Conceptual underpinnings and empirical support for the mood spectrum

Effective Connectivity between Major Nodes of the Limbic System, Salience and Frontoparietal Networks Differentiates Schizophrenia and Mood Disorders from Healthy Controls

This study was conducted to examine whether there are quantitative or qualitative differences in the connectome between psychiatric patients and healthy controls and to delineate the connectome features of major depressive disorder (MDD), schizophrenia (SCZ) and bipolar disorder (BD), as well as the severity of these disorders. Toward this end, we performed an effective connectivity analysis of resting state functional MRI data in these three patient groups and healthy controls. We used spectral Dynamic Causal Modeling (spDCM), and the derived connectome features were further subjected to machine learning. The results outlined a model of five connections, which discriminated patients from controls, comprising major nodes of the limbic system (amygdala (AMY), hippocampus (HPC) and anterior cingulate cortex (ACC)), the salience network (anterior insula (AI), and the frontoparietal and dorsal attention network (middle frontal gyrus (MFG), corresponding to the dorsolateral prefrontal cortex, and frontal eye field (FEF)). Notably, the alterations in the self-inhibitory connection of the anterior insula emerged as a feature of both mood disorders and SCZ. Moreover, four out of the five connectome features that discriminate mental illness from controls are features of mood disorders (both MDD and BD), namely the MFG→FEF, HPC→FEF, AI→AMY, and MFG→AMY connections, whereas one connection is a feature of SCZ, namely the AMY→SPL connectivity. A large part of the variance in the severity of depression (31.6%) and SCZ (40.6%) was explained by connectivity features. In conclusion, dysfunctions in the self-regulation of the salience network may underpin major mental disorders, while other key connectome features shape differences between mood disorders and SCZ, and can be used as potential imaging biomarkers.

Subthreshold psychiatric symptoms as potential predictors of postpartum depression

The authors' purpose in the present study is to examine the role of subthreshold mental disorders as predictors of Postpartum Depression (PPD). 110 pregnancy women were evaluated as follow: the General 5-Spectrum Measure at 26 weeks of gestation; the Edinburgh Postnatal Depression Scale at 3/6 months after delivery. Only 4.5% of the sample developed PPD at 3/6 months after delivery. Agoraphobia/panic, depressed mood, social anxiety and eating problems relate positively to PPD at 3/6 months. Early identification of symptoms that could indicate the development of future mood problems in the mother is of crucial importance for mental health and prevention.

Post-traumatic stress disorder in train crash survivors in Italy: the role of mood spectrum dysregulations and intrusiveness

BACKGROUND

To explore relationships among post-traumatic stress disorder (PTSD), depressive spectrum symptoms, and intrusiveness in subjects who survived the crash of a train derailed carrying liquefied petroleum gas and exploded causing a fire.

METHODS

A sample of 111 subjects was enrolled in Viareggio, Italy. AMOS version 21 (IBM Corp, 2012) was utilized for a structural equation model-path analysis to model the direct and indirect links between the exposure to the traumatic event, the occurrence of depressive symptoms, and intrusiveness. Subjects were administered with the SCID-IV (Structured Clinical Interview for DSM-IV), the Questionnaire for Mood Spectrum (MOODS-SR)-Last Month version, the Trauma and Loss Spectrum Questionnaire (TALS-SR), and the Impact of Event Scale-Revised version (IES-R).

RESULTS

Sixty-six (66/111; 59.4%) subjects met SCID-IV criteria for PTSD. Indices of goodness of fit were as followed: χ2/df = 0.2 P = .6; comparative fit index = 1 and root mean square error of approximation = 0.0001. A significant path coefficient for direct effect of potential traumatic events on depressive symptoms (β = 0.25; P < .04) and from depressive symptoms to intrusiveness (β = 0.34; P < .003) was found. An indirect effect was also observed: standardized value of potential traumatic events on intrusiveness was 0.86. The mediating factor of this indirect effect path was represented by depressive symptoms. Potential traumatic events explained 6.2% of the variance of depressive symptoms; 11.8% of the variance of intrusiveness was accounted for traumatic event and depressive symptoms.

CONCLUSIONS

Path analysis led us to speculate that depression symptoms might have mediated the relationship between the exposure to potential traumatic events and intrusiveness for the onset of PTSD.

PTSD and Burnout are Related to Lifetime Mood Spectrum in Emergency Healthcare Operator

Background:

PTSD and burnout are frequent conditions among emergency healthcare personnel because exposed to repeated traumatic working experiences. Increasing evidence suggests high comorbidity between PTSD and mood symptoms, particularly depression, although the real nature of this relationship still remains unclear. The purpose of this study was to investigate the relationship between PTSD, burnout and lifetime mood spectrum, assessed by a specific scale, among health-care professionals of a major University Hospital in Italy.

Methods:

N=110 Emergency Unit workers of the Azienda Ospedaliero-Universitaria Pisana (Pisa, Italy) were assessed by the TALS-SR, MOODS-SR lifetime version and the ProQOL R-IV.

Results:

Approximately 60% of participants met at least one PTSD symptom criterion (criterion B, 63.4%; criterion C, 40.2%; criterion D 29.3%; criterion E, 26.8%), according to DSM-5 diagnosis. Almost sixteen percent of the sample reported a full symptomatic DSM-5 PTSD (work-related) diagnosis, and these showed significantly higher scores in all MOODS-SR depressive domains, as well as in the rhythmicity domain, compared with workers without PTSD. Further, mood-depressive and cognition-depressive MOODS-SR domains resulted to be predictive for PTSD. Significant correlations emerged between either PTSD diagnosis and criteria or ProQOL subscales and all the MOOD-SR domains.

Conclusion:

A significant association emerged among PTSD, burnout and lifetime MOOD Spectrum, particularly the depressive component, in emergency health care operators, suggesting this population should be considered at-risk and undergo regular screenings for depression and PTSD.

Direct incremental healthcare costs associated with mood disorders in the United States, 2007-2017

BACKGROUND

This study provides nationally representative estimates of the direct incremental economic burden of mood disorders in the United States between 2007-2017, and examines trends in spending on mood disorders by healthcare setting over time.

METHODS

The Medical Expenditure Panel Survey (MEPS) was used to analyze nationally-representative data related to healthcare expenditures between 2007-2017. A two-part regression model was used to estimate healthcare expenditures for patients with mood disorders compared to those without, adjusting for several sociodemographic and health-related factors.

RESULTS

Total annual healthcare costs for patients with mood disorders were over twice as high as for those without, even after adjusting for potential confounders. A mood disorder diagnosis independently accounted for $6,591.60 in additional annual healthcare spending over this period. While healthcare spending on mood disorders increased significantly in the outpatient setting (14%), home health setting (84%), and on prescription medications (17%), it decreased in the inpatient setting and remained stable for emergency care.

LIMITATIONS

Study limitations include an inability to determine specific components of cost in each setting, analyze costs for distinct depressive and bipolar disorders by four- or five-digit diagnosis code, and the potential for recall bias during data collection.

CONCLUSIONS

Spending on outpatient care, prescription medications, and home health care for mood disorder patients grew significantly between 2007 and 2017, but decreased for inpatient care and remained stable in the emergency care setting. Future research should examine drivers of spending in these settings and explore ways to improve patient outcomes and stabilize growing healthcare expenditures.

Reviewing the diagnostic validity and utility of mixed depression (depressive mixed states)

Objective

To review the diagnostic validity and utility of mixed depression, i.e. co-occurrence of depression and manic/hypomanic symptoms.

Methods

PubMed 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.

Results

By 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.

Discussion

Categorically-defined mixed depression may have some diagnostic validity (family history is the current strongest validator). Its diagnostic utility seems supported by treatment response.

Mood Spectrum Disorders and Perception of Pain

Evaluation of pain perception in chronic pain patients with a concomitant mood-spectrum disorder.

