A review of antidepressant-induced hypomania in major depression: suggestions for DSM-V

Vortioxetine as a potential alternative for patients with escitalopram-induced jitteriness/anxiety syndrome: A report of three cases

Background

Jitteriness/anxiety syndrome is a recognized adverse effect observed during the initiation or change of dose in antidepressant treatment. Managing patients who develop this syndrome remains a challenge. While escitalopram is a widely used antidepressant known to cause these symptoms, this report explores vortioxetine as a therapeutic alternative.

Case Presentation

Three distinct clinical scenarios were observed in patients who manifested jitteriness/anxiety syndrome while on escitalopram treatment for depression. Patient A was initiated on escitalopram and experienced an initial alleviation in depressive symptoms, but 3 months later displayed mood elevation, talkativeness, and increased activity, which disturbed his daily life. A transition to vortioxetine subsequently resolved the mood elevation. Patient B exhibited elevated mood, hyperactivity, irritability, and talkativeness just 6 days post-initiation of treatment with escitalopram. After the discontinuation of escitalopram and unsuccessful trials with aripiprazole, lurasidone, and lamotrigine, her depressive mood intensified, culminating in suicidal ideation. Starting vortioxetine led to a consistent improvement of her symptoms, and she resumed work and was emotionally stable. Patient C was initially diagnosed with bipolar disorder and faced a relapse into depression despite undergoing various treatments. After 2 weeks on escitalopram, she exhibited irritability and self-harm urges. Three months later, after being re-diagnosed with depressive disorders with anxious distress, vortioxetine was administered, which significantly reduced her depressive symptoms and allowed her to continue her education.

Conclusion

Vortioxetine presents as a promising therapeutic alternative that is worth considering for patients with escitalopram-induced jitteriness/anxiety syndrome.

A phase 3, multicenter, double-blind, randomized, placebo-controlled clinical trial to verify the efficacy and safety of ansofaxine (LY03005) for major depressive disorder

Major depressive disorder (MDD) is the most prevalent form of depression and is becoming a great challenge for public health and medical practice. Although first-line antidepressants offer therapeutic benefits, about 35% of depressed patients are not adequately treated, creating a substantial unmet medical need. A multicenter, double-blind, randomized, placebo-controlled phase 3 clinical trial was conducted in patients with MDD in China to assess the efficacy and safety of ansofaxine (LY03005), a potential triple reuptake inhibitor of serotonin, norepinephrine, and dopamine. Eligible 588 MDD patients were included and randomly assigned (1:1:1) to 8-week treatment with ansofaxine 80 mg/day(n = 187), ansofaxine 160 mg/day(n = 186), or placebo(n = 185). The primary efficacy endpoint was the Montgomery-Åsberg Depression Rating Scale (MADRS) total score change from baseline to the end of the study. Safety indexes included adverse events, vital signs, physical examination, laboratory tests, 12-lead electrocardiogram (ECG), and evaluation of suicide tendency and sexual function. Significant differences were found in mean changes in MADRS total score at week 8 in the two ansofaxine groups (80 mg, -20.0; 160 mg, -19.9) vs. placebo (-14.6; p < 0.0001). All doses of ansofaxine were generally well-tolerated. Treatment-emergent adverse events (TEAEs) were reported by 137 (74.46%) patients in ansofaxine 80 mg group, 144 (78.26%) patients in ansofaxine 160 mg and 125 (67.93%) patients in the placebo group. The incidence of treatment-related adverse events (TRAEs) was 59.2% (109 patients), 65.22% (120 patients) in the 80, 160 mg ansofaxine groups, and 45.11% (83 patients) in the placebo group. The initial results of this trial indicate that ansofaxine at both the 80 mg/day and 160 mg/day was effective and safe in adult patients with MDD. ClinicalTrials.gov Identifier: NCT04853407.

Mood and Anxiety Disorders and Suicidality in Patients With Newly Diagnosed Focal Epilepsy: An Analysis of a Complex Comorbidity

BACKGROUND AND OBJECTIVES

Mood, anxiety disorders, and suicidality are more frequent in people with epilepsy than in the general population. Yet, their prevalence and the types of mood and anxiety disorders associated with suicidality at the time of the epilepsy diagnosis are not established. We sought to answer these questions in patients with newly diagnosed focal epilepsy and to assess their association with suicidal ideation and attempts.

