1
|
Ghaemi SN, Angst J, Vohringer PA, Youngstrom EA, Phelps J, Mitchell PB, McIntyre RS, Bauer M, Vieta E, Gershon S. Clinical research diagnostic criteria for bipolar illness (CRDC-BP): rationale and validity. Int J Bipolar Disord 2022; 10:23. [PMID: 36227452 DOI: 10.1186/s40345-022-00267-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/16/2022] [Indexed: 11/10/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- S Nassir Ghaemi
- Department of Psychiatry, Tufts University, 800 Washington St, Boston, MA, 02111, USA. .,Department of Psychiatry, Harvard Medical School, Boston, USA.
| | | | - Paul A Vohringer
- Department of Psychiatry, Tufts University, 800 Washington St, Boston, MA, 02111, USA.,Department of Psychiatry, University of Chile, Santiago, Chile
| | - Eric A Youngstrom
- Departments of Psychology, Neuroscience, and Psychiatry, University of North Carolina, Chapel Hill, NC, USA
| | - James Phelps
- Department of Psychiatry, Good Samaritan Regional Medical Center, Corvallis, OR, USA
| | - Philip B Mitchell
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, Australia
| | - Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Eduard Vieta
- Department of Psychiatry and Psychology, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Samuel Gershon
- Department of Psychiatry, University of Miami, Miami, USA
| |
Collapse
|
2
|
Benazzi F. Reviewing the diagnostic validity and utility of mixed depression (depressive mixed states). Eur Psychiatry 2020; 23:40-8. [PMID: 17764909 DOI: 10.1016/j.eurpsy.2007.07.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Revised: 07/15/2007] [Accepted: 07/15/2007] [Indexed: 12/01/2022] Open
Abstract
AbstractObjectiveTo review the diagnostic validity and utility of mixed depression, i.e. co-occurrence of depression and manic/hypomanic symptoms.MethodsPubMed search of all English-language papers published between January 1966 and December 2006 using and cross-listing key words: bipolar disorder, mixed states, criteria, utility, validation, gender, temperament, depression-mixed states, mixed depression, depressive mixed state/s, dysphoric hypomania, mixed hypomania, mixed/dysphoric mania, agitated depression, anxiety disorders, neuroimaging, pathophysiology, and genetics. A manual review of paper reference lists was also conducted.ResultsBy classic diagnostic validators, the diagnostic validity of categorically-defined mixed depression (i.e. at least 2–3 manic/hypomanic symptoms) is mainly supported by family history (the current strongest diagnostic validator). Its diagnostic utility is supported by treatment response (negative effects of antidepressants). A dimensionally-defined mixed depression is instead supported by a non-bi-modal distribution of its intradepression manic/hypomanic symptoms.DiscussionCategorically-defined mixed depression may have some diagnostic validity (family history is the current strongest validator). Its diagnostic utility seems supported by treatment response.
Collapse
Affiliation(s)
- Franco Benazzi
- Hecker Psychiatry Research Center, University of California at San Diego, San Diego, CA, USA.
| |
Collapse
|
3
|
Sverdlichenko I, Jansen K, Souza LDDM, da Silva RA, Kapczinski F, Cardoso TDA. Mixed episodes and suicide risk: A community sample of young adults. J Affect Disord 2020; 266:252-257. [PMID: 32056885 DOI: 10.1016/j.jad.2020.01.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/11/2019] [Accepted: 01/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Suicide is the second leading cause of death among young adults worldwide, and few studies have assessed the factors associated with suicidality in this specific population. Thus, the aim of this study was to assess the association between mixed episodes and suicidality in a community sample of young adults. For this aim, we compared young adults in a mixed episode with individuals in a depressive or (hypo)manic episode, and community controls. METHOD This is a cross-sectional population-based study including young adults aged 18-24 years old. Information about participants' age, sex, self-reported skin color and study status were obtained using a sociodemographic questionnaire. Mixed, (hypo)manic and depressive episodes, as well as suicide risk were assessed using the Mini International Neuropsychiatric Interview. RESULTS The sample included 1560 individuals. Young adults in a mixed episode showed a 13.50 times higher probability to have suicide risk, as compared to community controls (p < 0.001), 5.67 higher probability to have suicide risk as compared to individuals in a (hypo)manic episode (p < 0.001), and 2.18 times higher probability to have suicide risk as compared to young adults in a depressive episode (p < 0.001). LIMITATION The assessment of suicide risk includes both suicide attempts and ideation. CONCLUSION Young adults in a mixed episode showed a higher rate of suicide risk than individuals with depression or mania/hypomania. Considering the already increasing prevalence of suicide among young adults, there is an urgent need for the early diagnosis and treatment of mixed episodes in this specific population.