DESIGN

The observational retrospective study is based on patient data collected in psychosomatic consultations held at the Gift Institute for Integrative Medicine in Pisa, Italy, from 2002 to 2014. Evoked pain stimulus threshold and tolerance were evaluated using the cold pressor test. Clinical pain intensity and Sensorial, Affective, and Evaluative dimensions were assessed using the Italian Pain Questionnaire, and Anxiety and Depressive symptoms using the Hospital Anxiety Depression Scale. Mood-spectrum disorders were diagnosed via the Mini-International Neuropsychiatric Interview, and affective temperament in accordance with Akiskal and Pinto's criteria (1999). Of a total of 627 chronic pain clinic patients, 381 were diagnosed with a concomitant mood-spectrum (MS) disorder, unipolar (US) in 61.41%. Pain threshold (t = 2.28; p < 0.05) was lower, and all clinical pain dimensions (t = 2.28; p < 0.05) increased, in MS patients compared to those without psychiatric disorders. Pain intensity (F = 3.5, p < 0.05) and cognitive pain component scores (F = 7.84; p < 0.0001) were higher in US and, to a lesser extent Bipolar Spectrum, than in subjects with other (n.112) or no psychiatric disorders (n. 134). Suicide ideation was highest in US (F = 37.20; p < 0.0001), although in BS major depressive episodes had more melancholic features (F = 46.73; P < 0.0001), and a longer history of psychiatric disorders before the pain onset than US (F = 20.31; p < 0.0001). Pain management should take into account pre-existing psychiatric disorders.

An approach to revealing clinically relevant subgroups across the mood spectrum

BACKGROUND

Individuals diagnosed with bipolar 1 disorder (BP1), bipolar 2 disorder (BP2), or major depressive disorder (MDD) experience varying levels of depressive and (hypo)manic symptoms. Clarifying symptom heterogeneity is meaningful, as even subthreshold symptoms may impact quality of life and treatment outcome. The MOODS Lifetime self-report instrument was designed to capture the full range of depressive and (hypo)manic characteristics.

METHODS

This study applied clustering methods to 347 currently depressed adults with MDD, BP2, or BP1 to reveal naturally occurring MOODS subgroups. Subgroups were then compared on baseline clinical and demographic characteristics and as well as depressive and (hypo)manic symptoms over twenty weeks of treatment.

RESULTS

Four subgroups were identified: (1) high depressive and (hypo)manic symptoms (N=77, 22%), (2) moderate depressive and (hypo)manic symptoms (N=115, 33%), (3) low depressive and moderate (hypo)manic symptoms (N=82, 24%), and (4) low depressive and (hypo)manic symptoms (N=73, 21%). Individuals in the low depressive/moderate (hypo)manic subgroup had poorer quality of life and greater depressive symptoms over the course of treatment. Individuals in the high and moderate severity subgroups had greater substance use, longer duration of illness, and greater (hypo)manic symptoms throughout treatment. Treatment outcomes were primarily driven by individuals diagnosed with MDD.

LIMITATIONS

The sample was drawn from three randomized clinical trials. Validation is required for this exploratory study.

CONCLUSIONS

After validation, these subgroups may inform classification and personalized treatment beyond categorical diagnosis.

Swedish Version of Mood Spectrum Self-Report Questionnaire: Psychometric Properties of Lifetime and Last-week Version

BACKGROUND

Mood Spectrum Self Report (MOODS-SR) is an instrument that assesses mood spectrum symptomatology including subthreshold manifestations and temperamental features. There are different versions of the MOODS-SR for different time frames of symptom assessment: lifetime (MOODS-LT), last-month and last-week (MOODS-LW) versions.

OBJECTIVE

To evaluate the psychometric properties of the MOODS-LT the MOODS-LW.

METHODS

The reliability of the MOODS-LT and MOODS-LW was evaluated in terms of internal consistency and partial correlations among domains and subdomains. The known-group validity was tested by comparing out-patients with bipolar disorder (n=27), unipolar depression (n=8) healthy controls (n=68). The convergent and divergent validity of MOODS-LW were evaluated using the Montgomery Åsberg Depression Rating Scale (MADRS), the Young-Ziegler Mania Rating Scale (YMRS) in outpatients as well the General Health Questionnaire (GHQ-12) in healthy controls.

RESULTS

Both MOODS-LT and MOOODS-LW showed high internal consistency with the Kuder-Richardson coefficient ranging from 0.823 to 0.985 as well as consistent correlations for all domains and subdomains. The last-week version correlated significantly with MADRS (r= 0.79) and YMRS (r=0.46) in outpatients and with GHQ-12 (r= 0.50 for depression domain, r= 0.29 for rhythmicity) in healthy controls.

CONCLUSION

The Swedish version of the MOODS-LT showed similar psychometric properties to other translated versions. Regarding MOODS-LW, this first published psychometric evaluation of the scale showed promising psychometric properties including good correlation to established symptom assessment scales. In healthy controls, the depression and rhythmicity domain scores of the last-week version correlated significantly with the occurrence of mild psychological distress.

Impact of Mood Spectrum Spirituality and Mysticism Symptoms on Suicidality in Earthquake Survivors with PTSD

The aim of the present study was to explore the correlations between Spirituality/Mysticism/Psychoticism symptoms and suicidality in young adult survivors of the L'Aquila earthquake. The sample included 475 subjects recruited among high school seniors who had experienced the April 6, 2009, earthquake. Assessments included: Trauma and Loss Spectrum-Self Report and Mood Spectrum-Self Report (MOODS-SR). Mysticism/Spirituality dimension and suicidality were evaluated by means of some specific items of the MOOD-SR. The Spirituality/Mysticism/Psychoticism MOODS-SR factor score was significantly higher among subjects with PTSD diagnosis with respect to those without. Similarly, subjects with suicidal ideation, as well as those who committed a suicide attempt, reported significantly higher scores than those without.

Dimensions of Delusions in Major Depression: Socio-demographic and Clinical Correlates in an Unipolar-Bipolar Sample

Objective

The present study aims at exploring associations between a continuous measure of distorted thought contents and a set of demographic and clinical features in a sample of unipolar/bipolar depressed patients.

Methods

Our sample included 1,833 depressed subjects. Severity of mood symptoms was assessed by the 21 items Hamilton Depression Rating Scale (HAM-D). The continuous outcome measure was represented by a delusion (DEL) factor, extracted from HAM-D items and including items: 2 (“Feelings of guilt”), 15 (“Hypochondriasis”), and 20 (“Paranoid symptoms”). Each socio-demographic and clinical variable was tested by a generalized linear model test, having depressive severity (HAM-D score–DEL score) as the covariate.

Results

A family history of major depressive disorder (MDD; p=0.0006), a diagnosis of bipolar disorder, type I ( p=0.0003), a comorbid general anxiety disorder (p<0.0001), and a higher number of manic episodes during lifetime (p<0.0001), were all associated to higher DEL scores. Conversely, an older age at onset (p<0.0001) and a longer duration of hospitalization for depression over lifetime (p=0.0003) had a negative impact over DEL scores. On secondary analyses, only the presence of psychotic features (p<0.0001) and depressive severity (p<0.0001) were found to be independently associated to higher DEL scores.

Conclusion

The retrospective design and a non validated continuous measure for distorted thought contents were the main limitations of our study. Excluding the presence of psychotic features and depressive severity, no socio-demographic or clinical variable was found to be associated to our continuous measure of distorted thinking in depression.

The significance of mixed states in depression and mania

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.

Lifetime mood spectrum symptoms among bipolar patients and healthy controls: a cross sectional study with the Mood Spectrum Self-Report questionnaire

BACKGROUND

The "spectrum" model has advantages for the conceptualization of mental disorders, representing a complementary approach to the currently available categorical systems. We carried out a study in order to assess lifetime mood symptoms among patients with bipolar disorder (BD) and healthy controls from a dimensional perspective.

