A different depression: clinical distinctions between bipolar and unipolar depression

Identification of Predictors of Mood Disorder Misdiagnosis and Subsequent Help-Seeking Behavior in Individuals With Depressive Symptoms: Gradient-Boosted Tree Machine Learning Approach

BACKGROUND

Misdiagnosis and delayed help-seeking cause significant burden for individuals with mood disorders such as major depressive disorder and bipolar disorder. Misdiagnosis can lead to inappropriate treatment, while delayed help-seeking can result in more severe symptoms, functional impairment, and poor treatment response. Such challenges are common in individuals with major depressive disorder and bipolar disorder due to the overlap of symptoms with other mental and physical health conditions, as well as, stigma and insufficient understanding of these disorders.

OBJECTIVE

In this study, we aimed to identify factors that may contribute to mood disorder misdiagnosis and delayed help-seeking.

METHODS

Participants with current depressive symptoms were recruited online and data were collected using an extensive digital mental health questionnaire, with the World Health Organization World Mental Health Composite International Diagnostic Interview delivered via telephone. A series of predictive gradient-boosted tree algorithms were trained and validated to identify the most important predictors of misdiagnosis and subsequent help-seeking in misdiagnosed individuals.

RESULTS

The analysis included data from 924 symptomatic individuals for predicting misdiagnosis and from a subset of 379 misdiagnosed participants who provided follow-up information when predicting help-seeking. Models achieved good predictive power, with area under the receiver operating characteristic curve of 0.75 and 0.71 for misdiagnosis and help-seeking, respectively. The most predictive features with respect to misdiagnosis were high severity of depressed mood, instability of self-image, the involvement of a psychiatrist in diagnosing depression, higher age at depression diagnosis, and reckless spending. Regarding help-seeking behavior, the strongest predictors included shorter time elapsed since last speaking to a general practitioner about mental health, sleep problems disrupting daily tasks, taking antidepressant medication, and being diagnosed with depression at younger ages.

CONCLUSIONS

This study provides a novel, machine learning-based approach to understand the interplay of factors that may contribute to the misdiagnosis and subsequent help-seeking in patients experiencing low mood. The present findings can inform the development of targeted interventions to improve early detection and appropriate treatment of individuals with mood disorders.

Phase-based concerns of caregivers for individuals with a bipolar disorder

BACKGROUND

Caregivers have a key role in providing social and practical support for individuals with bipolar disorder. As such, their perspectives are uniquely important when collaborative decisions are made on management priorities and potential treatment options.

AIMS

This study aims to identify common concerns that caregivers have in the management of an individual with a bipolar disorder.

METHOD

111 caregivers were recruited from online advertisements and social media support groups. They completed a questionnaire that obtained demographic and clinical feature details, in addition to whether a series of generic and phase-specific (i.e. depressive or hypo/manic) management concerns reflected their experiences of caregiving.

RESULTS

Concerns about work capacity and family impacts were almost ubiquitous, as were general feelings of ineffectiveness and irritation. Depressive phases were more likely to elicit fears of suicide by caregivers, while during hypo/manic phases caregivers were more likely to be angered, have concerns for their own safety, call emergency services or to take safety precautions. There were no differences between bipolar subtypes with regards to concerns during depressive phases, but concerns around safety, reputational damage and risky behaviours were more likely in relation to those experiencing bipolar I manic phases compared to bipolar II hypomanic phases.

CONCLUSIONS

The concerns identified by caregivers in this paper are consistent with clinical expectations, with concerns regarding insularity and externalisation being prominent for depression and hypo/mania respectively. Not all of these caregivers' concerns would necessarily be communicated in a healthcare setting, highlighting the need for an embracive approach to improve management outcomes. Additionally, caregivers' emphasis on their distinctive altruistic concerns highlights their commitment to care despite the challenges, and thus further highlights the potential for clinicians to implement a more proactive role for them in patient care.

Multi-study evaluation of neuroimaging-based prediction of medication class in mood disorders

Clinicians often face a dilemma in diagnosing bipolar disorder patients with complex symptoms who spend more time in a depressive state than a manic state. The current gold standard for such diagnosis, the Diagnostic and Statistical Manual (DSM), is not objectively grounded in pathophysiology. In such complex cases, relying solely on the DSM may result in misdiagnosis as major depressive disorder (MDD). A biologically-based classification algorithm that can accurately predict treatment response may help patients suffering from mood disorders. Here we used an algorithm to do so using neuroimaging data. We used the neuromark framework to learn a kernel function for support vector machine (SVM) on multiple feature subspaces. The neuromark framework achieves up to 95.45% accuracy, 0.90 sensitivity, and 0.92 specificity in predicting antidepressant (AD) vs. mood stabilizer (MS) response in patients. We incorporated two additional datasets to evaluate the generalizability of our approach. The trained algorithm achieved up to 89% accuracy, 0.88 sensitivity, and 0.89 specificity in predicting the DSM-based diagnosis on these datasets. We also translated the model to distinguish responders to treatment from nonresponders with up to 70% accuracy. This approach reveals multiple salient biomarkers of medication-class of response within mood disorders.

Association Between Antenatal Depression Symptom Trajectories and Preterm Birth

OBJECTIVE

To evaluate whether, among pregnant people referred for mental health care, improvement in antenatal depression symptoms before delivery was associated with a reduction in preterm birth.

METHODS

This retrospective cohort study included all pregnant people referred to a perinatal collaborative care program for mental health care who delivered between March 2016 and March 2021. Those referred to the collaborative care program had access to subspecialty mental health treatment, including psychiatric consultation, psychopharmacotherapy, and psychotherapy. Depression symptoms were monitored with the self-reported PHQ-9 (Patient Health Questionnarie-9) screens in a patient registry. Antenatal depression trajectories were determined by comparing the earliest prenatal PHQ-9 score after collaborative care referral with the score closest to delivery. Trajectories were categorized as improved, stable, or worsened according to whether PHQ-9 scores changed by at least 5 points. Bivariable analyses were performed. A propensity score was generated to control for confounders that were significantly different on bivariable analyses according to trajectories. This propensity score was then included in multivariable models.

RESULTS

Of the 732 pregnant people included, 523 (71.4%) had mild or more severe depressive symptoms (PHQ-9 score 5 or higher) on their initial screen. Antenatal depression symptoms improved in 256 (35.0%), remained stable in 437 (59.7%), and worsened in 39 (5.3%); the corresponding incidence of preterm birth was 12.5%, 14.0%, and 30.8%, respectively ( P =.009). Compared with those with a worsened trajectory, pregnant people who had an improved antenatal depression symptom trajectory had a significantly decreased odds of preterm birth (adjusted odds ratio 0.37, 95% CI 0.15-0.89).

CONCLUSION

Compared with worsened symptoms, an improved antenatal depression symptom trajectory is associated with decreased odds of preterm birth for pregnant people referred for mental health care. These data further underscore the public health importance of incorporating mental health care into routine obstetric care.

Management challenges and choices in patients with bipolar disorder: An Egyptian observational study

BACKGROUND

Patients with bipolar disorder (BD) had contributed immensely to high health service utilization. Variation in clinical practices that miss to follow the standard guidelines all with the disorder complexity, deepened the management gap. This study aimed to provide an Egyptian epidemiological database of the ongoing clinical practices that framed different diagnostic and management choices in a sample of patients with bipolar disorder. Highlighting challenges and the need for optimized clinical practices.

METHODS

Over 4 months in 2014, 20 clinicians filled in a designed sheet of their routine healthcare practice with information about; caseload /month, management guidelines knowledge background. Out of 301 patients in acute episode BD, 300 patients aged 20 to 60 years from both sexes, completed their assessment using; (1) a semi-structured interview sheet, (2) Structured Clinical Interview for DSM-IV Axis I (SCID I) for psychiatric diagnoses, (3) Global Assessment of Functioning scale for illness impact.

RESULTS

Psychiatrists received 49.5 ± 37.0 (mean ± SD) patient /month. 95% of them reported positive knowledge background on BD diagnostic guidelines and treatment recommendations (G/R), 89.6% of patients had different initial diagnosis than BD.The most commonly given initial diagnosis was major depressive disorder (33%) followed by brief psychotic disorder(20.7%) and others. The median of time taken from the initial to bipolar diagnosis was 12.3 months. Majority of patients had evident functional impairment. Atypical antipsychotics were mostly used. Drug abuse and obesity were high comorbidities.

CONCLUSION

The evident gap in practice and BD complexity have negative impact on clinical outcomes. Physician's continuous medical education programs and individually tailored standard medical care are recommended for optimized practices.

Cognitive functioning in late life affective disorders: Comparing older adults with bipolar disorder, late life depression and healthy controls

INTRODUCTION

Both older age bipolar disorder (OABD) and late life depression (LLD) have been associated with cognitive dysfunction. It is unclear how cognitive functioning differs between these disorders and what the influence of current depressive symptoms is.

METHODS

We compared OABD (n = 148), LLD (n = 378) and healthy controls (HC) (n = 132) on cognitive functioning. Cognitive functioning was measured by an extensive neuropsychological assessment, and divided into four domains: episodic memory, processing speed, interference inhibition and working memory. Separate linear regression analyses were conducted with OABD as reference category, controlling for age, gender, level of education and severity of depressive symptoms.

