Guidelines for the recognition and management of mixed depression

How to treat major depressive disorder with shorter-duration hypomanic episodes? A case report

Here we report on a case of a 61-year-old female patient with 7-year history of major depressive disorder with shorter-duration hypomanic episodes who was prescribed with antidepressants which turned out to be ineffective. After a COVID-19 infection, the patient's clinical presentation became sufficient for the diagnosis of bipolar disorder and she was consistently effective on a mood stabilizer and an atypical antipsychotic. The course of treatment in this case suggests bipolar disorder is not a binary disorder, but a continuous spectrum disorder. For patients suffering from major depressive disorder with shorter-duration hypomanic episodes, mood stabilizers and atypical antipsychotics are possibly more suitable than antidepressants.

Patient-reported outcomes on sleep quality and circadian rhythm during treatment with intravenous ketamine for treatment-resistant depression

Background

Intravenous (IV) ketamine is a rapid acting antidepressant used primarily for treatment-resistant depression (TRD). It has been suggested that IV ketamine's rapid antidepressant effects may be partially mediated via improved sleep and changes to the circadian rhythm.

Objectives

This study explores IV ketamine's association with changes in patient-reported sleep quality and circadian rhythm in an adult population with TRD.

Methods

Adult patients (18-64 years) with TRD scheduled for IV ketamine treatment were recruited to complete patient rated outcomes measures on sleep quality using the Pittsburgh Sleep Quality Index (PSQI) and circadian rhythm using the Morningness-Eveningness Questionnaire (MEQ). Over a 4-week course of eight ketamine infusions, reports were obtained at baseline (T0), prior to second treatment (T1), prior to fifth treatment (T2), and 1 week after eighth treatment (T3).

Results

Forty participants with TRD (mean age = 42.8, 45% male) were enrolled. Twenty-nine (72.5%) had complete follow-up data. Paired t tests revealed statistically significant improvements at the end of treatment in sleep quality (PSQI) (p = 0.003) and depressive symptoms (Clinically Useful Depression Outcome Scale-Depression, p < 0.001) while circadian rhythm (MEQ) shifted earlier (p = 0.007). The PSQI subscale components of sleep duration (p = 0.008) and daytime dysfunction (p = 0.001) also improved. In an exploratory post hoc analysis, ketamine's impact on sleep quality was more prominent in patients with mixed features, while its chronobiotic effect was prominent in those without mixed features.

Conclusion

IV ketamine may improve sleep quality and advance circadian rhythm in individuals with TRD. Effects may differ in individuals with mixed features of depression as compared to those without. Since this was a small uncontrolled study, future research is warranted.

[Psychopharmacotherapy of mixed affective states in bipolar disorder]

On the example of a patient with a mixed affective episode within the framework of bipolar affective disorder, the clinical features of this psychopathological condition, the difficulties of diagnosis and selection of therapy in mixed states are presented. The use of the modern atypical antipsychotic ziprasidone in this category of patients is argued.

Identifying the DSM-5 mixed features specifier in depressed patients: A comparison of measures

BACKGROUND

A commonly used measure to assess mixed features in depressed patients is the Young Mania Rating Scale (YMRS), which only partially aligns with the DSM-5 criteria. Different algorithms on the YMRS have been used to approximate the DSM-5 mixed features criteria. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the agreement and validity of different approaches towards assessing the mixed features specifier.

METHODS

Three hundred nine depressed psychiatric patients were interviewed with the Structured Clinical Interview for DSM-IV, the DSM-5 Mixed Features Specifier Interview (DMSI) and the YMRS. Seven definitions of mixed features were examined, two based on the DMSI and five from the YMRS.

RESULTS

The prevalence of mixed features varied 8-fold amongst the 7 definitions. The level of agreement between the YMRS definitions and the DMSI was poor. For each definition, mixed features were significantly more common in patients with bipolar disorder than major depressive disorder. A family history of bipolar disorder was significantly associated with the DMSI assessment of mixed features but none of the YMRS approaches.

LIMITATIONS

The ratings on the measures were not independent of each other. The sample size was too small to compare the patients with bipolar I and bipolar II disorder.

CONCLUSIONS

While there was evidence of validity for both the DSM-5 and YMRS approaches towards identifying mixed features, the 2 approaches are not interchangeable. The algorithm on the YMRS used to classify patients has a significant impact on prevalence.

Are anxious and mixed depression two sides of the same coin? Similarities and differences in patients with bipolar I, II and unipolar disorders

BACKGROUND

Diagnostic criteria are not always useful to discriminate major depression with anxious distress (ADS-D; Diagnostic and Statistical Manual for Mental Disorders, version-5 [DSM-5] criteria) from mixed depression (Koukopoulos' criteria; KMX-D). So, clinicians need alternative tools to improve their diagnostic ability and to choose the most appropriate treatment. The aim of the present study is to identify socio-demographic and clinical features that discriminate patients with ADS-D from those with KMX-D.

METHODS

Two hundred and forty-one consecutive outpatients with unipolar (51%) and bipolar (49%) disorder, fulfilling DSM-5 criteria for a current major depressive episode (MDE) and with a 21-item Hamilton Depression Rating Scale score ≥ 14, were recruited and treated in a prospective observational study.

RESULTS

Ten percent of patients met criteria for KMX-D, 22% ADS-D, and 37% for both. Irritable premorbid temperament, mixed depression polarity at onset, mixed depression recurrence, and a high number of mania symptoms at intake were typical features of patients with KMX-D. Depressive polarity at onset, a low number of mania symptoms at intake, and generalized anxiety disorder comorbidity were typical features of patients with ADS-D. Multinomial logistic regression confirmed that higher rate of irritable temperament and higher Young Mania Rating Scale total score differentiated patients with KMX-D from patients with pure MDE.

CONCLUSION

Our findings suggest some clinical features that could help differentiate between ADS-D and KMX-D in patients meeting both conditions and to select the appropriate treatment. However, the small sample size may have limited the power to detect differences between the groups. Further research is needed to confirm the results of present study.

The immunomodulatory effect of lithium as a mechanism of action in bipolar disorder

Bipolar disorder (BD) is a chronic mental disorder characterized by recurrent episodes of mania and depression alternating with periods of euthymia. Although environmental and genetic factors have been described, their pathogenesis is not fully understood. Much evidence suggests a role for inflammatory mediators and immune dysregulation in the development of BD. The first-line treatment in BD are mood-stabilizing agents, one of which is lithium (Li) salts. The Li mechanism of action is not fully understood, but it has been proposed that its robust immunomodulatory properties might be one of the mechanisms responsible for its effectiveness. In this article, the authors present the current knowledge about immune system changes accompanying BD, as well as the immunomodulatory effect of lithium. The results of studies describing connections between immune system changes and lithium effectiveness are often incoherent. Further research is needed to understand the connection between immune system modulation and the therapeutic action of lithium in BD.

Gait disorders in unipolar and bipolar depression

Objectives

Bipolar and unipolar depressions have a similar clinical picture, but different neurological and psychological mechanisms. These misleading similarities can lead to overdiagnosis and increased suicide risk. Recent studies show that gait is a sensitive objective marker for distinguishing the type of depression. The present study aims to compare psychomotor reactivity disorders and gait activity in unipolar and bipolar depression.

Methods

A total of 636 people aged 40.7 ± 11.2 years are studied with an ultrasound cranio-corpo-graph. They are divided into three groups - patients with unipolar depression, with bipolar depression and healthy controls. Each person performs three psychomotor tasks - a classic Unterberger task, a simplified version with open eyes and a complex version with an additional cognitive task.

Results

We find significant differences in psychomotor activity and reactivity between the three groups. Bipolar patients have more inhibited psychomotor skills than unipolar and they are both more inhibited than the norms. The simplified variant of the equilibriometric task is the most sensitive one and psychomotor reactivity is a more precise marker than psychomotor activity.

