The evolving bipolar spectrum. Prototypes I, II, III, and IV

Managing the Dual Diagnosis Dilemma of Bipolar Disorder and Substance Abuse in Clinical Settings

OBJECTIVE

Drug addiction is a chronic mental disorder that significantly impacts all aspects of an individual's life, and substance use disorder in patients with bipolar disorder. The objective of this study is to assess the frequency of substance abuse among patients with bipolar spectrum disorder.

METHOD

This cross-sectional study evaluated the frequency of bipolar spectrum disorder in patients taking methadone through various screening measures, including Mini Mental State Examination (MMSE), DSM IV criteria, Mood Disorders Questionnaire (MDQ), Goodwin and Ghaemi's criteria, and Akiskal classification for bipolar disorders.

RESULTS

Out of the total 197 participants in the study, 77 were identified as individuals engaging in poly-substance abuse. The investigation assessed the frequency of bipolar spectrum disorder based on various diagnostic criteria: 24% according to DSM-IV criteria, 29.9% using MDQ, 29.9% based on Ghaemi and Goodwin's criteria, and the highest rate at 48.2% when applying Akiskal's classification.

CONCLUSIONS

This study highlights the high frequency of bipolar disorder among individuals with substance use disorder, especially those with concomitant depression. Therefore, it is crucial to pay special attention to individuals with substance use disorder with co-existing bipolar disorder.

Reward sensitivity and social rhythms during goal-striving: An ecological momentary assessment investigation of bipolar spectrum disorders

BACKGROUND

The reward/circadian rhythm model of bipolar spectrum disorders (BSDs) posits that when individuals with hypersensitive reward systems encounter reward-relevant events, they experience social and circadian rhythm disruption, leading to mood symptoms. The aim of the current study is to test an element of this theoretical model by investigating changes in social rhythms during and after an ecologically-valid reward-relevant event and evaluating whether the strength of these associations differ by trait reward sensitivity and BSD diagnostic group.

METHODS

Young adults from three groups (low BSD risk with moderate reward sensitivity [MRew], high BSD risk with high reward sensitivity [HRew], and high reward sensitivity with BSD [HRew+BSD]) completed a reward responsiveness task and 20-day ecological momentary assessment study structured around a participant-specific goal occurring on day 15. Social rhythm disruption (SRD) and social rhythm regularity (SRR) were assessed daily. Multilevel models examined whether reward sensitivity and group moderated associations between study phase (baseline [days 1-5], goal-striving [days 16-20], or outcome [days 16-20]) and social rhythms.

RESULTS

Participants experienced greater SRD after the goal-striving event during the outcome phase, compared to the baseline phase. The HRew+BSD group had significant decreases in SRR during the outcome phase, and this pattern differed significantly from the low-risk and high-risk groups. Greater task reward responsiveness also was associated with significant decreases in SRR during the outcome phase.

LIMITATIONS

This study did not test whether social rhythm irregularity was associated with subsequent mood change.

CONCLUSIONS

Participants exhibited social rhythm changes over the course of this ecologically valid goal-striving period, providing evidence for the interplay between reward-activating events and social rhythms. The HRew+BSD group showed a distinct pattern in which their social rhythms were more irregular after completing reward-relevant goal-striving that was not observed for the low-BSD risk or high-BSD risk groups. These findings provide additional support for Interpersonal and Social Rhythms Therapy.

Eveningness chronotype and depressive affective temperament associated with higher high-sensitivity C-reactive protein in unipolar and bipolar depression

BACKGROUND

Several studies investigated the role of inflammation in the etiopathogenesis of mood disorders. The aim of our cross-sectional study is evaluating baseline high-sensitivity C-reactive-protein (hsCRP) levels in a cohort of unipolar and bipolar depressive inpatients, in relation with psychopathological, temperamental and chronotype features.

METHODS

Among 313 screened inpatients, we retrospectively recruited 133 moderate-to-severe depressive patients who were assessed for hsCRP levels, chronotype with Morningness-Eveningness Questionnaire (MEQ) and affective temperament with Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS).

LIMITATIONS

The cross-sectional and retrospective design of the study, the small sample size, the exclusion of hypomanic, maniac and euthymic bipolar patients.

RESULTS

hsCRP levels were significantly higher among those with previous suicide attempt (p = 0.05), death (p = 0.018) and self-harm/self-injury thoughts (p = 0.011). Linear regression analyses, adjusted for all covariates, demonstrated that higher scores at the TEMPS-M depressive, while lower scores at the hyperthymic and irritable affective temperaments [F = 88.955, R² = 0.710, p < 0.001] and lower MEQ scores [F = 75.456, R² = 0.405, p < 0.001] statistically significantly predicted higher hsCRP.

CONCLUSION

Eveningness chronotype and a depressive affective temperament appeared to be associated with higher hsCRP levels during moderate-to-severe unipolar and bipolar depression. Further longitudinal and larger studies should better characterise patients with mood disorders by investigating the influence of chronotype and temperament.

The Expression of Affective Temperaments in Cystic Fibrosis Patients: Psychopathological Associations and Possible Neurobiological Mechanisms

The aim of this study was to investigate the association between Cystic Fibrosis (CF) and affective temperaments, considering the relevance of ionic balances in neural excitability, as a possible neurobiological basis for temperamental expression. A cross-sectional study involving 55 adult CF patients was conducted. Sociodemographic, clinical and therapeutic characteristics, temperamental and personality dispositions and depressive and anxiety symptoms were evaluated through standardized semi-structured and structured interviews. The majority of the enrolled CF patients were receiving Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) therapy (72.7%), and most of them had hyperthymic temperament predominance (29.1%). Different TEMPS-A (Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire) dimensions were not associated with the type of CF phenotype-related mutation or with the use of CFTR-modulator therapy. However, a tendency towards irritability was noted in patients not undergoing CFTR modulator therapy (6.7 ± 4.72 vs. 4.7 ± 4.33; p = 0.13). In light of the limitations imposed by the cross-sectional nature of the study, a hyperthymic temperament was found to be protective against current or lifetime psychopathologic events, whereas the other temperaments were associated with positive psychopathological anamnesis. Based on the measurement of temperament profiles and the study of their associations with clinically relevant variables, we argue that subjecting CF patients to such a temperament assessment could prove beneficial in the transition towards integrated and personalized care.

The Impact of Affective Temperaments on Suicidal Ideation and Behaviors: Results from an Observational Multicentric Study on Patients with Mood Disorders

Suicide ideation and behaviors are major health issues in the field of mental health. Several psychological and psychosocial factors have been taken into account as possible predictors of suicidality. Only recently affective temperaments have been considered as possible factors linked to suicide. This study aims to investigate the relationship between affective temperaments and suicidality, including the lifetime onset of suicide ideation, lifetime presence of suicide attempts and the total number of lifetime suicide attempts. This is a naturalistic multicentric observational study, involving outpatient units of seven University sites in Italy. Patients were administered with the short version of TEMPS-M and the Columbia Suicide Severity Rating Scale. A total of 653 participants were recruited, with a diagnosis of bipolar (55.7%), unipolar (35.8%) and cyclothymic disorder (8.4%). Regression models showed that the presence of lifetime suicide behaviors was increased in patients presenting trait related impulsivity (p < 0.0001), poor free-interval functioning (p < 0.05), higher number of affective episodes (p < 0.01), higher number of hospitalizations (p < 0.0001), cyclothymic and irritable affective temperaments (p < 0.05 and p < 0.05, respectively). Conversely, the presence of hyperthymic affective disposition reduced the likelihood of having suicidal behaviors (p < 0.01). Lifetime suicidal ideation was associated with trait-related impulsivity (p < 0.001), poor free-interval functioning (p < 0.05), higher number of affective episodes (p < 0.001) and of hospitalizations (p < 0.001). Depressive temperaments increased the likelihood of presenting suicidal ideation (p < 0.05), along with irritable temperaments (p < 0.01), contrary to hyperthymic affective (p < 0.05). Results of the present study confirm that affective disposition has a significant impact on the onset of suicidal ideation and behaviors, and that affective dispositions should be assessed in clinical settings to identify people at risk of suicide. Moreover, a wider clinical evaluation, including different clinical psychopathological dimensions, should be taken into consideration to develop effective preventive interventions.