METHODS

The data were derived from the Human Epilepsy Project study. A total of 347 consecutive adults aged 18-60 years with newly diagnosed focal epilepsy were enrolled within 4 months of starting treatment. The types of mood and anxiety disorders were identified with the Mini International Neuropsychiatric Interview, whereas suicidal ideation (lifetime, current, active, and passive) and suicidal attempts (lifetime and current) were established with the Columbia Suicidality Severity Rating Scale (CSSRS). Statistical analyses included the t test, χ2 statistics, and logistic regression analyses.

RESULTS

A total of 151 (43.5%) patients had a psychiatric diagnosis; 134 (38.6%) met the criteria for a mood and/or anxiety disorder, and 75 (21.6%) reported suicidal ideation with or without attempts. Mood (23.6%) and anxiety (27.4%) disorders had comparable prevalence rates, whereas both disorders occurred together in 43 patients (12.4%). Major depressive disorders (MDDs) had a slightly higher prevalence than bipolar disorders (BPDs) (9.5% vs 6.9%, respectively). Explanatory variables of suicidality included MDD, BPD, panic disorders, and agoraphobia, with BPD and panic disorders being the strongest variables, particularly for active suicidal ideation and suicidal attempts.

DISCUSSION

In patients with newly diagnosed focal epilepsy, the prevalence of mood, anxiety disorders, and suicidality is higher than in the general population and comparable to those of patients with established epilepsy. Their recognition at the time of the initial epilepsy evaluation is of the essence.

Affect Regulation-Related Emergent Brain Network Properties Differentiate Depressed Bipolar Disorder From Major Depression and Track Risk for Bipolar Disorder

BACKGROUND

Individuals with or at risk for bipolar disorder (BD) often present initially for the treatment of depressive symptoms. Unfortunately, pharmacological treatments for major depressive disorder (MDD) can be iatrogenic, precipitating mania that may not have otherwise occurred. Current diagnostic procedures rely solely on self-reported/observable symptoms, and thus alternative data sources, such as brain network properties, are needed to supplement current self-report/observation-based indices of risk for mania.

METHODS

Brain connectivity during affect maintenance/regulation was examined in a large (N = 249), medication-free sample of currently depressed patients with BD (n = 50) and MDD (n = 116) and healthy control subjects (n = 83). BD risk was categorized in a subset of patients with MDD. We used graph theory to identify emergent network properties that differentiated between patients with BD and MDD and between patients with MDD at high and low risk for BD.

RESULTS

BD and MDD differed in the extent to which the rostral anterior cingulate cortex was embedded in the local network, amount of influence the hippocampus exerted over global network communication, and clarity of orbitofrontal cortex communication. Patients with MDD at high risk for BD showed a pattern of local network clustering around the right amygdala that was similar to the pattern observed in healthy control subjects, whereas patients with MDD at low risk for BD deviated from this pattern.

CONCLUSIONS

BD and MDD differed in emergent network mechanisms subserving affect regulation, and amygdala properties tracked BD risk in patients with MDD. If replicated, our findings may be combined with other markers to assess the presence of BD and/or BD risk in individuals presenting with depressive symptoms to prevent the use of iatrogenic treatments.

Vortioxetine Induced Hypomania: A Case Presentation and Review of the Literature

Antidepressant-induced hypomania/mania is a complex issue that can be seen in mood disorders but is not clarified. There are case reports in the literature regarding vortioxetine-induced mania and hypomania; however, there is insufficient data. Here, we aim to present a case of vortioxetine-induced hypomania in a major depressive disorder patient who previously used various antidepressants but did not experience hypomania or mania. Our case is expected to contribute to the literature.

Black cohosh associated mania in a patient with unipolar depression

Black cohosh (actaea racemosa, cimicifuga racemosa) a popular complementary medicine, is commonly prescribed as an alternative drug to hormone replacement therapy for the treatment of menopause symptoms and menstrual pain. Studies on the black cohosh's psychological effects are generally focused on the perimenopausal depression and anxiety; and, its effects have been considered to be affiliated with its serotonergic and dopaminergic activities. We report a patient presenting with acute onset mania associated with black cohosh use, probably due to its psychopharmacological activities on serotonergic and dopaminergic receptors. We suggest that black cohosh must be used cautiously in the patients with history of unipolar depression or bipolar disorder.

