Bipolar disorders and suicidal behaviour

Development and validation of the risk score for estimating suicide attempt in patients with major depressive disorder

Early identification of high-risk patients with Major depressive disorder (MDD) having suicide attempts (SAs) is essential for timely targeted and tailored psychological interventions and medications. This study aimed to develop and validate a web-based dynamic nomogram as a personalized predictor of SA in MDD patients. A dynamic nomogram was developed using data collected from 1718 patients in China. The dynamic model was established based on a machine learning-based regression technique in the training cohort. We validated the nomogram internally using 1000 bootstrap replications. The nomogram performance was assessed using estimates of discrimination (via the concordance index) and calibration (calibration plots). The nomogram incorporated five predictors, including Hamilton anxiety rating scale (odds ratio [OR]: 1.255), marital status (OR: 0.618), clinical global impressions (OR: 2.242), anti-thyroid peroxidase antibodies (OR: 1.002), and systolic pressure levels (OR: 1.037). The model demonstrated good overall discrimination (Harrell's C-index = 0.823). Using decision curve analysis, this model also demonstrated good clinical applicability. An online web server was constructed ( https://odywong.shinyapps.io/PRSM/ ) to facilitate the use of the nomogram. Based on these results, our study developed a nomogram to predict SA in MDD patients. The application of this nomogram may help for patients and clinicians to make decisions.

Bipolar Disorders in the Emergency Department

Affective disorders affect the way that people think and feel and are classified into unipolar disorders and bipolar disorders. Bipolar disorders represent a spectrum of these chronic mental health illnesses. Patients with bipolar disorder have high recurrence of acute symptoms, and on average spend 20% of their life in exacerbations characterized by mania, depression, or psychosis. Given the increased morbidity and mortality associated with bipolar disorders, it is imperative that the emergency physician remain vigilant when these patients seek emergency care.

A multimodal prediction model for suicidal attempter in major depressive disorder

Background

Suicidal attempts in patients with major depressive disorder (MDD) have become an important challenge in global mental health affairs. To correctly distinguish MDD patients with and without suicidal attempts, a multimodal prediction model was developed in this study using multimodality data, including demographic, depressive symptoms, and brain structural imaging data. This model will be very helpful in the early intervention of MDD patients with suicidal attempts.

Methods

Two feature selection methods, support vector machine-recursive feature elimination (SVM-RFE) and random forest (RF) algorithms, were merged for feature selection in 208 MDD patients. SVM was then used as a classification model to distinguish MDD patients with suicidal attempts or not.

Results

The multimodal predictive model was found to correctly distinguish MDD patients with and without suicidal attempts using integrated features derived from SVM-RFE and RF, with a balanced accuracy of 77.78%, sensitivity of 83.33%, specificity of 70.37%, positive predictive value of 78.95%, and negative predictive value of 76.00%. The strategy of merging the features from two selection methods outperformed traditional methods in the prediction of suicidal attempts in MDD patients, with hippocampal volume, cerebellar vermis volume, and supracalcarine volume being the top three features in the prediction model.

Conclusions

This study not only developed a new multimodal prediction model but also found three important brain structural phenotypes for the prediction of suicidal attempters in MDD patients. This prediction model is a powerful tool for early intervention in MDD patients, which offers neuroimaging biomarker targets for treatment in MDD patients with suicidal attempts.

The Manic Idea Creator? A Review and Meta-Analysis of the Relationship between Bipolar Disorder and Creative Cognitive Potential

Even though a relationship between psychopathology and creativity has been postulated since the time of ancient Greece, systematic meta-analyses on this topic are still scarce. Thus, the meta-analysis described here can be considered the first to date that specifically focuses on the relationship between creative potential, as measured by divergent thinking, and bipolar disorder, as opposed to psychopathology in general. An extensive literature search of 4670 screened hits identified 13 suitable studies, including a total of 42 effect sizes and 1857 participants. The random-effects model showed an overall significant, positive, yet diminutively small effect (d = 0.11, 95% CI: [0.002, 0.209], p = 0.045) between divergent thinking and bipolar disorder. A handful of moderators were examined, which revealed a significant moderating effect for bipolar status, as either euthymic (d = 0.14, p = 0.043), subclinical (d = 0.17, p = 0.001), manic (d = 0.25, p = 0.097), or depressed (d = -0.51, p < 0.001). However, moderator analyses should be treated with caution because of the observed confounding of moderators. Finally, none of the employed methods for publication-bias detection revealed any evidence for publication bias. We discuss further results, especially regarding the differences between subclinical and clinical samples.

Self-mutilation in people with psychiatric diagnosis - literature review

Introduction: Self-mutilation is of an auto-aggressive nature. They take many forms. Usually they do not occur as an isolated phenomenon. Self-injuring persons often have a diagnosed mental disorder, and a psychiatric diagnosis is one of the risk factors for the occurrence of self-harm. Material and method: In this study, articles were analyzed that contained information on the occurrence of various mental disorders. These articles searched for information on the occurrence of self-mutilation, its type, origin and causes.  Discussion: Self-mutilation is common in patients with a psychiatric diagnosis. The frequency of such behaviors can range from 33% to 50% in people with autism, up to 22%, and even 49% in people diagnosed with psychotic disorders. Acts of selfharm may affect 50-78% of people diagnosed with border-line personality disorder. In adolescents with eating disorders, 41% of patients report self-harm. In the group of people diagnosed with bipolar disorder, it may be as high as 77.3%. People with depression are also a large self-injuring group. It is reported that it may be up to 71.2% of patients with unipolar disorder. Conclusions: Self-mutilation is a phenomenon that is more and more topical and common not only in the adolescent population. This is a multi-factorial issue. One of the risk factors are mental disorders. Self-mutineers choose various methods, and this choice depends, among others, on from recognition. The size of the phenomenon and its evolution make it necessary to study it in order to increase the level of knowledge, update information and, consequently, the ability to help people at risk of NSSI.  Keywords: self-mutilation, autism spectrum disorder, schizophrenia, bipolar disorder, personality disorders

Recurrent suicide attempts affect normalization of HPA axis dysregulation after recovery from major depression

More than 700,000 people worldwide die by suicide every year, and the number of suicide attempts is estimated as 20 times higher, most of them being associated with psychiatric disorders, especially major depression. Knowledge about effective methods for preventing suicide attempts in individuals at high risk for suicide is still scarce. Dysregulation of the neuroendocrine stress response system, i.e., the hypothalamic-pituitary-adrenocortical (HPA) axis, is one of the most consistent neurobiological findings in both major depression and suicidality. While the HPA axis is mostly overactive in depression, individuals with a history of suicide attempts exhibit an attenuated hormonal response to stress. It is unknown, however, whether the HPA axis is constantly attenuated in repeated suicide attempters or whether it regains normal responsivity after recovery from depression. Using the combined dexamethasone suppression/corticotropin-releasing hormone (dex/CRH) test, we assessed HPA axis regulation in acute depression (N = 237) and after recovery with respect to previous suicide attempts. Patients without previous suicide attempts show normalization of the stress hormone response to the second dex/CRH (basal ACTH response and cortisol response) after recovery from acute depression, while patients with multiple previous SA show an increased ACTH response. The change in HPA axis responsivity in patients with only one previous SA lies between the response patterns of the other groups with no change in HPA axis reactivity. Our findings suggest that patients with a history of suicide attempts belong to a subgroup of individuals that exhibit a distinct pattern of stress hormone response during acute depression and after recovery. Future studies may extend our approach by investigating additional psychological stress tasks to gain a broader understanding of the stress pathology of recurrent suicide attempters.