Trait-Related Impulsivity, Affective Temperaments and Mood Disorders: Results from a Real-World Multicentric Study

Trait-related impulsiveness is highly prevalent in patients with mood disorders, being associated with negative outcomes. The predictive role of affective temperaments on trait-related impulsivity is still understudied. The aim of the present study is to investigate the relationship between impulsivity and affective temperaments in a sample of euthymic patients with mood disorders. This is a real-world multicentric observational study, carried out at the outpatient units of seven university sites in Italy. All patients filled in the short version of Munster Temperament Evaluation of the Memphis, Pisa, Paris and San Diego and the Barratt Impulsiveness Scale. The study sample included 653 participants, mainly female (58.2%), with a mean age of 46.9 (±14.1). Regression analyses showed that higher levels of trait-related impulsivity were associated to suicide attempts (p < 0.000), the presence of psychotic symptoms during acute phases (p < 0.05), a seasonal pattern (p < 0.05), a lower age at onset of the disorder (p < 0.05), cyclothymic (p < 0.01) and irritable temperaments (p < 0.01). The results of our study highlight the importance to screen patients with mood disorders for impulsivity and affective temperaments in order to identify patients who are more likely to present a worse outcome and to develop personalized and integrated early pharmacological and psychosocial treatment plans. Novelties of the present paper include the recruitment of patients in a stable phase, which reduced possible bias in patients’ self-reports, and the multicentric nature of the study, resulting in the recruitment of a large sample of patients with mood disorders, geographically distributed across Italy, thus improving the generalizability of study results.

Positive moods are all alike? Differential affect amplification effects of 'elated' versus 'calm' mental imagery in young adults reporting hypomanic-like experiences

Positive mood amplification is a hallmark of the bipolar disorder spectrum (BPDS). We need better understanding of cognitive mechanisms contributing to such elevated mood. Generation of vivid, emotionally compelling mental imagery is proposed to act as an 'emotional amplifier' in BPDS. We used a positive mental imagery generation paradigm to manipulate affect in a subclinical BPDS-relevant sample reporting high (n = 31) vs. low (n = 30) hypomanic-like experiences on the Mood Disorder Questionnaire (MDQ). Participants were randomized to an 'elated' or 'calm' mental imagery condition, rating their momentary affect four times across the experimental session. We hypothesized greater affect increase in the high (vs. low) MDQ group assigned to the elated (vs. calm) imagery generation condition. We further hypothesized that affect increase in the high MDQ group would be particularly apparent in the types of affect typically associated with (hypo)mania, i.e., suggestive of high activity levels. Mixed model and time-series analysis showed that for the high MDQ group, affect increased steeply and in a sustained manner over time in the 'elated' imagery condition, and more shallowly in 'calm'. The low-MDQ group did not show this amplification effect. Analysis of affect clusters showed high-MDQ mood amplification in the 'elated' imagery condition was most pronounced for active affective states. This experimental model of BPDS-relevant mood amplification shows evidence that positive mental imagery drives changes in affect in the high MDQ group in a targeted manner. Findings inform cognitive mechanisms of mood amplification, and spotlight prevention strategies targeting elated imagery, while potentially retaining calm imagery to preserve adaptive positive emotionality.

Clinical research diagnostic criteria for bipolar illness (CRDC-BP): rationale and validity

BACKGROUND

In the 1970 s, scientific research on psychiatric nosology was summarized in Research Diagnostic Criteria (RDC), based solely on empirical data, an important source for the third revision of the official nomenclature of the American Psychiatric Association in 1980, the Diagnostic and Statistical Manual, Third Edition (DSM-III). The intervening years, especially with the fourth edition in 1994, saw a shift to a more overtly "pragmatic" approach to diagnostic definitions, which were constructed for many purposes, with research evidence being only one consideration. The latest editions have been criticized as failing to be useful for research. Biological and clinical research rests on the validity of diagnostic definitions that are supported by firm empirical foundations, but critics note that DSM criteria have failed to prioritize research data in favor of "pragmatic" considerations.

RESULTS

Based on prior work of the International Society for Bipolar Diagnostic Guidelines Task Force, we propose here Clinical Research Diagnostic Criteria for Bipolar Illness (CRDC-BP) for use in research studies, with the hope that these criteria may lead to further refinement of diagnostic definitions for other major mental illnesses in the future. New proposals are provided for mixed states, mood temperaments, and duration of episodes.

CONCLUSIONS

A new CRDC could provide guidance toward an empirically-based, scientific psychiatric nosology, and provide an alternative clinical diagnostic approach to the DSM system.

Impact of menstrual cycle events on bipolar disorder course: a narrative review of current evidence

Several lines of research suggest that reproductive-related hormonal events may affect the course of bipolar disorder in some women. However, data on associations between bipolar disorder and menarche, menstrual cycle, and menopause are mixed. This article reviews the literature on the potential effects of menarche, menstrual cycle, and menopause on bipolar disorder.A narrative review of published articles on bipolar disorder and menstrual cycle events was conducted. The primary outcome assessed was the impact of menarche, menstrual cycle and menopause on the course of bipolar illness. Databases searched were PubMed, Ovid, Scopus, PsycINFO, Medline, and Cochrane Libraries from inception to August 2021.Twenty-two studies were identified and included in the narrative synthesis. Research suggested that a subset of women with bipolar disorder are vulnerable to the impact of menstrual cycle events. Menarche seems to be associated with age at onset of bipolar illness especially in case of bipolar disorder type I and the specific age at menarche may predict some clinical features of the disorder. Menstrual cycle likely affects the course of bipolar disorder but the pattern of mood variability is not clear. Menopause appears to be not only a period of vulnerability to mood alteration, especially depressive episodes, and impairment of quality of life, but also a potential trigger of bipolar illness onset.The impact of menarche, menstrual cycle, and menopause on bipolar disorder is largely understudied. Preliminary evidence suggests that a subset of women with bipolar disorder may have their mood shifts affected by menstrual cycle events, with different patterns depending on the type of bipolar disorder also. Further researches are needed to deep the impact of menarche, menstrual cycle, and menopause on bipolar illness.

The assessment of cyclothymic-hypersensitive temperament in youth with mood disorders and attention deficit hyperactivity disorder

BACKGROUND

Cyclothymic-hypersensitive temperament (CHT) has been related to both depression and bipolarity, as well as to suicidality. Recently, a psychometrically sound way of assessment has been validated in youth (Cyclothymic-Hypersensitive Temperament Questionnaire, CHTQ), but data on clinical populations are still scant. Aim of our study is to further explore the structure and other psychometric properties of the revised version of CHTQ and its clinical implications in clinical samples.