A Review of Antidepressant-Associated Hypomania in Those Diagnosed with Unipolar Depression-Risk Factors, Conceptual Models, and Management

PURPOSE OF REVIEW

The nosology and management of antidepressant-associated hypomania (AAH) in the treatment of unipolar depression requires clarification. We sought to review recent studies examining AAH, focusing on risk factors, differing explanatory models, and management strategies.

RECENT FINDINGS

AAH occurs more frequently in those of female gender, younger age, and with a bipolar disorder (BP) family history. Depressive features (e.g., suicidal ideation, psychotic symptoms) in those with AAH were similar to those with established BPs. Explanatory models for AAH describe it as (i) a transient iatrogenic event, (ii) a specific "bipolar III" disorder, (iii) indicative of "conversion" to BP, (iv) acceleration of BP, and (v) coincidental and unrelated to antidepressant medication. Management recommendations include antidepressant cessation, atypical antipsychotic medications, or switching to a mood stabilizer. Determinants and management of AAH in the treatment of unipolar depression requires considerable clarification, likely to be achieved by close clinical review and refined research studies.

Looking for bipolarity in antidepressant discontinuation manic states: Update and diagnostic considerations of the phenomenon

BACKGROUND

Antidepressant withdrawal manic states are intriguing and under-recognized phenomena. The associated patho-physiological pathways are ill defined and the inclusion of the phenomena in the bipolar spectrum disorders is questionable. This study aims to update a review on antidepressant discontinuation manic states published in 2008 and to look for hints alluding to bipolar disorder in the affected published cases and in the literature. It also reviews the different hypotheses proposed to explain discontinuation mania.

METHODS

We searched Pubmed using the key words: 'antidepressant withdrawal' or 'antidepressant discontinuation' plus 'mania' or 'hypomania' from January 2008 until January 2018.

RESULTS

Five new eligible reports were identified since the last review in 2008, involving the antidepressants Amitriptyline, Fluoxetine, Escitalopram and Mirtazapine. Hypotheses involve the implication of Catecholamines, Acetylcholine and Serotonin in the pathophysiology of this paradoxical phenomenon. Careful analysis of the total 29 cases revealed psychiatric histories in favor of a bipolar spectrum disorder in 12 individuals while five were already known to have bipolar disorder.

LIMITATIONS

This review is based on case reports with associated recall bias, and lack of in-depth description at times.

CONCLUSIONS

Antidepressant discontinuation manic or hypomanic states do not occur randomly. An individual susceptibility to bipolar disorder must be considered.

Hypomania in clinical practice

Recent work suggests that a broad clinical spectrum of bipolar disorder is more common than previously thought and that the disorder may affect up to 5% of the population. The correct definition and diagnosis of hypomania is central to the identification of bipolar disorder. In this review we focus on recent diagnostic and clinical advances relating to bipolar disorder, with particular reference to hypomanic states. We also highlight some of the controversies in this field and discuss ways in which clinicians might improve their detection of bipolar disorders.

Dosage-related nature of escitalopram treatment-emergent mania/hypomania: a case series

OBJECTIVE

Several studies have documented that treatment with various antidepressant agents can result in mood switching during major depressive episodes. Escitalopram, one of the newer selective serotonin reuptake inhibitors (SSRIs), is considered preferable due to its relatively high efficacy and acceptability. Although a few cases of escitalopram treatment-emergent mania have been reported, it remains unknown whether this effect is dose-related.

METHOD

In the present report, we discuss three cases of treatment-emergent mania/hypomania in patients receiving escitalopram for major depressive episodes. No patients had a family or personal history of bipolar disorder.

RESULTS

In all three cases, manic or hypomanic symptoms emerged within 1 month right after the dosage of escitalopram was increased to 20 mg/day. Moreover, manic episodes subsided as the dosage of escitalopram was reduced. Mood switching was not observed after the cessation of escitalopram treatment.

CONCLUSION

Our case series indicates that escitalopram may induce treatment-emergent mania/hypomania in a dose-related manner. Treatment at lower doses and with careful upward titration might be favorable in certain patients with bipolar depression and major depressive disorder in order to minimize the risk of mood switching.

Diagnostic Conversion to Bipolar Disorder in Unipolar Depressed Patients Participating in Trials on Antidepressants

Objective

In unipolar depressed patients participating in trials on antidepressants, we investigated if illness characteristics at baseline could predict conversion to bipolar disorder.