Collapse
Affiliation(s)
- Irina Sverdlichenko
- Mood Disorders Program, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Karen Jansen
- Department of Health and Behavior, Catholic University of Pelotas, Pelotas, RS, Brazil
| | | | | | - Flavio Kapczinski
- Mood Disorders Program, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Taiane de Azevedo Cardoso
- Mood Disorders Program, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada; Department of Health and Behavior, Catholic University of Pelotas, Pelotas, RS, Brazil.
| |
Collapse
|
4
|
Lage RR, Santana CMT, Nardi AE, Cheniaux E. Mixed states and suicidal behavior: a systematic review. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2019; 41:191-200. [PMID: 31291413 DOI: 10.1590/2237-6089-2018-0042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 08/19/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The objective of this study was to identify whether mixed states in bipolar disorder (BD) are associated with more frequent suicidal behavior when compared to manic/hypomanic and depressive episodes. METHOD We performed a systematic search of the scientific literature on the subject using the PubMed, ISI Web Of Science, PsycINFO and SciELO databases. The terms chosen for the search were (bipolar) AND (suicid*) AND (mixed). We selected original studies comparing suicidal behavior of patients in mixed states and suicidal behavior of patients in other BD phases. RESULTS Sixteen papers fit the selection criteria. Twelve of the original 16 studies compared suicidal behavior in mixed states and pure mania, and the majority of these studies (n = 11) revealed that suicidal behavior was more frequent among individuals in mixed states. Five of the papers compared suicidal behavior between depressive and mixed phases of BD. One of these five papers reported more severe suicidal behavior in patients in mixed states and another described more frequent suicidal behavior in patients with pure depression. There were no significant statistical differences between groups in the remaining three of these five studies. CONCLUSION During acute BD episodes, suicidal behavior is more strongly associated with mixed states than with pure mania or hypomania. However, it was not possible to demonstrate that the association between suicidal behavior and mixed states is stronger than the association between suicidal behavior and depressive phases. The results hereby presented are worth considering in clinical practice to better evaluate suicide risk and to prevent suicide.
Collapse
Affiliation(s)
- Renata Reis Lage
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Cristina M T Santana
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Antonio Egidio Nardi
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Elie Cheniaux
- Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.,Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| |
Collapse
|
5
|
Abstract
Various terms have been used to describe mania when it is accompanied by depressive symptoms. In this article, we attempt to define and discuss 3 of these terms: dysphoric mania, mixed state, and mania with mixed features specifier. We conclude that whatever term is used, it is important to be aware that mania is more often unpleasant than pleasant, and that the unpleasantness is not limited to depression.
Collapse
|
6
|
Vieta E, Grunze H, Azorin JM, Fagiolini A. Phenomenology of manic episodes according to the presence or absence of depressive features as defined in DSM-5: Results from the IMPACT self-reported online survey. J Affect Disord 2014; 156:206-13. [PMID: 24439831 DOI: 10.1016/j.jad.2013.12.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 11/22/2013] [Accepted: 12/23/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to describe the phenomenology of mania and depression in bipolar patients experiencing a manic episode with mixed features as defined in the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5). METHODS In this multicenter, international on-line survey (the IMPACT study), 700 participants completed a 54-item questionnaire on demographics, diagnosis, symptomatology, communication of the disease, impact on life, and treatment received. Patients with a manic episode with or without DSM-5 criteria for mixed features were compared using descriptive and inferential statistics. RESULTS Patients with more than 3 depressive symptoms were more likely to have had a delay in diagnosis, more likely to have experienced shorter symptom-free periods, and were characterized by a marked lower prevalence of typical manic manifestations. All questionnaire items exploring depressive symptomatology, including the DSM-5 criteria defining a manic episode as "with mixed features", were significantly overrepresented in the group of patients with depressive symptoms. Anxiety associated with irritability/agitation was also more frequent among patients with mixed features. LIMITATIONS Retrospective cross-sectional design, sensitive to recall bias. Two of the 6 DSM-5 required criteria for the specifier "with mixed features" were not explored: suicidality and psychomotor retardation. CONCLUSIONS Bipolar disorder patients with at least 3 depressive symptoms during a manic episode self-reported typical symptomatology. Anxiety with irritability/agitation differentiated patients with depressive symptoms during mania from those with "pure" manic episodes. The results support the use of DSM-5 mixed features specifier and its value in research and clinical practice.