METHODS

The study is based on a dataset of patients with unipolar depression, bipolar disorder and attention deficit and hyperactivity disorder (ADHD) (243 patients, 135 males, mean age 14.22 ± 2.16 years, age range 9-18 years), compared to a community sample of adolescents (398 subjects, 95 boys, mean age 15.47 ± 1.96 years, age range 10-18 years) RESULTS: The two-correlated factor structure of CHT has been confirmed, with a moodiness/hypersensitiveness factor, correlated with internalizing symptoms, and an impulsiveness/emotional dysregulation factor, correlated with externalizing symptoms. All CHTQ scores correlate with global functioning. CHTQ total scores discriminate patients from healthy controls. Only CHTQ impulsiveness/emotional dysregulation subscale score is higher in bipolar patients, compared to unipolar depression and ADHD, whereas neither CHTQ moodiness/hypersensitiveness subscale score nor CHTQ total score discriminate between clinical groups.

LIMITATION

Data on current mood states are unavailable. Patients were recruited in a third level clinic. The unipolar depression group is relatively small.

CONCLUSION

CHT may be a rapid and reliable screening and diagnostic tool in the clinical practice with youth, exploring the cyclothymic dimension in different psychiatric disorders.

Bipolar spectrum disorders in neurologic disorders

Psychiatric symptoms frequently predate or complicate neurological disorders, such as neurodegenerative diseases. Symptoms of bipolar spectrum disorders (BSD), like mood, behavioral, and psychotic alterations, are known to occur - individually or as a syndromic cluster - in Parkinson's disease and in the behavioral variant of frontotemporal dementia (FTD). Nonetheless, due to shared pathophysiological mechanisms, or genetic predisposition, several other neurological disorders show significant, yet neglected, clinical and biological overlaps with BSD like neuroinflammation, ion channel dysfunctions, neurotransmission imbalance, or neurodegeneration. BSD pathophysiology is still largely unclear, but large-scale network dysfunctions are known to participate in the onset of mood disorders and psychotic symptoms. Thus, functional alterations can unleash BSD symptoms years before the evidence of an organic disease of the central nervous system. The aim of our narrative review was to illustrate the numerous intersections between BSD and neurological disorders from a clinical-biological point of view and the underlying predisposing factors, to guide future diagnostic and therapeutical research in the field.

Peripheral non-enzymatic antioxidants as biomarkers for mood disorders: Evidence from a machine learning prediction model

BACKGROUND

Oxidative stress is related to the pathogenesis of mood disorders, and the level of oxidative stress may differ between bipolar disorder (BD) and major depressive disorder (MDD). This study aimed to detect the differences in non-enzymatic antioxidant levels between BD and MDD and assess the predictive values of non-enzymatic antioxidants in mood disorders by applying a machine learning model.

METHODS

Peripheral uric acid (UA), albumin (ALB), and total bilirubin (TBIL) were measured in 1,188 participants (discover cohort: 157 with BD and 544 with MDD; validation cohort: 119 with BD and 95 with MDD; 273 healthy controls). An extreme gradient boosting (XGBoost) model and a logistic regression model were used to assess the predictive effect.

RESULTS

All three indices differed between patients with mood disorders and healthy controls; in addition, the levels of UA in patients with BD were higher than those of patients with MDD. After treatment, UA levels increased in the MDD group, while they decreased in the BD group. Finally, we entered age, sex, UA, ALB, and TBIL into the XGBoost model. The area under the curve (AUC) of the XGBoost model for distinguishing between BD and MDD reached 0.849 (accuracy = 0.808, 95% CI = 0.719-0.878) and for distinguishing between BD with depression episode (BD-D) and MDD was 0.899 (accuracy = 0.891, 95% CI = 0.856-0.919). The models were validated in the validation cohort. The most important feature distinguishing between BD and MDD was UA.

CONCLUSION

Peripheral non-enzymatic antioxidants, especially the UA, might be a potential biomarker capable of distinguishing between BD and MDD.

The impact of bipolar spectrum disorders on professional functioning: A systematic review

AIMS

The impact of bipolar spectrum (BS) disorders on professional functioning has not been systematically reviewed yet. Since even subsyndromal symptoms may disturb functioning, the determination of the prognostic value of the spectrum of bipolarity for employment seems extremely relevant. The aim of this study was to assess the impact of BS disorders on professional functioning.

MATERIALS AND METHODS

A systematic review of the literature (namely, cohort and cross-sectional studies) investigating a link between BS disorders and employment was performed in accordance with PRISMA guidelines. BS was defined based on the concept of two-dimensional BS by Angst. Occupational outcomes and factors affecting employment were evaluated as well.

RESULTS

Seventy-four studies were included. All disorders comprising BS had a negative impact on occupational status, work performance, work costs, and salary, with the greatest unfavorable effect reported by bipolar disorder (BD), followed by borderline personality disorder (BPD), major depressive disorder (MDD), and dysthymia. Employment rates ranged from 40 to 75% (BD), 33 to 67% (BPD), 61 to 88% (MDD), and 86% (dysthymia). The factors affecting employment most included: cognitive impairments, number/severity of symptoms, namely, subsyndromal symptoms (mainly depressive), older age, education, and comorbidity (substance abuse, personality disorders, anxiety, depression, ADHD, PTSD).

CONCLUSION

Bipolar spectrum symptoms exert a negative impact on professional functioning. Further evaluation of affecting factors is crucial for preventing occupational disability.

A piece of the puzzle: Does bipolarity partly explain the high prevalence of treatment resistance in depression?

In this cross-sectional study we examined whether the prevalence of treatment resistant depression (TRD) can be partly attributed to level of bipolarity. We included data of 201 patients with either episodic depression or TRD, who received treatment for their depression at either an outpatient or 2nd opinion/daytime setting, within a specialised mental healthcare department in the Netherlands. Whether level of TRD, assessed by the 'Dutch Measure for quantification of Treatment Resistance in Depression', can be partly explained by level of bipolarity, assessed by 'the Bipolarity Index', was examined using linear regression. We found no direct association between level of TRD and level of bipolarity, nor did comorbid anxiety disorders obscure an existing association. In this study we found no evidence for overlooked bipolarity contributing to the high prevalence of TRD. If replicated, we could state that additional screening on bipolarity with an instrument such as the 'Bipolarity Index' in the specialised mental health care is unnecessary.

Microcytic Anaemia as Susceptibility Factors in Bipolar Spectrum Disorders: Review of the Literature, Replication Survey, and Co-Segregation within Families

Background:

Potential interactions between mood disorders and microcytic anaemias have been suggested by case reports, surveys of haematological parameters in psychiatric populations, and surveys of psychiatric morbidity in thalassaemic carriers.

Objectives:

a) To review published studies.

b) To study the prevalence of microcytic anaemia in a sample of Sardinian outpatients with recurrent mood disorders.

c) To check whether mood disorders and microcytic anaemia co-segregate within families.

Methods:

We extracted data on blood count and serum iron concentrations from the records of patients admitted between January 1st, 2001 and December 31st, 2016, to our clinic for mood disorders. Moreover, we studied siblings of subjects with both major mood disorders (according to Research Diagnostic Criteria) and heterozygous thalassaemia (according to Mean Corpuscular Volume, serum iron, and haemoglobin A₂ concentrations). Siblings affected with a major mood disorder were examined for haematological concordance with the proband (reduced MCV and/or increased HbA₂ in case of heterozygous β-thalassaemia, or presence of gene deletions in case of α-thalassaemia).