Method

A long-term register-based follow-up study of 290 unipolar depressed patients with a mean age of 50.8 years (SD = 11.9) participating in three randomized trials on antidepressants conducted in the period 1985–1994. The independent effects of explanatory variables were examined by applying Cox regression analyses.

Results

The overall risk of conversion was 20.7%, with a mean follow-up time of 15.2 years per patient. The risk of conversion was associated with an increasing number of previous depressive episodes at baseline, [HR 1.18, 95% CI (1.10–1.26)]. No association with gender, age, age at first depressive episode, duration of baseline episode, subtype of depression or any of the investigated HAM-D subscales included was found.

Limitations

The patients were followed-up through the Danish Psychiatric Central Research Register, which resulted in inherent limitations such as possible misclassification of outcome.

Conclusion

In a sample of middle-aged hospitalized unipolar depressed patients participating in trials on antidepressants, the risk of conversion was associated with the number of previous depressive episodes. Therefore, this study emphasizes that unipolar depressed patients experiencing a relatively high number of recurrences should be followed more closely, or at least be informed about the possible increased risk of conversion.

Do antidepressants increase the risk of mania and bipolar disorder in people with depression? A retrospective electronic case register cohort study

OBJECTIVES

To investigate the association between antidepressant therapy and the later onset of mania/bipolar disorder.

DESIGN

Retrospective cohort study using an anonymised electronic health record case register.

SETTING

South London and Maudsley National Health Service (NHS) Trust (SLaM), a large provider of inpatient and community mental healthcare in the UK.

PARTICIPANTS

21,012 adults presenting to SLaM between 1 April 2006 and 31 March 2013 with unipolar depression.

EXPOSURE

Prior antidepressant therapy recorded in electronic health records.

MAIN OUTCOME MEASURE

Time to subsequent diagnosis of mania or bipolar disorder from date of diagnosis of unipolar depression, censored at 31 March 2014.

METHODS

Multivariable Cox regression analysis with age and gender as covariates.

RESULTS

The overall incidence rate of mania/bipolar disorder was 10.9 per 1000 person-years. The peak incidence of mania/bipolar disorder incidence was seen in patients aged between 26 and 35 years (12.3 per 1000 person-years). Prior antidepressant treatment was associated with an increased incidence of mania/bipolar disorder ranging from 13.1 to 19.1 per 1000 person-years. Multivariable analysis indicated a significant association with selective serotonin reuptake inhibitors (HR 1.34, 95% CI 1.18 to 1.52) and venlafaxine (1.35, 1.07 to 1.70).

CONCLUSIONS

In people with unipolar depression, antidepressant treatment is associated with an increased risk of subsequent mania/bipolar disorder. These findings highlight the importance of considering risk factors for mania when treating people with depression.

Clinical course of the bipolar II disorder in a Japanese sample

BACKGROUND

The bipolar II disorder has been recognized a mental disorder distinctive from the bipolar I disorder, showing the stability of diagnosis in prospective studies. However, the characterization of the bipolar II disorder still remains under investigation.

METHODS

The present study was conducted on consecutively admitted bipolar II inpatients diagnosed by DSM-IV-TR to delineate the clinical features.

RESULTS

The types of initial mood disorders of the bipolar II inpatients were divided into four groups, i.e., major depressive episode (MDE), hypomanic episode (HME), and dysthymic and cyclothymic disorders. Seventy-one percent of all the patients belonged to the MDE group, a half of which underwent the first HME following the first MDE. The number of patients that exhibited the HME within one year after the first MDE was the highest in a widely distributed interval of years between the first MDE and the first HME. The cyclothymic disorder group was relatively young at the onset and was more prone to attempt suicide. Moreover, there might be a complex connection with other psychiatric disorders, such as anxiety disorders, in the longitudinal course of the bipolar disorder.

LIMITATION

The present study was carried out on a limited number of patients admitted to one hospital. The data are partly based on the retrospective information from the patients and their relatives. The generalization of the results requires further studies.

CONCLUSION

The bipolar II disorder could be divided into heterogeneous groups in the longitudinal course. Hence, paying attention to the heterogeneity in clinical practice and a study of the disorder are required.