RESULTS

Our findings show that OABD and LLD patients exhibit more cognitive dysfunction than HC, with OABD showing worst cognitive functioning on all cognitive domains, except for interference inhibition. These differences remained significant, even after controlling for the effect of depressive symptoms at the time of testing.

DISCUSSION

Our findings suggest that cognitive dysfunction in OABD is more severe in magnitude albeit in the same domains as in LLD. This difference cannot be fully explained by the severity of depressive symptoms. Future research should focus on other disease characteristics and how these characteristics are associated with the complex concept of cognitive functioning in both OABD and LLD.

[Comorbidity patterns and structure of depressive episodes in patients with bipolar disorder and major depressive disorder]

OBJECTIVE

To conduct an exploratory analysis of comorbidity patterns and the structure of depressive episodes among Russian patients with bipolar disorder (BD) and major depressive disorder (MDD).

MATERIAL AND METHODS

This multicenter cross-sectional study included 178 patients with mood disorders, of which 78.1% (n=139) were women. The diagnosis of BD was made in 68.0% (n=121) patients, of them 37.1% (n=66) were diagnosed with BD type I. All study participants underwent a structured Mini International Neuropsychiatric Interview to verify the clinical diagnosis and identify concomitant mental disorders, and also filled out an electronic case report form. Statistical analysis was performed in RStudio v. 1.4.1717 using the standard R package and the «psych» package.

RESULTS

According to the results of stepwise regression, comorbid diagnoses of panic disorder (OR=5.3; 95% CI 1.9-19.1) and eating disorders (OR=7.7; 95% CI 2.8-27.4) were more associated with BD. In addition, depressive episodes in BD were more associated with symptoms of hypersomnia (OR=2.5; 95% CI 1.2-5.3) and psychomotor retardation (OR=3.2; 95% CI 1.5-7.6). Symptoms such as increased appetite (47.1% (n=57) vs 26.3% (n=15); p=0.009), ideas of guilt (92.6% (n=112) vs 7.2% (n=44); p=0.006) and thoughts of self-harm or death (70.2% (n=85) vs 45.6% (n=25); p=0.003) were also nominally more common in depressive episodes within the BD compared to MDD.

CONCLUSIONS

Mood disorders such as BD and MDD have significant differences in the patterns of comorbidity and the structure of depressive episodes, which is important to consider when conducting differential diagnosis of these disorders. The results also indicate the need for a comprehensive diagnostic interview with patients with mood disorders to assess the presence of comorbid mental disorders during life and the structure of depressive episodes throughout the clinical course from the moment of onset.

Optimization of the Mood Disorder Questionnaire in identification of perinatal bipolar disorder

BACKGROUND

The recognition of bipolar disorder during the perinatal period is often challenging because birthing people most commonly present in a depressive episode. The phenotypic expression of episodes of bipolar depression is difficult to differentiate from major depressive disorder and can lead to misdiagnosis and inappropriate treatment. The Mood Disorder Questionnaire is a readily available screening tool for bipolar disorder that has been validated in previous studies for use in the general and perinatal populations. However, the discriminatory capacity of the Mood Disorder Questionnaire for perinatal people who screen positive for depression in nonpsychiatric settings is still unclear.

OBJECTIVE

This study aimed to evaluate the discriminatory capacity of the Mood Disorder Questionnaire to identify bipolar disorder in perinatal people who screen positive for depression on the Patient Health Questionnaire-9.

STUDY DESIGN

This retrospective cohort study included individuals enrolled in the Collaborative Care Model for Perinatal Depression Support Services, a collaborative care program for perinatal mental health services implemented in a quaternary care setting, from January 2017 to April 2021. All individuals completed the Mood Disorder Questionnaire and psychiatric evaluation by a licensed clinical social worker. Clinical and sociodemographic characteristics were compared between those with and without a clinical diagnosis of bipolar disorder using bivariable analyses. The discriminatory capacity and test characteristics of the Mood Disorder Questionnaire were assessed at each score cutoff using the gold standard of a psychiatric clinical evaluation for comparison.

RESULTS

From January 2017 to April 2021, 1510 birthing people were enrolled in the Collaborative Care Model for Perinatal Depression Support Services and included in this study. Among this group, 62 (4.1%) were diagnosed with bipolar disorder by psychiatric clinical evaluation using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria. A score of ≥7 on question 1 is often used in the general population to identify bipolar disorder, which has a 60% sensitivity and 88% specificity in our perinatal sample with an area under the receiver operating characteristic curve of 0.74 (95% confidence interval, 0.72-0.76). Lowering the threshold to ≥4 improves sensitivity to 81% and the discriminatory capacity to an area under the receiver operating characteristic curve of 0.75 (95% confidence interval, 0.70-0.80), at the expense of a reduction in specificity to 69%.

CONCLUSION

The administration of the Mood Disorder Questionnaire in the perinatal period can help to identify which individuals who have screened positive for depression on the Patient Health Questionnaire-9 are at risk of a bipolar or unipolar disorder. In this context, lowering the Mood Disorder Questionnaire score threshold from that used in the nonperinatal population down to 4 improves test characteristics and reduces the risk of a missed diagnosis of bipolar disorder.

Decreased cortical gyrification in patients with bipolar disorder

BACKGROUND

An aberrant neural connectivity has been known to be associated with bipolar disorder (BD). Local gyrification may reflect the early neural development of cortical connectivity and has been studied as a possible endophenotype of psychiatric disorders. This study aimed to investigate differences in the local gyrification index (LGI) in each cortical region between patients with BD and healthy controls (HCs).

METHODS

LGI values, as measured using FreeSurfer software, were compared between 61 patients with BD and 183 HCs. The values were also compared between patients with BD type I and type II as a sub-group analysis. Furthermore, we evaluated whether there was a correlation between LGI values and illness duration or depressive symptom severity in patients with BD.

RESULTS

Patients with BD showed significant hypogyria in various cortical regions, including the left inferior frontal gyrus (pars opercularis), precentral gyrus, postcentral gyrus, superior temporal cortex, insula, right entorhinal cortex, and both transverse temporal cortices, compared to HCs after the Bonferroni correction (p < 0.05/66, 0.000758). LGI was not associated with clinical factors such as illness duration, depressive symptom severity, and lithium treatment. No significant differences in cortical gyrification according to the BD subtype were found.

CONCLUSIONS

BD appears to be characterized by a significant regionally localized hypogyria, in various cortical areas. This abnormality may be a structural and developmental endophenotype marking the risk for BD, and it might help to clarify the etiology of BD.

Diagnostic conversion from unipolar to bipolar affective disorder-A population-based study

OBJECTIVES

It is essential to clinically distinguish bipolar affective disorder from unipolar affective disorders. However, patients previously diagnosed with unipolar affective disorder are sometimes later diagnosed with bipolar affective disorder, known as diagnostic conversion. Here we investigated diagnostic conversion using data from a nationwide population-based register.

METHODS

We obtained claims data from 2007 to 2020 in Korea's Health Insurance Review Agency database and identified a cohort of patients who were diagnosed with unipolar depression in 2009 without prior psychiatric diseases within the previous 2 years. We studied the rate of diagnostic conversion and risk factors, especially antidepressants.

RESULTS

About 6.5% of patients underwent diagnostic conversion during the observation period. Younger age at disease onset and usage of antidepressants increased the relative risk for diagnostic conversion. Patients using serotonin-norepinephrine reuptake inhibitors (SNRI) showed more than twice the risk compared to no usage of antidepressant.

LIMITATION

First, this study was based on the population-based register data. Thus, we defined the patient cohort diagnosed with unipolar depression with strict inclusion criteria. Second, the exposure time differed between different antidepressants. Third, we estimated the relative risk for diagnostic conversion compared to no use of antidepressants. Moreover, we could not rule out the potential influence of antidepressant polypharmacy.

CONCLUSION

We confirmed diagnostic conversion in some patients and identified younger age or usage of antidepressants, especially SNRI, as risk factors. Because unipolar and bipolar affective disorders show different disease courses or prognoses and have different treatment strategies, clinicians should be mindful of diagnostic conversion.

Learnings from user feedback of a novel digital mental health assessment

Digital mental health interventions (DMHI) have the potential to address barriers to face-to-face mental healthcare. In particular, digital mental health assessments offer the opportunity to increase access, reduce strain on services, and improve identification. Despite the potential of DMHIs there remains a high drop-out rate. Therefore, investigating user feedback may elucidate how to best design and deliver an engaging digital mental health assessment. The current study aimed to understand 1304 user perspectives of (1) a newly developed digital mental health assessment to determine which features users consider to be positive or negative and (2) the Composite International Diagnostic Interview (CIDI) employed in a previous large-scale pilot study. A thematic analysis method was employed to identify themes in feedback to three question prompts related to: (1) the questions included in the digital assessment, (2) the homepage design and reminders, and (3) the assessment results report. The largest proportion of the positive and negative feedback received regarding the questions included in the assessment (n = 706), focused on the quality of the assessment (n = 183, 25.92% and n = 284, 40.23%, respectively). Feedback for the homepage and reminders (n = 671) was overwhelmingly positive, with the largest two themes identified being positive usability (i.e., ease of use; n = 500, 74.52%) and functionality (i.e., reminders; n = 278, 41.43%). The most frequently identified negative theme in results report feedback (n = 794) was related to the report content (n = 309, 38.92%), with users stating it was lacking in-depth information. Nevertheless, the most frequent positive theme regarding the results report feedback was related to wellbeing outcomes (n = 145, 18.26%), with users stating the results report, albeit brief, encouraged them to seek professional support. Interestingly, despite some negative feedback, most users reported that completing the digital mental health assessment has been worthwhile (n = 1,017, 77.99%). Based on these findings, we offer recommendations to address potential barriers to user engagement with a digital mental health assessment. In summary, we recommend undertaking extensive co-design activities during the development of digital assessment tools, flexibility in answering modalities within digital assessment, customizable additional features such as reminders, transparency of diagnostic decision making, and an actionable results report with personalized mental health resources.