Collapse
Affiliation(s)
- Eduard Vieta
- Bipolar Disorder Programme, Institute of Neuroscience, University of Barcelona Hospital Clínic, IDIBAPS, CIBERSAM, C/Villarroel 170, Barcelona 08036, Catalonia, Spain.
| | - Heinz Grunze
- Institute of Neuroscience, Academic Psychiatry, Newcastle upon Tyne, NE4 5PL, UK
| | - Jean-Michel Azorin
- Hospital Ste. Marguerite, 270 Bd Sainte Marguerite, 13274 Marseille, France
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, School of Medicine, Siena, Italy; Department of Mental Health, University of Siena Medical Center, Siena, Italy
| |
Collapse
|
7
|
Pompili M, Gonda X, Serafini G, Innamorati M, Sher L, Amore M, Rihmer Z, Girardi P. Epidemiology of suicide in bipolar disorders: a systematic review of the literature. Bipolar Disord 2013; 15:457-90. [PMID: 23755739 DOI: 10.1111/bdi.12087] [Citation(s) in RCA: 227] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 09/11/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Suicidal behavior is a major public health problem worldwide, and its prediction and prevention represent a challenge for everyone, including clinicians. The aim of the present paper is to provide a systematic review of the existing literature on the epidemiology of completed suicides in adult patients with bipolar disorder (BD). METHODS We performed a Pubmed/Medline, Scopus, PsycLit, PsycInfo, and Cochrane database search to identify all relevant papers published between 1980 and 2011. A total of 34 articles meeting our inclusion criteria were included in the present review. RESULTS Several prospective follow-up contributions, many retrospective analyses, and a few psychological autopsy studies and review articles investigated the epidemiology of completed suicides in patients with BD. The main finding of the present review was that the risk for suicide among BD patients was up to 20-30 times greater than that for the general population. CONCLUSION Special attention should be given to the characteristics of suicides in patients with BD. Better insight and understanding of suicide and suicidal risk in this very disabling illness should ultimately help clinicians to adequately detect, and thus prevent, suicidal acts in patients with BD.
Collapse
Affiliation(s)
- Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
8
|
Abstract
The recently released preliminary proposal for the DSM-5 diagnostic system includes modification of the mixed mania diagnosis symptom set. That definition includes the long-overdue exclusion of nonspecific signs and symptoms, as well as the inclusion of psychomotor retardation. Anxiety is specifically excluded from the definition. The current report reviews studies to establish that psychomotor retardation would have limited utility in the definition, in contrast to anxiety, which is a core symptom of the mixed manic subtype.
Collapse
|
9
|
Cassidy F, Yatham LN, Berk M, Grof P. Pure and mixed manic subtypes: a review of diagnostic classification and validation. Bipolar Disord 2008; 10:131-43. [PMID: 18199232 DOI: 10.1111/j.1399-5618.2007.00558.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To review issues surrounding the diagnosis and validity of bipolar manic states. METHODS Studies of the manic syndrome and its diagnostic subtypes were reviewed emphasizing historical development, conceptualizations, formal diagnostic proposals, and validation. RESULTS Definitions delineating mixed and pure manic states derive some validity from external measures. DSM-IV and ICD-10 diagnosis of bipolar mixed states are too rigid and less restrictive definitions can be validated. Anxiety is a symptom often overlooked in diagnosis of manic subtypes and may be relevant to the mixed manic state. The boundary for separation of mixed mania and depression remains unclear. A 'pure' non-psychotic manic state similar to Kraepelin's 'hypomania' has been observed in several independent studies. CONCLUSIONS Issues surrounding diagnostic subtyping of manic states remain complex and the debates surrounding categorical versus dimensional approaches continue. To the extent that categorical approaches for mixed mania diagnosis are adopted, both DSM-IV and ICD-10 are too rigid. Inclusion of non-specific symptoms in definitions of mixed mania, such as psychomotor agitation, does not facilitate and may hinder the diagnostic separation of pure and mixed mania. The inclusion of a diagnostic seasonal specifier for DSM-IV, which is currently based on seasonal patterns for depression might be expanded to include seasonal patterns for mania. Boundaries between subtypes may be 'fuzzy' rather than crisp, and graded approaches could be considered. With the continued development of new tools, such as imaging and genetics, alternative approaches to diagnosis other than the purely symptom-centric paradigms might be considered.