Prediction of suicidal behavior using self-reported suicidal ideation among patients with bipolar disorder

BACKGROUND

People with bipolar disorder have elevated suicide risk. We estimated the ability of the Patient Health Questionnaire (PHQ9) to predict suicide outcomes for outpatients with bipolar disorder.

METHODS

Visits by adults with bipolar disorder who completed a PHQ9 were identified using electronic health record (EHR) data. Bipolar diagnoses and suicide attempts were ascertained from EHR and claims data, and suicide deaths from state and federal records. Depression severity was assessed via the first eight items of the PHQ9, while suicidal ideation was assessed by the ninth item.

RESULTS

37,243 patients made 126,483 visits. Patients reported at least moderate symptoms of depression in 49% and suicidal ideation in 30% of visits. Risk of suicide attempt was 4.21% in the subsequent 90 days for those reporting nearly daily suicidal ideation compared to 0.74% in those reporting none. Patients with nearly daily suicidal ideation were 3.85 (95% CI 3.32-4.47) times more likely to attempt suicide and 13.78 (95% CI 6.56-28.94) times more likely to die by suicide in the subsequent 90 days than patients reporting none. Patients with self-harm in the last year were 8.86 (95% 7.84-10.02) times more likely to attempt suicide in the subsequent 90 days than those without.

LIMITATIONS

Our sample was limited to patients completing the PHQ9 and did not include data on some important social risk or protective factors.

CONCLUSIONS

The PHQ9 was a robust predictor of suicide. Suicidal ideation reported on the PHQ9 should be considered a strong indicator of suicide risk and prompt further evaluation.

Effects of weariness of life, suicide ideations and suicide attempt on HPA axis regulation in depression

The neuropathological mechanisms leading to suicidality are still unknown, which, in view of an annual toll of around 1 million completed suicides constitutes an urgent clinical and societal problem. Alterations of stress hormone (ACTH and cortisol, representing the activity of the hypothalamic-pituitary-adrenocortical, HPA axis) regulation has been repeatedly studied in context of suicidality. Following a suicide attempt, stress hormone activity seems to be blunted, while depressed patients with suicidal ideation often present with elevated HPA axis activity.

METHODS

We investigated the effects of different forms of suicidality on HPA axis regulation in 568 hospitalized patients of the Munich Antidepressant Response Signature (MARS) project. All patients had a diagnosis of a depressive disorder; 62 patients reported a recent suicide attempt, 192 patients suicide ideation, and 171 patients expressed weariness of life as the weakest form of suicidality, the latter not being analyzed in studies so far. All patients participated in the combined dexamethasone/corticotropin releasing hormone (dex/CRH) test for assessing HPA axis regulation shortly after admission to the hospital.

RESULTS

We found an increased ACTH and cortisol response following the dex/CRH-test in patients that were weary of life. In contrast, stress hormone response in suicide attempters and suicide ideators did not differ from non-suicidal patients. Further, repeated suicide attempts in patients' history were associated with more pronounced stress hormone attenuation.

CONCLUSION

In this so far largest study analyzing the HPA axis with respect to suicidality, we could not confirm the assumption of a general attenuation of HPA axis response in depressed suicide ideators and attempters. Conversely, HPA axis appears to be influenced by divergent effects of a specific suicidal psychopathology as well as outlasting effects of previous suicide attempts. We discuss these findings in the light of recent concepts of suicidality, pointing to multifactorial effects of acute and predisposing conditions on HPA axis reactivity in depressed patients.

The mindfulness trajectories of addressing suicidal behaviour: A systematic review

BACKGROUND AND OBJECTIVES

Suicidal behaviour has been a persistent concern in medical as well as general settings. Many psychotherapeutic approaches have tried to address suicidal behaviour in different ways. Mindfulness-based interventions (MBIs) have garnered much attention in the last decade because of their treatment efficacy. This systematic review aimed to examine evidence-based research regarding the effectiveness of MBIs as a psychotherapy intervention on suicidality and to deliver suggestions that might help future research.

METHOD

The identification of literature was made through an extensive search of the electronic databases, to extract studies relating to the efficacy of MBIs on addressing suicidal behaviour. Additional researches based on library sources were searched manually. The studies' selection was based on a pre-determined inclusion and exclusion criteria as well as the quality of the studies.

RESULTS

The present review helped us identify 13 studies, including six randomised controlled trials, two controlled studies and five pre-post observational studies. The findings reported in the studies were mostly favourable to MBIs as an effective intervention strategy for suicidal behaviour.

CONCLUSION

MBIs show promising effects as an intervention for suicidal behaviour. However, large scale, high-quality trials with active control, and long term intervention efficacy studies are needed to understand the mechanisms through which MBIs reduce suicidal behaviour.

COVID-19: Implications for bipolar disorder clinical care and research

The COVID-19 pandemic has posed significant challenges to health care globally, and individuals with bipolar disorder are likely disproportionally affected. Based on review of literature and collective clinical experience, we discuss that without special intervention, individuals with bipolar disorder will experience poorer physical and mental health outcomes due to interplay of patient, provider and societal factors. Some risk factors associated with bipolar disorder, including irregular social rhythms, risk-taking behaviours, substantial medical comorbidities, and prevalent substance use, may be compounded by lockdowns, social isolation and decrease in preventive and maintenance care. We further discuss implications for clinical research of bipolar disorders during the pandemic. Finally, we propose mitigation strategies on working with individuals with bipolar disorder in a clinical and research context, focusing on digital medicine strategies to improve quality of and accessibility to service.

Suicide risk factors across suicidal ideators, single suicide attempters, and multiple suicide attempters

Few studies have compared the three suicidality groups-suicidal ideators (SIs), single suicide attempters (SSAs), and multiple suicide attempters (MSAs)-in relation to the suicidal process. This cross-sectional study investigated trends and differences in suicide risk factors across suicidality groups. Using the baseline data of the Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior, we analyzed trends (Jonckheere-Terpstra or Mantel-Haenszel χ² test) and differences (analysis of covariance or logistic regression) in sociodemographic and clinical factors, psychiatric diagnoses, as well as clinical rating scores on psychopathology (suicidal ideation, depressive symptoms, anxiety symptoms, and problem drinking), trait impulsiveness, and stress across suicidality groups. Across suicidality groups comprising 193 SIs, 207 SSAs, and 376 MSAs, we observed a decreasing trend in age and increasing trends in history of early trauma, familial histories of suicide attempts and suicide, most diagnoses and psychopathologies (suicidal ideation, anxiety symptoms, and problem drinking), trait impulsiveness, and stress-with MSAs more likely to have histories of early trauma and familial suicide, almost uniformly higher proportions of diagnoses, and higher psychopathology rating scores. Overall, increasing trends in suicide risk factors were found across all suicidality groups. Notably, MSAs presented greater proportions of most psychiatric diagnoses and higher degrees of most psychopathologies, motor impulsiveness, and stress, indicating they were at more severe clinical states and were closer to suicide. Mental health professionals should ascertain the number of suicide attempts to identify MSAs, implement more thorough evaluations, and employ additional measures for reducing motor impulsiveness.

Suicidal Risks in 12 DSM-5 Psychiatric Disorders

OBJECTIVE

As modern studies evaluating suicidal behaviors in large samples of major psychiatric disorder patients are rare, we compared suicidal risks associated with a variety of psychiatric diagnoses.