Predictors of diagnostic transition from major depressive disorder to bipolar disorder: a retrospective observational network study

Many patients with bipolar disorder (BD) are initially misdiagnosed with major depressive disorder (MDD) and are treated with antidepressants, whose potential iatrogenic effects are widely discussed. It is unknown whether MDD is a comorbidity of BD or its earlier stage, and no consensus exists on individual conversion predictors, delaying BD's timely recognition and treatment. We aimed to build a predictive model of MDD to BD conversion and to validate it across a multi-national network of patient databases using the standardization afforded by the Observational Medical Outcomes Partnership (OMOP) common data model. Five "training" US databases were retrospectively analyzed: IBM MarketScan CCAE, MDCR, MDCD, Optum EHR, and Optum Claims. Cyclops regularized logistic regression models were developed on one-year MDD-BD conversion with all standard covariates from the HADES PatientLevelPrediction package. Time-to-conversion Kaplan-Meier analysis was performed up to a decade after MDD, stratified by model-estimated risk. External validation of the final prediction model was performed across 9 patient record databases within the Observational Health Data Sciences and Informatics (OHDSI) network internationally. The model's area under the curve (AUC) varied 0.633-0.745 (µ = 0.689) across the five US training databases. Nine variables predicted one-year MDD-BD transition. Factors that increased risk were: younger age, severe depression, psychosis, anxiety, substance misuse, self-harm thoughts/actions, and prior mental disorder. AUCs of the validation datasets ranged 0.570-0.785 (µ = 0.664). An assessment algorithm was built for MDD to BD conversion that allows distinguishing as much as 100-fold risk differences among patients and validates well across multiple international data sources.

Selective serotonin reuptake inhibitors and manic switch: A pharmacovigilance and pharmacodynamical study

BACKGROUND

There is still no approved mechanism of manic switch in bipolar disorder, yet many selective serotonin reuptake inhibitors were accused for this important adverse event. Therefore, we aimed to investigate to estimate SSRI's risk for reporting mania and elevated mood using FEARS database and investigate receptor mechanisms involved.

METHODS

Mania and relevant side effects approved by FDA were screened in this dataset from the first quarter of 2004 to the third quarter of 2020. Disproportionality analysis were performed to estimate reporting odds ratio (ROR) and linear regressions were conducted to investigate relationship between ROR and Ki values. Receptor occupancy ratios were calculated from in vitro receptor binding profiles. The pharmacodynamical profile was extracted from the International Union of Basic and Clinical Pharmacology and the British Pharmacology Society dataset. Child and adolescent population was also investigated separately.

RESULTS

The analysis showed that the odds of a spontaneous report of mania in the FAERS database involving an SSRI were higher than the odds that such a report involved other types of drugs (ROR: 5.324 [CI: 3.773; 7.514]). The largest effect size in this estimation was found in fluvoxamine (ROR: 13.957 [CI: 10.391; 18.747]). Significant effects were found in regression analysis for Ki values of H1 and M1 receptors on ROR. Receptor occupation was not found to have an effect on ROR.

CONCLUSION

Lower degress of Ki values on M1 and H1 may be plausible pharmacological mechanism. Further pharmacological data and clinical assessments may be important to validate this safety signal.

Differentiating white matter measures that protect against vs. predispose to bipolar disorder and other psychopathology in at-risk youth

Bipolar disorder (BD) is highly heritable. Identifying objective biomarkers reflecting pathophysiological processes predisposing to, versus protecting against BD, can help identify BD risk in offspring of BD parents. We recruited 21 BD participants with a first-degree relative with BD, 25 offspring of BD parents, 27 offspring of comparison parents with non-BD psychiatric disorders, and 32 healthy offspring of healthy parents. In at-risk groups, 23 had non-BD diagnoses and 29, no Axis-I diagnoses(healthy). Five at-risk offspring who developed BD post scan(Converters) were included. Diffusion imaging(dMRI) analysis with tract segmentation identified between-group differences in the microstructure of prefrontal tracts supporting emotional regulation relevant to BD: forceps minor, anterior thalamic radiation(ATR), cingulum bundle(CB), and uncinate fasciculus(UF). BD participants showed lower fractional anisotropy (FA) in the right CB (anterior portion) than other groups (q < 0.05); and in bilateral ATR (posterior portion) versus at-risk groups (q < 0.001). Healthy, but not non-BD, at-risk participants showed significantly higher FA in bilateral ATR clusters than healthy controls (qs < 0.05). At-risk groups showed higher FA in these clusters than BD participants (qs < 0.05). Non-BD versus healthy at-risk participants, and Converters versus offspring of BD parents, showed lower FA in the right ATR cluster (qs < 0.05). Low anterior right CB FA in BD participants versus other groups might result from having BD. High bilateral ATR FA in at-risk groups, and in healthy at-risk participants, versus healthy controls might protect against BD/other psychiatric disorders. Absence of elevated right ATR FA in non-BD versus healthy at-risk participants, and in Converters versus non-converter offspring of BD parents, might lower protection against BD in at-risk groups.

Depressive Disorders in HIV/AIDS: A Clinically Focused Narrative Review

After participating in this activity, learners should be better able to:• Assess strategies for diagnosing depressive disorders in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)• Identify factors that contribute to the development of depressive disorders in HIV/AIDS• Evaluate strategies for managing depressive disorders in HIV/AIDS ABSTRACT: Depressive disorders and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) are associated with major socioeconomic burdens. The negative impact of depressive disorders on HIV/AIDS is well known, including on treatment outcomes. Unfortunately, depressive disorders are underdiagnosed and undertreated in seropositive persons. This review summarizes clinically useful information on depressive disorders in HIV/AIDS. More specifically, we address assessment, differential diagnosis, contributing factors, management, and common challenges in the treatment of depressive disorders in seropositive individuals. Assessment and diagnosis of depression may be challenging in seropositive persons because of several biopsychosocial particularities associated with HIV/AIDS. One of the difficulties is the overlap between depression and HIV/AIDS symptoms, particularly in individuals with advanced AIDS, requiring consideration of a broad differential diagnosis. Several factors related to HIV/AIDS status contribute to the higher rates of depressive disorders, including infectious-immunological, psychosocial, and exogenous factors. The treatment of depressive disorders in HIV/AIDS involves three groups of interventions: (1) pharmacological interventions, (2) psychotherapeutic interventions, and (3) management of other contributing factors. Challenges in management include poor adherence to treatment and the risk of suicide. We provide evidence-based recommendations to improve assessment and management of depressive disorders in seropositive persons.

Symptoms and Characteristics of Youth Hospitalized for Depression: Subthreshold Manic Symptoms Can Help Differentiate Bipolar from Unipolar Depression

Background: Most people who have major depressive disorder (MDD) or bipolar disorder (BD) will have their first episode of depression in adolescence. However, in the absence of significant [hypo]manic symptoms, there are no clear guidelines for distinguishing bipolar from unipolar depression, which can lead to misdiagnosis and ineffective/harmful treatment. We aimed to compare phenomenological differences among youth with MDD or BD hospitalized for an acute episode of depression. Methods: A retrospective electronic chart review of adolescents hospitalized in an acute care inpatient unit who had a discharge diagnosis of MDD, MDD with mixed or psychotic features (MDD+), BD-I-current episode depressed, or BD-II-current episode depressed, was performed. Results: Altogether, 598 patients (mean age = 15.1 ± 1.5 years, female = 71%, and White = 46%) met study inclusion criteria, i.e., BD-I: n = 39, BD-II: n = 84, MDD: n = 422, and MDD+: n = 53 patients. The admission Hamilton Depression Rating Scale (HAMD) total score was significantly higher in the BD-I (29.3 ± 9.1) and MDD+ (31.2 ± 9.3) groups versus the MDD group (24.3 ± 9.7) (p < 0.05). Although there were some group differences in the severity of individual depression symptoms, these did not line up neatly across BD and MDD groups. At admission, Young Mania Rating Scale (YMRS) total scores were significantly higher in the BD-I (14.4 ± 7.4), BD-II (13.8 ± 6.5), and MDD+ groups (14.3 ± 6.6) versus the MDD group (8.2 ± 4.6, p < 0.05). Additionally, 9 of 11 and 4 of 11 YMRS items scored significantly higher in the BD-II and BD-I groups versus the MDD group, respectively. The motor activity and hypersexuality items, in particular, were scored consistently higher in the BD groups than MDD groups. Limitations: All diagnoses were made based on a clinical interview and not a structured diagnostic interview, and some of the subgroup sample sizes were relatively modest, limiting the power for group comparisons. Conclusion: The presence of subsyndromal manic symptoms during an episode of MDD currently offers the clearest way by which to differentiate bipolar depression from unipolar depression.