Collapse
Affiliation(s)
- Frederick Cassidy
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA.
| | | | | | | |
Collapse
|
10
|
McClellan J, Kowatch R, Findling RL. Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry 2007; 46:107-125. [PMID: 17195735 DOI: 10.1097/01.chi.0000242240.69678.c4] [Citation(s) in RCA: 268] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This practice parameter reviews the literature on the assessment and treatment of children and adolescents with bipolar disorder. The parameter focuses primarily on bipolar 1 disorder because that is the type most often studied in juveniles. The presentation of bipolar disorder in youth, especially children, is often considered atypical compared with that of the classic adult disorder, which is characterized by distinct phases of mania and depression. Children who receive a diagnosis of bipolar disorder in community settings typically present with rapid fluctuations in mood and behavior, often associated with comorbid attention-deficit/hyperactivity disorder and disruptive behavior disorders. Thus, at this time it is not clear whether the atypical forms of juvenile mania and the classic adult form of the disorder represent the same illness. The question of diagnostic continuity has important treatment and prognostic implications. Although more controlled trials are needed, mood stabilizers and atypical antipsychotic agents are generally considered the first line of treatment. Although patients may respond to monotherapy, combination pharmacotherapy is necessary for some youth. Behavioral and psychosocial therapies are also generally indicated for juvenile mania to address disruptive behavior problems and the impact of the illness on family and community functioning.
Collapse
|
11
|
Jones SH, Sellwood W, McGovern J. Psychological therapies for bipolar disorder: the role of model-driven approaches to therapy integration. Bipolar Disord 2005; 7:22-32. [PMID: 15654929 DOI: 10.1111/j.1399-5618.2004.00157.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The psychological and social aspects of bipolar disorder are receiving increasing recognition. Recently, there have been promising developments in psychological interventions, but there is scope for further improvement of therapeutic outcomes. This paper argues for the use of more detailed psychological models of bipolar disorder to inform the further development of therapeutic approaches. METHOD Evidence for psychological, family and social factors in bipolar disorder is reviewed. The efficacy of current individual and family interventions are discussed. A model, which has potential to synthesize group and individual approaches, is outlined. RESULTS Psychological, social and family factors have important influences on the onset, course and outcome of bipolar disorder. Interventions based on vulnerability stress models have proved effective. However, to enhance efficacy future developments need to be based on models that integrate current understandings of the multiple levels at which mood fluctuations occur. A particular recent model is discussed which leads to specific proposals for future intervention research. CONCLUSIONS Psychological and family approaches to BD have much potential. They clearly have a role in conjunction with appropriate pharmacological treatment. If this potential is to be fully realized future developments need to be based on psychological models that can accommodate the complexity of this illness.
Collapse
Affiliation(s)
- Steven H Jones
- Academic Division of Clinical Psychology, University of Manchester and Pennine Care Trust, Greater Manchester, UK.
| | | | | |
Collapse
|
12
|
González-Pinto A, Aldama A, Pinto AG, Mosquera F, Pérez de Heredia JL, Ballesteros J, Gutiérrez M. Dimensions of mania: differences between mixed and pure episodes. Eur Psychiatry 2004; 19:307-10. [PMID: 15276665 DOI: 10.1016/j.eurpsy.2004.04.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The presence of at least five dimensions in mania has recently been established. This study extends previous findings by comparing the dimensions of pure vs. mixed mania. MATERIALS AND METHOD One hundred and three inpatients with bipolar I disorder, manic or mixed (DSM IV), were assessed with SCID-I, YMRS and HDRS-21. The five-factor solution found after applying factorial analysis with Varimax rotation was compared between manic and mixed patients. RESULTS There were differences between pure mania and mixed states on factor 1 (depression) and factor 3 (hedonism). There was a tendency to present higher values on factor 5 (activation) in the pure manic group. No differences were found in factor 2 (dysphoria) and factor 4 (psychosis). DISCUSSION Hedonism and activation dimensions are present to a lesser degree in mixed states. Although the principal difference between mixed and pure bipolar disorder is the existence of depressive symptoms, the depressive dimension is strongly present in patients with pure mania. CONCLUSIONS There is need to search for core depressive symptoms in all patients suffering from mania and to evaluate their outcome in clinical trials.
Collapse
|
13
|
Baker RW, Brown E, Akiskal HS, Calabrese JR, Ketter TA, Schuh LM, Trzepacz PT, Watkin JG, Tohen M. Efficacy of olanzapine combined with valproate or lithium in the treatment of dysphoric mania. Br J Psychiatry 2004; 185:472-8. [PMID: 15572737 DOI: 10.1192/bjp.185.6.472] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Few controlled studies examine the treatment of depressive features in mania. AIMS To evaluate the efficacy of olanzapine, in combination with lithium or valproate, for treating depressive symptoms associated with mania. METHOD Secondary analysis of a 6-week, double-blind, randomised study of olanzapine (5-20 mg/day) or placebo combined with ongoing valproate or lithium open treatment for 344 patients in mixed or manic episodes. This analysis focused on a dysphoric subgroup with baseline Hamilton Rating Scale for Depression (HRSD) total scores of 20 or over contrasted with non-dysphoric patients. RESULTS In the dysphoric subgroup (n=85) mean HRSD total score improvement was significantly greater in olanzapine co-therapy patients than in those receiving placebo plus lithium or valproate (P<0.001). Substantial contributors to this superiority included the HRSD Maier sub-scale (P=0.013) and the suicide item (P=0.001). Total Young Mania Rating Scale improvement was also superior with olanzapine co-therapy. CONCLUSIONS In patients with acute dysphoric mania, addition of olanzapine to ongoing lithium or valproate monotherapy significantly improved depressive symptom, mania and suicidality ratings.