METHODS

We quantified rates of intake suicidal ideation and lifetime attempts, suicides, and violent acts (attempts + suicides) in 6050 adult patients in a European psychiatric center, diagnosed with 12 prevalent, DSM-5 psychiatric disorders.

RESULTS

Ideation ranged from 53.9% of subjects with bipolar disorder (BD) with mixed features, to 8.70% in anxiety disorders. Subjects making at least one suicide attempt were most prevalent in BD with mixed or psychotic features. Suicide rates ranked: substance abuse > BD with psychotic features > psychotic disorders ≥ BD-I > major depressive disorder (MDD). Suicidal intensity (acts/100 PEY) was highest with BD, psychotic disorders, and MDD; lethality (lower attempt/suicide ratio) was greatest with substance abuse, psychotic disorders, and BD with psychotic features. Rates of suicidal acts in BD vs. MDD were similarly high among ever-hospitalized subjects but much lower in never-hospitalized MDD subjects. Women had higher overall risks of ideation and attempts, but violent acts and suicide were more likely among men, whereas SMR for suicide was greater among women, presumably reflecting very low risks among women in the regional general population.

CONCLUSIONS

Suicidal risks were particularly high in BD with psychotic or mixed features as well as with substance abuse and in severe MDD with hospitalization.

Bipolar disorder and personality disorder

Patients with bipolar disorders experience cyclical changes in mood that present as a range of different syndromes. In classical mania, patients experience episodes of euphoria, whereas in depressive episodes they suffer from depression. In hypomania, patients experience a milder form of mania, and in mixed mania, patients may experience both manic and depressive symptoms simultaneously, or alternate between them rapidly. Because of this wide range of symptoms, bipolar disorders can appear to overlap with other mental disorders, especially personality disorders.

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.

Completed suicide in bipolar disorder patients: A cohort study after first hospitalization

BACKGROUND

Bipolar disorder (BD) is a mental health condition that has one of the greatest risk of completed suicide (CS). Hospitalization in affective disorders is associated with increased illness severity and suicide risk, so the study of suicide after the first hospitalization is of special interest.

METHOD

We studied a retrospective cohort consisting on all BD type I (BD-I) and II (BD-II) (according to DSM-IV criteria) admitted for the first time in their lives to the psychiatry unit of a general hospital between 1996 and 2016 from an area in Catalonia (Spain). All patients were also followed-up in a community center of mental health as outpatients until the end of 2017. Multiple variables were prospectively collected during the first hospital admission and were compared between patients who CS and those who did not.

RESULTS

14 of 313 (4.5%) bipolar patients included CS during the 11-year follow-up, and 93% used a violent method. In the univariate analysis we found that Bipolar II Disorder, treatment with antidepressants and/or with lamotrigine were associated with higher risk of CS, however, treatment with valproate and/or with antipsychotics were associated with lower risk of CS . After logistic regression multivariant analysis, only immediately previous violent suicide attempt and first-degree family history of CS remain significant risk factors of CS. A limitation is the relatively small sample from a local hospital and followed locally.

CONCLUSION

Followed during an average of 11 years after the first hospital admission, Bipolar patients completed suicide at a rate 58 times higher than the general population and almost always performed through a violent method. Violent attempted suicide before admission and first- degree family history of CS, are clear and potent predictors of completed suicide.

Relationships between recurrence and polarity in major depressive disorders: Pooled analysis of the BRIDGE and BRIDGE-II-MIX cohorts

BACKGROUND

current classifications of mood disorders focus on polarity rather than recurrence, separating bipolar disorder from major depressive disorder (MDD). The aim of the present study is to explore the possible relationships between number and frequency of depressive episodes and clinical variables associated to bipolarity, in a large sample of MDD patients.

METHODS

the clinical characteristics of 7055 patients with MDD were analyzed and compared according to the number and frequency of depressive episodes. Two stepwise backward logistic regression model were used to identify the predictive value of clinical features based on the presence of high number (≥3 episodes) and high frequency (≥3 episodes/year) of depressive episodes.

RESULTS

high-recurrence and high-frequency MDD patients showed greater family history for bipolar disorder, higher prevalence of psychotic features, more suicide attempts, higher rates of treatment resistance and mood switches with antidepressants (ADs) and higher rates of bipolarity diagnosis according to Angst criteria, compared to low-recurrence and low-frequency patients. Logistic regressions showed that a brief current depressive episode, a previous history of treatment resistance and AD-induced mood switches, a diagnosis of bipolarity and comorbid borderline personality disorder were the variables associated with both high-recurrence and high-frequency depression.

LIMITATIONS

the study participating centers were not randomly selected and several variables were retrospectively assessed.

CONCLUSIONS

even in the absence of hypomanic/manic episodes, high-recurrence and high-frequency MDD seem to be in continuity with the bipolar spectrum disorders in terms of clinical features and, perhaps, treatment response.

Relating irritability and suicidal ideation using mood and anxiety

BACKGROUND

Suicide is common in the context of depression and bipolar disorders, but there remains a lack of understanding as to how suicide ideation, a common symptom of mood disorders, progresses to suicidal behaviour. Irritability, a feature of some types of depression, is thought to contribute to the development of suicidal behaviour, but these associations are not well established.

OBJECTIVE

To examine the relationship between irritability and suicide ideation according to the subtype of depression expressed in patients with mood disorder.

METHODS

75 patients with mood disorders seen at the CADE (Clinical Assessment Diagnostic Evaluation) Clinic underwent clinical assessment for suicidal ideation (Paykel Suicide Scale), symptom severity (Young Mania Rating Scale (YMRS), Hamilton Rating Scale for Depression (HAM-D) (anxious depression), Montgomery-Åsberg Depression Rating Scale (MADRS) (melancholic depression)) and irritability (item 5 of the YMRS).

FINDINGS

Interestingly, irritability correlated with mania (r=0.734, p<0.001 (YMRS)) and depressive symptom scores (r=0.369, p<0.001 (MADRS); r=0.477, p<0.001 (HAM-D)), which in turn correlated with suicide ideation scores (r=0.364, p<0.01 (MADRS); r=0.275, p=0.017 (HAM-D)). However, despite this indirect association, there was no direct correlation between irritability and suicide ideation (r=0.050, p>0.05).

CONCLUSIONS

The nature of the relationship between irritability and suicidal ideation is determined by the emotional context within which irritability operates.

CLINICAL IMPLICATIONS

Findings suggest that rather than examining irritability alone, consideration of the subtype of depression, especially that of anxious depression, should be paramount in assessing suicide risk.

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

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

Prevalence of suicide attempt in individuals with major depressive disorder: a meta-analysis of observational surveys

BACKGROUND

Suicide attempt (SA), which is one of the strongest predictors of completed suicide, is common in major depressive disorder (MDD) but its prevalence across epidemiological studies has been mixed. The aim of this comprehensive meta-analysis was to examine the pooled prevalence of SA in individuals with MDD.

METHODS

A systematic literature search was conducted in PubMed, Embase, PsycINFO, Web of Science and Cochrane Library from their commencement date until 27 December 2017. Original studies containing data on prevalence of SA in individuals with MDD were analyzed.

RESULTS

In all, 65 studies with a total of 27 340 individuals with MDD were included. Using the random effects model, the pooled lifetime prevalence of SA was 31% [95% confidence interval (CI) 27-34%], 1-year prevalence was 8% (95% CI 3-14%) and 1-month prevalence was 24% (95% CI 15-34%). Subgroup analyses revealed that the lifetime prevalence of SA was significantly associated with the patient setting, study region and income level, while the 1-month prevalence of SA was associated with only the patient setting.

