensitivity Measure (IPSM) and the Semi-structured interview for Mood Disorder (SIMD-R) administered by experienced clinicians. Correlation and factorial analyses were conducted on temperamental and psychopathological measures. Comparative analyses were conducted on different temperamental subtypes based on the TEMPS-A, SASI and IPSM profile. RESULTS : Depressive, cyclothymic and irritable TEMPS-A score and SASI and IPSM total scores were positively and statistically correlated with each other. On the contrary, hyperthymic temperament score was negatively correlated with depressive temperament and not significantly correlated with the other temperamental and psychopathological dimensions. The factorial analysis of the TEMPS-A subscales and SASI and IPSM total scores allowed the extraction of 2 factors: the cyclothymic-sensitive (explaining 46% of the variance) that included, as positive components, depressive, cyclothymic, irritable temperaments and SASI and IPSM scores; the hyperthymic (explaining the 19% of the variance) included hyperthymic temperament as the only positive component and depressive temperament and IPSM, as negative components. Dominant cyclothymic-sensitive patients (n=49) were more frequently females and reported higher number of depressive, hypomanic and suicide attempts when compared to the dominant hyperthymic patients (n=40). On the contrary, these latter showed a higher number of manic episodes and hospitalizations than cyclothymic-sensitive patients. The rates of first-degree family history for both mood and anxiety disorders were higher in cyclothymic-sensitive than in hyperthymic patients. Cyclothymic sensitive patients also reported more axis I lifetime co-morbidities with Panic Disorder/Agoraphobia and Social Anxiety Disorder in comparison with hyperthymics. As concerns axis II co-morbidity the cyclothymic-sensitive patients met more frequently DSM-IV criteria 1, 5 and 7 for borderline personality disorder than the hyperthymics. On the contrary, antisocial personality disorder was more represented among hyperthymic than cyclothymic patients, in particular for DSM-IV criteria 1 and 6. LIMITATION : No blind evaluation and uncertain validity of personality inventory. CONCLUSION : Our results support the view that affective temperaments influence the clinical features of BD in terms of both clinical and course characteristics, family history and axis I and II co-morbidities. Hypothetical temperamental subtypes as measured by TEMPS-A presented important interrelationships that permit to reliably isolate two fundamental temperamental disposition: the first characterized by rapid fluctuations of mood and emotional instability, and the second by hyperactivity, high level of energy and emotional intensity. Dominant cyclothymic and hyperthymic bipolar I patients reported important differences in terms of gender distribution, number and polarity of previous episodes, hospitalizations, suicidality, rates of co-morbid anxiety and personality traits and disorders. Our data are consistent with the hypothesis that affective temperaments, and in particular cyclothymia, could be utilized as quantitative, intermediate phenotypes in order to identify BD susceptibility genes.
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Affiliation(s)
- G Perugi
- Department of Psychiatry, University of Pisa, Pisa, Italy; Institute of Behavioural Sciences, "G. De Lisio", Pisa, Italy.