METHODS

The Mood Spectrum Self-Report instrument (MOODS-SR) was administered to 101 bipolar patients (52 BD I, 32 BD II, and 17 BD NOS, 36 males/65 females, mean age+SD=36.10±13.34 years) and 38 healthy controls (16 males/22females, mean age+SD=35.18±13.70 years). The scores of the different MOOD-SR scales and subscales among patients and controls were compared using non-parametric tests (Mann-Whitney and Kruskal-Wallis).

RESULTS

Bipolar patients scored significantly higher than healthy controls on the total MOOD-SR scores (BD: mean±SD=98.65±22.17; HC: mean±SD=12.92±10.72; p<0.01) and all subdomains. Multiple comparisons revealed lower scores among controls when compared to each one of the subtypes of BD, also regarding the total scores and all subdomains (p<0.01). Comparisons across the different subtypes of BD revealed statistically significant higher scores among BD I patients when compared to BD II and BD NOS patients, only in regard to the total MOOD-SR scores (BD I: mean±SD=102.94±22.79; BD II: mean±SD=93.53±21.97; BD NOS: mean±SD= 94.88±18.68; p=0.03) and two subdomains: mood mania and energy mania.

CONCLUSIONS

These results, although preliminary, suggest that even though the MOODS-SR seems effective in distinguishing BD patients from HC, it is not as good in discriminating different subtypes of BD, especially in respect to lifetime depressive symptoms.

LIMITATIONS

Our sample size was small, and comprised by outpatients. The MOOD-SR measures only lifetime symptoms and does not take into account the progression of mood symptoms or the current mood state of patients.

An empirically derived approach to the classification and diagnosis of mood disorders

This article describes a system for diagnosing mood disorders that is empirically derived and designed for its clinical utility in everyday practice. A random national sample of psychiatrists and clinical psychologists described a randomly selected current patient with a measure designed for clinically experienced informants, the Mood Disorder Diagnostic Questionnaire (MDDQ), and completed additional research forms. We applied factor analysis to the MDDQ to identify naturally occurring diagnostic groupings within the patient sample. The analysis yielded three clinically distinct mood disorder dimensions or spectra, consistent with the major mood disturbances included in the DSM and ICD over successive editions (major depression, dysthymia, and mania), along with a suicide risk index. Diagnostic criteria were determined strictly empirically. Initial data using diagnostic efficiency statistics supported the accuracy of the dimensions in discriminating DSM-IV diagnoses; regression analyses supported the discriminant validity of the MDDQ scales; and correlational analysis demonstrated coherent patterns of association with family history of mood disorders and functional outcomes, supporting validity. Perhaps most importantly, the MDDQ diagnostic scales demonstrated incremental validity in predicting adaptive functioning and psychiatric history over and above DSM-IV diagnosis. The empirically derived syndromes can be used to diagnose mood syndromes dimensionally without complex diagnostic algorithms or can be combined into diagnostic prototypes that eliminate the need for ever-expanding categories of mood disorders that are clinically unwieldy.

Evaluation of mood disorder patients in a primary care practice: measures of affective temperament, mental health risk factors, and functional health in a retrospective, descriptive study of 35 patients

OBJECTIVE

THE PURPOSE OF THIS RETROSPECTIVE, DESCRIPTIVE STUDY WAS TO EVALUATE PRIMARY CARE PATIENTS DIAGNOSED WITH A MOOD DISORDER ON THE BASIS OF THE FOLLOWING: (1) comorbid medical illnesses, (2) risk factors for mood disorders and longitudinal presence of symptoms, (3) presence of affective temperament, and (4) functional status and quality of life.

METHOD

Patients (N = 35) were a convenience sample diagnosed in the Mood Disorder Clinic (MDC), a family practice site-based mental health treatment consultation service. All study patients were assessed using a semistructured interview and diagnosed according to DSM-IV-TR criteria. Data were collected using both chart review and secondary analysis of a computerized touch-screen mood disorders database that included the 36-item Short-Form Medical Outcomes Study Health Survey (SF-36) and an affective temperament survey. The study was conducted from January 2000 through August 2000.

RESULTS

A total of 62 comorbid medical illnesses were present in this group of patients; only 2 patients had no comorbid illnesses. Psychiatric diagnoses included 25 cases (78.1%) of bipolar depression, 5 cases (15.6%) of unipolar or dysthymic depression, and 2 cases (6.3%) of nonmood or anxiety disorders. All patients (100%) had a positive family history for mood disorders or substance abuse. Twenty-four patients (70.6%) had onset of their depressive symptoms prior to age 21, and 11 patients (35.5%) had a positive history of sexual abuse. Affective temperaments were positive in the 30 patients who completed this section. SF-36 scale scores were predominantly below national norms.

CONCLUSION

The medical comorbidities in our study were expected; the positive family and individual histories for risk along with low SF-36 scores reflect the severity and chronicity of mood disorders in this population.

Distinguishing affective depersonalization from anhedonia in major depression and bipolar disorder

BACKGROUND

Affective depersonalization has received limited attention in the literature, although its conceptualization may have implications in terms of identification of clinical endophenotypes of mood disorders. Thus, this study aims to test the hypothesis that anhedonia and affective depersonalization represent 2 distinct psychopathological dimensions and to investigate their clinical correlates in patients with major depressive disorder (MDD) and bipolar disorder (BD).

METHODS

Using a data pool of 258 patients with mood and anxiety disorders, an item response theory-based factor analysis approach was carried out on 16 items derived from 2 clinical instruments developed in the Spectrum Project (the Structured Clinical Interview for Mood Spectrum and the Structured Clinical Interview for Derealization-Depersonalization Spectrum). Clinical correlates of these psychometrically derived dimensions were subsequently investigated in patients with BD or MDD.

RESULTS

Using an item response theory-based factor analysis, a 2-factor solution was identified, accounting overall for the 47.0% of the variance. Patients with BD showed statistically significant higher affective depersonalization factor scores than those with MDD (Z = 2.215, P = .027), whereas there was no between-groups difference in anhedonia scores (Z = 0.825 P = .411). In patients with BD, age of onset of the disease correlated with affective depersonalization factor scores (rho = -0.330, P = .001) but not with anhedonia factor scores (rho = -0.097, P = .361).

CONCLUSIONS

Affective depersonalization and anhedonia seem to be 2 distinct psychopathological dimensions, although closely related, bearing the opportunity to identify patients with a specific profile for a better clinical and neurobiological definition.

Phenotypic effects of a bipolar liability gene among individuals with major depressive disorder

Variations in voltage-dependent calcium channel L-type, alpha 1C subunit (CACNA1C) gene have been associated with bipolar disorder in a recent meta-analysis of genome-wide association studies [Ferreira et al., 2008]. The impact of these variations on other psychiatric disorders has not been yet investigated. Caucasian non-Hispanic participants in the STAR*D study of treatment for depression for whom DNA was available (N = 1213) were genotyped at two single-nucleotide polymorphisms (SNPs) (rs10848635 and rs1006737) in the CACNA1C gene. We examined putative phenotypic indicators of bipolarity among patients with major depression and elements of longitudinal course suggestive of latent bipolarity. We also considered remission and depression severity following citalopram treatment. The rs10848635 risk allele was significantly associated with lower levels of baseline agitation (P = 0.03; beta = -0.09). The rs1006737 risk allele was significantly associated with lesser baseline depression severity (P = 0.04; beta = -0.4) and decreased likelihood of insomnia (P = 0.047; beta = -0.22). Both markers were associated with an increased risk of citalopram-emergent suicidality (rs10848635: OR = 1.29, P = 0.04; rs1006737: OR = 1.34, P = 0.02). In this exploratory analysis, treatment-emergent suicidality was associated with two risk alleles in a putative bipolar liability gene.