Conclusion

Both psychomotor activity and reactivity in gait could be sensitive markers for distinguishing similar psychiatric conditions. The application of the cranio-corpo-graph and the possible development of similar devices could lead to new diagnostic and therapeutic approaches, including early detection and prediction of the type of depression.

Investigating racing thoughts via ocular temporal windows: deficits in the control of automatic perceptual processes

BACKGROUND

Racing thoughts have been found in several states of bipolar disorder (BD), but also in healthy populations with subclinical mood alterations. The evaluation of racing thoughts relies on subjective reports, and objective measures are sparse. The current study aims at finding an objective neuropsychological equivalent of racing thoughts in a mixed group of BD patients and healthy controls by using a bistable perception paradigm.

METHOD

Eighty-three included participants formed three groups based on participants' levels of racing thoughts reported via the Racing and Crowded Thoughts Questionnaire. Participants reported reversals in their perception during viewing of the bistable Necker cube either spontaneously, while asked to focus on one interpretation of the cube, or while asked to accelerate perceptual reversals. The dynamics of perceptual alternations were studied both at a conscious level (with manual temporal windows reflecting perceptual reversals) and at a more automatic level (with ocular temporal windows derived from ocular fixations).

RESULTS

The rate of windows was less modulated by attentional conditions in participants with racing thoughts, and most clearly so for ocular windows. The rate of ocular windows was especially high when participants with racing thoughts were asked to focus on one interpretation of the Necker cube and when they received these instructions for the first time.

CONCLUSIONS

Our results indicate that in subjects with racing thoughts automatic perceptual processes escape cognitive control mechanisms. Racing thoughts may involve not only conscious thought mechanisms but also more automatic processes.

Multiplatform-Integrated Identification of Melatonin Targets for a Triad of Psychosocial-Sleep/Circadian-Cardiometabolic Disorders

Several psychosocial, sleep/circadian, and cardiometabolic disorders have intricately interconnected pathologies involving melatonin disruption. Therefore, we hypothesize that melatonin could be a therapeutic target for treating potential comorbid diseases associated with this triad of psychosocial-sleep/circadian-cardiometabolic disorders. We investigated melatonin's target prediction and tractability for this triad of disorders. The melatonin's target prediction for the proposed psychosocial-sleep/circadian-cardiometabolic disorder triad was investigated using databases from Europe PMC, ChEMBL, Open Targets Genetics, Phenodigm, and PheWAS. The association scores for melatonin receptors MT1 and MT2 with this disorder triad were explored for evidence of target-disease predictions. The potential of melatonin as a tractable target in managing the disorder triad was investigated using supervised machine learning to identify melatonin activities in cardiovascular, neuronal, and metabolic assays at the cell, tissue, and organism levels in a curated ChEMBL database. Target-disease visualization was done by graphs created using "igraph" library-based scripts and displayed using the Gephi ForceAtlas algorithm. The combined Europe PMC (data type: text mining), ChEMBL (data type: drugs), Open Targets Genetics Portal (data type: genetic associations), PhenoDigm (data type: animal models), and PheWAS (data type: genetic associations) databases yielded types and varying levels of evidence for melatonin-disease triad correlations. Of the investigated databases, 235 association scores of melatonin receptors with the targeted diseases were greater than 0.2; to classify the evidence per disease class: 37% listed psychosocial disorders, 9% sleep/circadian disorders, and 54% cardiometabolic disorders. Using supervised machine learning, 546 cardiovascular, neuronal, or metabolic experimental assays with predicted or measured melatonin activity scores were identified in the ChEMBL curated database. Of 248 registered trials, 144 phase I to IV trials for melatonin or agonists have been completed, of which 33.3% were for psychosocial disorders, 59.7% were for sleep/circadian disorders, and 6.9% were for cardiometabolic disorders. Melatonin's druggability was evidenced by evaluating target prediction and tractability for the triad of psychosocial-sleep/circadian-cardiometabolic disorders. While melatonin research and development in sleep/circadian and psychosocial disorders is more advanced, as evidenced by melatonin association scores, substantial evidence on melatonin discovery in cardiovascular and metabolic disorders supports continued R&D in cardiometabolic disorders, as evidenced by melatonin activity scores. A multiplatform analysis provided an integrative assessment of the target-disease investigations that may justify further translational research.

Which patients with bipolar depression receive antidepressant augmentation? Results from an observational multicenter study

BACKGROUND

To identify demographic and clinical characteristics of bipolar depressed patients who require antidepressant (AD) augmentation, and to evaluate the short- and long-term effectiveness and safety of this therapeutic strategy.

METHODS

One hundred twenty-two bipolar depressed patients were consecutively recruited, 71.7% of them received mood stabilizers (MS)/second-generation antipsychotics (SGA) with AD-augmentation and 28.3% did not. Patients were evaluated at baseline, and after 12 weeks and 15 months of treatment.

RESULTS

The AD-augmentation was significantly higher in patients with bipolar II compared with bipolar I diagnosis. Patients with MS/SGA + AD had often a seasonal pattern, depressive polarity onset, depressive index episode with anxious features, a low number of previous psychotic and (hypo)manic episodes and of switch. They had a low irritable premorbid temperament, a low risk of suicide attempts, and a low number of manic symptoms at baseline. After 12 weeks of treatment, 82% of patients receiving ADs improved, 58% responded and 51% remitted, 3.8% had suicidal thoughts or projects, 6.1% had (hypo)manic switch, and 4.1% needed hospitalization. During the following 12 months, 92% of them remitted from index episode, 25.5% did not relapse, and 11% needed hospitalization. Although at the start advantaged, patients with AD-augmentation, compared with those without AD-augmentation, did not significantly differ on any outcome as well on adverse events in the short- and long-term treatment.

CONCLUSION

Our findings indicate that ADs, combined with MS and/or SGA, are short and long term effective and safe in a specific subgroup for bipolar depressed patients.

Harm Reduction, Humanistic Psychology, and the CRPD

Harm reduction, which was initially developed as a public health response to illicit drug use, has relevance to the prescription of psychotropic medication. Indeed, focusing on the agency of people who use drugs—licit or illicit—facilitates a more authentic engagement with treatment. In this paper, we show how the framework of harm reduction is congruent with the guiding principles of both humanistic psychology and the Convention on the Rights of Persons with Disabilities (CRPD). Moreover, applying a harm reduction model to psychotropic drug use raises awareness that there are risks to taking these medications, risks which are frequently glossed over because of the emphasis on medication adherence and compliance. We provide case examples of organizations that take a person-centered (vs. medication-centered) approach to people experiencing mental health crises. In their unique ways, these organizations embody the principles of harm reduction and the humanistic impulse that informs the CRPD.

Chronic treatment with escitalopram and venlafaxine affects the neuropeptide S pathway differently in adult Wistar rats exposed to maternal separation

Neuropeptide S (NPS), which is a peptide that is involved in the regulation of the stress response, seems to be relevant to the mechanism of action of antidepressants that have anxiolytic properties. However, to date, there have been no reports regarding the effect of long-term treatment with escitalopram or venlafaxine on the NPS system under stress conditions. This study aimed to investigate the effects of the above-mentioned antidepressants on the NPS system in adult male Wistar rats that were exposed to neonatal maternal separation (MS). Animals were exposed to MS for 360 min. on postnatal days (PNDs) 2-15. MS causes long-lasting behavioral, endocrine and neurochemical consequences that mimic anxiety- and depression-related features. MS and non-stressed rats were given escitalopram or venlafaxine (10mg/kg) IP from PND 69 to 89. The NPS system was analyzed in the brainstem, hypothalamus, amygdala and anterior olfactory nucleus using quantitative RT-PCR and immunohistochemical methods. The NPS system was vulnerable to MS in the brainstem and amygdala. In the brainstem, escitalopram down-regulated NPS and NPS mRNA in the MS rats and induced a tendency to reduce the number of NPS-positive cells in the peri-locus coeruleus. In the MS rats, venlafaxine insignificantly decreased the NPSR mRNA levels in the amygdala and a number of NPSR cells in the basolateral amygdala, and increased the NPS mRNA levels in the hypothalamus. Our data show that the studied antidepressants affect the NPS system differently and preliminarily suggest that the NPS system might partially mediate the pharmacological effects that are induced by these drugs.