| | - C Toni
- Department of Psychiatry, University of Pisa, Pisa, Italy; Institute of Behavioural Sciences, "G. De Lisio", Pisa, Italy
| | - I Maremmani
- Department of Psychiatry, University of Pisa, Pisa, Italy; Institute of Behavioural Sciences, "G. De Lisio", Pisa, Italy
| | - G Tusini
- Department of Psychiatry, University of Pisa, Pisa, Italy; Institute of Behavioural Sciences, "G. De Lisio", Pisa, Italy
| | - S Ramacciotti
- Department of Psychiatry, Civitanova Marche (AN), Italy
| | - A Madia
- Department of Psychiatry, Barcellona Pozzo di Gotto (ME), Italy
| | - M Fornaro
- Department of Psychiatry University of Genoa, Italy
| | - H S Akiskal
- International Mood Disorder Center, Department of Psychiatry at the University of California at San Diego, La Jolla, USA
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Souery D, Zaninotto L, Calati R, Linotte S, Mendlewicz J, Sentissi O, Serretti A. Depression across mood disorders: review and analysis in a clinical sample. Compr Psychiatry 2012; 53:24-38. [PMID: 21414619 DOI: 10.1016/j.comppsych.2011.01.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 01/20/2011] [Accepted: 01/27/2011] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES In this article we aimed to: (1) review literature concerning the clinical and psychopathologic characteristics of Bipolar (BP) depression; (2) analyze an independent sample of depressed patients to identify any demographic and/or clinical feature that may help in differentiating mood disorder subtypes, with special attention to potential markers of bipolarity. METHODS A sample of 291 depressed subjects, including BP -I (n = 104), BP -II (n = 64), and unipolar (UP) subjects with (n = 53) and without (n = 70) BP family history (BPFH), was examined to evidence potential differences in clinical presentation and to validate literature-derived markers of bipolarity. Demographic and clinical variables and, also, single items from the Hamilton Depression Rating Scale (HDRS), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Young Mania Rating Scale (YMRS) were compared among groups. RESULTS UP subjects had an older age at onset of mood symptoms. A higher number of major depressive episodes and a higher incidence of lifetime psychotic features were found in BP subjects. Items expressing depressed mood, depressive anhedonia, pessimistic thoughts, and neurovegetative symptoms of depression scored higher in UP, whereas depersonalization and paranoid symptoms' scores were higher in BP. When compared with UP, BP I had a significantly higher incidence of intradepressive hypomanic symptoms. Bipolar family history was found to be the strongest predictor of bipolarity in depression. CONCLUSIONS Overall, our findings confirm most of the classical signs of bipolarity in depression and support the view that some features, such as BPFH, together with some specific symptoms may help in detecting depressed subjects at higher risk for BP disorder.
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Affiliation(s)
- Daniel Souery
- Laboratoire de Psychologie Medicale, Université Libre de Bruxelles and Psy Pluriel, Centre Europeén de Psychologie Medicale, Brussels, Belgium
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Souery D, Zaninotto L, Calati R, Linotte S, Sentissi O, Amital D, Moser U, Kasper S, Zohar J, Mendlewicz J, Serretti A. Phenomenology of psychotic mood disorders: lifetime and major depressive episode features. J Affect Disord 2011; 135:241-50. [PMID: 21889213 DOI: 10.1016/j.jad.2011.07.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 07/29/2011] [Accepted: 07/29/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND The nosological and clinical implications of psychotic features in the course of mood disorders have been widely debated. Currently, no specification exists for defining a subgroup of lifetime Psychotic Mood Disorder (PMD) patients. METHODS A total of 2178 patients were examined, including subjects with Bipolar Disorder (BP) type I (n=519) and II (n=207) and Major Depressive Disorder (n=1452). Patients were divided between PMD (n=645) and non-psychotic Mood Disorders (MD) (n=1533) by the lifetime presence of at least one mood episode with psychotic features. Subjects having a depressive episode at the time of assessment were also examined: HAM-D and YMRS scores were compared between MD and PMD subjects, both with and without current psychotic features. RESULTS A diagnosis of BP-I, a higher familial load for BP, a higher number of mood episodes lifetime, and a higher prevalence of OCD and somatic comorbidities were all associated to PMD. A diagnosis of BP (OR=4.48) was the only significant predictor for psychosis. PMD with non-psychotic depression were apparently less severe than MD patients and had a lower rate of "non-responders" to AD treatment. Sub-threshold manic symptoms and suicidal risk were also more pronounced among PMD. LIMITATIONS The lack of information about number and polarity of previous psychotic mood episodes may be the major limitations of our study. CONCLUSIONS BP diagnosis is the most significant predictor for psychosis in mood disorders. Non-psychotic mood episodes in PMD patients may be characterized by a distinctive symptom profile and, possibly, a different response to treatment.
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Affiliation(s)
- Daniel Souery
- Laboratoire de Psychologie Medicale, Université Libre de Bruxelles and Psy Pluriel, Centre Européen de Psychologie Medicale, Brussels, Belgium
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Abstract
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.