Results:

Microcytic anaemia was highly prevalent (81/337 = 24.0%) among outpatients with mood disorders. Starting from 30 probands with heterozygous ß-thalassaemia, concordance for reduced MCV and/or increased HbA₂ was found in 78% (35/45) of affected siblings. Starting from 3 probands with heterozygous α-thalassaemia, only one of the 5 affected siblings carried four α-globin functional genes.

Conclusion:

Based on the review of the literature, the high prevalence of microcytic anaemia in outpatients, and the concordance between affected siblings, we can conclude that a role of heterozygous thalassaemias is highly probable. Future studies are required to establish the relevance of heterozygous thalassaemias and evaluate the magnitude of the effect, possibly using a molecular diagnosis also in the case of heterozygous β-thalassaemia.

Treatment of bipolar disorders in older adults: a review

BACKGROUND

Old age bipolar disorder has been an orphan of psychiatric research for a long time despite the fact that bipolar disorder (BD)-I and II together may affect 0.5-1.0% of the elderly. It is also unclear whether aetiology, course of illness and treatment should differ in patients with a first manifestation in older age and patients suffering from a recurrence of a BD known for decades. This narrative review will summarize the current state of knowledge about the epidemiology, clinical features, and treatment of BD in the elderly.

METHODS

We conducted a Medline literature search from 1970 to 2021 using MeSH terms "Bipolar Disorder" × "Aged" or "Geriatric" or "Elderly". Search results were complemented by additional literature retrieved from examining cross references and by hand search in text books. Varying cut-off ages have been applied to differentiate old age from adult age BD. Within old age BD, there is a reasonable agreement of distinct entities, early and late-onset BD. They differ to some extent in clinical symptoms, course of illness, and some co-morbidities. Point prevalence of BD in older adults appears slightly lower than in working-age adults, with polarity of episodes shifting towards depression. Psychopharmacological treatment needs to take into account the special aspects of somatic gerontology and the age-related change of pharmacokinetic and pharmacodynamic characteristics. The evidence for commonly used treatments such as lithium, mood-stabilizing antiepileptics, antipsychotics, and antidepressants remains sparse. Preliminary results support a role of ECT as well as psychotherapy and psychosocial interventions in old age BD.

CONCLUSIONS

There is an obvious need of further research for all treatment modalities of BD in old age. The focus should be pharmacological and psychosocial approaches, as well as their combination, and the role of physical treatment modalities such as ECT.

Preexisting Bipolar Disorder Influences the Subsequent Phenotype of Parkinson's Disease

Background

Patients with bipolar spectrum disorders (BSDs) exhibit an increased risk of Parkinson's disease (PD).

Objective

The aim is to investigate whether a previous diagnosis of BSDs influences the phenotype of PD.

Methods

Of 2660 PD patients followed for at least 6 years (6–27), 250 (BSD‐PD) had BSDs, 6–20 years before PD diagnosis; 48%–43% had a PD or BSD family history, and 34 carried glucocerebrosidase (GBA) and Parkin (PRKN) mutations. The cohort was split into a subset of 213 BSD‐PD patients, compared with 426 matched PD patients without BSDs, and a subset of 34 BSD‐PD and 79 PD patients carrying GBA or PRKN mutations. Carriers of mutations absent in BSD‐PD patients and of synuclein triplication were excluded. Structured clinical interviews and mood disorder questionnaires assessed BSDs. Linear mixed models evaluated the assessment scales over time. Thirteen BSD‐PD patients underwent subthalamic nucleus deep brain stimulation (STN‐DBS) and were compared with 27 matched STN‐DBS‐treated PD patients.

Results

Compared to PD patients, BSD‐PD showed (1) higher frequency of family history of PD (odds ratio [OR] 3.31; 2.32–4.71) and BSDs (OR 6.20; 4.11–9.35) 5); (2) higher incidence of impulse control disorders (hazard ratio [HR] 5.95, 3.89–9.09); (3) higher frequency of functional disorders occurring before PD therapy (HR, 5.67, 3.95–8.15); (4) earlier occurrence of delusions or mild dementia (HR, 7.70, 5.55–10.69; HR, 1.43, 1.16–1.75); and (5) earlier mortality (1.48; 1.11–1.97). Genetic BSD‐PD subjects exhibited clinical features indistinguishable from nongenetic BSD‐PD subjects. STN‐DBS‐treated BSD‐PD patients showed no improvements in quality of life compared to the control group.

Conclusions

BSDs as a prodrome to PD unfavorably shape their course and are associated with detrimental neuropsychiatric features and treatment outcomes. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

Neglected but not negligible aspects of antidepressants and their availability in bipolar depression

OBJECTIVES

Although many antidepressants are available, they are not always used appropriately. For appropriate use of antidepressants, the old concept of a linear dose-response relationship, in which the dose is linearly increased to achieve a sufficient antidepressant effect, should be reconsidered. Furthermore, there is ongoing debate on the safe and appropriate use of antidepressants in patients with bipolar depression. Antidepressants may be used under certain conditions in patients with bipolar depression. These neglected-but not negligible-aspects of antidepressants have been discussed herein.

METHODS

A narrative qualitative review RESULTS: Dose-response relationships of antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are not linear. They may be bell-shaped, with efficacy initially increasing with an increase in dose but decreasing when the dose is increased beyond a certain point. Despite using international diagnostic criteria, uncertainty remains on whether operationally diagnosed depression is latent bipolar I depression, latent bipolar II depression, or true depression. Furthermore, operationally diagnosed bipolar II depression may be latent bipolar I depression, true bipolar II depression, or depression with false hypomanic episodes. Manic/hypomanic switches are most likely to occur in patients receiving tricyclic antidepressants, followed by those receiving serotonin and noradrenaline reuptake inhibitors and SSRIs, in that order. Also, these switches are most likely to occur in patients with bipolar I depression, followed by those with bipolar II depression and true depression, in that order.

CONCLUSIONS

Considering the diagnostic subtype of bipolar depression and antidepressant properties may help to determine the optimal treatment strategy.

Neurocognition Function of Patients With Bipolar Depression, Unipolar Depression, and Depression With Bipolarity

Much evidence shows that some Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)-defined unipolar depression (UD) with bipolarity manifests bipolar diathesis. Little is known about the cognitive profiles of patients with depression with bipolarity (DWB). The study aimed to investigate the differences in cognitive profiles among patients with bipolar depression (BD), major depressive disorder (namely, UD), and DWB. Drug-naïve patients with BD, UD, and DWB and healthy controls (HC) were recruited (30 cases in each group). Cognitive function was evaluated by THINC-it (THINC-intelligent tool), Wisconsin Card Sorting Test (WCST), and continuous performance test (CPT). For THINC-it, no significant differences of the Z-scores in both objective and subjective factors were found between the DWB group and BD group, but the Z-scores in the BD group were significantly lower than those in the UD group. For WCST, significant differences were found between the BD group and DWB group in the number of responses, categories completed, trails to completed first category, perseverative responses, and perseverative errors. All the indices of WCST in the DWB group were significantly worse than those in the UD group except for trails to completed first category and total number of response correct. For CPT, only scores of leakage responses and false responses in the four-digit number in the BD group and DWB group were significantly higher than those in the UD group; no significant difference was found between the BD group and DWB group. The results indicated that patients with DWB might perform differently from those with UD but similarly to those with BD with cognition impairment.