The factor structure of lifetime depressive spectrum in patients with unipolar depression

BACKGROUND

While previous attempts to elucidate the factor structure of depression tended to agree on a central focus on depressed mood, other factors were not replicated across studies. By examining data from a large number of items covering the range of depressive symptoms, the aim of the present study is to contribute to the identification of the structure of depression on a lifetime perspective.

METHODS

The study sample consisted of 598 patients with unipolar depression who were administered the Mood Spectrum Self-Report (lifetime version) in Italian (N=415) or English (N=183). In addition to classical exploratory factor analysis using tetrachoric correlation coefficients, an IRT-based factor analysis approach was adopted to analyze the data on 74 items of the instrument that explore cognitive, mood and energy/activity features associated with depression.

RESULTS

Six factors were identified, including 'Depressive Mood', 'Psychomotor Retardation', 'Suicidality', 'Drug/Illness related depression', 'Psychotic Features' and 'Neurovegetative Symptoms', accounting overall for 48.3% of the variance of items.

LIMITATIONS

Clinical information on onset of depression and duration of illness is available only for 350 subjects. Therefore, differences between sites can only be partially accounted using available data.

CONCLUSIONS

Our study confirms the central role of depressed mood, psychomotor retardation and suicidality and identifies the factors 'Drug/Illness related depression', 'Psychotic features' and the neurovegetative dysregulation not captured by the instruments most frequently used in previous studies. The identification of patients with specific profiles on multiple factors may be useful in achieving greater precision in neuroimaging studies and in informing treatment selection.

The structure of lifetime manic-hypomanic spectrum

BACKGROUND

The observation that bipolar disorders frequently go unrecognized has prompted the development of screening instruments designed to improve the identification of bipolarity in clinical and non-clinical samples. Starting from a lifetime approach, researchers of the Spectrum Project developed the Mood Spectrum Self-Report (MOODS-SR) that assesses threshold-level manifestations of unipolar and bipolar mood psychopathology, but also atypical symptoms, behavioral traits and temperamental features. The aim of the present study is to examine the structure of mania/hypomania using 68 items of the MOODS-SR that explore cognitive, mood and energy/activity features associated with mania/hypomania.

METHODS

A data pool of 617 patients with bipolar disorders, recruited at Pittsburgh and Pisa, Italy was used for this purpose. Classical exploratory factor analysis, based on a tetrachoric matrix, was carried out on the 68 items, followed by an Item Response Theory (IRT)-based factor analytic approach.

RESULTS

Nine factors were initially identified, that include Psychomotor Activation, Creativity, Mixed Instability, Sociability/Extraversion, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Inflated Self-esteem, Euphoria, Wastefulness/Recklessness, and account overall for 56.4% of the variance of items. In a subsequent IRT-based bi-factor analysis, only five of them (Psychomotor Activation, Mixed Instability, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Euphoria) were retained.

CONCLUSIONS

Our data confirm the central role of Psychomotor Activation in mania/hypomania and support the definitions of pure manic (Psychomotor Activation and Euphoria) and mixed manic (Mixed Instability and Mixed Irritability) components, bearing the opportunity to identify patients with specific profiles for a better clinical and neurobiological definition.

Psychologists' and social workers' self-descriptions using DSM-IV psychopathology

There is limited information on mental health of psychologists and social workers despite their rendering mental health services, so their subjective perception of mental disorder was explored via a self-evaluation survey in which they self-diagnosed the presence of DSM-IV disorders within themselves. The sample of 128 professionals included 63 psychologists and 65 social workers. The presence of Axis I traits was reported by 81.2%, the three most frequent traits being mood, obsessive-compulsive disorder, and eating disorder. Axis II traits were reported by 73.4% of subjects, the three most frequent conditions being narcissistic, avoidant, and obsessive-compulsive personality traits. While a high percentage of subjects reported the presence of either an Axis I or Axis II disorder, the average severity reported was low. More psychologists reported on mood, social phobia, and eating problems than social workers, while the latter reported more on psychotic problems. Psychologists reported more Axis II traits, especially paranoid, narcissistic, and avoidant subtypes. More women than men reported eating problems, while more men reported schizoid and avoidant personality traits. In conclusion, manifestations of subthreshold psychiatric conditions were prominently reported. These findings suggest encouraging mental health care professionals to explore treatment for problems if present.

Validity and reliability of the Structured Clinical Interview for Depersonalization-Derealization Spectrum (SCI-DER)

This study evaluates the validity and reliability of a new instrument developed to assess symptoms of depresonalization: the Structured Clinical Interview for the Depersonalization-Derealization Spectrum (SCI-DER). The instrument is based on a spectrum model that emphasizes soft-signs, sub-threshold syndromes as well as clinical and subsyndromal manifestations. Items of the interview include, in addition to DSM-IV criteria for depersonalization, a number of features derived from clinical experience and from a review of phenomenological descriptions. Study participants included 258 consecutive patients with mood and anxiety disorders, 16.7% bipolar I disorder, 18.6% bipolar II disorder, 32.9% major depression, 22.1% panic disorder, 4.7% obsessive compulsive disorder, and 1.5% generalized anxiety disorder; 2.7% patients were also diagnosed with depersonalization disorder. A comparison group of 42 unselected controls was enrolled at the same site. The SCI-DER showed excellent reliability and good concurrent validity with the Dissociative Experiences Scale. It significantly discriminated subjects with any diagnosis of mood and anxiety disorders from controls and subjects with depersonalization disorder from controls. The hypothesized structure of the instrument was confirmed empirically.

Borderline personality disorder and mood spectrum

Several lines of evidence have raised the question of whether Borderline Personality Disorder (BPD) is an independent disease entity or it might be better conceptualized as belonging to the spectrum of mood disorders. This study explores a wide array of lifetime mood features (mood, cognitions, energy, and rhythmicity and vegetative functions) in patients with BP and mood disorders. The sample consisted of 25 BPD patients who did not meet the criteria for bipolar disorders, 16 bipolar disorders patients who did not meet the criteria for BPD, 19 unipolar patients who did not meet the criteria for BPD, and 30 non-clinical subjects. Clinical diagnoses were determined by administering the structured clinical interviews for DSM-IV disorders. The Mood Spectrum Self-Report (MOODS-SR) was used for measuring lifetime mood phenomenology. Clinical subjects displayed higher mean scores than normal subjects in all domains of the MOODS-SR, and BPD patients displayed higher scores than unipolar patients in the Mood and Cognition depressive subdomains. Differences between patients with BP and bipolar disorders on MOODS psychopathology did not attain statistical significance for any (sub)domain considered. The results of this study are consistent with previous findings suggesting the importance of mood dysregulations in patients with BPD.

The link between neurosteroids and syndromic/syndromal components of the mood spectrum disorders in women during the premenstrual phase

OBJECTIVES

Females with a lifetime diagnosis of major mood disorder (Bipolar Disorder BD, Major Depressive Disorder MMD) investigated during the luteal phase of their menstrual cycle and in a condition of clinical well-being showed higher blood serum concentrations of progesterone and allopregnanolone compared to healthy controls. Women with BD presented even higher levels than those affected by MDD. This study attempted to verify, in line with a dimensional approach, if the possible differences in neurohormonal levels may be directly linked to some syndromal clusters (dimensions) of the mood spectrum disorders indipendently of diagnosis.

METHODS

Premenstrual concentrations of allopregnanolone, THDOC, progesterone, and cortisol were measured in 3 groups of women: 17 BD and 14 MDD outpatients, and 16 control subjects. Psychiatric evaluation was performed with the SCID-I interview and the SCI-MOODS-SR questionnaire. The correlation between steroid levels and mood disorder syndromal cluster (SCI-MOODS-SR domains and sub-domains) was evaluated by means of analysis of main components with Varimax rotation and Kaiser's normalization (which provided for inclusion of all components with an Eigen value >1).

RESULTS

Analysis of the main components evidenced the presence of 3 components: 1) mania, 2) depression both with mixed component 3) steroid + manic cognitivity and suicidal ideas.