Which mixed depression model? A comparison between DSM-5-defined mixed features and Koukopoulos' criteria

BACKGROUND

The criteria of the Diagnostic and Statistical Manual of Mental Disorders 5th edition "with mixed features specifier" (DSM-5 MFS) are considered controversial since they include only typical manic symptoms. By contrast, Koukopoulos developed an alternative model of mixed depression (MxD) focusing primarily on the excitatory component.

OBJECTIVE

To compare DSM-5 MFS and Koukopoulos' MxD (KMxD) in terms of prevalence, associated clinical variables, and discriminative capacity for bipolar depression in patients with major depressive episode (MDE).

METHODS

A total of 300 patients with MDE-155 with major depressive disorder and 145 with bipolar disorder (BD)-were recruited. The discriminative capacity of DSM-5 MFS and KMxD criteria for BD was estimated using the area under the curves of receiver operating characteristic (ROC_AUC). The clinical variables associated with these two diagnostic constructs were assessed by performing a logistic regression.

RESULTS

A total of 44 and 165 patients met the DSM-5 MFS and KMxD criteria, respectively. The ROC_AUCs and their confidence intervals for BD according to DSM-5 MFS and KMxD were 77.0% (72.0%-82.1%) and 71.9% (66.2%-77.7%), respectively. The optimal thresholds (combining sensitivity and specificity measures) for BD diagnosis were ≥1 (77%/68%) for DSM-5 MFS and ≥3 symptoms (78%/66%) for KMxD. However, considering the DSM-5 MFS cut-off (≥3 symptoms), the specificity (97%) increased at the expense of sensitivity (26%).

CONCLUSIONS

KMxD and DSM-5-MFS showed an overlapping discriminative capacity for bipolar depression. The current diagnostic threshold of DSM-5 MFS did not prove to be very inclusive, if compared with the greater diagnostic sensitivity of KMxD, which also yielded better association with clinical variables related to mixedness.

Pragmatic issues and prescribing patterns in bipolar disorder: A mental health professional's survey

BACKGROUND

There is substantial treatment gap between the suggested guidelines and pragmatic clinical practice for psychotropic usage in bipolar disorder (BD) due to the lack of naturalistic studies and not taking into account the transcultural differences and diverse background. We intend to study this treatment gap and elucidate the preference of psychotropics and prescription patterns, critical clinical issues faced and related pragmatics in BD by conducting the mental health professionals survey.

METHODOLOGY

After focused discussions, Canadian Network for Mood and Anxiety Treatments guidelines being the primary anchor, a 46-item online survey questionnaire was prepared. With 25.4% response rate, 127 psychiatrists were evaluated using Survey Monkey® electronic platform on the demographics, predominant polarity; usage of antipsychotics, antidepressants, and electroconvulsive therapy, psychotropic's preference (monotherapy vs. polytherapy) in the acute and maintenance phase of BD.

RESULTS

Majority of the participants were males (70.9%) and placed in government institute or medical colleges. Majority agreed that child and adolescent and old age bipolar probands are not routinely seen but subthreshold BD cases are frequent; did not prefer mood stabilizer in pregnancy (61.4%) and antidepressants, preferred polytherapy in acute but monotherapy in maintenance phase (after 3^rd episode), seldom preferred ECT as an option (more in suicidality), agreed to a subset of BD being refractory and neuroprogressive.

CONCLUSION

This study elucidates the importance of treatment preferences, prescribing patterns and pragmatic issues faced by the clinicians. These patterns if studied longitudinally in a systematic manner would help in modifying the potential treatment strategies and reduce treatment gap.

Aripiprazole as First-Line Therapy for Late-Life Depression: A Case Note Review

BACKGROUND

Aripiprazole, structurally considered a third-generation antipsychotic agent, is an effective adjuvant strategy for managing treatment-resistant depression. It has been used successfully as an add-on agent in late-life depression (LLD), but there are no controlled trials on its use as first-line therapy, either alone or in combination with an antidepressant.

METHODS

This is a case note review of aripiprazole prescribed to outpatients with LLD as a first-line therapy either in combination with an antidepressant or as a monotherapy. The local ethics committee approved the audit. Case notes of subjects with Hamilton Rating Scale for Depression scores of ≥11 and with at least 1 follow-up visit were included in the review. Remission was defined as the first occurrence of achieving a Hamilton Rating Scale for Depression score of <10.

RESULTS

Case notes of 54 subjects (mean age, 68.6 ± 6.9 years) were included, 52 of whom had unipolar depression. Aripiprazole alone was prescribed in 21 subjects, and with an antidepressant in the remaining subjects. The overall remission rate was 59% over 21 weeks, and in the remitted subjects (n = 32), the cumulative remission rate increased from 22% at week 2 to 82% at week 10. No subject discontinued treatment because of poor tolerability or serious adverse events.

CONCLUSIONS

Aripiprazole was found to be an effective first-line antidepressant in LLD. The remission rates in the present study were considerably higher than the published literature on antidepressant monotherapy in fresh episodes of LLD. This warrants controlled trials of aripiprazole as a first-line antidepressant for this disease entity.

Atypical antipsychotics: Managing adverse effects

PURPOSE

The purpose of this article is to provide an overview of common adverse effects and management strategies related to atypical antipsychotic use.

CONCLUSIONS

Atypical antipsychotics are commonly prescribed. While effective, atypical antipsychotics are associated with metabolic syndrome, extrapyramidal symptoms, and tardive dyskinesia, among others adverse effects. Management strategies can mitigate adverse effects and promote optimum quality of life.

PRACTICE IMPLICATIONS

To be able to identify and manage adverse effects associated with the use of atypical antipsychotics, it is important to build a supportive therapeutic environment at each interaction with patients and their caregivers.

Mixed Depression: A Mini-Review to Guide Clinical Practice and Future Research Developments

The debate on mixed states (MS) has been intense for decades. However, several points remain controversial from a nosographic, diagnostic, and therapeutic point of view. The different perspectives that have emerged over the years have turned into a large, but heterogeneous, literature body. The present review aims to summarize the evidence on MS, with a particular focus on mixed depression (MxD), in order to provide a guide for clinicians and encourage the development of future research on the topic. First, we review the history of MS, focusing on their different interpretations and categorizations over the centuries. In this section, we also report alternative models to traditional nosography. Second, we describe the main clinical features of MxD and list the most reliable assessment tools. Finally, we summarize the recommendations provided by the main international guidelines for the treatment of MxD. Our review highlights that the different conceptualizations of MS and MxD, the variability of clinical pictures, and the heterogeneous response to pharmacological treatment make MxD a real challenge for clinicians. Further studies are needed to better characterize the phenotypes of patients with MxD to help clinicians in the management of this delicate condition.