Lithium as a Neuroprotective Agent for Bipolar Disorder: An Overview

Lithium (Li⁺) is a first option treatment for adult acute episodes of Bipolar Disorder (BD) and for the prophylaxis of new depressed or manic episodes. It is also the preferred choice as maintenance treatment. Numerous studies have shown morphological abnormalities in the brains of BD patients, suggesting that this highly heritable disorder may exhibit progressive and deleterious changes in brain structure. Since treatment with Li⁺ ameliorates these abnormalities, it has been postulated that Li⁺ is a neuroprotective agent in the same way atypical antipsychotics are neuroprotective in patients diagnosed with schizophrenia spectrum disorders. Li⁺'s neuroprotective properties are related to its modulation of nerve growth factors, inflammation, mitochondrial function, oxidative stress, and programmed cell death mechanisms such as autophagy and apoptosis. Notwithstanding, it is not known whether Li⁺-induced neuroprotection is related to the inhibition of its putative molecular targets in a BD episode: the enzymes inositol-monophosphatase, (IMPase), glycogen-synthase-kinase 3β (GSK3), and Protein kinase C (PKC). Furthermore, it is uncertain whether these neuroprotective mechanisms are correlated with Li⁺'s clinical efficacy in maintaining mood stability. It is expected that in a nearby future, precision medicine approaches will improve diagnosis and expand treatment options. This will certainly contribute to ameliorating the medical and economic burden created by this devastating mood disorder.

Serum levels of glial cell line-derived neurotrophic factor as a biomarker for mood disorders and lithium response

Glial cell line-derived neurotrophic factor (GDNF) plays an important role in the pathophysiology of neuropsychiatric disorders. We examined serum GDNF levels in bipolar disorder (BD) patients and major depressive disorder (MDD) patients and their association with response to lithium therapy. We used a multicenter (six sites), exploratory, cross-sectional case-control design and recruited 448 subjects: 143 BD patients, 116 MDD patients, and 158 healthy controls (HCs). We evaluated the patients' clinical severity using the Clinical Global Impression (CGI), and responses to lithium therapy using the Alda scale. The serum GDNF levels were significantly decreased in the BD and MDD groups compared to the HCs, with no significant difference between the BD and MDD groups. After adjustment, the serum GDNF levels in the BD and MDD patients in remission or depressive states were decreased compared to the HC values. Lower serum GDNF levels in BD patients were associated with higher CGI and Alda scores (i.e., severe illness and good response to lithium therapy, respectively). Our findings suggest that the serum GDNF level may be a biomarker for both BD and MDD in remission or depressive states. The serum GDNF level may be associated with the lithium response of BD patients.

Anger and cluster B personality traits and the conversion from unipolar depression to bipolar disorder

INTRODUCTION

Feelings of anger and irritability are prominent symptoms of bipolar disorder (BD) that may occur during hypomanic, depressive and, especially, during mixed mood states. We aimed to determine whether such constructs are associated with the conversion to BD in subjects with a history of unipolar depression.

METHODS

Data were derived from the depressed participants of Netherlands Study of Depression and Anxiety with 9 years of follow-up. Hypomania was ascertained using the Composite International Diagnostic Interview at 2, 4, 6, and 9 years follow-up. Cross-sectionally, we studied the association between prevalent hypomania and anger related constructs with the "Spielberger Trait Anger subscale," the "Anger Attacks" questionnaire, the cluster B personality traits part of the "Personality Disorder Questionnaire," and "aggression reactivity." Prospectively, we studied whether aggression reactivity predicted incident hypomania using Cox regression analyses.

RESULTS

Cross-sectionally, the bipolar conversion group (n = 77) had significantly higher scores of trait anger and aggression reactivity, as well as a higher prevalence on "anger attacks," "antisocial traits," and "borderline traits" compared to current (n = 349) as well as remitted (n = 1159) depressive patients. In prospective analyses in 1744 participants, aggression reactivity predicted incident hypomania (n = 28), with a multivariate-adjusted hazard ratio of 1.4 (95% confidence interval: 1.02-1.93; p = .037).

CONCLUSION

Anger is a risk factor for conversion from unipolar depression to BD. In addition, patients who converted to BD showed on average more anger, agitation and irritability than people with a history of unipolar depression who had not converted.

The Delta Study - Prevalence and characteristics of mood disorders in 924 individuals with low mood: Results of the of the World Health Organization Composite International Diagnostic Interview (CIDI)

OBJECTIVES

The Delta Study was undertaken to improve the diagnosis of mood disorders in individuals presenting with low mood. The current study aimed to estimate the prevalence and explore the characteristics of mood disorders in participants of the Delta Study, and discuss their implications for clinical practice.

METHODS

Individuals with low mood (Patients Health Questionnaire-9 score ≥5) and either no previous mood disorder diagnosis (baseline low mood group, n = 429), a recent (≤5 years) clinical diagnosis of MDD (baseline MDD group, n = 441) or a previous clinical diagnosis of BD (established BD group, n = 54), were recruited online. Self-reported demographic and clinical data were collected through an extensive online mental health questionnaire and mood disorder diagnoses were determined with the World Health Organization Composite International Diagnostic Interview (CIDI).

RESULTS

The prevalence of BD and MDD in the baseline low mood group was 24% and 36%, respectively. The prevalence of BD among individuals with a recent diagnosis of MDD was 31%. Participants with BD in both baseline low mood and baseline MDD groups were characterized by a younger age at onset of the first low mood episode, more severe depressive symptoms and lower wellbeing, relative to the MDD or low mood groups. Approximately half the individuals with BD diagnosed as MDD (49%) had experienced (hypo)manic symptoms prior to being diagnosed with MDD.

CONCLUSIONS

The current results confirm high under- and misdiagnosis rates of mood disorders in individuals presenting with low mood, potentially leading to worsening of symptoms and decreased well-being, and indicate the need for improved mental health triage in primary care.

Neutrophil-to-Lymphocyte Ratio, a Novel Inflammatory Marker, as a Predictor of Bipolar Type in Depressed Patients: A Quest for Biological Markers

(1) Background: Recent research suggests inflammation as a factor involved in the pathophysiology of mood disorders. Neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte (MLR), platelet-to-lymphocyte (PLR), and systemic immune-inflammatory (SII) index ratios have been studied as peripheral markers of inflammation in bipolar and major depressive disorders. The purpose of this study is to comparatively analyze these inflammatory ratios among manic episodes of bipolar disorder, bipolar depression and unipolar depression. (2) Methods: 182 patients were retrospectively included in the study and divided into three groups: 65 manic patients, 34 patients with bipolar depression, and 83 unipolar depressive patients. White blood cells, neutrophils, monocytes, lymphocytes, and platelets were retrieved from the patients' database. NLR, MLR, PLR, and SII index were calculated using these parameters. (3) Results: Patients with manic episodes had elevated NLR (p < 0.001), MLR (p < 0.01), PLR (p < 0.05), and SII index (p < 0.001) compared to unipolar depression and increased NLR (p < 0.05) and SII index (p < 0.05) when compared to bipolar depression. NLR (p < 0.01) and SII index (p < 0.05) were higher in the bipolar depression than unipolar depression. NLR is an independent predictor of the bipolar type of depression in depressive patients. (4) Conclusions: The results confirm the role of inflammation in the pathophysiology of mood disorders and suggest the ability of NLR as a marker for the differentiation of bipolar from unipolar depression.

TMS-EEG: An emerging tool to study the neurophysiologic biomarkers of psychiatric disorders

The etiology of psychiatric disorders remains largely unknown. The exploration of the neurobiological mechanisms of mental illness helps improve diagnostic efficacy and develop new therapies. This review focuses on the application of concurrent transcranial magnetic stimulation and electroencephalography (TMS-EEG) in various mental diseases, including major depressive disorder, bipolar disorder, schizophrenia, autism spectrum disorder, attention-deficit/hyperactivity disorder, substance use disorder, and insomnia. First, we summarize the commonly used protocols and output measures of TMS-EEG; then, we review the literature exploring the alterations in neural patterns, particularly cortical excitability, plasticity, and connectivity alterations, and studies that predict treatment responses and clinical states in mental disorders using TMS-EEG. Finally, we discuss the potential mechanisms underlying TMS-EEG in establishing biomarkers for psychiatric disorders and future research directions.

Symptom Profile and Clinical Course of Inpatients with Unipolar versus Bipolar Depression

BACKGROUND

Although differences in symptom profiles and outcome between depressive patients with an underlying major depressive disorder (MDD) and bipolar depression (BD) have been reported, studies with sequential short-interval assessments in a real-life inpatient setting are scarce.

OBJECTIVES

To examine potential differences in symptom profile and course of depressive symptomatology in depressive inpatients with underlying MDD and BD.

METHODS

A cohort of 276 consecutive inpatients with MDD (n = 224) or BD (n = 52) was followed during their hospitalization using routine outcome monitoring (ROM), which included a structured diagnostic interview at baseline (Mini-International Neuropsychiatric Interview Plus [MINI-Plus]) and repeated 17-item Hamilton Depression Rating Scale every 2 weeks. MDD and BD were compared regarding their symptom profiles and time to response and remission. Furthermore, the concordance between the MINI-Plus and clinical diagnosis was analyzed.

RESULTS

Patients were on average 52 and 47 years old in the MDD and BD group, respectively, and 66 versus 64% were female. Compared to patients with BD, patients with MDD scored higher on weight loss (p = 0.02), whereas the BD group showed a higher long-term likelihood of response (hazard ratio = 1.93, 95% confidence interval 1.16-3.20, p for interaction with time = 0.04). Although the same association was seen for remission, the interaction with time was not significant (p = 0.48). Efficiency between the MINI-Plus and clinical diagnosis of BD was high (0.90), suggesting that the MINI-Plus is an adequate ROM diagnostic tool.