CONCLUSION

Levels of allopregnanolone and progesterone do not correlate with the association of the depressive and manic syndromes, but rather with mixed symptomatological aspects, and in particular with cognitive manic and depressive (with suicidal thoughts) dimensions. Further studies should be carried out to confirm these findings.

Validity and utility of bipolar spectrum models

The bipolar spectrum model suggests that several patient presentations not currently recognized by the DSM warrant consideration as part of a mood disorders continuum. These include hypomania or mania associated with antidepressants; manic symptoms which fall short of the current DSM threshold for hypomania; and depression attended by multiple non-manic markers that are associated with bipolar course. Evidence supporting the inclusion of these groups within the realm of bipolar disorder (BP) is examined. Several diagnostic tools for detecting and characterizing these patient groups are described. Finally, options for altering DSM-IV criteria to allow some of the above patient presentations to be recognized as bipolar are considered. More data on the validity and utility of these alterations would be useful, but limited changes appear warranted now. We describe an additional BP Not Otherwise Specified (BP NOS) example which creates a subthreshold hypomanic analogue to cyclothymia, consistent with existing BP NOS criteria. This change should be accompanied by additional requirements for the assessment and reporting of non-manic bipolar markers.

Bipolar II disorder : epidemiology, diagnosis and management

Bipolar II disorder (BP-II) is defined, by DSM-IV, as recurrent episodes of depression and hypomania. Hypomania, according to DSM-IV, requires elevated (euphoric) and/or irritable mood, plus at least three of the following symptoms (four if mood is only irritable): grandiosity, decreased need for sleep, increased talking, racing thoughts, distractibility, overactivity (an increase in goal-directed activity), psychomotor agitation and excessive involvement in risky activities. This observable change in functioning should not be severe enough to cause marked impairment of social or occupational functioning, or to require hospitalisation. The distinction between BP-II and bipolar I disorder (BP-I) is not clearcut. The symptoms of mania (defining BP-I) and hypomania (defining BP-II) are the same, apart from the presence of psychosis in mania, and the distinction is based on the presence of marked impairment associated with mania, i.e. mania is more severe and may require hospitalisation. This is an unclear boundary that can lead to misclassification; however, the fact that hypomania often increases functioning makes the distinction between mania and hypomania clearer. BP-II depression can be syndromal and subsyndromal, and it is the prominent feature of BP-II. It is often a mixed depression, i.e. it has concurrent, usually subsyndromal, hypomanic symptoms. It is the depression that usually leads the patient to seek treatment.DSM-IV bipolar disorders (BP-I, BP-II, cyclothymic disorder and bipolar disorder not otherwise classified, which includes very rapid cycling and recurrent hypomania) are now considered to be part of the 'bipolar spectrum'. This is not included in DSM-IV, but is thought to also include antidepressant/substance-associated hypomania, cyclothymic temperament (a trait of highly unstable mood, thinking and behaviour), unipolar mixed depression and highly recurrent unipolar depression.BP-II is underdiagnosed in clinical practice, and its pharmacological treatment is understudied. Underdiagnosis is demonstrated by recent epidemiological studies. While, in DSM-IV, BP-II is reported to have a lifetime community prevalence of 0.5%, epidemiological studies have instead found that it has a lifetime community prevalence (including the bipolar spectrum) of around 5%. In depressed outpatients, one in two may have BP-II. The recent increased diagnosing of BP-II in research settings is related to several factors, including the introduction of the use of semi-structured interviews by trained research clinicians, a relaxation of diagnostic criteria such that the minimum duration of hypomania is now less than the 4 days stipulated by DSM-IV, and a probing for a history of hypomania focused more on overactivity (increased goal-directed activity) than on mood change (although this is still required for a diagnosis of hypomania). Guidelines on the treatment of BP-II are mainly consensus based and tend to follow those for the treatment of BP-I, because there have been few controlled studies of the treatment of BP-II. The current, limited evidence supports the following lines of treatment for BP-II. Hypomania is likely to respond to the same agents useful for mania, i.e. mood-stabilising agents such as lithium and valproate, and the second-generation antipsychotics (i.e. olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole). Hypomania should be treated even if associated with overfunctioning, because a depression often soon follows hypomania (the hypomania-depression cycle). For the treatment of acute BP-II depression, two controlled studies of quetiapine have not found clearcut positive effects. Naturalistic studies, although open to several biases, have found antidepressants in acute BP-II depression to be as effective as in unipolar depression; however, one recent large controlled study (mainly in patients with BP-I) has found antidepressants to be no more effective than placebo. Results from naturalistic studies and clinical observations on mixed depression, while in need of replication in controlled studies, indicate that antidepressants may worsen the concurrent intradepression hypomanic symptoms. The only preventive treatment for both depression and hypomania that is supported by several, albeit older, controlled studies is lithium. Lamotrigine has shown some efficacy in delaying depression recurrences, but there have also been several negative unpublished studies of the drug in this indication.

Depressive and manic-hypomanic spectrum psychopathology in patients with anorexia nervosa

OBJECTIVE

We used a dimensional measure of mood psychopathology to document lifetime depressive and manic-hypomanic spectrum symptoms in 50 patients with anorexia nervosa (AN).

METHOD

Participants provided demographic information and completed the Self-Report Questionnaire for Mood Spectrum, a 161-item instrument that documents lifetime symptoms, traits, and behaviors characteristic of threshold and subthreshold mood episodes. Analyses focused on the association of depressive and manic-hypomanic component scores with indicators of clinical severity in AN.

RESULTS

Lifetime severity of depressive (M[SD] = 39.1[13.9]) and manic-hypomanic (M[SD] = 23.8[12.1]) spectrum symptoms exceeded the established thresholds for clinical significance on these scales (ie, score > or =22). There was a positive correlation between the number of manic-hypomanic items endorsed and the number of depressive items endorsed. After controlling for lifetime history of mood disorder, severity of depressive and manic-hypomanic spectrum symptomatology also was associated with a history of self-induced vomiting and suicidality in patients with AN.

CONCLUSION

These data provide initial evidence for the clinical significance of depressive and manic-hypomanic spectrum symptoms in patients with AN. Future work is needed to determine how mood spectrum psychopathology might impact the course and treatment of AN.

Does age at onset support a dimensional relationship between Bipolar II disorder and major depressive disorder?

The current categorical splitting of bipolar and depressive disorders has been questioned. Age at onset is an important variable used to support such a division. Study aim was to assess the distribution of age at onset between bipolar II disorder (BP-II) and major depressive disorder (MDD), and onset age-bipolar family history, onset age-BP-II diagnosis dose-response relationships. No bi-modal distribution and no presence of dose-response relationships would not support a categorical distinction between BP-II and MDD. Consecutive 389 BP-II and 261 MDD major depressive episode (MDE) outpatients were interviewed with the DSM-IV Structured Clinical Interview and the Family History Screen, by a mood specialist psychiatrist in a private practice. Age at onset was defined as age at onset of the first MDE. Distribution of age at onset between BP-II and MDD was studied by Kernel density estimate and histogram methods, dose-response relationships by ROC analysis. BP-II, versus MDD, had significantly lower age at onset, more recurrences, and more bipolar family history. Kernel density estimate and histogram distributions of age at onset showed no bi-modality. Likelihood ratios between age at onset and bipolar family history loading, and between age at onset and BP-II diagnosis, showed dose-response relationships. The bi-modality and dose-response approaches, versus classic diagnostic validators, seem to support a dimensional relationship between BP-II and MDD.

Is there a continuity between bipolar and depressive disorders?

BACKGROUND

Recent studies questioned the current categorical split of mood disorders into bipolar disorders (BP) and depressive disorders (MDD).