Efficacy and safety of 24-week pramipexole augmentation in patients with treatment resistant depression. A retrospective cohort study

Pramipexole is a dopamine agonist with potential antidepressant, neuroprotective, antioxidant and anti-inflammatory activity. In the present study we investigated the 24 weeks effect and safety of traditional AD augmentation with pramipexole for treatment-resistant depression. The study includes 116 patients, 37 (32%) with bipolar disorders and 79 (68%) with major depressive disorder, who failed to respond to at least 2 ADs trials of different classes and that were treated with AD augmented with pramipexole. Mood stabilizers and/or second-generation antipsychotics were added in patients with bipolar or mixed depression. Exclusion criteria were psychotic depression, rapid cycling bipolar course and previous unsuccessful treatment with pramipexole. After 24 weeks of pramipexole augmentation (median max dose 1.05 mg/day, IQR 0.72-1.08) 74.1% of patients responded (≥50% reduction of baseline Hamilton Depression Rating Scale₂₁ total score) and 66.4% remitted (Hamilton Depression Rating Scale₂₁ total score < 7). Global Assessment of Functioning score significantly increase from 53 (50-60) at baseline to 80 (71-81) at 24 weeks (Wilcoxon signed rank test = 8.174, p < 0.001]. Ten patients (8.6%) dropped out (8 due to side effects and 2 for lack of efficacy) and 1 experienced an induced hypomanic switch. No patient committed a suicide attempt, had suicidal ideation, needed hospitalization, reported lethargy, gambling, hypersexuality and compulsive shopping. The limitations of the study are the observational design, the lack of a control group, the inclusion of outpatients only, the unblinded outcomes assessment, and the flexibility of the add-on schedule. The findings of the present study showed that off-label use of pramipexole as augmentation of traditional AD is an effective and safe 24 weeks treatment of resistant unipolar and bipolar depression. These results need confirmation from randomized clinical trials on larger samples.

Antidepressant use and expenditure in the treatment of patients with depression: Evidence from China urban medical claims data

OBJECTIVES

Few studies have analyzed the use of antidepressants among population suffering from depression in China. This study aimed to describe the prevalence and the cost of commonly prescribed antidepressants among patients with depression.

METHODS

This study used data that comprised 5% random sample of claims data from China's Urban Basic Medical Insurance between 2013 and 2016. We estimated the prevalence, calculated the proportions of those on antidepressant treatment as well as those on specific drugs.

RESULTS

Among 26 826 patients with depression, 62.31% were prescribed with antidepressants in urban China, and the estimated average annual total cost of antidepressants per patient was RMB887.7(USD140.9). The prevalence of antidepressant prescription was higher among patients aged 15-24 years, having URBMI insurance, with recurrent depression and having severe or moderate depression. Approximately 9.3% of patients used more than one type of antidepressants and 19% of patients have only one prescription of antidepressant in a year.

CONCLUSION

Our analyses showed that antidepressant prescribing was prevalent among patients with depression, particularly in adolescents and youth groups, and are subject to variation with clinical features and different insurance scheme. Further investigation of antidepressant use patterns, such as duration, combination and switching, as well as treatment trajectories will facilitate our understanding of the pharmacotherapy practices of depressive disorders.

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.

Sex Differences in Bipolar Disorders: Impact on Psychopathological Features and Treatment Response

INTRODUCTION

Sex differences were demonstrated in bipolar disorders (BD) concerning epidemiological, clinical, and psychopathological characteristics, but consensus is lacking. Moreover, data concerning the influence of sex on treatment response in BD is contrasting. The present cross-sectional study aimed to analyze sex differences in a population of BD subjects, with specific focus on psychopathological features and treatment response.

MATERIALS AND METHODS

Subjects diagnosed with BD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th version (DSM-5) were recruited. Socio-demographic and clinical characteristics were collected. The Hamilton Rating Scale for Depression, the Mania Rating Scale (MRS), the brief version of the Temperament Evaluation of Memphis, Pisa and San Diego-Münster version (briefTEMPS-M), and the Barratt Impulsiveness Scale-11 items (BIS-11) were used for psychopathological assessment. Treatment response was appraised with the Alda Scale. We performed bivariate analyses to compare socio-demographic, clinical, and psychopathological characteristics between men and women (p < 0.05). A logistic regression was run to analyze features that were significantly associated with female sex.

RESULTS

Among the recruited 219 BD subjects, 119 (54.3%) were females. Women had a lower scholarity (p = 0.015) and were less frequently employed (p = 0.001). As for psychopathological features, a higher MRS total score (p < 0.001) was detected among women, as well as higher BIS-11 total score (p = 0.040), and briefTEMPS-M score for anxious temperament (p = 0.006). Men showed higher prevalence of DSM-5 mixed features (p = 0.025), particularly during a depressive episode (p = 0.014). Women reported longer duration of untreated illness (DUI) (p < 0.001). There were no sex differences in the Alda Scale total score when considering the whole sample, but this was significantly higher among men (p = 0.030) when evaluating subjects treated with anticonvulsants. At the logistic regression, female sex was positively associated with longer DUI (p < 0.001; OR 1.106, 95% CI 1.050-1.165) and higher MRS total score (p < 0.001; OR 1.085, 95% CI 1.044-1.128) and negatively associated with employment (p = 0.003; OR 0.359, 95% CI 0.185-0.698) and DSM-5 mixed features (p = 0.006; OR 0.391, 95% CI 0.200-0.762).

CONCLUSIONS

The clinical presentation of BD may differ depending on sex. The severity of BD should not be neglected among women, who may also display worse treatment response to anticonvulsants.

Is aripiprazole similar to quetiapine for treatment of bipolar depression? Results from meta-analysis of Chinese data

OBJECTIVE

To study the similarities and differences in the clinical efficacy of aripiprazole and quetiapine in Chinese patients with bipolar depression through meta-analysis. Additionally, to provide evidence of aripiprazole in treatment for bipolar depression.

METHODS

We searched Chinese literature related to the study of aripiprazole and quetiapine in treatment for bipolar depression, among which results such as comments, letters, reviews, and case reports were excluded. The clinical efficacy between aripiprazole and quetiapine was synthesized and discussed.

RESULT

A total of 1,546 subjects were included in 17 studies. The random effect model was used to review the data by RevMan 5.2. The results showed that there was no significant difference in the remission rate between patients treated with aripiprazole and quetiapine evidenced by the scale used to evaluate the patients being treated for bipolar depression (221/501 vs. 193/501, Z = 1.12, P = 0.26). But the results also showed that the remission rate of aripiprazole with lithium carbonate was significantly higher than quetiapine with lithium carbonate in the treatment of bipolar depression (111/232 vs. 69/232, Z = 3.92, P < 0.0001). The results showed that the effective rate of aripiprazole was similar to quetiapine (426/572 vs. 386/572, Z = 2.70, P = 0.007). Overall, there was no difference in the Hamilton Rating Scale for Depression (HAMD) score between patients treated with aripiprazole and quetiapine (Z = 1.68, P = 0.09). The results also show that the drop-out rate of aripiprazole was similar to quetiapine in the treatment of patients with bipolar depression (Z = 1.80, P = 0.07).

CONCLUSION

As an atypical antipsychotic, aripiprazole may be similar to quetiapine for treating bipolar depression with similar drop-out and higher remission rates when combined with lithium carbonate. However, the results of this study need to be read with caution given the poor quality of collected/analyzed literature.

Treatment of mixed depression with theta-burst stimulation (TBS): results from a double-blind, randomized, sham-controlled clinical trial

Mixed depression is probably different in terms of clinical course and response to treatment. Repetitive transcranial magnetic stimulation (rTMS) is well established in non-mixed depression, and theta-burst stimulation (TBS) protocol is replacing conventional protocols because of noninferiority and reduced delivery time. However, TBS has not been adequately studied in mixed states. This study was a double-blind, six-week, sham-controlled, and randomized clinical trial of bilateral TBS targeting the right and left dorsolateral prefrontal cortex, respectively. Adults with bipolar and major depressive disorder experiencing an acute mixed depression were eligible if they had not benefited from a first- or second-line treatment for acute unipolar or bipolar depression recommended by the Canadian Network for Mood and Anxiety Treatments. Out of 100 patients included, 90 composed modified intention-to-treat sample, which was patients that completed at least one week of the intervention. There were no significant differences in Montgomery-Asberg depression rating scale score changes (least squares mean difference between groups at week 3, -0.06 [95% CI, - 3.39 to 3.51; P = 0.97] in favor of sham TBS). Response and remission rates per MADRS were also not statistically different among active and sham groups (35.7% vs. 43.7%, and 28.5% vs. 37.5% respectively at week 6, ps > 0.51). No other analyses from baseline to weeks 3 or 6 revealed significant time x group interaction or mean differences among groups in the mITT sample. Bilateral TBS targeting the DLPFC is not efficacious as an add-on treatment of acute bipolar and unipolar mixed depression. ClinicalTrials.govIdentifier: NCT04123301.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) recommendations for the management of patients with bipolar disorder with mixed presentations

OBJECTIVES

The 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines provided clinicians with pragmatic treatment recommendations for bipolar disorder (BD). While these guidelines included commentary on how mixed features may direct treatment selection, specific recommendations were not provided-a critical gap which the current update aims to address.