CONCLUSION

This meta-analysis confirmed that SA was common in individuals with MDD across the world. Careful screening and appropriate interventions should be implemented for SA in the MDD population.

Genetic biomarkers for differential diagnosis of major depressive disorder and bipolar disorder: A systematic and critical review

Depressive symptoms are present in the depressive mood state of bipolar disorder (BPD) and major depression disorder (MDD). Often, in clinical practice, BPD patients are misdiagnosed with MDD. Therefore, genetic biomarkers could contribute to the improvement of differential diagnosis between BPD and MDD. This systematic and critical review aimed to find in literature reliable genetic biomarkers that may show differences between BPD and MDD. This systematic review followed the PRISMA-P method. The terms used to search PubMed, Scopus, PsycINFO, and Web of Science were depress*, bipolar, diagnos*, genetic*, biomark*. After applying the selection criteria, N = 27 studies were selected, being n = 9 about biomarkers for BPD; n = 15, about MDD; and n = 3 for distinguishing MDD from BPD. A total of N = 3086 subjects were assessed in the selected studies (n = 486 in BPD group; n = 1212 in MDD group; and n = 1388, healthy control group). The articles were dated up to June 2017. Of the N = 27 studies, n = 16 assessed gene, n = 1 miRNA, n = 2 lcnRNA and n = 3 protein expressions, n = 4 methylation, and n = 4 polymorphisms. Some studies applied more than one of these genetic analyses. To find reliable genetic biomarkers we have taken into account the methodological care during the studies development and their validity. The genetic biomarkers selected are related to genes that play a fundamental role in synaptic plasticity, neurogenesis, mood control, brain ageing, immune-inflammatory processes and mitochondrial respiratory chain. BDNF gene expression was one of the genetic biomarkers that highlighted because of its capacity of distinguishing BPD and MDD groups, and being adequately reproduced by more than one selected study.

Memory Impairment and Plasma BDNF Correlates of the BDNF Val66Met Polymorphism in Patients With Bipolar II Disorder

Studies suggest that a functional polymorphism of brain-derived neurotrophic factor (BDNF), polymorphism BDNF Val⁶⁶Met affects cognitive functions, however, the effect is unclear in bipolar II (BD-II) disorder. We used the Wechsler Memory Scale-third edition (WMS-III), the presence of the BDNF Val⁶⁶Met polymorphism, and plasma concentrations of BDNF to investigate the association between memory impairment and BDNF in BD-II disorder. We assessed the memory functions of 228 BD-II patients and 135 healthy controls (HCs). BD-II patients had significantly lower scores on five of the eight WMS-III subscales. In addition to education, the BDNF polymorphism were associated with the following subscales of WMS-III, auditory delayed memory, auditory delayed recognition memory and general memory scores in BD-II patients, but not in HC. Moreover, BD-II patients with the Val-homozygote scored significantly higher on the visual immediate memory subscale than did those with the Met/Met and Val/Met polymorphisms. The significantly positive effect of the Val-homozygote did not have a significantly positive effect on memory in the HC group, however. We found no significant association between BDNF polymorphisms and plasma concentrations of BDNF. The plasma BDNF was more likely to be associated with clinical characteristics than it was with memory indices in the BD-II group. The impaired memory function in BD-II patients might be dependent upon the association between the BDNF Val⁶⁶Met polymorphism and peripheral BDNF levels.

Psychopathological Features of Bipolar Depression: Italian Validation of the Bipolar Depression Rating Scale (I-BDRS)

Background: Aim of the study was the validation of the Bipolar Disorder Rating Scale (BDRS) in an Italian population. Secondary aim was the evaluation of differences between unipolar and bipolar depression and between bipolar I and II depressed patients.

Method: 125 Bipolar Disorder and 60 Major Depressive Disorder patients were administered an Italian translation of the BDRS (I-BDRS), Hamilton Depression Rating Scale (HDRS), Montgomery-Asberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS) and Temperament and Character Inventory-Revised (TCI-R).

Results: I-BDRS showed considerable validity and reliability. Factor analysis found 3 subscales, two linked to depressive symptoms and one to mixed symptoms. Measures concerning depression (MADRS and HAM-D) were positively related to the I-BDRS's subscales, but mostly to the two subscales measuring depression. In mixed symptoms, the mean of the bipolar group was significantly higher than the unipolar group suggesting that the BDRS was able to distinguish between unipolar and bipolar depressed patients.

Conclusion: I-BDRS is a valid scale for the measurement of depression in BD patients, with a notable internal consistency (Cronbach's α 0.82), a significant consistency between items/total (Cronbach's α from 0.80 to 0.82) and positive correlation with other scales (MADRS r = 0.67, p < 0.001; HDRS r = 0.81, p < 0.001; YMRS r = 0.46 p < 0.0001). The mixed state sub-scale shows usefulness in differentiating bipolar from unipolar patients. I-BDRS could be a sensitive tool, both in pure depression and in mixed states, and could be used in the everyday screening and treatment of Bipolar Disorder.

Modeling suicide in bipolar disorders

INTRODUCTION

Suicide is a multicausal human behavior, with devastating and immensely distressing consequences. Its prevalence is estimated to be 20-30 times greater in patients with bipolar disorders than in the general population. The burden of suicide and its high prevalence in bipolar disorders make it imperative that our current understanding be improved to facilitate prediction of suicide and its prevention. In this review, we provide a new perspective on the process of suicide in bipolar disorder, in the form of a novel integrated model that is derived from extant knowledge and recent evidence.

METHODS

A literature search of articles on suicide in bipolar disorder was conducted in recognized databases such as Scopus, PubMed, and PsycINFO using the keywords "suicide", "suicide in bipolar disorders", "suicide process", "suicide risk", "neurobiology of suicide" and "suicide models". Bibliographies of identified articles were further scrutinized for papers and book chapters of relevance.

RESULTS

Risk factors for suicide in bipolar disorders are well described, and provide a basis for a framework of epigenetic mechanisms, moderated by neurobiological substrates, neurocognitive functioning, and social inferences within the environment. Relevant models and theories include the diathesis-stress model, the bipolar model of suicide and the ideation-to-action models, the interpersonal theory of suicide, the integrated motivational-volitional model, and the three-step theory. Together, these models provide a basis for the generation of an integrated model that illuminates the suicidal process, from ideation to action.

CONCLUSION

Suicide is complex, and it is evident that a multidimensional and integrated approach is required to reduce its prevalence. The proposed model exposes and provides access to components of the suicide process that are potentially measurable and may serve as novel and specific therapeutic targets for interventions in the context of bipolar disorder. Thus, this model is useful not only for research purposes, but also for future real-world clinical practice.

Stem cell contributions to neurological disease modeling and personalized medicine

Human induced pluripotent stem cells (iPSCs) represent a revolutionary tool for disease modeling and drug discovery. The generation of tissue-relevant cell types exhibiting a patient's genetic and molecular background offers the ability to develop individual and effective therapies. In this review, we present some major achievements in the neuroscience field using iPSCs and discuss promising perspectives in personalized medicine. In addition to disease modeling, the understanding of the cellular and molecular basis of neurological disorders is explored, including the discovery of new targets and potential drugs. Ultimately, we highlight how iPSC technology, together with genome editing approaches, may bring a deep impact on pre-clinical trials by reducing costs and increasing the success of treatments in a personalized fashion.