CONCLUSIONS

In routine clinical inpatient care, minor differences in the symptom profile and the course of depressive symptomatology may be helpful in distinguishing MDD and BD, particularly when using sequential ROM assessments.

Categorical differentiation of the unipolar and bipolar disorders

There has been a longstanding debate as to whether the bipolar disorders differ categorically or dimensionally, with some dimensional or spectrum models including unipolar depressive disorders within a bipolar spectrum model. We analysed manic/hypomanic symptom data in samples of clinically diagnosed bipolar I, bipolar II and unipolar patients, employing latent class analyses to determine if separate classes could be identified. Mixture analyses were also undertaken to determine if a unimodal, bimodal or a trimodal pattern was present. For both a refined 15-item set and an extended 30-item set of manic/hypomanic symptoms, our latent class analyses favoured three-class solutions, while mixture analyses identified trimodal distributions of scores. Findings argue for a categorical distinction between unipolar and bipolar disorders, as well as between bipolar I and bipolar II disorders. Future research should aim to consolidate these results in larger samples, particularly given that the size of the unipolar group in this study was a salient limitation.

Inflammation is correlated with abnormal functional connectivity in unmedicated bipolar depression: an independent component analysis study of resting-state fMRI

BACKGROUND

Inflammation might play a role in bipolar disorder (BD), but it remains unclear the relationship between inflammation and brain structural and functional abnormalities in patients with BD. In this study, we focused on the alterations of functional connectivity (FC), peripheral pro-inflammatory cytokines and their correlations to investigate the role of inflammation in FC in BD depression.

METHODS

In this study, 42 unmedicated patients with BD II depression and 62 healthy controls (HCs) were enrolled. Resting-state-functional magnetic resonance imaging was performed in all participants and independent component analysis was used. Serum levels of Interleukin-6 (IL-6) and Interleukin-8 (IL-8) were measured in all participants. Correlation between FC values and IL-6 and IL-8 levels in BD was calculated.

RESULTS

Compared with the HCs, BD II patients showed decreased FC in the left orbitofrontal cortex (OFC) implicating the limbic network and the right precentral gyrus implicating the somatomotor network. BD II showed increased IL-6 (p = 0.039), IL-8 (p = 0.002) levels. Moreover, abnormal FC in the right precentral gyrus were inversely correlated with the IL-8 (r = -0.458, p = 0.004) levels in BD II. No significant correlation was found between FC in the left OFC and cytokines levels.

CONCLUSIONS

Our findings that serum IL-8 levels are associated with impaired FC in the right precentral gyrus in BD II patients suggest that inflammation might play a crucial role in brain functional abnormalities in BD.

Platelet-derived growth factor BB: A potential diagnostic blood biomarker for differentiating bipolar disorder from major depressive disorder

Bipolar disorder (BD) is frequently misdiagnosed as major depressive disorder (MDD) due to overlapping depressive symptoms. This study investigated whether serum platelet-derived growth factor BB (PDGF-BB) is a differential diagnostic biomarker for BD and MDD. An initial SOMAscan proteomics assay of 1311 proteins in small samples from patients with BD and MDD and healthy controls (HCs) suggested that serum levels of PDGF-BB differed between BD and MDD. We then conducted a two-step, exploratory, cross-sectional, case-control study at our institute and five sites that included a total of 549 participants (157 with BD, 144 with MDD, and 248 HCs). Clinical symptoms were assessed using the Hamilton Depression Rating Scale and the Young Mania Rating Scale. In the initial analysis at our institute, serum PDGF-BB levels in the MDD group (n = 36) were significantly lower than those in the BD (n = 39) and HC groups (n = 36). In the multicenter study, serum PDGF-BB levels in the MDD group were again significantly lower than those in the BD and HC groups, with no significant difference between the BD and HC groups. Treatment with sodium valproate was associated with significantly lower serum PDGF-BB levels in patients with BD. After controlling for confounding factors (sex, age, body mass index, clinical severity, and valproate medication), serum PDGF-BB levels were lower in the MDD group than in the BD group regardless of mood state. Our findings suggest that serum PDGF-BB may be a potential biomarker to differentiate BD and MDD.

Psychometric Properties of the Chinese Version of the Bipolar Depression Rating Scale for Bipolar Disorder

INTRODUCTION

Unlike unipolar depression, depressive episode of bipolar disorder is often associated with clinical characteristics, such as atypical and mixed symptoms. However, there are currently no valid and reliable specific tools available to assess the specific psychiatric symptomatology of depressive episode of bipolar disorder in China. Therefore, we aimed to evaluate the psychometric properties of the Chinese version of the Bipolar Depression Rating Scale (BDRS) in Chinese patients with bipolar disorder.

METHODS

The sample of this study included 111 patients with bipolar disorder (30 male, 81 female). All participants were interviewed with the Chinese version of the BDRS (BDRS-C), the 17-item Hamilton Depression Rating Scale (HAMD-17), the Montgomery-Asberg Depression Rating Scale (MADRS) and the Young Mania Rating Scale (YMRS). A psychometric analysis of the BDRS was conducted.

RESULTS

The Cronbach's alpha coefficient of the BDRS-C reached a value of 0.869. The BDRS-C score and scores for the HAMD-17 (r = 0.819, p < 0.01), the MADRS (r = 0.882, p < 0.01) and the YMRS (r = 0.355, p < 0.01) exhibited significant positive correlations. Close correlations were observed between the mixed subscale score of the BDRS-C and the YMRS score (r = 0.784, p < 0.01). Exploratory factor analysis resulted in three factors: a primary depressive symptoms cluster, a secondary depressive symptoms cluster, and a mixed symptoms cluster.

CONCLUSION

The Chinese version of the BDRS has satisfactory psychometric properties. This is a valid and reliable instrument to assess depressive symptomatology in patients with bipolar disorder.

Disrupted dynamic functional connectivity in right amygdalar subregions differentiates bipolar disorder from major depressive disorder

Notwithstanding being the object of a growing field of clinical research, the investigation of the dynamic resting-state functional connectivity alterations in psychiatric illnesses is still in its early days. Current research on major depressive disorder (MDD) and bipolar disorder (BD) has evidenced abnormal resting-state functional connectivity (rsFC), especially in regions subserving emotional processing and regulation such as the amygdala. However, dynamic changes in functional connectivity within the amygdalar subregions in distinguishing BD and MDD has not yet been fully understood. In this paper, we aim at analyzing the patterns characterizing dynamic FC (dFC) in the right amygdala to investigate the differences between similarly depressed BD and MDD. A number of 40 BD patients, 61 MDD patients and 63 healthy controls (HCs) underwent functional magnetic resonance imaging (fMRI) at rest. Using the right-amygdala as seed region, we compared the dFC within three subdivisions, namely, laterobasal (LB), centromedial (CM) and superficial (SF) between all the groups. To do so, one-way ANOVA followed by post-hoc t-tests were employed. Compared to HCs, patients with BD had a decreased dFC between right LB and the left postcentral gyrus as well as an increased dFC between right CM and the right cerebellum.Compared to BD patients, patients with MDD showed a decreased dFC between right CM and the cerebellum and an increased dFC between right LB and the left postcentral gyrus. These findings present initial evidence that abnormal patterns of the right-amygdalar subregions shared by BD and MDD supports the differential pathophysiology of these disorders.

Am I Really Bipolar? Personal Accounts of the Experience of Being Diagnosed With Bipolar II Disorder

Bipolar disorder (BD) is a complex and chronic mental illness with highs and lows beyond the ordinary, which induces a significant risk of suicide. The aim of this study was to explore the experience of being diagnosed with BD and the impact that receiving a correct diagnosis had had on life situations and relationships with others. Semi-structured qualitative interviews were conducted with seven people diagnosed with BD. The results showed that the primary treatment all participants had received or were currently receiving was pharmacotherapy, typically without any psychological component. A major concern that arose was delayed diagnosis, leading to inadequate treatment, and lack of knowledge among professionals about non-typical forms of BD. Moreover, the experiences of others’ reactions were multifold, though generally surprisingly positive. Generally, the participants had learned to recognize, understand and tackle early symptoms of both hypomanic and depressive episodes to avoid developing a full-blown acute episode. This study highlights the crucial importance of a collaborative relationship between the clinician and the patient.

Symptom networks in acute depression across bipolar and major depressive disorders: A network analysis on a large, international, observational study

Major Depressive Episode (MDE) is a transdiagnostic nosographic construct straddling Major Depressive (MDD) and Bipolar Disorder (BD). Prognostic and treatment implications warrant a differentiation between these two disorders. Network analysis is a novel approach that outlines symptoms interactions in psychopathological networks. We investigated the interplay among depressive and mixed symptoms in acutely depressed MDD/BD patients, using a data-driven approach. We analyzed 7 DSM-IV-TR criteria for MDE and 14 researched-based criteria for mixed features (RBDC) in 2758 acutely depressed MDD/BD patients from the BRIDGE-II-Mix study. The global network was described in terms of symptom thresholds and symptom centrality. Symptom endorsement rates were compared across diagnostic subgroups. Subsequently, MDD/BD differences in symptom-network structure were examined using permutation-based network comparison test. Mixed symptoms were the most central and highly interconnected nodes in the network, particularly agitation followed by irritability. Despite mixed symptoms, appetite gain and hypersomnia were significantly more endorsed in BD patients, associations between symptoms were highly correlated across MDD/BD (Spearman's r = 0.96, p<0.001). Network comparison tests showed no significant differences among MDD/BD in network strength, structure, or specific edges, with strong edges correlations (0.66-0.78). Upstream differences in MDD/BD may produce similar symptoms networks downstream during acute depression. Yet, mixed symptoms, appetite gain and hypersomnia are associated to BD rather than MDD. Symptoms during mixed-MDE might aggregate according to 2 different clusters, suggesting a possible stratification within mixed states. Future symptom-based studies should implement clinical, longitudinal, and biological factors, in order to establish tailored therapeutic strategies for acute depression.