METHOD

Overview of research regarding mixed presentations in BD, with treatment recommendations developed using a modified CANMAT/ISBD rating methodology. Limitations are discussed, including the dearth of high-quality data and reliance on expert opinion.

RESULTS

No agents met threshold for first-line treatment of DSM-5 manic or depressive episodes with mixed features. For mania + mixed features second-line treatment options include asenapine, cariprazine, divalproex, and aripiprazole. In depression + mixed features, cariprazine and lurasidone are recommended as second-line options. For DSM-IV defined mixed episodes, with a longer history of research, asenapine and aripiprazole are first-line, and olanzapine (monotherapy or combination), carbamazepine, and divalproex are second-line. Research on maintenance treatments following a DSM-5 mixed presentation is extremely limited, with third-line recommendations based on expert opinion. For maintenance treatment following a DSM-IV mixed episode, quetiapine (monotherapy or combination) is first-line, and lithium and olanzapine identified as second-line options.

CONCLUSION

The CANMAT and ISBD groups hope these guidelines provide valuable support for clinicians providing care to patients experiencing mixed presentations, as well as further influence investment in research to improve diagnosis and treatment of this common and complex clinical state.

Individuals with bipolar disorder have a higher level of uric acid than major depressive disorder: a case-control study

At present, no well-established biomarkers were ever found to distinguish unipolar depression and bipolar disorder (BD). This study aimed to provide a clearer comparison of UA levels between BD and major depressive disorder. Peripheral UA of 119 patients with BD in acute stage (AS) and 77 in remission stage (RS), and 95 patients with UD in AS and 61 in RS were measured, so were 180 healthy controls. UA levels in BD group were higher than UD and HC groups regardless of the AS or RS, while differences in UA levels between UD group and HC group were not significant. Differences in UA levels of BD-M (bipolar mania/hypomania) were higher than BD-D (bipolar depression) subgroups, and UA levels of BD-M and BD-D subgroups were higher than UD and HC groups. The comparison of number of participants with hyperuricemia among groups confirmed the above results. There were no significant differences in UA levels of between drug-use and drug-free/naïve subgroups. UA could distinguish BD and UD significantly both in acute and remission stage. The study suggests patients with BD had a higher level of UA than UD, especially in mania episode. UA may be a potential biomarker to distinguish BD from UD.

Vocal features obtained through automated methods in verbal fluency tasks can aid the identification of mixed episodes in bipolar disorder

There is a lack of consensus on the diagnostic thresholds that could improve the detection accuracy of bipolar mixed episodes in clinical settings. Some studies have shown that voice features could be reliable biomarkers of manic and depressive episodes compared to euthymic states, but none thus far have investigated whether they could aid the distinction between mixed and non-mixed acute bipolar episodes. Here we investigated whether vocal features acquired via verbal fluency tasks could accurately classify mixed states in bipolar disorder using machine learning methods. Fifty-six patients with bipolar disorder were recruited during an acute episode (19 hypomanic, 8 mixed hypomanic, 17 with mixed depression, 12 with depression). Nine different trials belonging to four conditions of verbal fluency tasks-letter, semantic, free word generation, and associational fluency-were administered. Spectral and prosodic features in three conditions were selected for the classification algorithm. Using the leave-one-subject-out (LOSO) strategy to train the classifier, we calculated the accuracy rate, the F1 score, and the Matthews correlation coefficient (MCC). For depression versus mixed depression, the accuracy and F1 scores were high, i.e., respectively 0.83 and 0.86, and the MCC was of 0.64. For hypomania versus mixed hypomania, accuracy and F1 scores were also high, i.e., 0.86 and 0.75, respectively, and the MCC was of 0.57. Given the high rates of correctly classified subjects, vocal features quickly acquired via verbal fluency tasks seem to be reliable biomarkers that could be easily implemented in clinical settings to improve diagnostic accuracy.

Navigating the diagnostic challenges of bipolar disorder in youth

ABSTRACT

Bipolar disorder in youth is difficult to diagnose and treat, but early detection is important to mitigate risks and improve patient outcomes. This article evaluates the unique challenges of diagnosing and treating bipolar disorder in children and adolescents. Bipolar disorder is associated with a significant personal and societal health burden and frequently is misdiagnosed and incorrectly treated. More research is needed to understand the pathophysiology of bipolar disorder and which treatment options are best throughout the lifespan.

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.

Bipolar disorder: Treatment strategies for women of childbearing age

PURPOSE

Bipolar disorder is associated with increased rates of morbidity and mortality, magnified in women of childbearing age. The purpose of this paper is to provide an overview of the differential diagnosis and management of bipolar disorder in women of childbearing age.

CONCLUSIONS

Differential diagnoses for bipolar disorder include depressive disorders, anxiety disorders, trauma-related disorders, attention-deficit/hyperactivity disorder, and personality disorders. Pharmacotherapeutic options for the treatment of bipolar disorder include lithium, anti-epileptic medications, and atypical antipsychotics. In regard to women of childbearing age, consideration of risks, benefits, and alternative therapies is needed before initiating therapy.

PRACTICE IMPLICATIONS

Caring for patients with bipolar disorder, particularly women of childbearing age, requires careful differentiation of bipolar disorder from other mental health problems, and prudent consideration of pharmacotherapeutic options.

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.

Is short-term antidepressant treatment effective and safe in bipolar depression? Results from an observational multicenter study

OBJECTIVES

To investigate the short-term effectiveness and the short-term and long-term safety of acute antidepressant (AD) treatment of bipolar depression in a naturalistic setting.

METHODS

Patients with bipolar (n = 86) or unipolar (n = 111) depression were consecutively recruited and treated with AD (combined with mood stabilizer [MS] and/or second-generation antipsychotics in bipolar depression). Exclusion criteria were mixed depression, high mood instability, previous predominantly mixed depression (both bipolar and unipolar depression), rapid cycling course and previous switch AD-emerging (bipolar depression).

RESULTS

After 12 weeks of treatment, no difference was found in remission, response and improvement rates between bipolar and unipolar depression. Concerning short-term safety, switching and suicidality did not differ significantly between the two groups, and no suicide attempt was observed. Concerning long-term safety, patients with bipolar depression had a significant reduction of depressive and total recurrences during the year of follow-up, compared to the year before entering the study, without significant changes in (hypo)mania and mixed depression recurrences, and suicide rates.

CONCLUSIONS

Acute AD treatment of bipolar depression is effective in the short-term and safe in the short- and long-term, when administered in combination with MSs and/or second-generation antipsychotics, with a low risk of switch, mixed depression and cycle acceleration.

Treatment-resistant depression: An overview for psychiatric advanced practice nurses

PURPOSE

Treatment-resistant depression (TRD) can require complex management. The purpose of this paper is to provide an update on the hypothesized neurobiology of depression, and to describe treatment options for patients impacted by TRD.

CONCLUSIONS

Recent neurobiological findings support the use of augmenting pharmacological agents, neuromodulation techniques, and esketamine as effective in achieving remission for those with TRD.

PRACTICE IMPLICATIONS

First-line interventions for depression can be safely managed by primary care providers. Psychiatric advanced practice nurses must be well versed and capable of treating more complicated cases, including TRD, that may require second- or third-line approaches.