METHODS

Medline database search of papers from the last 10 years on the categorical-dimensional classification of mood disorders. Various combinations of the following key words were used: mood disorders, bipolar, unipolar, major depressive disorder, spectrum, category/categorical, classification, continuity. Only English language clinical papers were included, review papers were excluded, similar papers selected by quality. The number of papers found was 1,141. The number of papers selected was 109.

RESULTS

The continuity/spectrum between BP (mainly BP-II) and MDD was supported by the following findings:(1) high frequency of mixed states (mixed mania, mixed hypomania, mixed depression, i.e. co-occurring depression and noneuphoric manic/hypomanic symptoms) because opposite polarity symptoms in the same episode do not support a hypomania/mania-depression splitting; (2) MDD was the most common mood disorder in BP probands' relatives; (3) no bimodal distribution of distinguishing symptoms between BP and MDD; (4) bipolar signs not uncommon in MDD; (5) many MDD shifting to BP; (6) many lifetime manic/hypomanic symptoms in MDD; (7) correlation between lifetime manic/hypomanic symptoms and MDD symptoms; (8) hypomania factors in MDD; (9) MDD often recurrent; (10) similar cognitive style. The categorical distinction between BP (mainly BP-I) and MDD was supported by the following findings: (1) BP more common in BP probands' relatives; (2) lower age at BP onset; (3) females as common as males in BP-I, more common than males in MDD; (4) BP-I depression more atypical and retarded, MDD depression more sleepless and agitated; (5) BP more recurrent.

CONCLUSIONS

Focusing on mood spectrum's extremes (BP-I vs. MDD), a categorical distinction seems supported. Focusing on midway disorders (BP-II and MDD plus bipolar signs), a continuity/spectrum seems supported. Results seem to support both a categorical and a dimensional view of mood disorders.

Bipolar disorder--focus on bipolar II disorder and mixed depression

Bipolar II disorder (recurrent depressive and hypomanic episodes) and related disorders (united in the bipolar spectrum) are understudied, despite a prevalence of about 5% in the community and about 50% in depressed outpatients. The apparent increase in prevalence of the bipolar spectrum is related to several changes in diagnostic criteria, including improved probing for history of hypomania (focused more on overactivity than on mood change), lower minimum duration of hypomania, and inclusion of unipolar depressions with bipolar signs (eg, family history of bipolar disorder, mixed depression). Prevalence of mixed depression, a combination of depression and manic or hypomanic symptoms, is high in patients with bipolar disorders. Controlled studies are needed to investigate treatment of mixed depression; antidepressants can worsen manic and hypomanic symptoms, and mood stabilising agents might be necessary.

Mixed depression and the dimensional view of mood disorders

BACKGROUND

Mixed depression (MxD), i.e. depression plus cooccurring noneuphoric manic/hypomanic symptoms, questions the current categorical dividing of mood disorders into bipolar disorders and depressive disorders, and supports a dimensional approach. The study aim was to test a dimensional approach to mood disorders by looking for a progressive grading of age at onset and bipolar family history loading between bipolar II disorder (BP-II) and major depressive disorder (MDD).

METHODS

Consecutive 389 BP-II and 261 MDD major depressive episode outpatients were interviewed (off psychoactive drugs) with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide (to assess intradepressive noneuphoric hypomanic symptoms), and the Family History Screen, by a mood disorder specialist psychiatrist in a private practice. BP-II and MDD MxD and non-MxD were compared on age at onset and bipolar family history loading (the diagnostic validators). A dose-response was tested between the number of intradepressive hypomanic symptoms and bipolar family history loading, and a correlation was tested between the number of intradepressive hypomanic symptoms and age at onset.

RESULTS

MxD was present in 64.5% of BP-II and in 32.1% of MDD. There were significant differences in classic diagnostic validators (onset age, bipolar family history). The comparisons between BP-II and MDD MxD and non-MxD on age at onset and bipolar family history found a clear and significant grading in age at onset from BP-II MxD to MDD non-MxD (a progressive increase), and a clear and significant grading in bipolar family history loading from BP-II MxD to MDD non-MxD (a progressive decrease). A dose-response relationship was found between the number of intradepressive hypomanic symptoms and bipolar family history loading. The area under the ROC curve was small. A significant correlation was found between the number of intradepressive hypomanic symptoms and age at onset.

CONCLUSIONS

The presence of MxD in a significant proportion of MDD, the progressive grading of age at onset and bipolar family history from BP-II MxD to MDD non-MxD, the dose-response relationship between intradepressive hypomanic symptoms and bipolar family history loading, and the correlation between intradepressive hypomanic symptoms and age at onset could support a dimensional approach to mood disorders (BP-II and MDD). On the other hand, the significant differences on classic diagnostic validators could support a categorical distinction. A mixed approach (dimensional and categorical) to mood disorders could be supported.

The Mood Spectrum Self-Report: validation and adaptation into Spanish

This study explores the psychometric properties of the Spanish adaptation of the Mood Spectrum Self-Report (MOODS-SR), an instrument designed to assess a broad range of manifestations of mood psychopathology. A total of 71 Spanish subjects participated: 49 outpatients who met criteria for a mood disorder or generalized anxiety disorder, and 22 normal controls. The instrument proved to have good internal consistency and test-retest reliability. Significant positive correlations were found between the depressive subdomains of the questionnaire and the Beck Depression Inventory, as well as between the manic-hypomanic subdomains and the Clinician-Administered Rating Scale for Mania. Clinical subjects displayed higher mean scores than normal subjects in all domains, and patients with bipolar disorder displayed higher scores than patients with unipolar disorder in the Manic component, particularly in the Energy and the Cognition subdomains. Differences between patients with generalized anxiety and mood disorders were small. The former, however, did not differ from normal controls in several subdomains, whereas patients with mood disorders did.

The continuum/spectrum concept of mood disorders: is mixed depression the basic link?

BACKGROUND

Mixed states, i.e., opposite polarity symptoms in the same mood episode, question the bipolar/unipolar splitting of mood disorders, and support a spectrum view. Study aim was assessing the distribution of intradepressive hypomanic symptoms between bipolar-II (BP-II) and major depressive disorder (MDD) depressions, and testing a dose-response relationship between number of intradepressive hypomanic symptoms and bipolar family history. No bi-modality, and a dose-response relationship, would not support a categorical distinction.

METHODS

Consecutive 389 BP-II and 261 MDD depressed outpatients were interviewed by the structured clinical interview for DSM-IV, hypomania interview guide, and family history screen, by a mood specialist psychiatrist, in a private practice. Intradepressive hypomanic symptoms were systematically assessed. Mixed depression was defined as the combination of depression and three or more intradepressive hypomanic symptoms, a validated definition.

RESULTS

BP-II, versus MDD, had significantly more intradepressive hypomanic symptoms. The distribution of intradepressive hypomanic symptoms between BP-II and MDD was not bi-modal but normal-like, and a dose-response relationship was found between the number of intradepressive hypomanic symptoms and bipolar family history.

CONCLUSIONS

Study findings question the categorical division of BP-II and MDD, and may support the spectrum view of mood disorders.

Challenging DSM-IV criteria for hypomania: diagnosing based on number of no-priority symptoms

BACKGROUND

DSM-IV definition of hypomania of bipolar-II disorder (BP-II), which includes elevated/irritable mood change as core feature (i.e., it must always be present), is not based on sound evidence.

STUDY AIM

Following classic descriptions of hypomania, was to test if hypomania could be diagnosed on the basis of its number (9) of DSM-IV symptoms, setting no-priority symptom.

METHODS

Consecutive 422 depression-remitted outpatients were re-interviewed by a mood specialist psychiatrist using the Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version [a semi-structured interview modified by Benazzi and Akiskal (J Affect Disord, 2003; J Clin Psychiatry, 2005) to improve the probing for BP-II] in a private practice. History of episodes of subthreshold (i.e., 2 or more symptoms) and threshold (i.e., meeting DSM-IV criteria of elevated mood plus at least 3 symptoms, or irritable mood plus at least 4) hypomania, lasting at least 2 days, and which were the most common symptoms during the episodes, were systematically assessed.