Schizophrenia-schizoaffective-bipolar spectra: an epistemological perspective

For decades clinicians and researchers have been thinking and writing about the spectrum of schizophrenia disorders. Indeed both Kraepelin and Bleuler believed in schizophrenia as a spectrum, both in a clinical (individual) and hereditary (family) continuum, from just some exquisite personality traits to unquestionable chronic and debilitating psychosis. Other authors would put the schizophrenia spectrum disorders on different levels of continuum: developmental, psychofunctional, existential, and genetic. Here, we would like to present an historical chronology for the schizophrenia-schizoaffective-bipolar spectra plus a tridimensional model for these spectra: the first axis for categories (affective versus nonaffective psychoses), the second axis for dimensions (personality versus full blown psychosis), and a third axis for biomarkers (remission versus relapse). We believe that without the schizophrenia-schizoaffective-bipolar spectra concept in our minds all our efforts will keep failing one the hardest quest: searching for biomarkers in schizophrenia and related disorders.

Brain Structure and Subclinical Symptoms: A Dimensional Perspective of Psychopathology in the Depression and Anxiety Spectrum

Human psychopathology is the result of complex and subtle neurobiological alterations. Categorial DSM or ICD diagnoses do not allow a biologically founded and differentiated description of these diverse processes across a spectrum or continuum, emphasising the need for a scientific and clinical paradigm shift towards a dimensional psychiatric nosology. The subclinical part of the spectrum is, however, of special interest for early detection of mental disorders. We review the current evidence of brain structural correlates (grey matter volume, cortical thickness, and gyrification) in non-clinical (psychiatrically healthy) subjects with minor depressive and anxiety symptoms. We identified 16 studies in the depressive spectrum and 20 studies in the anxiety spectrum. These studies show effects associated with subclinical symptoms in the hippocampus, anterior cingulate cortex, and anterior insula similar to major depression and changes in amygdala similar to anxiety disorders. Precuneus and temporal areas as parts of the default mode network were affected specifically in the subclinical studies. We derive several methodical considerations crucial to investigations of brain structural correlates of minor psycho(patho)logical symptoms in healthy participants. And we discuss neurobiological overlaps with findings in patients as well as distinct findings, e.g. in areas involved in the default mode network. These results might lead to more insight into the early pathogenesis of clinical significant depression or anxiety and need to be enhanced by multi-centre and longitudinal studies.

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.

Impulsivity as a Risk Factor for Suicide in Bipolar Disorder

The accurate assessment of suicide risk in psychiatric, especially affective disorder diagnosed patients, remains a crucial clinical need. In this study, we applied temperament and character inventory (TCI), Barratt impulsiveness scale 11 (BIS-11), PEBL simple reaction time (SRT) test, continuous performance task (CPT), and Iowa gambling task (IGT) to seek for variables linked with attempted suicide in bipolar affective disorder group (n = 60; attempters n = 17). The main findings were: strong correlations between self-report tool scores and objective parameters in CPT; the difference between attempters and non-attempters was found in the number of correctly responded trials in IGT; only one parameter differed between attempters and non-attempters in BPI diagnosis; and no significant differences between suicide attempters and non-attempters in TCI, BIS-11, and SRT were found. These justify the conclusion that impulsivity itself is not a strong predictor, and used as a single variable might not be sufficient to indicate the high suicide risk group among bipolar patients.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

Prevalence and correlates of bipolar spectrum disorders in Singapore: Results from the 2016 Singapore Mental Health Study (SMHS 2016)

BACKGROUND

Prevalence estimates of Bipolar Spectrum Disorders (BSD) remain scant in Southeast Asia. This study aims to investigate the prevalence of BSD, its correlates with sociodemographic factors, and the associations between the BSD subgroups and clinical severity, impairment, and disability in Singapore.

METHODS

This study utilizes data gathered from the second Singapore Mental Health Study (SMHS)- a nationwide cross-sectional survey conducted between 2016 and 2018 (response rate: 69.5%). Respondents were randomly selected and administered, in a single visit, interviewer-led surveys of the World Health Organization Composite International Diagnostic Interview version 3.0 (CIDI 3.0) in their preferred language (i.e. Chinese, Malay, Tamil, or English). A total of 6126 residents completed the study.

RESULTS

The lifetime weighted prevalence of BSD, Bipolar I, II, and subthreshold bipolar disorder was 3.1%, 1.5%, 0.03%, and 1.6% respectively. A higher prevalence of Bipolar Disorders (BPD) was significantly associated with younger age, being divorced or separated, and being unemployed. Lifetime comorbidity of BSD with at least one other psychiatric or physical condition was 45% and 51% respectively. BSD was most comorbid with Obsessive Compulsive Disorder (psychiatric condition) and Chronic pain (physical condition).

LIMITATIONS

This study relies on self-report data which may be subject to unintended response biases leading to the under or over-reporting of results.

DISCUSSION

In addition to the high prevalence of BPD, there is also a concerning shift and increase in the proportion of those who experience severe symptoms of mania/hypomania and depression. Subthreshold bipolar disorder is found to be clinically significant and cross-culturally valid in a multi-cultural setting.

The Globalization of Biological Psychiatry and the Rise of Bipolar Spectrum Disorder in Iran

In recent years, psychiatry in Iran witnessed a dramatic increase in the use of the diagnosis of bipolar spectrum disorder (BSD). This qualitative study maps the journey of the BSD diagnosis from the West to Iran, examines the controversy surrounding the diagnosis and its treatment, and explores some of the structural factors that facilitate and maintain the widespread use of the BSD diagnosis in Iran and related practices of prescribing neuroleptic and mood stabilizers. The study methods include archival research and semi-structured interviews with 25 prominent Iranian psychiatrists in the field of mood disorders. Results show the importance of factors in addition to economics in driving changes in diagnostic fashion. Most psychiatrists interviewed reported what they viewed as an over-diagnosis of bipolar disorder and over-prescription of mood stabilizers and atypical antipsychotics among Iranian psychiatrists over the past decade. In addition to the influence of leading figures of American psychiatry, the dominance of Western psychiatric classifications and textbooks in Iran's psychiatry, and indirect intervention by pharmaceutical companies, local structural and political factors have played a significant role in the Iranian psychiatric system's embrace of the new concept of bipolarity. In Iran, the medicalization of social conflict has been embraced by government, families, and psychiatrists for cross-cutting purposes. These challenges and the continued controversy over the adoption of American psychiatric fads in a non-Western country like Iran point to the importance of elaborating a more ecosocial and cultural view of psychiatric practice to disentangle some of the complex trade-offs involved in adopting particular modes of diagnostic practice.

The Conceptual Framework of Dual Disorders and Its Flaws

When psychiatric illness and substance use disorder coexist, the clinical approach to the patient is, unsurprisingly, awkward. This fact is due to a cultural context and, more directly, to the patient’s psychiatric condition and addiction behaviors—a situation that does not favor a scientific approach. In dual disorder facilities, several types of professionals work together: counselors, social workers, psychologists, and psychiatrists. Treatment approaches vary from one service to another and even within the same service. It is crucial to provide dual disorder patients with multiple treatments, comprising hospitalization, rehabilitative and residential programs, case management, and counselling. Still, when treating dual disorder (DD) heroin use disorder (HUD) patients, it is advisable to follow a hierarchical algorithm. First, we must deal with addiction: by detoxification, whenever possible. This means starting most patients on anti-craving pharmacological maintenance, though aversion therapy may be appropriate for a few of them. Opiate antagonists may be used with heroin-addicted patients as long as those patients are only mildly ill. In contrast, agonist opioid medications, i.e., buprenorphine and methadone suit moderately and severely ill patients, respectively. Achieving control of mood instability or psychotic episodes is the next step, to be followed by a prevention strategy to counteract residual cravings and dominate mood disorders or psychotic episodes through long-term pharmacological maintenance that is focused on a double target.