Differentiating multiple vs single lifetime suicide attempters with bipolar disorders: A retrospective study

BACKGROUND

The risk of suicide in Bipolar Disorder (BD) has been estimated up to 20-30 times higher compared with the general population. Previous suicide attempts (SAs) represent a well-established risk factor for further attempts and for death by suicide in patients with psychiatric disorders. However, little is known about the socio-demographic and clinical profile of BD patients with a history of multiple SAs (MSAs). The present study sought to characterize BD patients with MSAs versus single suicide attempt (SSA) within a large Italian sample.

METHODS

An original sample of 354 bipolar patients, recruited at the University Clinic and related community services at the Department of Psychiatry, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan (Italy), was screened for the presence of previous SAs (n=95). Socio-demographic and clinical variables were then compared between patients with multiple vs single lifetime suicide attempts.

RESULTS

Bipolar patients with MSAs versus SSA had longer bipolar illness duration (26.9±12.6 vs 21.2±12.8years; p=0.05), and more frequently lived alone (38.5% vs 17.2%; p<0.05), had more than one psychiatric comorbidity (39.3% vs 17.5%; p=0.04), and utilized substance ingestion (e.g., overdose) (78.6% vs 47.2%, p=0.009), although the latter was the most common suicide attempt method in both groups.

CONCLUSION

Present findings suggest different socio-demographic and clinical characteristics in bipolar patients with MSAs versus SSA. Further investigation is needed to confirm reported data.

Patterns of cannabis use and clinical correlates among individuals with Major Depressive Disorder and Bipolar Disorder

BACKGROUND

Major Depressive Disorder (MDD) and Bipolar Disorder (BPD) are the most severe mood disorders globally. Previous reports indicate high co-occurrence of cannabis use and cannabis use disorders (CUDs) associated with both disorders, yet studies comparing patterns of cannabis use between individuals with MDD and BPD are scarce.

METHODS

Data were drawn from Wave 1 (2001-2002) of the National Epidemiologic survey on Alcohol and Related Conditions (NESARC). Cannabis users who qualified for a diagnosis of past-year MDD (N=217) were compared to those with BPD (N=168) in frequency and daily dose of cannabis use, rates of comorbid psychiatric disorders including specific criteria of CUDs, treatment utilization and suicidality.

RESULTS

Among past-year cannabis users, individuals with BPD reported using cannabis more frequently and smoking more joints per day compared to those with MDD. They were also more likely to suffer from comorbid personality disorders and qualify for specific CUD-criteria, including use in physically hazardous situations and unsuccessful efforts to control substance use.

CONCLUSIONS

Our results indicate that individuals with BPD may present more intensive patterns of cannabis use compared to those with MDD. This may have potential effects on the course of BPD and should be further explored in longitudinal studies.

Self-Harm, Affective Traits, and Psychosocial Functioning in Adults With Depressive and Bipolar Disorders

Self-harm refers to the purposeful destruction of bodily tissue without suicidal intention and for purposes that are not socially sanctioned. Little is known about the associations between a history of self-harm, mood symptoms, and functioning in adults with different types of mood disorders. Lifetime histories of self-harm, current mood symptoms, global functioning, and affective traits were collected on 142 adults with mood disorders. The prevalence of lifetime self-harm was higher in patients with bipolar disorder compared with patients with a unipolar depressive disorder. Self-harm was also more strongly linked to impulsivity in individuals with bipolar disorder compared with unipolar depressive disorder. Across both diagnoses, histories of self-harm were related to lower levels of current global functioning, more severe depressive symptoms, and high self-reported emotional dysregulation and neuroticism. Findings indicate that self-harm is a potent prognostic variable for symptoms, global functioning, and personality functioning in individuals with mood disorders.

Disentangling Working Memory Functioning in Mood States of Bipolar Disorder: A Systematic Review

Working memory (WM) deficits are often reported in patients with Bipolar Disorder (BD). However, it is not clear about the nature of these WM deficits (update or serial order processes) and their association with each BD states (euthymic, mania, and depressive). This review investigated the association between BD patient's states and the functioning of WM components. For this purpose, we carried out a systematic review fulfilling a search in the databases Medline, Scopus, SciELO, and Web of Science using specific terms in the abstracts of the articles that generated 212 outcomes in the restricted period from 2005 to 2016. Twenty-three papers were selected, completely read, and analyzed using PICOS strategy. The mood episodes predicted deficits in different components of WM in BD patients (the phonological loop or visuospatial sketchpad) and were associated with different WM processes (updating and serial recall). Lower cognitive scores persist even in remission of symptoms. This result suggests that WM deficit apparently is stage-independent in BD patients. Furthermore, findings suggest that the neutral point on Hedonic Detector component of WM could be maladjusted by BD.

A Systematic Review and Critical Appraisal of Economic Evaluations of Pharmacological Interventions for People with Bipolar Disorder

BACKGROUND

Bipolar disorder (BD) is a chronic mood disorder that causes substantial psychological and financial burden. Various pharmacological treatments are effective in the management and prevention of acute episodes of BD. In an era of tighter healthcare budgets and a need for more efficient use of resources, several economic evaluations have evaluated the cost effectiveness of treatments for BD.

OBJECTIVE

The aim of this study was to systematically review and appraise published economic evaluations of pharmacological interventions for BD.

METHODS

A systematic search combining search terms specific to BD with a health economics search filter was conducted on six bibliographic databases (EMBASE, MEDLINE, PsycINFO, HTA, NHS EED, CENTRAL) in order to identify trial- or model-based full economic evaluations of pharmacological treatments of any phase of the disorder that were published between 1 January 1990 and 18 December 2015. Studies that met the inclusion criteria were critically appraised using the Quality of Health Economic Studies (QHES) checklist, and synthesised in a narrative way.

RESULTS

The review included 19 economic studies, which varied with regard to the type and number of interventions assessed, the study design, the phase of treatment (acute or maintenance), the source of efficacy data and the method for evidence synthesis, the outcome measures, the time horizon and the countries/settings in which the studies were conducted. The study quality was variable but the majority of studies were of high or fair quality.

CONCLUSION

Pharmacological interventions are cost effective, compared with no treatment, in the management of BD, both in the acute and maintenance phases. However, it is difficult to draw safe conclusions on the relative cost effectiveness between drugs due to differences across studies and limitations characterising many of them. Future economic evaluations need to consider the whole range of treatment options available for the management of BD and adopt appropriate methods for evidence synthesis and economic modelling, to explore more robustly the relative cost effectiveness of pharmacological interventions for people with BD.

Molecular Mechanisms of Bipolar Disorder: Progress Made and Future Challenges

Bipolar disorder (BD) is a chronic and progressive psychiatric illness characterized by mood oscillations, with episodes of mania and depression. The impact of BD on patients can be devastating, with up to 15% of patients committing suicide. This disorder is associated with psychiatric and medical comorbidities and patients with a high risk of drug abuse, metabolic and endocrine disorders and vascular disease. Current knowledge of the pathophysiology and molecular mechanisms causing BD is still modest. With no clear biological markers available, early diagnosis is a great challenge to clinicians without previous knowledge of the longitudinal progress of illness. Moreover, despite recommendations from evidence-based guidelines, polypharmacy is still common in clinical treatment of BD, reflecting the gap between research and clinical practice. A major challenge in BD is the development of effective drugs with low toxicity for the patients. In this review article, we focus on the progress made and future challenges we face in determining the pathophysiology and molecular pathways involved in BD, such as circadian and metabolic perturbations, mitochondrial and endoplasmic reticulum (ER) dysfunction, autophagy and glutamatergic neurotransmission; which may lead to the development of new drugs.