RESULTS

Bipolar-II disorder (BP-II) patients (according to DSM-IV criteria, apart from hypomania duration) were 260, and major depressive disorder (MDD) patients were 162. Mood change was present in all BP-II by definition. The most common symptoms were overactivity, which was present in almost all BP-II, followed by elevated mood and racing thoughts. ROC analysis of the number of hypomanic symptoms predicting BP-II found that a cut point of 5 or more symptoms over 9 had the best combination of sensitivity (90%) and specificity (84%), and the highest figure of correctly classified (87%) BP-II. History of episodes of 5 or more hypomanic symptoms was met by almost all BP-II.

LIMITATIONS

Single interviewer.

CONCLUSIONS

Following classic descriptions of hypomania, not setting any priority among the three basic domains of hypomania (mood, thinking, behavior), results suggest that a cutoff number of 5 symptoms over 9 (of those listed by DSM-IV) could be used to diagnose hypomania of BP-II. Diagnosing hypomania by counting a checklist of symptoms should make it easier to diagnose BP-II, and should reduce the current high misdiagnosis of BP-II as MDD, significantly impacting the treatment of depression.

A continuity between bipolar II depression and major depressive disorder?

BACKGROUND

A recent series of studies has questioned the current categorical split of mood disorders into bipolar and depressive disorders. Mixed states, especially mixed depression (i.e., depression plus co-occurring, noneuphoric, hypomanic symptoms) might support a continuity between bipolar II (BP-II) depression and major depressive disorder (MDD). The aim of the study was to assess the distribution of intradepressive hypomanic symptoms rating between BP-II and MDD depressions. A bi-modal distribution would support a categorical distinction, and no bi-modality would support continuity.

METHODS

Consecutive 389 BP-II and 261 MDD major depressive episode (MDE) outpatients were interviewed (off psychoactive drugs) with the Structured Clinical Interview for DSM-IV, the Hypomania Interview Guide (HIG, to assess intradepressive hypomanic symptoms), and the Family History Screen, by a mood specialist psychiatrist in a private practice. Mixed depression was defined as MDE plus 3 or more intradepressive, noneuphoric hypomanic symptoms, a definition validated by Akiskal and Benazzi. The distribution of intradepressive hypomanic symptoms rating was studied by Kernel density estimate and by histogram.

RESULTS

BP-II depression, versus MDD depression, had significantly lower age at onset, was significantly more likely to be atypical and mixed, had more depression recurrences, and a higher bipolar family history loading. BP-II depression, versus MDD depression, had significantly more irritability, racing/crowded thoughts, distractibility, psychomotor agitation, talkativeness, increased goal-directed activity, and excessive risky activities. HIG scores were significantly higher in BP-II. The distribution of intradepressive hypomanic symptoms rating showed no bi-modality in the entire depression sample.

CONCLUSIONS

Interpretation of study findings relies on the method used to define a categorical disorder. By using classic diagnostic validators (such as family history and age at onset), BP-II and MDD depressions would seem to be distinct disorders. Instead, by using the 'bi-modality' approach, a continuity would seem to be supported. Which of these methods for classification is the best has yet to be shown.

Increased neuroactive steroid concentrations in women with bipolar disorder or major depressive disorder

Changes in the plasma concentrations of neuroactive steroids have been associated with various neuropsychiatric disorders. However, the possible role of neuroactive steroids in bipolar disorder (BD) has remained unknown. We therefore determined the plasma levels of neuroactive steroids during the luteal phase of the menstrual cycle in women with BD or major depressive disorder (MDD). The plasma concentrations of 3alpha-hydroxy-5alpha-pregnan-20-one (3alpha,5alpha-THPROG), 3alpha,21-dihydroxy-5alpha-pregnan-20-one, progesterone, and cortisol were determined in 17 outpatients with BD, 14 outpatients with MDD, and 16 healthy control subjects. All patients were in a state of well-being and without relapse or recurrence for at least 3 months. Plasma concentrations of progesterone and 3alpha,5alpha-THPROG were significantly greater in patients than in controls, also being higher in BD patients than in MDD patients. Drug-free patients with BD or MDD showed similar differences in steroid concentrations relative to controls, as did drug-treated patients. Comorbidity with panic disorder, obsessive-compulsive disorder, or eating disorder had no effect on the association of mood disorders with steroid concentrations. Women with BD or MDD in a state of well-being showed higher plasma concentrations of progesterone and 3alpha,5alpha-THPROG in the luteal phase than did healthy controls. These differences did not seem to be attributable simply to drug treatment or to comorbidity with other psychiatric conditions in the patients.

Social anxiety and obsessive-compulsive spectra: validation of the SHY-SR and the OBS-SR among the Spanish population

The study focuses on the adaptation into Spanish and on the validation of the Social Phobia Spectrum Self-Report (SHY-SR) and the Obsessive-Compulsive Spectrum Self-Report (OBS-SR). The questionnaires were designed to measure a broad range of subtle and atypical features related to social anxiety and obsessive-compulsive phenomenology, respectively. Sixty-two outpatients who met DSM-IV criteria for social phobia (SP, n = 20), obsessive-compulsive disorder (OCD, n = 22) and major depression (MD, n = 20), and 25 non-clinical subjects participated. The spectra questionnaires were administered along with the Liebowitz Social Anxiety Scale and the Maudsley Obsessional Compulsive Inventory. The instruments proved to have satisfactory internal consistency and test-retest reliability. Convergent validity with other instruments was excellent for the SHY-SR and moderate for the OBS-SR. Both questionnaires were able to detect differences between patients with the disorder of interest (SP in the case of the SHY-SR scores and OCD in the case of the OBS-SR scores) and either normal controls or patients with MD. Receiver-Operating Characteristic Curve analyses were conducted to determine cut-off values in the Spanish versions of the questionnaires denoting the presence of significant SP and OCD symptomatology. Are the questionnaires available on the website?

The DSM-IV and ICD-10 categories of recurrent [major] depressive and bipolar II disorders: evidence that they lie on a dimensional spectrum

BACKGROUND

Presently it is a hotly debated issue whether unipolar and bipolar disorders are categorically distinct or lie on a spectrum. We used the ongoing Ravenna-San Diego Collaboration database to examine this question with respect to major depressive disorder (MDD) and bipolar II (BP-II).

METHODS

The study population in FB's Italian private practice setting comprised consecutive 650 outpatients presenting with major depressive episode (MDE) and ascertained by a modified version of the Structured Clinical Interview for DSM-IV. Differential assignment of patients into MDD versus BP-II was made on the basis of discrete hypomanic episodes outside the timeframe of an MDE. In addition, hypomanic signs and symptoms during MDE (intra-MDE hypomania) were systematically assessed and graded by the Hypomania Interview Guide (HIG). The frequency distributions of the HIG total scores in each of the MDD, BP-II and the combined entire sample were plotted using the kernel density estimate. Finally, bipolar family history (BFH) was investigated by structured interview (the Family History Screen).

RESULTS

There were 261 MDD and 389 BP-II. As in the previous smaller samples, categorically defined BP-II compared with MDD had significantly earlier age at onset, higher rates of familial bipolarity (mostly BP-II), history of MDE recurrences (>or=5), and atypical features. However, examining hypomania scores dimensionally, whether we examined the MDD, BP-II, or the combined sample, kernel density estimate distribution of these scores had a normal-like shape (i.e., no bimodality). Also, in the combined sample of MDE, we found a dose-response relationship between BFH loading and intra-MDE hypomania measured by HIG scores.

LIMITATIONS

Although the interviewer (FB) could not be blind to the diagnostic status of his private patients, the systematic rigorous interview process in a very large clinical population minimized any unintended biases.