Mood spectrum symptoms during a major depressive episode: Differences between 145 patients with bipolar disorder and 155 patients with major depressive disorder. Arguments for a dimensional approach

BACKGROUND

Several studies have challenged the traditional unipolar-bipolar dichotomy in favor of a more dimensional approach.

OBJECTIVE

To evaluate the differences in mood spectrum between patients with bipolar disorder (BD) and major depressive disorder (MDD) during a major depressive episode (MDE).

METHOD

Study participants were 145 patients with BD and 155 patients with MDD recruited at three University Medical Centers in Italy. All study subjects met Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for MDE and completed the Mood Spectrum-Self-Report-Last Month questionnaire.

RESULTS

Patients with BD endorsed more items in the mood manic/hypomanic and energy depressive subdomains of the MOODS-SR questionnaire. Significant differences were also found for specific depressive and manic items, which were more frequently endorsed by patients with BD. A large number of patients with BD, but also a considerable number of patients with MDD, endorsed manic items during a depressive episode.

CONCLUSIONS

There are differences between BD and MDD in terms of the number and type of mood spectrum items that are endorsed during a MDE, which may help to identify patients with BD when a retrospective assessment of a history of mania or hypomania is not possible or not reliable. A high number of patients with BD and a considerable number of patients with MDD endorsed several items in the manic section of the mood, energy, and cognition domains, this confirming the centrality of mixed features in patients with mood disorders and the need for a unitary, dimensional, descriptive and dynamic approach to MDD and BD, such as the recently proposed ACE (Activity, Cognition, Energy) model.

Minocycline and celecoxib as adjunctive treatments for bipolar depression: a multicentre, factorial design randomised controlled trial

BACKGROUND

Several small studies suggest that the adjunctive use of anti-inflammatory agents might improve depressive symptoms in bipolar disorder. However, there are few well designed, appropriately powered clinical trials assessing the efficacy of these novel treatment strategies. We aimed to assess the efficacy of adjunctive minocycline or celecoxib in this setting.

METHODS

This double-blind, 12-week, randomised, placebo-controlled trial was done in four outpatient psychiatric clinics in Pakistan. Eligible participants were adults (aged 18-65 years) with DSM-5 bipolar disorder (type I or II) and a major depressive episode. In a 2 × 2 factorial design, participants were randomly assigned (1:1:1:1) to receive either active minocycline plus active celecoxib, active minocycline plus placebo celecoxib, placebo minocycline plus active celecoxib, or placebo minocycline plus placebo celecoxib. The primary outcome was the mean change from baseline to week 12 in score on the 17-item Hamilton Depression Rating Scale (HAMD-17), assessed in all randomised participants (missing data were imputed and assumed to be missing at random). The trial was registered with ClinicalTrials.gov, NCT02703363.

FINDINGS

266 (17%) of 1542 patients assessed between May 1, 2016, and March 31, 2019, were randomly assigned to receive minocycline plus celecoxib (n=68), minocycline plus placebo (n=66), celecoxib plus placebo (n=66), or placebo plus placebo (n=66). From baseline to week 12, depressive symptoms as per HAMD-17 reduced in all four groups (from 24·5-25·2 to 11·3-12·8), but these reductions did not differ significantly between the groups. In terms of main effects, reductions in HAMD-17 did not differ for patients treated with minocycline (mean adjusted difference vs non-minocycline 1·48 [95% CI -0·41 to 3·36]; p=0·123) or for celecoxib (mean adjusted difference vs non-celecoxib -0·74 [-2·61 to 1·14]; p=0·443). Rates of serious adverse effects did not differ between groups (31 participants had a manic switch, two self-harmed, and one died in a motor vehicle accident).

INTERPRETATION

We found no evidence that minocycline or celecoxib was superior to placebo for the treatment of bipolar depression. This large trial casts doubt on the potential therapeutic benefits of adjunctive anti-inflammatory drugs for the acute management of bipolar depression.

FUNDING

Stanley Medical Research Institute.

Fast versus slow onset of depressive episodes: A clinical criterion for subtyping patients with major depression

Purpose:

The speed of onset of depressive episodes is a clinical aspect of affective disorders that has not been sufficiently investigated. Thus, we aimed to explore whether patients with fast onset of the full-blown depressive symptomatology (≤ 7 days) differ from those with slow onset (> 7 days) with regard to demographic and clinical aspects.

Subjects and methods:

Data were obtained within an observational study conducted in outpatients with major depression who were treated with duloxetine (30–120 mg/day). Onset of depression (without any preceding critical life event) was fast in 416 (less than one week) and slower in 2220 patients.

Results:

Compared to patients with slow onset, those with fast onset of depression had more suicide attempts in the previous 12 months (2.7% versus 1.3%, P = 0.046) and less somatic comorbidity (61.7% versus 74.1%, P < 0.0001). In addition, they were slightly younger at onset of depression (mean ± SD 40.2 ± 14.6 versus 42.8 ± 14.2 years, P < 0.001) and used analgesics at baseline significantly less frequently (22.8% versus 33.4%, P < 0.0001).

Discussion and conclusion:

The speed of onset of depression has to be regarded as a relevant clinical characteristic in patients with unipolar depression.

Differential biomarker signatures in unipolar and bipolar depression: A machine learning approach

OBJECTIVE

This study used machine learning techniques combined with peripheral biomarker measurements to build signatures to help differentiating (1) patients with bipolar depression from patients with unipolar depression, and (2) patients with bipolar depression or unipolar depression from healthy controls.

METHODS

We assessed serum levels of interleukin-2, interleukin-4, interleukin-6, interleukin-10, tumor necrosis factor-α, interferon-γ, interleukin-17A, brain-derived neurotrophic factor, lipid peroxidation and oxidative protein damage in 54 outpatients with bipolar depression, 54 outpatients with unipolar depression and 54 healthy controls, matched by sex and age. Depressive symptoms were assessed using the Hamilton Depression Rating Scale. Variable selection was performed with recursive feature elimination with a linear support vector machine kernel, and the leave-one-out cross-validation method was used to test and validate our model.

RESULTS

Bipolar vs unipolar depression classification achieved an area under the receiver operating characteristics (ROC) curve (AUC) of 0.69, with 0.62 sensitivity and 0.66 specificity using three selected biomarkers (interleukin-4, thiobarbituric acid reactive substances and interleukin-10). For the comparison of bipolar depression vs healthy controls, the model retained five variables (interleukin-6, interleukin-4, thiobarbituric acid reactive substances, carbonyl and interleukin-17A), with an AUC of 0.70, 0.62 sensitivity and 0.7 specificity. Finally, unipolar depression vs healthy controls comparison retained seven variables (interleukin-6, Carbonyl, brain-derived neurotrophic factor, interleukin-10, interleukin-17A, interleukin-4 and tumor necrosis factor-α), with an AUC of 0.74, a sensitivity of 0.68 and 0.70 specificity.

CONCLUSION

Our findings show the potential of machine learning models to aid in clinical practice, leading to more objective assessment. Future studies will examine the possibility of combining peripheral blood biomarker data with other biological data to develop more accurate signatures.

Distinctive Neuroanatomical Substrates for Depression in Bipolar Disorder versus Major Depressive Disorder

No neuroanatomical substrates for distinguishing between depression of bipolar disorder (dBD) and major depressive disorder (dMDD) are currently known. The aim of the current multicenter study was to identify neuroanatomical patterns distinct to depressed patients with the two disorders. Further analysis was conducted on an independent sample to enable generalization of results. We directly compared MR images of these subjects using voxel-based morphometry (VBM) and a support vector machine (SVM) algorithm using 1531 participants. The VBM analysis showed significantly reduced gray matter volumes in the bilateral dorsolateral prefrontal (DLPFC) and anterior cingulate cortices (ACC) in patients with dBD compared with those with dMDD. Patients with the two disorders shared small gray matter volumes for the right ACC and left inferior frontal gyrus when compared with healthy subjects. Voxel signals in these regions during SVM analysis contributed to an accurate classification of the two diagnoses. The VBM and SVM results in the second cohort also supported these results. The current findings provide new evidence that gray matter volumes in the DLPFC and ACC are core regions in displaying shared and distinct neuroanatomical substrates and can shed light on elucidation of neural mechanism for depression within the bipolar/major depressive disorder continuum.