Onset polarity in bipolar disorder: A strong association between first depressive episode and suicide attempts

BACKGROUND

The role of onset polarity (OP) in patients with bipolar disorder (BD) has been increasingly investigated over the last few years, for its clinical, prognostic, and therapeutic implications. The present study sought to assess whether OP was associated with specific correlates, in particular with a differential suicidal risk in BD patients.

METHODS

A sample of 362 recovered BD patients was dichotomized by OP: depressed (DO) or elevated onset (EO: hypomanic/manic/mixed). Socio-demographic and clinical variables were compared between the subgroups. Additionally, binary logistic regression was performed to assess features associated with OP.

RESULTS

DO compared with EO patients had older current age and were more often female, but less often single and unemployed. Clinically, DO versus EO had a more than doubled rate of suicide attempts, as well as significantly higher rates of BD II diagnosis, lifetime stressful events, current psychotropics and antidepressants use, longer duration of the most recent episode (more often depressive), but lower rates of psychosis and involuntary commitments.

LIMITATIONS

Retrospective design limiting the accurate assessment of total number of prior episodes of each polarity.

CONCLUSIONS

Our results support the influence of OP on BD course and outcome. Moreover, in light of the relationship between DO and a higher rate of suicide attempts, further investigation may help clinicians in identifying patients at higher risk of suicide attempts.

Bipolar disorder moderates associations between linoleic acid and markers of inflammation

Dietary polyunsaturated fatty acids (PUFA) and inflammatory proteins associate with immune activation and have been implicated in the pathophysiology of mood disorders. We have previously reported that individuals with bipolar disorder (BPD) have decreased PUFA intake, including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and arachidonic acid (AA); and decreased PUFA concentration of plasma EPA and linoleic acid (LA). We have also reported an association between plasma LA and its metabolites and burden of disease measures in BPD. In the current cross-sectional study we collected blood samples and diet records from both bipolar (n = 91) and control subjects (n = 75) to quantify plasma cytokine concentrations and dietary LA intake, respectively. Using multiple linear regression techniques, we tested for case control differences in plasma cytokine levels and associations between cytokines and dietary LA intake, adjusting for sex, age, BMI, and total energy intake. We found significantly higher plasma levels of interleukin 18 (IL-18) (p = 0.036), IL-18 binding protein (IL-18BP) (p = 0.001), soluble tumor necrosis factor receptor (sTNFR) 1 (p = 0.006), and sTNFR2 (p = 0.007) in BPD compared with controls. Moreover, BPD significantly moderated the associations of dietary LA intake with plasma levels of IL-18, sTNFR1 and sTNFR2, which were inverse associations in bipolar individuals and positive associations in controls (p for dietary LA x BPD diagnosis interaction < 0.05 for all three). These findings suggest potential dysregulation of LA metabolism in BPD, which may extend to a modified influence of dietary LA on specific inflammatory pathways in individuals with BPD compared to healthy controls.

Family history of suicide and interpersonal functioning in suicide attempters

Difficulties in interpersonal relationships are associated with a wide range of psychiatric diagnoses and have been reported as a trigger for suicidal behavior, too. The aim of this study was to examine the relationship between interpersonal problems and family history of suicide in suicide attempters and to describe relevant patterns of interpersonal problems in this patient group. The study involves 181 patients having their clinical follow-up after a suicide attempt. Family history of suicide was assessed by using the Karolinska Self Harm History Interview or retrieved in patient records. The Inventory of Interpersonal Problems was used to assess personal style in an interpersonal context. Suicide attempters with a family history of suicide had significantly more often an intrusive personal style. The results remained significant after adjustment for personality disorder. The specific interpersonal patterns associated with family history of suicide may interfere with the ability to create stable, long-lasting relationships. In regards to treatment, these personal qualities could cause difficulties in the alliance with health care personnel and make it harder for suicide attempters to accept or benefit from treatment. Attention to suicide attempters' interpersonal problems is of importance to lower their distress.

Thwarted interpersonal needs and suicide ideation: Comparing psychiatric inpatients with bipolar and non-bipolar mood disorders

Psychiatric inpatients are at heightened risk for suicide, and evidence suggests that psychiatric inpatients with bipolar mood disorders may be at greater risk for suicide ideation compared to those with non-bipolar mood disorders. There is a paucity of research directly comparing risk factors for suicide ideation in bipolar versus non-bipolar mood disorders in an inpatient sample. The current study sought to clarify the association between two constructs from the interpersonal theory of suicide (i.e., perceived burdensomeness and thwarted belongingness) in leading to suicide ideation among psychiatric inpatients with bipolar and non-bipolar mood disorders. Participants were (N=90) psychiatric inpatients with a bipolar (n = 20) or non-bipolar mood disorder (n=70; per their medical charts). Perceived burdensomeness, but not thwarted belongingness, was significantly associated with suicide ideation after adjusting for other covariates. This suggests perceived burdensomeness may play a key role in suicide ideation among psychiatric inpatients with any mood disorder and highlights the importance of assessment and intervention of perceived burdensomeness in this population. Contrary to our hypothesis, mood disorder group (i.e., bipolar versus non-bipolar) did not moderate the relations between perceived burdensomeness/thwarted belongingness and suicide ideation.

The Experience of Participation in Suicide Research From the Perspective of Individuals With Bipolar Disorder

Reasons underlying the elevated prevalence of suicide in bipolar disorder remain underresearched and poorly understood. Participation in suicide-focused research may pose a risk to vulnerable groups, such as those with bipolar disorder. Participants were asked to provide feedback about their experience of participating in a suicide-focused qualitative research interview. The data set was analyzed using inductive thematic analysis. Qualitative themes were (1) talking about suicide was not distressing, (2) negative interview expectations, (3) personal benefits, (4) value of suicide research, (5) interview advice, and (6) talking about suicide was difficult. Suicide-focused research can be conducted with minimal participant distress. Sufficient procedures must be in place, both to identify those at risk of experiencing distress and to efficiently deal with any distress that might occur.

Differential endorsement of suicidal ideation and attempt in bipolar versus unipolar depression: a testlet response theory analysis

BACKGROUND

Published data concerning differences in suicide risk across the mood disorders spectrum remain mixed. The current study used testlet response theory methods to evaluate differences in the endorsement of suicidal ideation and attempt in an epidemiological sample of individuals with bipolar and unipolar depression.

METHOD

Participants with lifetime history of bipolar I (n=1154), bipolar II (n=494), and unipolar (n=5695) depression were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, which included 4 structured queries concerning suicidal ideation/attempt. We estimated differential item functioning between groups with a 2-pl parametric item response model.

RESULTS

Endorsement of suicide items increased as a function of underlying depression severity. Equating for severity, endorsement of suicidal ideation and attempt was generally more frequent in bipolar versus unipolar depression, and in bipolar I versus bipolar II depression. Yet findings were not consistent across all suicide items, and differences were small in magnitude.

LIMITATIONS

The NESARC relied upon lifetime endorsement of suicide items, and suicide risk was only evaluated within the context of a major depressive episode. Thus, this study could not evaluate endorsement of suicide items within the context of (hypo)manic or mixed states.

CONCLUSION

Although there were some group differences, patterns of item endorsement were more similar than different. These data support a transdiagnostic model of suicide that emphasizes underlying depression severity over mood disorder class.