CONCLUSIONS

Unlike previous studies that have examined the number of DSM-IV hypomanic signs and symptoms both outside and during MDE, the present analyses relied on the more precise hypomania scores as measured by the HIG. The finding of a dose-response relationship between BFH and HIG scores in the sample at large strongly suggests a continuity between BP-II and MDD. Our data indicate that even in those clinically depressed patients without past hypomanic episodes (so-called "unipolar" MDD), such scores are normally rather than bimodally distributed during MDE. Moreover, the absence of a 'zone of rarity' in the distribution of hypomanic scores in the combined total, MDD and BP-II MDE samples, indicates that MDD and BP-II exist on a dimensional spectrum. From a nosologic perspective, our data are contrary to what one would expect from a categorical unipolar-bipolar distinction. In practical terms, intra-MDE hypomania and BFH, especially in recurrent MDD, represent strong indicators of bipolarity.

The mood spectrum: improving the diagnosis of bipolar disorder

Although the distinction between bipolar and unipolar disorders served our field well in the early days of psychopharmacology, in clinical practice it is apparent that their phenotypes are only partially described by current diagnostic classification systems. A substantial body of evidence has accrued suggesting that clinical variability needs to be viewed in terms of a broad conceptualization of mood disorders and their common threshold or subthreshold comorbidity. The spectrum model provides a useful dimensional approach to psychopathology and is based on the assumption that early-onset and enduring symptoms shape the adult personality and establish a vulnerability to the subsequent development of Axis-I disorders. To obtain a clearer understanding of the depressive phenotype, it is pivotal that we increase our detection of hypomanic symptoms so that clinicians can better distinguish bipolar II disorder from unipolar depression. Diagnostic criteria sensitive to hypomanic symptoms have been identified that suggest bipolar II disorder is at least as prevalent as major depression. Moreover, the comorbidities of these illnesses are very different and alcoholism in particular appears to be a greater problem in bipolar II disorder than in unipolar depression. Structured clinical interviews and patient self-report questionnaires have also successfully identified the presence of hypomanic symptoms in patients with unipolar disorder and support the concept of a spectrum of bipolar illness. In conclusion, the importance of subthreshold syndromes should not be underestimated as failure to recognize bipolar spectrum disorder could delay treatment and worsen prognosis.

'Big build': hidden depression in men

OBJECTIVE

To investigate men's experience of depression.

METHOD

A sample of male and female teachers and students was recruited from four sites of a tertiary education institution to a series of focus groups. A grounded theory approach to qualitative data analysis was used to elucidate men's experience of depression. Content analysis was applied to the women's data to examine similarities and contrasts with the men. Standard measures of mood and dispositional optimism confirmed the non-clinical status of the group.

RESULTS

The findings suggest that some men who are depressed can experience a trajectory of emotional distress manifest in avoidant, numbing and escape behaviours which can lead to aggression, violence and suicide. Gender differences appear not in the experience of depression per se, but in the expression of depression.

CONCLUSION

Emotional distress, constrained by traditional notions of masculinity, may explain why depression in men can often be hidden, overlooked, not discussed or 'acted out'. There are implications for the types of questions asked of men to detect depressive symptoms.

Agitated depression: a valid depression subtype?

PURPOSE

The diagnostic validity of agitated depression (AD, a major depressive episode (MDE) with psychomotor agitation) is unclear. It is not classified in DSM-IV and ICD-10 classification of mental and behavioural disorder (ICD-10). Some data support its subtyping. This study aims to test the subtyping of AD.

METHODS

Consecutive 245 bipolar-II (BP-II) and 189 major depressive disorder (MDD) non-tertiary-care MDE outpatients were interviewed (off psychoactive drugs) with Structured Clinical Interview for DSM-IV Axis I Disorders--Clinician Version (SCID-CV), Hypomania Interview Guide (HIGH-C), and Family History Screen. Intra-MDE hypomanic symptoms were systematically assessed. AD was defined as an MDE with psychomotor agitation. Mixed AD was defined as an MDE with four or more hypomanic symptoms (including agitation).

FINDINGS

AD was present in 34.7% of patients. AD was mixed in 70.1% of AD patients. AD, vs. non-AD, had significantly (at alpha = 0.05) lower age at onset, more BP-II, females, atypical depressions, bipolar-I (BP-I) and BP-II family history, and was more mixed; racing/crowded thoughts, irritability, more talkativeness, and risky behaviour were significantly more common. Mixed AD, vs. non-AD, had significantly (at alpha = 0.01) lower age at onset, more intra-MDE hypomanic symptoms, BP-II, females, atypical depressions, BP-II family history, and specific hypomanic symptoms (distractibility, racing thoughts, irritable mood, more talkativeness, risky activities). Mixed AD, vs. non-mixed AD, had significantly more intra-MDE hypomanic symptoms (by definition), more recurrences, and more specific hypomanic symptoms (by definition). Non-mixed AD, vs. non-AD, had significantly more intra-MDE hypomanic symptoms and more talkativeness.

CONCLUSIONS

AD was common in non-tertiary-care depression outpatients, supporting its diagnostic utility. AD and many bipolar diagnostic validators were associated, supporting its link with the bipolar spectrum. Mixed AD, but not non-mixed AD, had differences vs. non-AD similar to those of AD, suggesting that psychomotor agitation by itself may not be enough to identify AD as a subtype. Findings seem to support the subtyping of mixed AD. This subtyping may have important treatment impact, as antidepressants alone might increase agitation.

Serotonin-mediated phosphorylation of extracellular regulated kinases in platelets of patients with panic disorder versus controls

Phosphorylation of extracellular signal-regulated kinases (ERK 1/2) represents a converging intracellular signalling pathway which is involved in the modulation of gene transcription and may contribute to the feed-back regulation of neurotransmitter receptor functioning. The purpose of the current study was to investigate the serotonin-mediated phosphorylation of ERK 1/2 in platelets from patients (n = 17) with panic disorder, with respect to healthy volunteers (n = 17). Patients presented a severe symptomatology as assessed by the self-report rating scales for panic-agoraphobic (PAS-SR) and mood (MOOD-SR) spectrum, and by Clinical Global Impression Severity Scale (CGI-S). In platelets from healthy volunteers, serotonin induced a rapid increase of ERK 1/2 phosphorylation with a transient monophasic kinetic. The dose-response curves showed this effect was concentration dependent with an average of the EC(50) value of 22.8 +/- 2.4 microM. Platelet pre-incubation with 5HT(1A) and 5HT(2A) antagonists, pindobind and ritanserin, significantly inhibited serotonin-mediated kinase activation with an EC(50) of 3.2 +/- 0.2 and 1.99 +/- 0.08 nM, respectively, suggesting an involvement of these specific receptor subtypes in serotonin-mediated response. Furthermore, the 5HT(1A) and 5HT(2A) agonists, 8-hydroxy-N,N-dipropyl-aminotetralin (8OH-DPAT) and 1-(2,5-dimethoxy)-4-iodophenyl-2-aminopropane (DOI), were able to modulate ERK 1/2 phosphorylation in a concentration-dependent manner with an EC(50) value of 3.1 +/- 0.2 and 76 +/- 4.5 nM, respectively. ERK 1/2 phosphorylation was not observed after serotonin treatment of platelets from drug-free panic disorder patients, suggesting an alteration in intracellular phosphorylative pathways. Since ERK 1/2 responsiveness to other stimulus, such as collagen and thrombin, was comparable in platelets from healthy volunteers and patients, our results suggested that a specific alteration of serotonergic system occurred in panic disorder. Further studies to investigate 5HT(1A) and 5HT(2A) receptor expression and threonine phosphorylation levels showed that, nevertheless no significant differences in the receptor expression levels were detected, an increase of both 5HT receptor phosphorylation, on threonine residues, occurred in platelet from panic patients with respect to controls, suggesting that a reduction of serotonin receptor functioning was involved in the loss of serotonin responsiveness in panic.