Bipolar depression: the clinical characteristics and unmet needs of a complex disorder

Objective: We reviewed important clinical aspects of bipolar depression, a progressive psychiatric condition that is commonly treated in primary care. Bipolar depression is associated with considerable burden of illness, high suicide risk, and greater morbidity and mortality than bipolar mania. Methods: We identified articles relevant to our narrative review using a multistep search of the literature and applying terms that were relevant to bipolar depression or bipolar disorder. Results: Bipolar depression accounts for the majority of time spent unwell for patients with bipolar disorder; high rates of morbidity and mortality arise from full symptomatic episodes and interepisode subsyndromal symptoms. Bipolar depression is an important contributor to long-term dysfunction for patients with bipolar disorder due to psychosocial impairment, loss of work productivity and high rates of substance abuse. Missed and delayed diagnosis is prevalent due to overlapping symptoms with unipolar depression and other diagnoses. Medical comorbidities (i.e. cardiovascular disease, hypertension, obesity, metabolic syndrome) and psychiatric comorbidities (i.e. anxiety disorder, personality disorder, eating disorder, attention-deficit/hyperactivity disorder) are common. Currently, only three treatments are FDA-approved for bipolar depression; monotherapy antidepressants are not a recommended treatment option. Conclusions: Bipolar disorder is common among primary care patients presenting with depression; it is often treated exclusively in primary care. Clinicians should be alert for symptoms of bipolar disorder in undiagnosed patients, know what symptoms probabilistically suggest bipolar versus unipolar depression, have expertise in providing ongoing treatment to diagnosed patients, and be knowledgeable about managing common medication-related side effects and comorbidities. Prompt and accurate diagnosis is critical.

Advanced melatonin onset relative to sleep in women with unmedicated major depressive disorder

Studies on circadian timing in depression have produced variable results, with some investigations suggesting phase advances and others phase delays. This variability may be attributable to differences in participant diagnosis, medication use, and methodology between studies. This study examined circadian timing in a sample of unmedicated women with and without unipolar major depressive disorder. Participants were aged 18-28 years, had no comorbid medical conditions, and were not taking medications. Eight women were experiencing a major depressive episode, nine had previously experienced an episode, and 31 were control participants with no history of mental illness. Following at least one week of actigraphic sleep monitoring, timing of salivary dim light melatonin onset (DLMO) was assessed in light of <1 lux. In currently depressed participants, melatonin onset occurred significantly earlier relative to sleep than in controls, with a large effect size. Earlier melatonin onset relative to sleep was also correlated with poorer mood for all participants. Our results indicate that during a unipolar major depressive episode, endogenous circadian phase is advanced relative to sleep time. This is consistent with the early-morning awakenings often seen in depression. Circadian misalignment may represent a precipitating or perpetuating factor that could be targeted for personalized treatment of major depression.

Clinical features of differential diagnosis between unipolar and bipolar depression in a drug-free sample of young adults

INTRODUCTION

Subjects with bipolar disorder suffering of a depressive episode are frequently misdiagnosed as unipolar depression, being important studies assessing the differential diagnosis between bipolar and unipolar depression.

OBJECTIVE

To assess the sociodemographic and clinical features of drug-free young adults in a depressive episode of bipolar or unipolar disorder in order to identify factors that may differentiate these psychiatric conditions.

METHODS

This is a cross-sectional study with 241 young adults aged between 18 and 29 years who were evaluated using the Structured Clinical Interview for DSM-IV (SCID). The sample comprised patients with BD (n = 89) and major depressive disorder (n = 152), experiencing a depressive episode and not using psychoactive drugs or illicit psychoactive substances.

RESULTS

The characteristics associated with bipolar depression were being male (p < 0.001), with a family history of BD (p = 0.013), a higher frequency of childhood traumatic experiences (p = 0.001), younger age of onset of mood disorder (p = 0.004), many previous depressive episodes (p = 0.027), greater severity of depressive symptoms (p < 0.001) and day/night reversal (p = 0.013). Those with unipolar depression showed a higher frequency of biological rhythm disturbances (p < 0.001), and diurnal preference (p = 0.028).

LIMITATIONS

The sample has not included subjects with severe suicide risk, a possible important marker in differentiate unipolar from bipolar depression.

CONCLUSION

Some clinical aspects may contribute to an early differential diagnosis of both bipolar and unipolar depression even in the initial stages of the disease.

Intraday Activity Levels May Better Reflect the Differences Between Major Depressive Disorder and Bipolar Disorder Than Average Daily Activity Levels

It is important to establish an objective index to differentiate mood disorders (i.e., bipolar disorder; BD and major depressive disorder; MDD). The present study focused on the pattern of changes of physical activity in the amount of activity intraday, and examined the relationship between activity patterns and mood disorders. One hundred and eighteen inpatients with MDD or BD in a depressive state provided the activity data by using wearable activity trackers for 3 weeks. In order to illuminate the characteristic patterns of intraday activities, Principal Component Analysis (PCA) was adopted to extract the main components of intraday activity changes. We found that some of the PCs reflected the differences between the types of mood disorder. BD participants showed high activity pattern in the morning and low activity pattern in evenings. However, MDD showed the opposite. Our results suggest that activity tracking focused on daytime activity patterns may provide objective auxiliary diagnostic information.

Differential clinical characteristics and possible predictors of bipolarity in a sample of unipolar and bipolar inpatients

Major affective conditions including both unipolar (UD) and bipolar disorders (BD) are associated with significant disability throughout the life course. We aimed to investigate the most relevant socio-demographic/clinical differences between UD and BD subjects. Our sample included 180 inpatients, of which 82 (45.5%) participants were diagnosed with UD and 98 (54.5%) with BD. Relative to UD patients, BD individuals were more likely to report prior psychoactive medications, lifetime psychotic symptoms, nicotine abuse, a reduced ability to provide to their needs, gambling behavior, and fewer nonsuicidal self-harm episodes. Moreover, BD patients were more likely to report severe side effects related to medications, a younger age at illness onset and first hospitalization, higher illness episodes, and longer illness duration in years than UD subjects. In a multivariate logistic analysis accounting for age, gender, and socio-demographic characteristics, a significant positive contribution to bipolarity was found only for higher lifetime psychotic symptoms (β = 1.178; p ≤ .05) and number of illness episodes (β = .155; p ≤ .05). The present findings suggest that specific clinical factors may be used in order to better distinguish between UD and BD subgroups. Further studies are required to replicate these findings in larger samples.

A bittersweet relationship: What does it mean to be the caregiver of a patient with bipolar disorder?

BACKGROUND

As with most of the chronic illnesses, the changes and consequences brought on by bipolar disorder (BD) are not exclusive to the patient and often spread to those around them, especially for direct caregivers of these patients. It is known that there is a significant emotional and physical toll among persons who coexist daily with those who suffer from this disorder.

OBJECTIVE

Aware of the importance of the role played by informal caregivers (especially the family) in the stability and evolution of patients with bipolar disorder, this study seeks to explore the perception that family members responsible for bipolar persons have of themselves as caregivers of these patients.

METHOD

This is a qualitative study using a phenomenological design, for which the technique of focused or semi-structured interviews was employed. Ten caregivers of people with diagnosis of BD agreed to participate.

RESULTS

Within the family, it is a single individual who has the role of caregiver. Experiences and meanings that are generated into the nucleus of the patient-caregiver relationship are full of ambivalence and involve many aspects worthy of analysing, such as the development of identities, the feminization of patient care, the process of therapeutic decision-making and the evolution of the disease.

CONCLUSIONS

It is necessary to integrate evaluation and attention for patients' caregivers, recognizing them as individuals and elucidating their constructed meanings and the dynamics established in their relationship with patients. In this way, there would be a more integrative clinical approach of the patient-caregiver relationship, considering not only the necessary pharmacological treatments but also accompanying both patient and family, along the path they travel as they experience BD.

Cortical abnormalities in bipolar disorder: an MRI analysis of 6503 individuals from the ENIGMA Bipolar Disorder Working Group

Despite decades of research, the pathophysiology of bipolar disorder (BD) is still not well understood. Structural brain differences have been associated with BD, but results from neuroimaging studies have been inconsistent. To address this, we performed the largest study to date of cortical gray matter thickness and surface area measures from brain magnetic resonance imaging scans of 6503 individuals including 1837 unrelated adults with BD and 2582 unrelated healthy controls for group differences while also examining the effects of commonly prescribed medications, age of illness onset, history of psychosis, mood state, age and sex differences on cortical regions. In BD, cortical gray matter was thinner in frontal, temporal and parietal regions of both brain hemispheres. BD had the strongest effects on left pars opercularis (Cohen's d=-0.293; P=1.71 × 10^-21), left fusiform gyrus (d=-0.288; P=8.25 × 10^-21) and left rostral middle frontal cortex (d=-0.276; P=2.99 × 10^-19). Longer duration of illness (after accounting for age at the time of scanning) was associated with reduced cortical thickness in frontal, medial parietal and occipital regions. We found that several commonly prescribed medications, including lithium, antiepileptic and antipsychotic treatment showed significant associations with cortical thickness and surface area, even after accounting for patients who received multiple medications. We found evidence of reduced cortical surface area associated with a history of psychosis but no associations with mood state at the time of scanning. Our analysis revealed previously undetected associations and provides an extensive analysis of potential confounding variables in neuroimaging studies of BD.