Cyclothymic-hypersensitive temperament in youths: Refining the structure, the way of assessment and the clinical significance in the youth population

BACKGROUND

Although a better understanding of the prodromes of affective disorders in youth has important clinical and research implications, empirical data are still unconclusive. Cyclothymic-hypersensitive temperament (CHT) has been linked to both depression and bipolarity, as well as to suicidality. Its conceptualization is still debated, as well as a comprehensive, psychometrically sound way of assessment.

METHODS

factor structure, reliability, measurement invariance, convergent and divergent validity of the previously published CHT questionnaire (a youth version derived from Temperament Evaluation in Memphis Pisa and San Diego (TEMPS) was assessed in a school-based sample of 2959 students aged from 10 to 14 years (mean age = 11.8 ± 0.97 years). Furthermore, accuracy, sensitivity and specificity were calculated for a new cut-off score related to the presence of general psychopathology symptoms.

RESULTS

CHT is better conceptualized in a two-correlated factors model, a moodiness/hypersensitiveness factor, more associated with internalizing symptoms, and an impulsiveness/emotional dysregulation factor, more associated with externalizing symptoms. The revised 22-items version of the CHT questionnaire with a cut-off score of 15 for females and 17 for males results accurate, sensitive and specific enough for the recognition of cyclothymic adolescents with clinical symptoms.

LIMITATION

the cross sectional design and the self-report nature of the measures limit the findings.

DISCUSSION

Cyclothymic-hypersensitive temperament is a relevant concept in the realm of affective disorder and can be reliably assessed in youths. It may describe youths with the coexistence of both internalizing and externalizing symptoms that can be difficult to diagnose with a DSM perspective.

State-of-the-Art: Inflammatory and Metabolic Markers in Mood Disorders

Mounting evidence highlights the involvement of inflammatory/immune systems and their relationships with neurotransmitters and different metabolic processes in mood disorders. Nevertheless, there is a general agreement that available findings are still inconclusive. Therefore, further investigations are required, aimed at deepening the role of possible alterations of biomarkers in the pathophysiology of mood disorders that might lead to more focused and tailored treatments. The present study is a comprehensive review on these topics that seem to represent intriguing avenues for the development of real innovative therapeutic strategies of mood disorders.

Cortisol levels in unmedicated patients with unipolar and bipolar major depression using hair and saliva specimens

Background

Differentiating between unipolar and bipolar depression can be clinically challenging, especially at first presentation. Patterns of cortisol secretion could aid diagnostic discrimination in affective disorders although there has been little comparative research to date. In this study, we investigated acute (saliva) and chronic (hair) cortisol levels concurrently in unmedicated unipolar and bipolar disorders by using conventional diagnostic criteria and self-report measures.

Methods

Patients with unipolar and bipolar major depression and healthy controls were recruited and assessed. Cortisol levels were extracted from saliva and hair specimens. Depressive features were investigated according to diagnostic groups and with a continuous self-report measure of bipolarity using the Hypomania Checklist (HCL-33).

Results

Whilst a trend towards a reduction in the total daily salivary cortisol output—area under the curve with respect to the ground (AUCg)—was detected in depressive disorders across diagnosis, the self-administrated bipolarity index suggested that an increase in bipolarity symptoms predicted lower cortisol levels using AUCg. Chronic cortisol measurement did not discriminate unipolar from bipolar depression.

Conclusion

Results suggested that whilst a low total daily salivary cortisol output (AUCg) might be associated with depressive symptoms, a self-reported measure of bipolarity predicts lower daily cortisol output.

Psychopathology of Mixed States

Mixed states are frequent clinical pictures in psychiatric practice but are not well described in nosologic systems. Debate exists as to defining mixed states. We review factor and cluster analytical studies and prominent clinical/conceptual models of mixed states. While mania involves standard manic symptoms and depression involves standard depressive symptoms, core additional features of the mixed state are, primarily, psychomotor activation and, secondarily, dysphoria. Those features are more pronounced in mixed mania than in mixed depression but are present in both.

Diagnosis, Clinical Features, and Therapeutic Implications of Agitated Depression

Agitated "unipolar" depression is a clinical entity characterized by excitement together with depressed mood during the same episode. The clinical picture of agitated "unipolar" depression is characterized by a depressed and anxious mood with inner, psychic agitation, whereas motor agitation may or may not be present. Some investigators have conceptualized this disorder as a mixed affective state, laying on the bipolar disorder spectrum, but controversies still persist. The diagnosis of agitated "unipolar" depression has important prognostic and therapeutic implications, with many clinicians reporting difficulties to adequately diagnose and treat it.

Serum miRNA as a possible biomarker in the diagnosis of bipolar II disorder

The diagnosis of Bipolar II disorder (BD-II) is currently based on the patients' description of symptoms and clinical behavioral observations. This study explored the possibility of miRNA in peripheral blood (serum) as a specific biomarker for BD-II. We identified 6 candidate miRNAs to differentiate BD-II patients from controls using next-generation sequencing. We then examined these candidate miRNAs using real-time PCR in the first cohort (as training group) of 79 BD-II and 95 controls. A diagnostic model was built based on these candidate miRNAs and then tested on an individual testing group (BD-II: n = 20, controls: n = 20). We found that serum expression levels of miR-7-5p, miR-23b-3p, miR-142-3p, miR-221-5p, and miR-370-3p significantly increased in BD-II compared with controls in the first cohort, whereas that of miR-145-5p showed no significant difference. The diagnostic power of the identified miRNAs was further analyzed using receiver-operating characteristic (ROC). Support vector machine (SVM) measurements revealed that a combination of the significant miRNAs reached good diagnostic accuracy (AUC: 0.907). We further examined an independent testing group and the diagnostic power reached fair for BD-II (specificity = 90%, sensitivity = 85%). We constructed miRNA panels using SVM model, which may aid in the diagnosis for BD-II.

Validation of the brief TEMPS-M temperament questionnaire in a clinical Italian sample of bipolar and cyclothymic patients

BACKGROUND

To assess psychometric proprieties of the short version of TEMPS-M in an Italian clinical sample of patients with bipolar disorder type I (BDI), type II (BDI) or cyclothymic disorder (CYC).

METHODS

All participants were recruited in two Italian university sites. They were asked to complete the Italian version of the short TEMPS-M, consisting of 35 items on a five-point Likert scale ranging from 1 to 5. The factorial structure of the instrument was assessed by principal components analysis with varimax rotation. The reliability of the subscales was assessed with Cronbach's alpha.

RESULTS

The 815 recruited patients had a diagnosis of BDI (430), CYC (227) or BDII (158); 60% of them were female and with a mean age of 44.4 (±14.6) years. Cronbach's alpha coefficients of subscales ranged from 0.808 to 0.898. The factor analysis confirmed five dimensions (depressive, cyclothymic, hyperthymic, irritable, anxious), as in the English version of the scale. All temperaments were more represented in CYC than in BDI patients. Depressive and anxious temperaments were more represented in BDII than in BDI; the hyperthymic temperament was represented more in BDI than in BDII patients.

LIMITATIONS

No other assessment instrument was used as a reference to assess the external or predictive validity of TEMPS-M; several socio-demographic and clinical characteristics have not been assessed.