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Affiliation(s)
- Robin Nusslock
- Department of Psychology, Northwestern University, Evanston, IL 60208, USA.
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Paris J. Differential diagnosis of bipolar and borderline personality disorders. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/npy.11.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Maremmani I, Dell'Osso L, Rovai L, Arduino G, Montagnari A, Abbenante D, Popovic D, Maremmani AGI, Perugi G, Akiskal K, Akiskal HS. Discriminant and convergent validity of TEMPS-A[P] correlation with MMPI and the emotional-affective state following a stressful situation. J Affect Disord 2011; 129:27-33. [PMID: 20708277 DOI: 10.1016/j.jad.2010.06.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Accepted: 06/28/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND The temperament evaluation of the Memphis, Pisa, Paris and San Diego questionnaire (TEMPS), in its rater-wise and its self-evaluation forms, has been designed to evaluate temperamental characteristics in clinical and non-clinical populations. The validation process is currently in progress in various countries. In order to improve this validation process we have extended the area of correlations of its self-evaluation form (TEMPS-A[P]) to MMPI, and to a special RS that allows assessment of the emotional-affective state following a stressful situation. METHODS In 693 candidates applying to become cadets in the Italian Air Force we have assessed the correlation between the TEMPS-A[P] and the MMPI validity and clinical scales, and administered an emotional-affective state questionnaire (EAS-RS) after they had gone through the stressful challenge of taking an academy entrance examination. RESULTS As regards MMPI validity scales, TEMPS-A[P] depressive candidates tend to report their symptoms sincerely. Hyperthymic candidates tend to give false answers so that others will see them in a good light. Cyclothymic and irritable candidates tend to exaggerate symptoms. As regards the MMPI clinical scales, a low level of linkage between affective temperaments and abnormal personality traits was found. As regards EAS-RS: hyperthymic temperament on one hand, and cyclothymic and depressive temperaments on the other, are characterized by counter-polar emotional states following the test; these are desirable in the first case and undesirable in the other two. CONCLUSIONS The convergent and discriminant validity of TEMPS-A[P] was confirmed. From a personalistic point of view, temperaments seem to belong to the realm of normality rather than to that of pathology, in line with their putative adaptive role.
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Antidepressant-resistant depression and antidepressant-associated suicidal behaviour: the role of underlying bipolarity. DEPRESSION RESEARCH AND TREATMENT 2011; 2011:906462. [PMID: 21603142 PMCID: PMC3096313 DOI: 10.1155/2011/906462] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 02/08/2011] [Indexed: 11/26/2022]
Abstract
The complex relationship between the use of antidepressants and suicidal behaviour is one of the hottest topics of our contemporary psychiatry. Based on the literature, this paper summarizes the author's view on antidepressant-resistant depression and antidepressant-associated suicidal behaviour. Antidepressant-resistance, antidepressant-induced worsening of depression, antidepressant-associated (hypo)manic switches, mixed depressive episode, and antidepressant-associated suicidality among depressed patients are relatively most frequent in bipolar/bipolar spectrum depression and in children and adolescents. As early age at onset of major depressive episode and mixed depression are powerful clinical markers of bipolarity and the manic component of bipolar disorder (and possible its biological background) shows a declining tendency with age antidepressant-resistance/worsening, antidepressant-induced (hypo)manic switches and "suicide-inducing" potential of antidepressants seem to be related to the underlying bipolarity.
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Balsamo M. Anger and Depression: Evidence of a Possible Mediating Role for Rumination. Psychol Rep 2010; 106:3-12. [DOI: 10.2466/pr0.106.1.3-12] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Tendency to ruminate may mediate the relationship between anger and depression. In this preliminary study, 353 Italian community participants completed the State-Trait Anger Expression Inventory–2, the Padua Inventory's Tendency to Doubt and to Ruminate subscale, and the Beck Depression Inventory–II. Trait anger and depression were expected to have a positive relationship, and separate relationships with the tendency to ruminate. Theoretically, a new hypothesis was that the tendency to ruminate would mediate the relationship between depression and anger. Zero-order and partial correlations and a path analysis based on Baron and Kenny's method for calculating multiple regression analyses were calculated. Consistent with the hypotheses, anger and depression were strongly associated; the tendency to ruminate was significantly associated with both anger and depression; and the mediation model fit the data. Behaviors related to the tendency to ruminate could help to explain how depression is related to anger.