Collapse
Affiliation(s)
- Robert W Baker
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN 46285, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Abstract
We suggest that the core feature of bipolar disorder (BPD) is marked state fluctuations. The pathophysiology of switches into depressed, irritable, and extreme positive valence states requires study, with the latter deserving particular focus because it represents a pathognomonic feature of BPD in both adults and children. Hypotheses regarding the pathophysiology of pediatric BPD must account for these marked state fluctuations as well as for specific developmental aspects of the illness. These developmental aspects include marked irritability (in addition to euphoria and depression) and very rapid cycles, along with high rates of attention-deficit/hyperactivity disorder. We review research on neural mechanisms underlying positive valence states and state regulation, focusing on those data relevant to BPD and to development. Researchers are beginning to explore the response of manic patients and control subjects to positive affective stimuli, and considerable research in both nonhuman primates and humans has focused on the cortico-limbic-striatal circuits mediating responses to rewarding stimuli. In control subjects, positive affect affects cognition, and data indicate that prefrontal electroencephalogram asymmetry may differ between control subjects with consistently positive affect and those with more negative affect; however, this latter generalization may not apply to adolescents. With regard to the pathophysiology of state switching in pediatric BPD, data in control subjects indicating that attention regulation plays a role in emotion regulation may be germane. In addition, research detailing physiologic and psychological responses to negative emotional stimuli in bipolar patients and control subjects may increase our understanding of the mechanisms underlying both irritability and rapid cycling seen in children with BPD. Potential foci for research on the pathophysiology of pediatric BPD include reactivity to standardized positive and negative emotional stimuli, and the interaction between emotion regulation and attentional processes.
Collapse
Affiliation(s)
- Ellen Leibenluft
- Mood and Anxiety Program, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20892, USA
| | | | | |
Collapse
|
15
|
Baker RW, Tohen M, Fawcett J, Risser RC, Schuh LM, Brown E, Stauffer VL, Shao L, Tollefson GD. Acute dysphoric mania: treatment response to olanzapine versus placebo. J Clin Psychopharmacol 2003; 23:132-7. [PMID: 12640214 DOI: 10.1097/00004714-200304000-00005] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A substantial number of patients with mania have significant concomitant depressive features, and they may respond differently to mood stabilizers than patients with pure mania. This post-hoc analysis explored the response characteristics of olanzapine versus placebo in bipolar I manic patients with dysphoric and nondysphoric mania (differentiated by baseline Hamilton Depression Rating Scale [HAM-D] score of >20). Two similar, double-blind, randomized trials comparing olanzapine, 5-20 mg, to placebo were pooled for these analyses (N = 246). Mean changes in Young-Mania Rating Scale (Y-MRS) and HAM-D scores during 3 weeks of treatment were examined. Twenty-eight percent of patients had dysphoric mania (olanzapine, n = 33; placebo, n = 35). Among these patients, olanzapine-treated patients had greater improvement within 1 week than did placebo-treated patients on both mania ratings (Y-MRS: -9.7 vs. -3.0 points; = 0.011) and depressive symptom ratings (HAM-D: -9.9 vs. -5.4 points; = 0.025). Among those manic subjects without prominent depressive symptoms (olanzapine, n = 91; placebo, n = 87), mean Y-MRS improvement from baseline to endpoint with olanzapine (-11.5 points) versus placebo (-6.13 points) was comparable to the improvement seen with olanzapine versus placebo in the dysphoric mania subgroup ( = 0.476, test of interaction). In acutely ill manic patients with significant depressive symptoms, olanzapine demonstrated a broad spectrum of efficacy, effectively treating both manic and depressive symptoms. The magnitude of the antimanic response appears similar, regardless of baseline depressive features. Additional experience with putative mood stabilizers and atypical agents in mixed mania should include an exploration of their efficacy in treating both manic and depressive mood symptoms.
Collapse
Affiliation(s)
- Robert W Baker
- Lilly Research Laboratories, Indianapolis, Indiana 46285, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|