Diagnosing and treating major depressive episodes that lie along the mood disorders spectrum: focus on depression with mixed features

Growing evidence indicates that historical descriptions of mixed depression-broadly defined as major depressive episodes with subthreshold manic or hypomanic (hypo/manic) symptoms-are incredibly clinically relevant in this day-and-age. However, the first operational definition of mixed depression did not occur in the modern nomenclature until 2013 with publication of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), and there has not been enough time to evaluate these criteria empirically. Thus, the most valid operational definition of a mixed depressive episode is still unknown, widely accepted treatment guidelines are not available, and no treatment has regulatory approval for mixed depression-whether associated with bipolar I disorder, bipolar II disorder, or major depressive disorder. This is despite seven drugs having regulatory indications for mixed episodes, defined as the co-occurrence of syndromal depression and syndromal mania, and now recognized as mania with mixed features by DSM-5. Indeed, we found only two randomized, placebo-controlled trials in patients with protocol defined mixed depression, one with ziprasidone and one with lurasidone. Both studies were positive, suggesting treatment with second-generation antipsychotics may be helpful for mixed depressive episodes associated with bipolar II or unipolar disorder. We found no randomized control trial of antidepressant monotherapy in mixed depression and many clinical reports that such treatment may worsen mixed depression Randomized, placebo-controlled trials of antidepressants, antipsychotics, and mood stabilizers-alone and in combination-in individuals with carefully defined mixed depression are needed before firm treatment guidelines can be produced.

A new approach for seasonal pattern: is it related to bipolarity dimension? Findings from an Italian multicenter study

OBJECTIVE

The aims of this study were to assess the impact of seasonal pattern on several clinical dimensions in inpatients with a current major depressive episode and to evaluate clinical differences between unipolar and bipolar depression according to seasonal pattern.

METHODS

Study participants were 300 patients affected by major depressive disorder (MDD) or bipolar disorder (BD) currently experiencing a major depressive episode (MDE) and were recruited at three University Medical Centres in Italy. All study subjects completed several evaluation scales for depressive and hypomanic symptoms, quality of life and functioning, impulsiveness, and seasonal pattern.

RESULTS

Several differences between BD with and without seasonal pattern, MDD with and without seasonal pattern but in particular between BD and MDD with seasonal pattern were found. Patients with MDE with seasonal pattern had more frequently received a longitudinal diagnosis of BD.

CONCLUSIONS

A large number of patients with BD and seasonal pattern, but also a considerable number of patients with MDD and seasonal pattern, endorsed manic items during a current MDE. Seasonal pattern should be associated with a concept of bipolarity in mood disorders and not only related to bipolar disorder. A correct identification of seasonal patterns may lead to the implementation of personalised pharmacological treatment approaches.KEY POINTSHigh prevalence of mixed features in mood disorders with seasonal pattern, supporting the need for a dimensional approach to major depressive disorder and bipolar disorder.Significant percentage of patients with a primary diagnosis of major depressive disorder had seasonal pattern.Significant percentage of patients with a primary diagnosis of major depressive disorder reported (hypo)manic symptomatology.

Adoption of Digital Health Technologies in the Practice of Behavioral Health: Qualitative Case Study of Glucose Monitoring Technology

Background

Evaluation of patients with serious mental illness (SMI) relies largely on patient or caregiver self-reported symptoms. New digital technologies are being developed to better quantify the longitudinal symptomology of patients with SMI and facilitate disease management. However, as these new technologies become more widely available, psychiatrists may be uncertain about how to integrate them into daily practice. To better understand how digital tools might be integrated into the treatment of patients with SMI, this study examines a case study of a successful technology adoption by physicians: endocrinologists’ adoption of digital glucometers.

Objective

This study aims to understand the key facilitators of and barriers to clinician and patient adoption of digital glucose monitoring technologies to identify lessons that may be applicable across other chronic diseases, including SMIs.

Methods

We conducted focus groups with practicing endocrinologists from 2 large metropolitan areas using a semistructured discussion guide designed to elicit perspectives of and experiences with technology adoption. The thematic analysis identified barriers to and facilitators of integrating digital glucometers into clinical practice. Participants also provided recommendations for integrating digital health technologies into clinical practice more broadly.

Results

A total of 10 endocrinologists were enrolled: 60% (6/10) male; a mean of 18.4 years in practice (SD 5.6); and 80% (8/10) working in a group practice setting. Participants stated that digital glucometers represented a significant change in the treatment paradigm for diabetes care and facilitated more effective care delivery and patient engagement. Barriers to the adoption of digital glucometers included lack of coverage, provider reimbursement, and data management support, as well as patient heterogeneity. Participant recommendations to increase the use of digital health technologies included expanding reimbursement for clinician time, streamlining data management processes, and customizing the technologies to patient needs.

Conclusions

Digital glucose monitoring technologies have facilitated more effective, individualized care delivery and have improved patient engagement and health outcomes. However, key challenges faced by the endocrinologists included lack of reimbursement for clinician time and nonstandardized data management across devices. Key recommendations that may be relevant for other diseases include improved data analytics to quickly and accurately synthesize data for patient care management, streamlined software, and standardized metrics.

Efficacy and safety of lamotrigine in the treatment of bipolar disorder across the lifespan: a systematic review

BACKGROUND

Bipolar disorder (BD) is a cyclic mood disorder characterised by alternating episodes of mania/hypomania and depression interspersed with euthymic periods. Lamotrigine (LTG) demonstrated some mood improvement in patients treated for epilepsy, leading to clinical studies in patients with BD and its eventual introduction as maintenance therapy for the prevention of depressive relapse in euthymic patients. Most current clinical guidelines include LTG as a recommended treatment option for the maintenance phase in adult BD, consistent with its global licencing status.

AIMS

To review the evidence for the efficacy and safety of LTG in the treatment of all phases of BD.

METHODS

PubMed was searched for double-blind, randomised, placebo-controlled trials using the keywords: LTG, Lamictal, 'bipolar disorder', 'bipolar affective disorder', 'bipolar I', 'bipolar II', cyclothymia, mania, manic, depression, depressive, 'randomised controlled trial', 'randomised trial', RCT and 'placebo-controlled' and corresponding MeSH terms. Eligible articles published in English were reviewed.

RESULTS

Thirteen studies were identified. The strongest evidence supports utility in the prevention of recurrence and relapse, particularly depressive relapse, in stabilised patients. Some evidence suggests efficacy in acute bipolar depression, but findings are inconsistent. There is little or no strong evidence in support of efficacy in acute mania, unipolar depression, or rapid-cycling BD. Few controlled trials have evaluated LTG in bipolar II or in paediatric patients. Indications for safety, tolerability and patient acceptability are relatively favourable, provided there is slow dose escalation to reduce the probability of skin rash.

CONCLUSION

On the balance of efficacy and tolerability, LTG might be considered a first-line drug for BD, except for acute manic episodes or where rapid symptom control is required. In terms of efficacy alone, however, the evidence favours other medications.