CONCLUSION

The Italian version of the short TEMPS-M shows good reliability and validity. It might be used in clinical and research settings, for the dimensional exploration of the investigated domains.

The affective temperament traits and pregnancy-related depression in mothers may constitute risk factors for their children with attention deficit and hyperactivity disorder

We investigated whether the affective temperaments of mothers and maternal depression before and during the index pregnancy are related to the development of Attention-Deficit Hyperactivity Disorder (ADHD) in their children. One hundred and twenty children were screened for the diagnosis of ADHD. After exclusion and inclusion criteria were applied for children and their mothers, we compared the mothers of children with (n = 63) and without ADHD (n = 60) in terms of affective temperament traits, depression before and during the index pregnancy, and some environmental risk factors. The rate of boys were significantly higher among children with ADHD compared to healthy controls. The mothers of children with ADHD had significantly lower education levels, more cigarette consumption during pregnancy, and more depression rates before the pregnancy than those of healthy children. Male gender (p = .002), Hamilton Depression Rating Scale (HDRS) (p = .002), cyclothymic (p = .022), irritable (p = .035) and anxious temperament scores (p = .016) significantly predicted the association between the mothers and their children with ADHD. Our findings might suggest that male child gender, the severity of depression at index pregnancy, higher cyclothymic, irritable, and anxious temperament scores in mothers may constitute as important risk factors for the development of ADHD in their children.Impact statementWhat is already known on this subject? Although the effects of maternal depression on ADHD were extensively investigated, the relationship between affective temperament traits of mothers and ADHD in their children has not been sufficiently examined. To investigate the roles of maternal affective temperament traits and pregnancy-related depression on offspring ADHD would help us to understand the etiopathogenic bases of ADHD.What do the results of this study add? Cyclothymic, irritable and anxious temperaments of mothers were significantly associated with the offspring ADHD after adjusting for the gender, maternal smoking, prepartum and antenatal depression.What are the implications of these findings for clinical practice and/or further research? These findings might demonstrate that some maternal affective temperaments and depression during pregnancy are suggestive of an inherited predisposition to ADHD in offsprings. Longitudinal studies are required to demonstrate the relationship between maternal affective temperament features and the development of affective illness in children with ADHD.

Bipolar spectrum disorder: What evidence for pharmacological treatment? A systematic review

BACKGROUND AND OBJECTIVES

Bipolar spectrum disorder (BSD) is an extended concept of bipolar disorder (BD) that includes conditions that do not fulfill the criteria. There is no recommendation today about its treatment. We reviewed relevant literature focusing on pharmacological treatments, looking for high-strength evidence leading to guidelines.

METHODOLOGY

A literature search was conducted using MedLine / PubMed database and Google Scholar up to September 2018. Search words were related to BSD and pharmacological treatment.

RESULTS

The literature search yielded 621 articles. Out of these, 35 articles met our selection criteria. There was limited high quality data. Only one randomized control trial (RCT) and one randomized open label trial were found. Most studies used different definition of BSD.

CONCLUSIONS

There is a considerable lack of data and no evidence supporting efficacy of pharmacological treatment for BSD. There is a need for a consensus on the definition of BSD and more evidence studies to evaluate drug's effectiveness in this condition.

Bipolar subtypes and their clinical correlates in a sample of 391 bipolar individuals

Differences between BD-I and BD-II patients with regard to specific illness characteristics are poorly understood. This study is mainly aimed to compare socio-demographic and clinical characteristics between BD-I and BD-II patients with the goal of clarifying possible predictors of clinical course. The sample of this cohort study is composed of 391 currently euthymic bipolar patients. Participants were all receiving only maintenance treatment; their psychopharmacological regimens and psychopathological conditions were stable at assessment. After univariate analyses, BD-II patients were more likely to be female, had more frequently a recent depressive episode and substance abuse/dependence relative to BD-I subjects. BD-II patients were also less likely to have a positive history of psychiatric conditions in family, psychotic symptoms at first episode, and first depressive illness episode. Moreover, BD-II were older at their illness onset and first treatment than BD-I patients. Furthermore, BD-I were more likely to have higher depressive, manic, anxiety, and symptoms severity than BD-II patients. After logistic regression analyses, being female (OR = 0.289), having psychiatric conditions in family (OR = 0.273), and higher severity of illness at CGI (OR = 0.604) were all significantly associated with BD-II. Additional studies are required to replicate these results, and facilitate the prediction of BD outcomes according to the specified profile.

[Features of cognitive remediation in patients with affective disorders]

The article presents a literature review on the problem of cognitive deficit in patients with affective disorders. Cognitive deficit in patients with bipolar affective disorder and recurrent depression affects cognitive and executive functions, information processing, and has certain specific features. Specifics of cognitive deficit in patients with affective disorders hampers the use of rehabilitation programs. Consequently, the topic evokes increased interest of specialists and the need for further research.

Differences in metacognitive beliefs among patients with bipolar disorder with or without previous suicide attempts

Purpose: The aim of this study is to compare differences in metacognitive beliefs between patients with bipolar disorder type I (BPDI) with previous suicide attempts (BPDI+), those without suicide attempts (BPDI-), and a control group. It also discusses the relationship between metacognitive beliefs and suicidal behavioral parameters. Materials and methods: The study included 72 BPDI+ and 73 BPDI- euthymic patients and 86 healthy age- and gender-matched individuals. All participants completed a sociodemographic data form, the Beck Depression Inventory, Metacognition Questionnaire-30 (MCQ-30), Suicide Behaviors Questionnaire, and Structured Clinical Interview for DSM-IV Axis I. In addition, the Young Mania Rating Scale was used for the patient groups. Results: Both the BPDI+ and BPDI- patients had higher MCQ-30 scores than the control group (p < .01). Scores for the 'need to control thoughts' subscale were higher in the BPDI+ group than in the BPDI- group and were also higher in both the BPDI+ and BPDI- groups compared to the control group (p < .01). In addition, the 'cognitive self-consciousness' sub-scores of the BPDI- group were higher than those of the BPDI+ and the control group. Conclusion: The scores of 'cognitive self-consciousness' and 'need to control thoughts' vary across BPDI+ and BPDI- patients. It seems important to consider metacognitive beliefs regarding 'need to control thoughts' and 'cognitive self-consciousness' in terms of suicide prevention.

Affective temperaments are associated with the white matter microstructure in healthy participants

OBJECTIVES

Five affective temperaments are regarded as potential precursors of bipolar disorder. These are depressive, cyclothymic, hyperthymic, irritable, and anxious temperaments. However, the neural substrates underlying these temperaments have not been identified. The aim of this study was to determine whether these temperaments are associated with specific neural substrates related to the brain white matter integrity in healthy participants.

METHODS

We conducted a cross-sectional neuroimaging study of 71 healthy participants (38 males and 33 females) with affective temperaments. All participants screened for past and present psychiatric disorders. The scores of the five affective temperaments were measured by the temperament scale of Memphis, Pisa, Paris, and San Diego-autoquestionnaire. We analyzed the association between the fractional anisotropy (FA) and mean diffusivity (MD) of the brain white matter and these affective temperaments using tract-based spatial statistics (TBSS).

RESULTS

The cyclothymic temperament score had a significant positive association with the FA and a significant negative association with the MD in the white matter in the right frontal part of brain. The hyperthymic temperament score was negatively associated with the MD in a wide area of the brain white matter. The anxious temperament score was positively associated with the FA in the bilateral frontal, temporal, and parietal regions of the brain white matter. The depressive and irritable temperament scores were not associated with either the FA or the MD.