Comorbid panic disorder as an independent risk factor for suicide attempts in depressed outpatients

OBJECTIVE

Although comorbid panic disorder is associated with more severe symptoms and poorer therapeutic response in depressive patients, the relationship between panic disorder and risk of suicide attempt has not been confirmed. This study aimed to examine the relationship between comorbid panic disorder and clinical characteristics associated with suicidal risk as well as the likelihood of suicide attempt.

METHOD

A total of 223 outpatients with current major depressive disorder participated in the study. Both subjects with panic disorder (33%) and those without panic disorder (67%) were compared based on history of suicide attempts, current psychopathologies, and traits of impulsivity and anger.

RESULTS

Subjects with panic disorder had higher levels of impulsivity, depression, and hopelessness and were more likely to report a history of suicide attempts. Subjects with panic disorder were younger at the time of first suicide attempt than those without panic disorder. Logistic regression analyses indicated that comorbid panic disorder was significantly associated with a history of suicide attempts after adjusting for other clinical correlates (odds ratio = 2.8; p < 0.01).

CONCLUSIONS

These findings suggest that comorbid panic disorder in patients with major depressive disorder may be associated with a more severe burden of illness and may independently increase the likelihood of suicide attempt.

Suicide Behaviors in Bipolar Disorder: A Review and Update for the Clinician

Suicide behaviors (ideation, attempts, and completions) are unfortunately common in patients with bipolar disorder. It is estimated that 25 to 50% attempt suicide at least once during their lifetime, and 6% to 19% complete suicide. Risk factors include a family history of suicide, previous suicide attempts, younger age of onset, comorbid psychiatric illnesses, and psychological constructs like hopelessness. Pharmacologic treatment may impact suicidal behaviors, either increasing vulnerability or resilience. Clinicians need to be particularly sensitive to their patient's thoughts and beliefs about death, particularly during stressful times of life or when in a depressive/mixed episode of bipolar disorder.

Symptom characteristics of depressive episodes prior to the onset of mania or hypomania

OBJECTIVE

Depressive episodes are typically the initial presentation of bipolar disorder. The evidence as to whether depressive episodes occurring in persons who later convert to bipolar disorder are symptomatically distinct from episodes of unipolar depression remains controversial. As there are crucial differences in the therapeutic management, symptom profiles indicating subsequent bipolar conversion may aid in appropriate treatment.

METHOD

A representative community sample of originally N = 3021 adolescents and young adults aged 14-24 years at baseline was assessed up to four times over 10 years. Assessment of symptoms was conducted by clinically trained interviewers using the standardized M-CIDI. Symptom profiles of depressive episodes were compared via logistic regression between subjects that subsequently developed (hypo-)manic episodes (n = 35) or remained unipolar depressive (n = 659).

RESULTS

Initial depression amongst prospective converters was characterized by significantly increased suicidality (odds ratio, OR = 2.31), higher rates of feelings of worthlessness and excessive guilt (OR = 2.52), complete loss of pleasure (OR = 2.53) and diurnal variation (OR = 4.30). No differences were found for hyperphagia, hypersomnia and psychomotor alterations.

CONCLUSION

Findings suggest that the symptom profile of initial depressive episodes may be useful in the identification of subjects with an elevated risk for the subsequent conversion to bipolar disorder.

The differences in temperament-character traits, suicide attempts, impulsivity, and functionality levels of patients with bipolar disorder I and II

BACKGROUND

The primary aim of this study was to compare the differences in temperament-character traits, suicide attempts, impulsivity, and functionality levels of patients with bipolar disorder I (BD-I) and bipolar disorder II (BD-II).

METHODS

Fifty-two BD-I patients and 49 BD-II patients admitted to Erenköy Mental and Neurological Disease Training and Research Hospital psychiatry clinic and fifty age- and sex-matched healthy control subjects were enrolled in this study. A structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Axis I Disorders, Temperament and Character Inventory, Barrett Impulsiveness Scale-11 (BIS-11), Hamilton Depression Inventory Scale, Young Mania Rating Scale, and Bipolar Disorder Functioning Questionnaire (BDFQ) were administered to patients and to control group.

RESULTS

No statistically significant difference in sociodemographic features existed between the patient and control groups (P>0.05). Thirty-eight subjects (37.62%) in the patient group had a suicide attempt. Twenty-three of these subjects (60.52%) had BD-I, and 15 of these subjects (39.47%) had BD-II. Suicide attempt rates in BD-I and II patients were 60.52% and 39.47%, respectively (P<0.05). Comparison of BD-I and II patients with healthy control subjects revealed that cooperativeness (C), self-directedness (Sdi), and self-transcendence (ST) scores were lower and novelty seeking (NS1 and NS2), harm avoidance (HA4), and reward dependence (RD2) subscale scores were higher in patients with BD-I. When BD-I patients were compared with BD-II patients, BIS-11 (attention) scores were higher in patients with BD-II and BIS-11 (motor and nonplanning impulsivity) scores were higher in patients with BD-I. According to BDFQ, relations with friends, participation in social activities, daily activities and hobbies, and occupation subscale scores were lower and taking initiative subscale scores were higher in patients with BD-I. Social withdrawal subscale scores were higher in patients with BD-II.

CONCLUSION

In our study, NS, HA, and RD scores that may be found high in suicide attempters and Sdi scores that may be found low in suicide attempters were as follows: NS1, NS2, HA4, and RD2 subscale scores were high and Sdi scores were low in patients with BD-I, suggesting a higher rate of suicide attempts in this group of patients. In addition, C and Sdi scores that indicate a predisposition to personality disorder were significantly lower in patients with BD-I than patients with BD-II and healthy controls, suggesting a higher rate of personality disorder comorbidity in patients with BD-I. Higher impulsivity and suicidality rates and poorer functionality in patients with BD-I also suggest that patients with BD-I may be more impulsive and more prone to suicide and have poorer functionality in some areas.

DEPRESSION MEDIATES THE RELATION OF INSOMNIA SEVERITY WITH SUICIDE RISK IN THREE CLINICAL SAMPLES OF U.S. MILITARY PERSONNEL

BACKGROUND

A growing body of empirical research suggests insomnia severity is directly related to suicide ideation, attempts, and death in nonmilitary samples, even when controlling for depression and other suicide risk factors. Few studies have explored this relationship in U.S. military personnel.

METHODS

The present study entailed secondary data analyses examining the associations of insomnia severity with suicide ideation and attempts in three clinical samples: Air Force psychiatric outpatients (n = 158), recently discharged Army psychiatric inpatients (n = 168), and Army psychiatric outpatients (n = 54). Participants completed the Beck Scale for Suicide Ideation, the Beck Depression Inventory-II or Patient Health Questionnaire-9, the Insomnia Severity Index, and the Posttraumatic Stress Disorder Checklist at baseline; two samples also completed these measures during follow-up.

RESULTS

Sleep disturbance was associated with concurrent (β's > 0.21; P's < 0.059) and prospective (β's > 0.39; P's < 0.001) suicide ideation in all three samples. When adjusting for age, gender, depression, and posttraumatic stress, insomnia severity was no longer directly associated with suicide ideation either concurrently (β's < 0.19; P's > 0.200) or prospectively (β's < 0.26; P's > 0.063), but depression was (β's > 0.22; P's < 0.012). Results of a latent difference score mediation model indicated that depression mediated the relation of insomnia severity with suicide ideation.