Bipolar disorders

Bipolar disorders are a complex group of severe and chronic disorders that includes bipolar I disorder, defined by the presence of a syndromal, manic episode, and bipolar II disorder, defined by the presence of a syndromal, hypomanic episode and a major depressive episode. Bipolar disorders substantially reduce psychosocial functioning and are associated with a loss of approximately 10-20 potential years of life. The mortality gap between populations with bipolar disorders and the general population is principally a result of excess deaths from cardiovascular disease and suicide. Bipolar disorder has a high heritability (approximately 70%). Bipolar disorders share genetic risk alleles with other mental and medical disorders. Bipolar I has a closer genetic association with schizophrenia relative to bipolar II, which has a closer genetic association with major depressive disorder. Although the pathogenesis of bipolar disorders is unknown, implicated processes include disturbances in neuronal-glial plasticity, monoaminergic signalling, inflammatory homoeostasis, cellular metabolic pathways, and mitochondrial function. The high prevalence of childhood maltreatment in people with bipolar disorders and the association between childhood maltreatment and a more complex presentation of bipolar disorder (eg, one including suicidality) highlight the role of adverse environmental exposures on the presentation of bipolar disorders. Although mania defines bipolar I disorder, depressive episodes and symptoms dominate the longitudinal course of, and disproportionately account for morbidity and mortality in, bipolar disorders. Lithium is the gold standard mood-stabilising agent for the treatment of people with bipolar disorders, and has antimanic, antidepressant, and anti-suicide effects. Although antipsychotics are effective in treating mania, few antipsychotics have proven to be effective in bipolar depression. Divalproex and carbamazepine are effective in the treatment of acute mania and lamotrigine is effective at treating and preventing bipolar depression. Antidepressants are widely prescribed for bipolar disorders despite a paucity of compelling evidence for their short-term or long-term efficacy. Moreover, antidepressant prescription in bipolar disorder is associated, in many cases, with mood destabilisation, especially during maintenance treatment. Unfortunately, effective pharmacological treatments for bipolar disorders are not universally available, particularly in low-income and middle-income countries. Targeting medical and psychiatric comorbidity, integrating adjunctive psychosocial treatments, and involving caregivers have been shown to improve health outcomes for people with bipolar disorders. The aim of this Seminar, which is intended mainly for primary care physicians, is to provide an overview of diagnostic, pathogenetic, and treatment considerations in bipolar disorders. Towards the foregoing aim, we review and synthesise evidence on the epidemiology, mechanisms, screening, and treatment of bipolar disorders.

Major depressive disorder with mixed features and treatment response to lurasidone: A symptom network model

BACKGROUND

To investigate the symptom network structure of major depressive disorder (MDD) with mixed features and implications for treatment.

METHODS

In this post-hoc analysis of a previously reported randomized trial, patients meeting DSM-IV-TR criteria for MDD presenting with two or three manic symptoms (DSM-5 mixed features specifier) were randomized to 6 weeks of double-blind treatment with lurasidone 20-60 mg/d (N = 109) or placebo (N = 100). The network structure of symptoms at baseline and their treatment moderating effects were investigated.

RESULTS

Network analyses showed that both ``elevated mood'' (YMRS item 1) and ``increased motor activity-energy'' (YMRS item 2) were associated with ``sleep disturbance'' ("bridge" symptom) and the depressive symptom cluster. Presence of both "elevated mood" and "increased motor activity-energy" at baseline predicted significantly less improvement in MADRS and CGI-S score at week 6 with lurasidone (vs. placebo) compared to patients without these manic symptoms at baseline. The network model also showed "rapid/pressured speech" (YMRS item 6) at baseline predicted improvement in both manic and depressive symptoms with lurasidone vs. placebo treatment.

LIMITATIONS

This was a post-hoc analysis where findings need to be confirmed by prospective controlled studies.

CONCLUSIONS

This post-hoc analysis describes the symptom network structure of MDD with mixed features in a patient sample at study baseline. Specific manic symptoms were found to be linked to sleep disturbance (characterized as a "bridge" symptom), which in turn linked the manic and depressive symptom clusters. The presence (vs. absence) of the specific manic symptoms we identified moderated the antidepressant and antimanic effects of lurasidone in the treatment of MDD with mixed (subthreshold hypomanic) features.

The effectiveness of ketamine on anxiety, irritability, and agitation: Implications for treating mixed features in adults with major depressive or bipolar disorder

OBJECTIVE

To determine the effectiveness of intravenous (IV) ketamine on anxiety, irritability, agitation, and suicidality, in adults with treatment-resistant major depressive disorder (MDD) or bipolar disorder (BD).

METHOD

Adults (N = 201) with treatment-resistant MDD or BD received repeat-dose IV ketamine treatment at a community-based clinic. Mixed features were measured using symptoms of anxiety, irritability, and agitation (AIA), as measured by the Generalized Anxiety Disorder-7 (GAD-7) scale. The Quick Inventory for Depressive Symptomatology Self-Report-16 (QIDS-SR₁₆ ) was used to measure overall treatment response, and the QIDS-SR₁₆ suicidal ideation (SI) item was used to measure change in SI symptoms with ketamine treatment. The anxiety, irritability, and agitation items on the GAD-7 were used to assess effectiveness of IV ketamine in treating symptoms of mixed features.

RESULTS

In this retrospective analysis, 113 participants met AIA criteria. Participants with AIA experienced a significantly greater reduction in overall depressive symptoms (F(1, 558) = 9.49, P = .002), SI (F(1, 558) = 3.103, P = .079), anxiety (F(1, 198) = 5.52, P = .007), irritability (F(1, 198) = 28.35, P < .001), and agitation as measured by "trouble relaxing" (F(1, 198) = 6.70, P = .010) from baseline compared to the non-AIA group, regardless of number of treatments received.

CONCLUSIONS

Our preliminary results suggest that IV ketamine is effective in rapidly treating AIA and SI in adults with treatment-resistant mood disorders. This observation suggests that IV ketamine could be considered a treatment alternative for adults with MDD or BD presenting with mixed features.

Dissecting major depression: The role of blood biomarkers and adverse childhood experiences in distinguishing clinical subgroups

BACKGROUND

The syndromic diagnosis of major depressive disorder (MDD) is associated with individual differences in prognosis, course, treatment response, and outcome. There is evidence that patients with a history to adverse childhood experiences (ACEs) may belong to a distinct clinical subgroup. The combination of data on ACEs and blood biomarkers could allow the identification of diagnostic MDD subgroups.

METHODS

We selected several blood markers (global DNA methylation, and VEGF-a, TOLLIP, SIRT1, miR-34a genes) among factors that contribute to the pathogenetic mechanisms of MDD. We examined their level in 37 MDD patients and 30 healthy subjects. ACEs were measured by the Parental Bonding Instrument and the Childhood Trauma Questionnaire.

RESULTS

We found significant differences between patients and healthy subjects in three biomarkers (TOLLIP, VEGF-a, and global DNA methylation), independently from the confounding effect of parental care received. By contrast, SIRT1 differences were modulated by quality of parental care. The lowest levels of SIRT1 were recorded in patients with active symptoms and low maternal/paternal care. miR-34a and SIRT1 levels were associated with MDD symptoms especially in early-life stressed patients.

LIMITATIONS

Small sample size, no information on personality comorbidity and suicidal history, cross-sectional definition of remission, and lack of follow-up.

CONCLUSIONS

Our findings suggest that the levels of global DNA methylation, TOLLIP, and VEGF-a reflect pathophysiological changes associated with MDD that are independent from the long-term effects of low parental care. This study also suggests that SIRT1 may be an additional variable distinguishing the ecophenotype that includes MDD patients with exposure to ACEs.

The clinical characterization of the adult patient with depression aimed at personalization of management

Depression is widely acknowledged to be a heterogeneous entity, and the need to further characterize the individual patient who has received this diagnosis in order to personalize the management plan has been repeatedly emphasized. However, the research evidence that should guide this personalization is at present fragmentary, and the selection of treatment is usually based on the clinician's and/or the patient's preference and on safety issues, in a trial-and-error fashion, paying little attention to the particular features of the specific case. This may be one of the reasons why the majority of patients with a diagnosis of depression do not achieve remission with the first treatment they receive. The predominant pessimism about the actual feasibility of the personalization of treatment of depression in routine clinical practice has recently been tempered by some secondary analyses of databases from clinical trials, using approaches such as individual patient data meta-analysis and machine learning, which indicate that some variables may indeed contribute to the identification of patients who are likely to respond differently to various antidepressant drugs or to antidepressant medication vs. specific psychotherapies. The need to develop decision support tools guiding the personalization of treatment of depression has been recently reaffirmed, and the point made that these tools should be developed through large observational studies using a comprehensive battery of self-report and clinical measures. The present paper aims to describe systematically the salient domains that should be considered in this effort to personalize depression treatment. For each domain, the available research evidence is summarized, and the relevant assessment instruments are reviewed, with special attention to their suitability for use in routine clinical practice, also in view of their possible inclusion in the above-mentioned comprehensive battery of measures. The main unmet needs that research should address in this area are emphasized. Where the available evidence allows providing the clinician with specific advice that can already be used today to make the management of depression more personalized, this advice is highlighted. Indeed, some sections of the paper, such as those on neurocognition and on physical comorbidities, indicate that the modern management of depression is becoming increasingly complex, with several components other than simply the choice of an antidepressant and/or a psychotherapy, some of which can already be reliably personalized.