A neurobiological hypothesis of treatment-resistant depression - mechanisms for selective serotonin reuptake inhibitor non-efficacy

First-line treatment of major depression includes administration of a selective serotonin reuptake inhibitor (SSRI), yet studies suggest that remission rates following two trials of an SSRI are <50%. The authors examine the putative biological substrates underlying "treatment resistant depression (TRD)" with the goal of elucidating novel rationales to treat TRD. We look at relevant articles from the preclinical and clinical literature combined with clinical exposure to TRD patients. A major focus was to outline pathophysiological mechanisms whereby the serotonin system becomes impervious to the desired enhancement of serotonin neurotransmission by SSRIs. A complementary focus was to dissect neurotransmitter systems, which serve to inhibit the dorsal raphe. We propose, based on a body of translational studies, TRD may not represent a simple serotonin deficit state but rather an excess of midbrain peri-raphe serotonin and subsequent deficit at key fronto-limbic projection sites, with ultimate compromise in serotonin-mediated neuroplasticity. Glutamate, serotonin, noradrenaline, and histamine are activated by stress and exert an inhibitory effect on serotonin outflow, in part by "flooding" 5-HT1A autoreceptors by serotonin itself. Certain factors putatively exacerbate this scenario - presence of the short arm of the serotonin transporter gene, early-life adversity and comorbid bipolar disorder - each of which has been associated with SSRI-treatment resistance. By utilizing an incremental approach, we provide a system for treating the TRD patient based on a strategy of rescuing serotonin neurotransmission from a state of SSRI-induced dorsal raphe stasis. This calls for "stacked" interventions, with an SSRI base, targeting, if necessary, the glutamatergic, serotonergic, noradrenergic, and histaminergic systems, thereby successively eliminating the inhibitory effects each are capable of exerting on serotonin neurons. Future studies are recommended to test this biologically based approach for treatment of TRD.

Treatment and outcome of antidepressant treatment-associated hypomania in unipolar major depression: a 3-year follow-up study

BACKGROUND

The main aim of this study was to propose a standardized acute and maintenance/continuation treatment protocol for acute antidepressant treatment-associated hypomania (AAH) in major unipolar depression. The second objective was to describe outcomes at three-year follow-up in a cohort of patients with AAH who had been included in this standardized therapeutic protocol.

METHODS

The study consisted of two distinct prospective phases: a 1-year follow-up first phase in which all consecutive patients with a diagnosis of moderate/severe unipolar depressive disorder received acute and continuation/maintenance antidepressant treatment; and a second phase, in which patients who had suffered AAH during the first phase were admitted to a 3-year follow-up with the authors-designed standardized acute and continuation/maintenance treatment protocol.

RESULTS

In our patient sample, the reintroduction of antidepressant treatment according to the proposed protocol was not accompanied by new AAH episodes following 11-36 months of pharmacological antidepressant treatment. The second notable result was that no subject presented manic episodes or spontaneous hypomania (once antidepressant maintenance treatment had finished) during three years of follow-up.

LIMITATIONS

We should be cautious when generalizing these results to patients with mild major depressive episode or other type of unipolar affective disorder.

CONCLUSIONS

Based on these results, we should not refuse the prescription of antidepressant drugs to patients with unipolar depression and subsequent AAH. The treatment protocol which we describe in this study can serve as a basis for future studies and, in anticipation of future consensus, as a practical proposal for clinical psychiatrists.

Differences in Affective Temperaments in Anxiety Disorders: Comparison of Panic Disorder and Obsessive Compulsive Disorder

INTRODUCTION

In this study, probable differences in affective temperament among anxiety disorders were investigated via a comparison of panic disorder (PD) and obsessive-compulsive disorder (OCD).

METHOD

44 patients with OCD and 42 patients with PD, who were admitted to Bakirkoy Prof. Dr. Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery outpatient clinics with complaints of OCD and PD and were diagnosed according to DSM IV criteria, were consecutively included in the study after informed consent was taken. A sociodemographic form, the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I), Hamilton Depression Rating Scale (HAM-D), Beck Anxiety Inventory, Panic and Agoraphobia Scale, Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the temperament evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) were given to the patients. PD and OCD patients were compared in terms of affective temperament characteristics.

RESULTS

Mean age, educational status and gender distribution of OCD and PD patients were similar (p>0.05). Dominant depressive temperament was more prominent in OCD group than in PD group (p=0.021). Hyperthymic temperament scores were higher in PD group than in OCD group (p=0.002). Dominant hyperthymic temperament was not encountered in either group.