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Affiliation(s)
- Michela Balsamo
- Department of Biomedical Sciences “G. d'Annunzio” University, Chieti Postgraduate School of Cognitive Psychotherapy
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SWANN ALANC, STEINBERG JOELL, LIJFFIJT MARIJN, MOELLER GERARDF. Continuum of depressive and manic mixed states in patients with bipolar disorder: quantitative measurement and clinical features. World Psychiatry 2009; 8:166-72. [PMID: 19812754 PMCID: PMC2758583 DOI: 10.1002/j.2051-5545.2009.tb00245.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Bipolar mixed states combine depressive and manic features, presenting diagnostic and treatment challenges and reflecting a severe form of the illness. DSM-IV criteria for a mixed state require combined depressive and manic syndromes, but a range of mixed states has been described clinically. A unified definition of mixed states would be valuable in understanding their diagnosis, mechanism and treatment implications. We investigated the manner in which depressive and manic features combine to produce a continuum of mixed states. In 88 subjects with bipolar disorder (DSM-IV), we evaluated symptoms and clinical characteristics, and compared depression-based, mania-based, and other published definitions of mixed states. We developed an index of the extent to which symptoms were mixed (Mixed State Index, MSI) and characterized its relationship to clinical state. Predominately manic and depressive mixed states using criteria from recent literature, as well as Kraepelinian mixed states, had similar symptoms and MSI scores. Anxiety correlated significantly with depression scores in manic subjects and with mania scores in depressed subjects. Discriminant function analysis associated mixed states with symptoms of hyperactivity and negative cognitions, but not subjective depressive or elevated mood. High MSI scores were associated with severe course of illness. For depressive or manic episodes, characteristics of mixed states emerged with two symptoms of the opposite polarity. This was a cross-sectional study. Mixed states appear to be a continuum. An index of the degree to which depressive and manic symptoms combine appears useful in identifying and characterizing mixed states. We propose a depressive or manic episode with three or more symptoms of the opposite polarity as a parsimonious definition of a mixed state.
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Affiliation(s)
- ALAN C. SWANN
- Department of Psychiatry and Behavioral Sciences, University of Texas Medical School, 1300 Moursund Street, Houston, TX 77030, USA
| | - JOEL L. STEINBERG
- Department of Psychiatry and Behavioral Sciences, University of Texas Medical School, 1300 Moursund Street, Houston, TX 77030, USA
| | - MARIJN LIJFFIJT
- Department of Psychiatry and Behavioral Sciences, University of Texas Medical School, 1300 Moursund Street, Houston, TX 77030, USA
| | - GERARD F. MOELLER
- Department of Psychiatry and Behavioral Sciences, University of Texas Medical School, 1300 Moursund Street, Houston, TX 77030, USA
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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.
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Abstract
Recent suggestions to extend the boundaries of bipolar disorder to a broader spectrum lead to a concept of bipolarity different from that of classical psychiatry. It has been proposed that many patients with unipolar depression are actually bipolar and that many cases of substance abuse, personality disorders, and childhood behavioral disorders lie within the spectrum. However, since this expanded notion of bipolarity has been defined entirely on the basis of phenomenology, any expansion needs to meet broader criteria for validity. Bipolar spectrum disorders have a different phenomenology, family history, and course than classical bipolar disorders and do not respond in the same way to drugs. Until further research clarifies the boundaries of bipolarity, we should be conservative about extending its scope.
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Affiliation(s)
- Joel Paris
- Department of Psychiatry, McGill University, Institute of Community and Family Psychiatry and Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Canada.
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