Cariprazine efficacy in bipolar I depression with and without concurrent manic symptoms: post hoc analysis of 3 randomized, placebo-controlled studies

OBJECTIVE

Mixed presentations, defined by simultaneous occurrence of depressive and manic symptoms, are difficult to treat. Antidepressants, although commonly used, have weak evidence of efficacy and may increase risk of mood destabilization. The aim of this pooled post hoc analysis was to evaluate the efficacy of cariprazine in the treatment of bipolar depression with or without concurrent manic symptoms.

METHODS

Patients from 3 randomized, double-blind, placebo-controlled studies who met DSM-IV-TR or DSM-5 criteria for bipolar I disorder with a current major depressive episode were identified to have concurrent manic symptoms by baseline Young Mania Rating Scale total score ≥4. Efficacy was assessed in cariprazine 1.5 and 3 mg/day dose groups versus placebo; analyses included the least squares mean change from baseline to week 6 in Montgomery-Åsberg Depression Rating Scale (MADRS) total score.

RESULTS

Of 1383 patients randomized to treatment, 808 (58.4%) had concurrent manic symptoms. For patients with manic symptoms, mean reduction in MADRS total score from baseline to week 6 was significantly greater for both cariprazine 1.5 and 3 mg/day compared with placebo, with least squares mean differences (LSMDs) versus placebo of -2.5 (p = .0033) and -2.9 (p = .0010), respectively; for patients without manic symptoms, the LSMD was significant for 1.5 mg/day (-3.3; p = .0008), but not for 3 mg/day (-1.9; p = .0562).

CONCLUSION

The results of this post hoc analysis suggest that cariprazine may be an appropriate treatment option for patients with bipolar I depression with or without manic symptoms, with higher doses potentially more effective in patients with manic symptoms.

Deconstructing major depressive episodes across unipolar and bipolar depression by severity and duration: a cross-diagnostic cluster analysis on a large, international, observational study

A cross-diagnostic, post-hoc analysis of the BRIDGE-II-MIX study was performed to investigate how unipolar and bipolar patients suffering from an acute major depressive episode (MDE) cluster according to severity and duration. Duration of index episode, Clinical Global Impression-Bipolar Version-Depression (CGI-BP-D) and Global Assessment of Functioning (GAF) were used as clustering variables. MANOVA and post-hoc ANOVAs examined between-group differences in clustering variables. A stepwise backward regression model explored the relationship with the 56 clinical-demographic variables available. Agglomerative hierarchical clustering with two clusters was shown as the best fit and separated the study population (n = 2314) into 65.73% (Cluster 1 (C1)) and 34.26% (Cluster 2 (C2)). MANOVA showed a significant main effect for cluster group (p < 0.001) but ANOVA revealed that significant between-group differences were restricted to CGI-BP-D (p < 0.001) and GAF (p < 0.001), showing greater severity in C2. Psychotic features and a minimum of three DSM-5 criteria for mixed features (DSM-5-3C) had the strongest association with C2, that with greater disease burden, while non-mixed depression in bipolar disorder (BD) type II had negative association. Mixed affect defined as DSM-5-3C associates with greater acute severity and overall impairment, independently of the diagnosis of bipolar or unipolar depression. In this study a pure, non-mixed depression in BD type II significantly associates with lesser burden of clinical and functional severity. The lack of association for less restrictive, researched-based definitions of mixed features underlines DSM-5-3C specificity. If confirmed in further prospective studies, these findings would warrant major revisions of treatment algorithms for both unipolar and bipolar depression.

Depression Preceding Diagnosis of Bipolar Disorder

This paper focuses on depression that precedes an onset of manifest bipolar disorder as early stage bipolar disorder. First, we review how to pragmatically identify the clinical characteristics of patients presenting with an episode of depression who subsequently go on to develop episodes of mania or hypomania. The existing literature shows a strong consensus: accurate identification of depression with early onset and recurrent course with multiple episodes, subthreshold hypomanic and/or mixed symptoms, and family history of bipolar disorder or completed suicide have been shown by multiple authors as signs pointing to bipolar diagnosis. This contrasts with relatively limited information available to guide management of such "pre-bipolar" (pre-declared bipolar) patients, especially those in the adult age range. Default assumption of unipolar depression at this stage carries significant risk. Antidepressants are still the most common pharmacological treatment used, but clinicians need to be aware of their potential harm. In some patients with unrecognized bipolar depression, antidepressants can not only produce switch to (hypo)mania, but also mixed symptoms, or worsening of depression with an increased risk of suicide. We review pragmatic management strategies in the literature beyond clinical guidelines that can be considered for this at-risk group encompassing the more recent child and adolescent literature. In the future, genetic research could make the early identification of bipolar depression easier by generating informative markers and polygenic risk scores.

Association between affective temperaments and mood features in bipolar disorder II: The role of insomnia and chronobiological rhythms desynchronization

BACKGROUND

Bipolar disorders are complex disorders involving the interaction of multiple factors. Affective temperaments, insomnia, and chronobiological rhythms desynchronization may all contribute to bipolar disorder. Since there is a paucity of research examining this topic we aimed to study how they are interrelated and collectively associated with clinical features of bipolar disorder.

METHOD

One-hundred patients with Bipolar Disorder type II depressive episode with and without mixed features were recruited and compared. Subjects were evaluated with SCID -5, the Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN), the Insomnia Severity Index (ISI), and the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Auto-questionnaire (TEMPS-A) while evaluating depressive (Beck Depression Inventory-BDI-II) and manic (Young Mania Rating Scale-YMRS) symptoms. Logistic regression and mediation analyses were conducted.

RESULTS

Subjects with mixed features showed a higher scores in both insomnia and chronobiological rhythms scores. When considering affective temperaments not only depressive, cyclothymic and irritable temperaments predicted mood symptoms but also insomnia (depressive symptoms O.R. 4.17, p = 0.043) and chronobiological sleep de-synchronization (manic symptoms O.R. 8.69, p = 0.001). Insomnia symptoms and chronobiological alterations mediated the association between affective temperaments and mood symptoms.

LIMITATIONS

the cross-sectional design limited any causal interpretation.

CONCLUSION

Subjects with mixed features showed a greater severity of insomnia and chronobiological rhythm de-synchronization compared to subjects without. Insomnia and chronobiological alterations may contribute to mood disorders together with affective temperaments in a complex interplay also mediating their effect on mood. Preventive strategies for bipolars should also act on the dysregulation of sleep and circadian rhythms.

Pharmacologic Treatment of Mixed States

Despite the relatively high prevalence of mixed symptoms and features among patients with mood disorders, the current literature supporting the specific efficacy of second-generation antipsychotics and mood stabilizers for the treatment of mixed symptoms is limited. Several studies have demonstrated that acute affective episodes with mixed symptoms or features tend to respond unsatisfactory to treatments that are usually more effective for the management of other affective phases. There is clearly a need for clinical trials in order to determine the more adequate pharmacologic option for the treatment of individuals suffering from affective episodes with mixed features.

Suicidal Behavior Associated with Mixed Features in Major Mood Disorders

Mixed features of the opposite nominal mood-polarity are increasingly recognized in both depressive and [hypo]manic phases of major affective disorders. They are associated with major increases of risk of suicidal behaviors. The authors reviewed the association of suicidal behavior with mixed features in both major depressive and bipolar disorders, as well as potentially relevant adverse effects of antidepressant treatment and use of alternative treatments aimed at minimizing agitation and suicidal risk.

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.