CONCLUSION

Dominant depressive temperament was more prominent in OCD group whereas hyperthymic temperament scores were higher in PD group. These findings should be evaluated in studies with larger sample sizes.

Is antidepressant-associated mania always an evidence of a bipolar spectrum disorder? A case report and review of the literature

OBJECTIVE

The authors consider the clinical implications of characterizing every case of antidepressant-induced mania as evidence of an underlying bipolar diathesis.

METHOD

The authors report the case of a 45-year-old man, with no personal or family history of bipolar symptoms, who developed manic symptoms after sertraline initiation for a first lifetime depressive episode.

RESULTS

The patient's manic symptoms resolved rapidly with cessation of sertraline. His depressive symptoms responded to mirtazapine, and he had no further mood episodes during 2-year follow-up.

DISCUSSION

It may not always be appropriate to identify selective serotonin reuptake inhibitor-induced manic symptoms as pathognomonic for the bipolar diathesis, particularly as the bipolar formulation has distinct implications for future pharmacologic choices.

Sensation seeking in major depressive patients: relationship to sub-threshold bipolarity and cyclothymic temperament

BACKGROUND

High levels of sensation seeking (SS) have been traditionally reported for lifetime bipolar disorder (BD) and/or substance use disorder (SUD) rather than major depressive disorder (MDD). Nonetheless, a renewed clinical attention toward the burden of sub-threshold bipolarity in MDD, solicits for a better assessment of "unipolar" major depressive episodes (MDEs) via characterization of putative differential psychopathological patterns, including SS and predominant affective temperament.

METHODS

Two hundred and eighty currently depressed cases of MDD and 87 healthy controls were screened using the Zuckerman's sensation seeking scale-Form-V, the Hypomania Check List-32-item (HCL-32), the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto-questionnaire-110-item, the Barratt Impulsivity Scale-11-item, the State-Trait Anxiety Inventory modules and the Structured Clinical Interview for DSM-IV axis-I disorders. Cases were divided into HCL-32(+)(sub-threshold bipolar)/HCL-32(-)("true" unipolar depressed) depending on the HCL-32 total score.

RESULTS

Upon correlation and multivariate regression analyses, the HCL-32(+) patients showed the highest levels of SS, higher prevalence of cyclothymic temperament, and higher rates of multiple lifetime axis-I co-morbidities, including SUD.

LIMITS

Recall bias on some diagnoses, including BD, grossly matched healthy control group, lack of ad-hoc validated measures for ADHD, SUD, or axis-II disorders.

CONCLUSIONS

In our sample, the occurrence of higher levels of SS in "sub-threshold" bipolar cases outlined a differential psychopathological profile compared to DSM-defined "true unipolar" cases of MDE. If confirmed by replication studies, these findings may aid clinicians in delivering a more accurate diagnosis and a safer use of antidepressants in some MDD cases.

Could the underestimation of bipolarity obstruct the search for novel antidepressant drugs?

INTRODUCTION

Despite the clinical and social relevance of depression, and the availability of numerous antidepressants and non-pharmacological interventions, response rates remain unsatisfactory and novel therapeutic targets are being explored.

AREAS COVERED

This review starts with a brief overview of the evolution of the current antidepressant drug scenario and ends with a focus on the potential influence of the underestimation of bipolarity on the exploration of novel antidepressant drugs.

EXPERT OPINION

The field of antidepressant drug development has suffered from a relative decline recently and, with the exception of agomelatine, innovative non-monoaminergic antidepressants have yet to be developed. The need for more effective compounds is evident. Clinicians and researchers should pay greater attention to the impact of bipolarity in depression. The ultimate goal of this review is not to discourage the use of antidepressants but rather to encourage judicious prescriptions, and also to solicit a better collaboration between clinicians and preclinical researchers so that more reliable diagnostic criteria can be adopted.

Depression across mood disorders: review and analysis in a clinical sample

OBJECTIVES

In this article we aimed to: (1) review literature concerning the clinical and psychopathologic characteristics of Bipolar (BP) depression; (2) analyze an independent sample of depressed patients to identify any demographic and/or clinical feature that may help in differentiating mood disorder subtypes, with special attention to potential markers of bipolarity.