Identification of plasma biomarkers for distinguishing bipolar depression from major depressive disorder by iTRAQ-coupled LC-MS/MS and bioinformatics analysis

It is important to differentiate between bipolar disorder (BD) and major depressive disorder (MDD) in the first depressive episode because of the potential treatment implications. Previous studies have mainly focused on the different clinical features or pathological biomarkers to distinguish these two diseases; however, a better understanding of the proteomics profiling of BD may help aid future therapeutic strategies. Here, we applied isobaric tags for relative and absolute quantification (iTRAQ) technology combined with liquid chromatography-tandem mass spectrometry (LC-MS/MS) to identify differentially expressed proteins between MDD and bipolar depression (BP). In total, 30 MDD, 30 BP and 30 healthy subjects were included. Proteins from depleted plasma samples were digested into peptides, individually labeled with iTRAQ reagents, combined and subjected to LC-MS/MS and further bioinformatics analyses. Our results showed that 9 proteins were significantly altered between MDD and BP. Briefly, B2RAN2, B4E1B2, APOA1, ENG, SBSN and QSOX2 were up-regulated, whereas ORM1, MRC2 and SLPI were down-regulated. Most identified proteins were related to the immune system. The bioinformatics analysis showed that B2RAN2 (highly similar to vanin-1) was involved in the significantly enriched KEGG pathways "pantothenate and CoA biosynthesis" (P=0.009). B2RAN2 and ENG may play important roles in depression. They may serve as candidate biomarkers for distinguishing MDD and BP. Further validation and investigation are required to illuminate the roles of B2RAN2 and ENG in MDD and BP. The current study provided a potential and novel biomarker panel that may, in turn, aid the diagnosis of BD.

Coeliac disease and psychiatric comorbidity: epidemiology, pathophysiological mechanisms, quality-of-life, and gluten-free diet effects

Coeliac Disease (CD) is an autoimmune disease in which an environmental factor, gluten, triggers a pathological reaction. It results in intra- and entra-intestinal manifestations of disease, including, most frequently, diarrhoea, weight loss, and anaemia. CD occurs in ∼1% of the western population, being one of the most common autoimmune lifelong disorders, and may present with a variety of psychiatric comorbidities. Psychiatric comorbidity in CD often complicates the diagnosis, reduces the quality-of-life, and worsens the prognosis of affected patients. This review summarizes the epidemiological studies that underline this connection, and focuses on the potential mechanisms related to this comorbility, such as nutritional deficiencies, immune responses, interference in brain processes, and dysfunctions in the gut-brain axis. Factors that play a central role on patients' quality of life, psychological well-being and adherence are presented. Finally, evidence of regression in psychiatric symptoms following the introduction of a gluten-free diet is underlined as well.

Characteristics of depression among offspring at high and low familial risk of bipolar disorder

OBJECTIVES

Having a parent with bipolar disorder (BP) is a very strong risk factor for developing BP. Similarly, depression among youth is a clinical risk factor for subsequent BP. We evaluated whether mood symptomatology in depressed youth is different between those at high and low familial risk to develop BP.

METHODS

The most severe major depressive episode in BP offspring (N=61) and community control offspring (N=20) was evaluated using expanded depression and mania rating scales derived from the Schedule for Affective Disorders and Schizophrenia for Children Present Version. The results were adjusted for any between-group significant demographic differences and for multiple comparisons.

RESULTS

The severity of depressive symptoms and the percentage of offspring with severe depressive symptoms, especially atypical depressive features, were significantly higher in the depressed offspring of BP parents compared to the depressed controls (P_s <.05). The depressive symptoms were helpful to identify a high-risk group (e.g., odds ratio [OR] for hypersomnia: 22.4, 95% confidence interval [CI]: 1.3-404, P=.04). In addition, there were significantly more depressed offspring of BP parents with subsyndromal manic symptoms than controls (52.5% vs 20%, OR: 4.2, 95% CI: 1.2-14.7, P<.01).

CONCLUSIONS

Depressed BP offspring had more severe depression including atypical depressive symptoms, and were more likely to have subsyndromal mixed manic symptoms than depressed control offspring. Prospective studies to evaluate whether these youth are at high risk to develop BP are warranted. If replicated, the results of this study have important clinical (e.g., treatment of depression in depressed offspring of BP parents) and research implications.

Circuits Regulating Pleasure and Happiness in Bipolar Disorder

According to our model, the motivation for appetitive-searching vs. distress-avoiding behaviors is regulated by two parallel cortico-striato-thalamo-cortical (CSTC) re-entry circuits that include the core and the shell parts of the nucleus accumbens, respectively. An entire series of basal ganglia, running from the caudate nucleus on one side to the centromedial amygdala on the other side, control the intensity of these reward-seeking and misery-fleeing behaviors by stimulating the activity of the (pre)frontal and limbic cortices. Hyperactive motivation to display behavior that potentially results in reward induces feelings of hankering (relief leads to pleasure); while, hyperactive motivation to exhibit behavior related to avoidance of aversive states results in dysphoria (relief leads to happiness). These two systems collaborate in a reciprocal fashion. We hypothesized that the mechanism inducing the switch from bipolar depression to mania is the most essential characteristic of bipolar disorder. This switch is attributed to a dysfunction of the lateral habenula, which regulates the activity of midbrain centers, including the dopaminergic ventral tegmental area (VTA). From an evolutionary perspective, the activity of the lateral habenula should be regulated by the human homolog of the habenula-projecting globus pallidus, which in turn might be directed by the amygdaloid complex and the phylogenetically old part of the limbic cortex. In bipolar disorder, it is possible that the system regulating the activity of this reward-driven behavior is damaged or the interaction between the medial and lateral habenula may be dysfunctional. This may lead to an adverse coupling between the activities of the misery-fleeing and reward-seeking circuits, which results in independently varying activities.

Distinguishing Bipolar Depression from Unipolar Depression in Youth: Preliminary Findings

OBJECTIVES

To identify mood symptoms that distinguishes bipolar disorder (BP) depression versus unipolar depression in youth during an acute depressive episode.

METHODS

Youth with BP (N = 30) were compared with youth with unipolar depression (N = 59) during an acute depressive episode using the depression and mania items derived from the Schedule for Affective Disorders and Schizophrenia for Children (K-SADS)-Present Version. The results were adjusted for multiple comparisons, and any significant between-group differences in demographic, nonmood comorbid disorders, and psychiatric family history.

RESULTS

In comparison with unipolar depressed youth, BP depressed youth had significantly higher scores in several depressive symptoms and all subsyndromal manic symptoms, with the exception of increased goal-directed activity. Among the depressive symptoms, higher ratings of nonsuicidal physical self-injurious acts and mood reactivity, and lower ratings of aches/pains, were the symptoms that best discriminated BP from unipolar depressed youth. Subsyndromal manic symptoms, particularly motor hyperactivity, distractibility, and pressured speech, were higher in BP depressed youth and discriminated BP depressed from unipolar depressed youth.

CONCLUSIONS

The results of this study suggest that it is possible to differentiate BP depression from unipolar depression based on depressive symptoms, and in particular subsyndromal manic symptoms. If replicated, these results have important clinical and research implications.

Associations among Substance Use, Mental Health Disorders, and Self-Harm in a Prison Population: Examining Group Risk for Suicide Attempt

Substance use disorders (SUD) and mental health disorders are significant public health issues that co-occur and are associated with high risk for suicide attempts. SUD and mental health disorders are more prevalent among offenders (i.e., prisoners or inmates) than the non-imprisoned population, raising concerns about the risk of self-harm. This cross-sectional study examined the population of a state prison system (10,988 out of 13,079) to identify associations among SUD (alcohol, cannabis, intravenous drugs, narcotics, and tobacco smoking), mental health disorders (anxiety, bipolar, depression, and psychotic disorders), and suicide attempts. The primary aim was to determine which groups (SUD, mental health disorders, and co-occurrences) were strongly association with suicide attempts. Groups with a documented SUD or mental health disorders compared to peers without these issues had 2.0 and 9.2 greater odds, respectively, for attempting suicide, which was significant at p < 0.0001 for both conditions. There were also significant differences within SUD and mental health disorders groups in regard to suicide attempts. Groups with the greatest odds for suicide attempts were offenders with comorbid bipolar comorbid and anxiety, alcohol combined with depression, and cannabis co-occurring with depression. Documentation of suicide attempts during imprisonment indicates awareness, but also suggest a need to continue enhancing screening and evaluating environmental settings.

Diagnostic Conversion to Bipolar Disorder in Unipolar Depressed Patients Participating in Trials on Antidepressants

Objective

In unipolar depressed patients participating in trials on antidepressants, we investigated if illness characteristics at baseline could predict conversion to bipolar disorder.

Method

A long-term register-based follow-up study of 290 unipolar depressed patients with a mean age of 50.8 years (SD = 11.9) participating in three randomized trials on antidepressants conducted in the period 1985–1994. The independent effects of explanatory variables were examined by applying Cox regression analyses.

Results

The overall risk of conversion was 20.7%, with a mean follow-up time of 15.2 years per patient. The risk of conversion was associated with an increasing number of previous depressive episodes at baseline, [HR 1.18, 95% CI (1.10–1.26)]. No association with gender, age, age at first depressive episode, duration of baseline episode, subtype of depression or any of the investigated HAM-D subscales included was found.

Limitations

The patients were followed-up through the Danish Psychiatric Central Research Register, which resulted in inherent limitations such as possible misclassification of outcome.

Conclusion

In a sample of middle-aged hospitalized unipolar depressed patients participating in trials on antidepressants, the risk of conversion was associated with the number of previous depressive episodes. Therefore, this study emphasizes that unipolar depressed patients experiencing a relatively high number of recurrences should be followed more closely, or at least be informed about the possible increased risk of conversion.