CONCLUSIONS

Across three clinical samples of military personnel, depression explained the relationship between insomnia severity and suicide risk.

The bipolar II disorder personality traits, a true syndrome?

BACKGROUND

The author was struck by the similarities and commonality of complaints, aside from mood swings, made by Bipolar II patients and started registrating these complaints. This registrational work eventually led to the development of The Bipolar II Syndome Checklist. The aim of this work was to understand how widely the Bipolar II disorder affects the personality, and what disturbing personality traits are the most common? Deliberately, no attempt was made to diagnose psychiatric comorbidities, in the hope that one would get a clearer view of what symptoms, if any, could be considered a natural part of the Bipolar II Disorder. As far as the author knows this is a novel approach.

METHOD

105 Bipolar II patients completed the Bipolar II Syndrome Checklist. The answers to the 44 questions on the list are presented in tables.

RESULTS

Symptoms like anxiety, low self esteem, paranoia, extreme hurtfulness, migraine, Post Partum Depression, obsessive traits, alcoholism in the family are amongst the findings which will be presented in greater detail.

LIMITATIONS

No control group. Bipolar I patients excluded. The Bipolar II Syndrome Checklist has not been systematically validated.

CONCLUSIONS

The results show that Bipolar II Disorder causes multiple symptoms so commonly that it may be justified to describe it as a syndrome, The Bipolar II Syndrome. Also these disturbances commonly lie in families of Bipolar II patients and are in all likelihood, greatly underdiagnosed. The clinical relevance of this study lies in increasing our knowledge and understanding of the nature of the Bipolar II Disorder, which in all probability will increase the diagnostic and treatment accuracy, since clinicians are more likely to scan for other symptoms needing treatment.

The Use of Cannabis as a Predictor of Early Onset of Bipolar Disorder and Suicide Attempts

Introduction. Bipolar disorder (BD) implies risk of suicide. The age at onset (AAO) of BD carries prognostic significance. Substance abuse may precede the onset of BD and cannabis is the most common illicit drug used. The main goal of this study is to review the association of cannabis use as a risk factor for early onset of BD and for suicide attempts. Materials and Methods. PubMed database was searched for articles using key words “bipolar disorder,” “suicide attempts,” “cannabis,” “marijuana,” “early age at onset,” and “early onset.” Results. The following percentages in bipolar patients were found: suicide attempts 3.6–42%; suicide attempts and substance use 5–60%; suicide attempts and cannabis use 15–42%. An early AAO was associated with cannabis misuse. The mean age of the first manic episode in individuals with and without BD and cannabis use disorder (CUD) was 19.5 and 25.1 years, respectively. The first depressive episode was at 18.5 and 24.4 years, respectively. Individuals misusing cannabis showed increased risk of suicide. Discussion. Cannabis use is associated with increased risk of suicide attempts and with early AAO. However, the effect of cannabis at the AAO and suicide attempts is not clear.

Differential diagnosis of bipolar disorder and major depressive disorder

BACKGROUND

Patients with bipolar disorder spend approximately half of their lives symptomatic and the majority of that time suffering from symptoms of depression, which complicates the accurate diagnosis of bipolar disorder.

METHODS

Challenges in the differential diagnosis of bipolar disorder and major depressive disorder are reviewed, and the clinical utility of several screening instruments is evaluated.

RESULTS

The estimated lifetime prevalence of major depressive disorder (i.e., unipolar depression) is over 3 and one-half times that of bipolar spectrum disorders. The clinical presentation of a major depressive episode in a bipolar disorder patient does not differ substantially from that of a patient with major depressive disorder (unipolar depression). Therefore, it is not surprising that without proper screening and comprehensive evaluation many patients with bipolar disorder may be misdiagnosed with major depressive disorder (unipolar depression). In general, antidepressants have demonstrated little or no efficacy for depressive episodes associated with bipolar disorder, and treatment guidelines recommend using antidepressants only as an adjunct to mood stabilizers for patients with bipolar disorder. Thus, correct identification of bipolar disorder among patients who present with depression is critical for providing appropriate treatment and improving patient outcomes.

LIMITATIONS

Clinical characteristics indicative of bipolar disorder versus major depressive disorder identified in this review are based on group differences and may not apply to each individual patient.

CONCLUSION

The overview of demographic and clinical characteristics provided by this review may help medical professionals distinguish between major depressive disorder and bipolar disorder. Several validated, easily administered screening instruments are available and can greatly improve the recognition of bipolar disorder in patients with depression.

Balancing benefits and harms of treatments for acute bipolar depression

BACKGROUND

Bipolar depression is more pervasive than mania, but has fewer evidence-based treatments.

METHODS

Using data from multicenter, randomized, double-blind, placebo-controlled trials and meta-analyses, we assessed the number needed to treat (NNT) for response and the number needed to harm (NNH) for selected side effects for older and newer acute bipolar depression treatments.

RESULTS

The 2 older FDA-approved treatments for bipolar depression, olanzapine-fluoxetine combination (OFC) and quetiapine (QTP) monotherapy, were efficacious (response NNT=4 for OFC, NNT=6 for QTP), but similarly likely to yield harms (OFC weight gain NNH=6; QTP sedation/somnolence NNH=5). Commonly used unapproved agents (lamotrigine monotherapy and adjunctive antidepressants) tended to be well-tolerated (with double-digit NNHs), although this advantage was at the cost of inadequate efficacy (response NNT=12 for lamotrigine, NNT=29 for antidepressants). In contrast, the newly approved agent lurasidone was not only efficacious (response NNT=5 for monotherapy, NNT=7 as adjunctive therapy), but also had enhanced tolerability (NNH=15 for akathisia [monotherapy], NNH=16 for nausea [adjunctive]). Although adjunctive armodafinil appeared well tolerated, its efficacy in bipolar depression has not been consistently demonstrated in randomized controlled trials.

LIMITATIONS

NNT and NNH are categorical metrics; only selected NNHs were assessed; limited generalizability of efficacy (versus effectiveness) studies.

CONCLUSION

For acute bipolar depression, older approved treatments may have utility in high-urgency situations, whereas lamotrigine and antidepressants may have utility in low-urgency situations. Newly approved lurasidone may ultimately prove useful in diverse situations. New drug development needs to focus on not only efficacy but also on tolerability.

Gender differences in the association of agitation and suicide attempts among psychiatric inpatients

OBJECTIVE

To determine if the relationship of agitation with suicide ideation and suicide attempts differed between men and women.

METHOD

Self-reported severity of agitation and other suicide risk factors was obtained from 7698 consecutive patients during admission for inpatient psychiatric treatment during a 5-year period.

RESULTS

Agitation was highest among men with a history of suicide attempts. Agitation was significantly associated with frequency of suicide ideation and history of suicide attempt, but the gender-by-suicide interaction was only significant as a predictor of suicide attempt history. For men, agitation was associated with significantly increased risk for suicide attempt, but for women, agitation was not associated with risk for suicide attempt history. Results were unchanged when analyses were repeated among the subgroup of patients with suicide ideation.

CONCLUSIONS

Agitation is associated with history of suicide attempt among male but not female psychiatric inpatients. Agitation differentiates between those men who have only thought about suicide and those who have made suicide attempts.

Does the stigma of mental illness contribute to suicidality?

Mental disorders are associated with suicidality and with stigma. Many consequences of stigma, such as social isolation, unemployment, hopelessness or stress, are risk factors for suicidality. Research is needed on the link between stigma and suicidality as well as on anti-stigma interventions and their effects on suicidality.