METHODS

A sample of 291 depressed subjects, including BP -I (n = 104), BP -II (n = 64), and unipolar (UP) subjects with (n = 53) and without (n = 70) BP family history (BPFH), was examined to evidence potential differences in clinical presentation and to validate literature-derived markers of bipolarity. Demographic and clinical variables and, also, single items from the Hamilton Depression Rating Scale (HDRS), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Young Mania Rating Scale (YMRS) were compared among groups.

RESULTS

UP subjects had an older age at onset of mood symptoms. A higher number of major depressive episodes and a higher incidence of lifetime psychotic features were found in BP subjects. Items expressing depressed mood, depressive anhedonia, pessimistic thoughts, and neurovegetative symptoms of depression scored higher in UP, whereas depersonalization and paranoid symptoms' scores were higher in BP. When compared with UP, BP I had a significantly higher incidence of intradepressive hypomanic symptoms. Bipolar family history was found to be the strongest predictor of bipolarity in depression.

CONCLUSIONS

Overall, our findings confirm most of the classical signs of bipolarity in depression and support the view that some features, such as BPFH, together with some specific symptoms may help in detecting depressed subjects at higher risk for BP disorder.

Factors associated with the course of symptoms in bipolar disorder during a 1-year follow-up: depression vs. sub-threshold mixed state

BACKGROUND

Mixed mood states, even in their sub-threshold forms, may significantly affect the course and outcome of bipolar disorder (BD).

AIM

To compare two samples of BD patients presenting a major depressive episode and a sub-threshold mixed state in terms of global functioning, clinical outcome, social adjustment and quality of life during a 1-year follow-up.

METHODS

The sample was composed by 90 subjects (Group 1, D) clinically diagnosed with a major depressive episode and 41 patients (Group 2, Mx) for a sub-threshold mixed state. All patients were administered with a pharmacological treatment and evaluated for depressive, anxious and manic symptoms by common rating scales. Further evaluations included a global assessment of severity and functioning, social adjustment and quality of life. All evaluations were performed at baseline and after 1, 3, 6 and 12 months of treatment.

RESULTS

The two groups were no different for baseline as well as improvement in global severity and functioning. Though clearly different for symptoms severity, the amount of change of depressive and anxiety symptoms was also no different. Manic symptoms showed instead a trend to persist over time in group 2, whereas a slight increase of manic symptoms was observed in group 1, especially after 6 months of treatment. Moreover, in group 1, some manic symptoms were also detected at the Young Mania Rating Scale (n = 24, 26.6%). Finally, improvement in quality of life and social adjustment was similar in the two groups, though a small trend toward a faster improvement in social adjustment in group 1.

CONCLUSIONS

Sub-threshold mixed states have a substantial impact on global functioning, social adjustment and subjective well-being, similarly to that of acute phases, or at least major depression. In particular, mixed features, even in their sub-threshold forms, tend to be persistent over time. Finally, manic symptoms may be still often underestimated in depressive episodes, even in patients for BD.

Antidepressant-associated mania or hypomania: a comparison with personality and bipolarity features of bipolar I disorder

BACKGROUND

Hypomania/mania during antidepressant treatment is often neglected by clinicians. There are no specific diagnostic criteria for hypomania and mania associated by antidepressant treatment in the bipolar spectrum. The aim of this study is to compare various characteristics of bipolar I disorder and antidepressant-associated mania.

METHOD

In this study, 76 bipolar patients who met DSM-IV criteria for bipolar disorder-type I in remission from mania or depression (Group 1; n = 44) and patients with major depression in remission, who had mania associated by antidepressant treatment (Group 2; n = 32), were admitted. All patients were assessed using the SCID I, Bipolarity Index (BI) and a patient data form. First-degree relatives of all patients were evaluated using the Mood Disorder Questionnaire (MDQ).

RESULTS

Sociodemographic features of both groups were similar. The rate of major depression in the relatives of Group 2 was significantly higher than in Group 1. The severity of manic symptoms in Group 2 was significantly lower than in Group 1. Those in Group 2 who were diagnosed with their first episode had atypical depressive features. First-degree relatives of patients in Group 1 had higher positive scores on the MDQ. A statistically significant difference was found between the two groups on all dimensions of the BI except family history.

LIMITATIONS

This is a cross-sectional study with a relatively small number of subjects. There is no control group of major depressive patients who did not develop mania during antidepressive treatment.

CONCLUSIONS

Our results suggest that antidepressant-associated hypomania/mania could be a different subgroup in the bipolar spectrum.