CONCLUSION

The present findings suggest that cyclothymic, hyperthymic, and anxious temperaments are associated with brain white matter integrity in healthy participants.

[Clinical features of depressive episode with onset in adolescence and the risk of bipolar depression]

AIM

To study clinical features of depressive episode with the onset in late adolescence associated with the risk of bipolar affective disorder (BAD).

MATERIAL AND METHODS

Forty patients with BAD (ICD-10 F31), who experienced depressive state at the age of 15-18 years corresponding to the diagnostic criteria of 'Depressive episode' (F32), were examined. The duration of follow-up was from 3 to 5 years. Clinical-psychopathologic, follow-up, statistical methods were applied.

RESULTS

Duration of depressive episodes did not exceed 6 months in 70% of patients with BAD. Characteristic clinical features included the frequent presence of psychomotor retardation, anergia, anhedonia, melancholy, irritability, affective instability with increased emotional reactivity, hypersomnia. Other 'atypical' depressive symptoms were less characteristic. There was a significant incidence of suicidal tendencies, comorbid psychopathic-like behavioral disorders and substance abuse. In most cases, the depressive state was accompanied by a deterioration in social functioning and led to educational maladaptation.

CONCLUSION

Characteristic clinical features of bipolar depression manifested in late adolescence were a relatively short duration, the prevalence of typical depressive symptoms (melancholy, psychomotor retardation), irritability, increased emotional reactivity, hypersomnia, a significant incidence of suicidal tendencies.

Affective Temperaments and Clinical Course of Bipolar Disorder: An Exploratory Study of Differences among Patients with and without a History of Violent Suicide Attempts

Background and Objectives: Suicide is the leading cause of death in patients with Bipolar Disorder (BD). In particular, the high mortality rate is due to violent suicide attempts. Several risk factors associated with suicide attempts in patients with BD have been identified. Affective temperaments are associated with suicidal risk, but their predictive role is still understudied. The aim of this study is to assess the relationship between affective temperaments and personal history of violent suicide attempts. Materials and Methods: 74 patients with Bipolar Disorder type I (BD-I) or II (BD-II) were included. All patients filled in the short version of Munster Temperament Evaluation of the Memphis, Pisa, Paris and San Diego (short TEMPS-M) and the Temperament and Character Inventory, revised version (TCI-R). The sample was divided into two groups on the basis of a positive history for suicidal attempts and the suicidal group was further divided into two subgroups according to violent suicide attempts. Results: Violent suicide attempts were positively associated with the cyclothymic temperament and inversely to the hyperthymic one. BD-I patients and patients with a clinical history of rapid cycling were significantly more represented in the group of patients with a history of violent suicide attempts. Conclusions: Our study highlights that several clinical and temperamental characteristics are associated with violent suicide attempts, suggesting the importance of affective temperaments in the clinical management of patients with BPI.

The geography of a controversial diagnosis: A bibliographic analysis of published academic perspectives on 'paediatric bipolar disorder'

BACKGROUND

The hypothesis that bipolar disorder presents before puberty with atypical mania has proved to be controversial. Published academic perspectives on the validity of Paediatric Bipolar Disorder (PBD) appear to vary between the United States and the rest of the world.

METHODS

We examined the perspectives of articles citing four seminal articles. The citing articles were grouped as either supportive or non-supportive of the PBD hypothesis, and the perspectives of the articles by US authors were compared with those by non-US authors.

RESULTS

There were 787 citing articles commenting on PBD, mostly published in US-based journals. Most authors were affiliated with several US institutions. Among the 624 articles with US authorship, the majority (83%) supported PBD. Of the 163 articles by non-US authors, most (60%) supported the traditional view that bipolar disorders are rare before mid-adolescence. Published academic perspectives in favour of the PBD hypothesis are mostly concentrated in several US institutions.

CONCLUSION

There is majority support for PBD among citing articles from the United States, whereas the traditional perspective predominates in articles from most other countries.

Is there a relationship between depression with anxious distress DSM-5 specifier and bipolarity? A multicenter cohort study on patients with unipolar, bipolar I and II disorders

BACKGROUND

To estimate the prevalence of DSM-5 anxious distress specifier (ADS) in depressed patients with major depressive disorder (MDD) or bipolar I or II disorder (BD), and to compare socio-demographic and clinical characteristics, and response to naturalistic short-term treatment between ADS and non-ADS group.

METHODS

241 outpatients with a major depressive episode (MDE) were consecutively recruited. Outcome were remission (HDRS₂₁ total score < 7), response (≥50% reduction of baseline HDRS₂₁) and improvement (CGI-i score ≤ 2) after 12 weeks of treatment sustained for 4 weeks.

RESULTS

ADS was more frequent in BD than in MDD (respectively, 66.9% and 51.2%, χ² = 6.1, p = 0.013). Compared with those non-ADS, patients with ADS had more severe depressive (respectively, HDRS₂₁ total score 20.0 ± 4.4 and 18.6 ± 3.9, t-test = 2.67, p = 0.008) and mania symptoms (respectively, Y-MRS total score 2.2 ± 2.9 and 1.3 ± 2.3, M-W-test = 2.86; p = 0.004) at intake, a higher rate of BD family history (respectively, 35.2% and 22.2%, Χ²-test 10.4, p = 0.004) and more previous hypomanic episodes (respectively, (median (range) 0 (0-20) and 0 (0-15), MW-test = 2.39 p = 0.017). In the MDD group, patients with ADS had higher scores on hyperthymic temperament and mania symptoms (Y-MRS total score (median (range) 2.2 (0-26) and 0 (0-11), respectively, M-W test 2.071, p = 0.038). ADS and no-ADS patients did not significantly differ on outcome measures.

LIMITATIONS

The observational nature of the study and the absence of blinding in outcome assessment.

CONCLUSIONS

ADS is the most common DSM-5 specifier for MDE, is more frequent in BD and need a personalized treatment with moderate use of antidepressants, mostly tricyclic.

A systematic review on neuropsychological function in bipolar disorders type I and II and subthreshold bipolar disorders-something to think about

Neuropsychological dysfunction is a well-established finding in individuals with bipolar disorder type I (BP-I), even during euthymic periods; however, it is less clear whether this also pertains to bipolar disorder type II (BP-II) or those with subthreshold states (SBP; subthreshold bipolar disorder), such as bipolar not otherwise specified (BP-NOS). Herein, we compare the literature regarding neuropsychological performance in BP-II vs BP-I to determine the extent of relative impairment, and we present and review all related studies on cognition in SBP. After systematically searching PubMed, Medline, PsycINFO, and The Cochrane Library, we found 17 papers that comprise all the published studies relevant for this review. The areas that are consistently found to be impaired in BP are executive function, verbal memory, visual spatial working memory, and attention. More studies than not show no significant difference between BP-I and BP-II, particularly in euthymic samples. Preliminary evidence suggests that patients experiencing major depressive episodes who also meet criteria for SBP show similar profiles to BP-II; however, these results pertain only to a depressed sample. SBP were found to perform significantly better than both MDD and healthy controls in a euthymic sample. A consensus on mood state, patient selection, and neuropsychological testing needs to be agreed on for future research. Furthermore, no studies have used the most recent DSM-5 criteria for SBP; future studies should address this. Finally, the underlying bases of cognitive dysfunction in these diagnostic groups need to be further investigated. We suggest recommendations on all of the above current research challenges.