Treatment-induced manic switch in the course of unipolar depression can predict bipolarity: cluster analysis based evidence

BACKGROUND

Antidepressants are known to induce manic switch in patients with depression. Treatment-induced mania is not considered as bipolar disorder in DSM IV. The aim of this study was to assess whether clinical characteristics of patients with unipolar depression with a history of treatment-induced mania were similar to those of patients with bipolar disorder.

METHOD

The study included 217 consecutive patients with DSM-IV mood disorders, diagnosed as: bipolar disorder type I (BP-I, n = 58) or type II (BP-II, n = 18) whose first episodes were depression, recurrent (unipolar) major depressive disorder with a history of antidepressant treatment-induced mania (switchers = sUD; n = 61) and without such an event (rUD; n = 80). First, the groups were compared with regard to clinical features and course specifiers using variance and chi-square analysis. Variables that differed significantly between the four groups were included in two-step cluster analysis to explore naturally occurring subgroups in all diagnoses. Subsequently, the relationship between the naturally occurring clusters and pre-defined DSM-IV diagnoses were investigated.

RESULTS

Two-step cluster analysis revealed two different naturally occurring groups. Higher severity of depressive episodes, with higher rate of melancholic features, higher number of hospitalization and suicide attempts were represented in one cluster where switchers (77%), bipolar I (94.8%) and II (83.3%) patients clustered together.

CONCLUSION

The findings of this study confirm that treatment-induced mania is a clinical phenomenon that belongs within the bipolar spectrum rather than a coincidental treatment complication, and that it should be placed under "bipolar disorders" in future classification systems.

LIMITATIONS

The study includes the limitations of any naturalistic retrospective study.

Subthreshold hypomanic symptoms in progression from unipolar major depression to bipolar disorder

OBJECTIVE

The authors assessed whether subthreshold hypomanic symptoms in patients with major depression predicted new-onset mania or hypomania.

METHOD

The authors identified 550 individuals followed for at least 1 year in the National Institute of Mental Health Collaborative Depression Study with a diagnosis of major depression at intake. All participants were screened at baseline for five manic symptoms: elevated mood, decreased need for sleep, unusually high energy, increased goal-directed activity, and grandiosity. Participants were followed prospectively for a mean of 17.5 years and up to 31 years. The Longitudinal Interval Follow-up Examination was used to monitor course of illness and to identify any hypomania or mania. The association of subthreshold hypomanic symptoms at baseline with subsequent hypomania or mania was determined in survival analyses using Cox proportional hazards regression.

RESULTS

With a cumulative probability of one in four on survival analysis, 19.6% (N=108) of the sample experienced hypomania or mania, resulting in revision of diagnoses for 12.2% to bipolar II disorder and 7.5% to bipolar I disorder. Number of subthreshold hypomanic symptoms, presence of psychosis, and age at illness onset predicted progression to bipolar disorder. Decreased need for sleep, unusually high energy, and increased goal-directed activity were specifically implicated.

CONCLUSIONS

Symptoms of hypomania, even when of low intensity, were frequently associated with subsequent progression to bipolar disorder, although the majority of patients who converted did not have any symptoms of hypomania at baseline. These results suggest that continued monitoring for the possibility of progression to bipolar disorder is necessary over the long-term course of major depressive disorder.

Is unrecognized bipolar disorder a frequent contributor to apparent treatment resistant depression?

BACKGROUND

There is widespread clinical belief that unrecognized bipolar disorder (BD) is a frequent contributor to apparent treatment resistant depression (TRD). This review attempts to assess the degree to which prevailing empirical data supports that view.

METHODS

All English-language articles published between January 1998 and January 2008 that focused on adults with major depressive disorder (MDD) and BD bearing on the question "Is unrecognized BD a frequent contributor to apparent TRD in patients initially diagnosed with MDD?" were reviewed.

RESULTS

196 articles were reviewed; the preponderance of the data suggested: 1) TRD populations demonstrate high rates of hidden bipolar disorder, 2) there is not sufficient evidence to unequivocally support or reject the hypothesis that patients who relapse despite continued antidepressant treatment are likely to have bipolar spectrum disorder, 3) patients initially diagnosed with MDD do not demonstrate high rates of switching to mania or hypomania when treated with antidepressants and 4) in patients diagnosed with BD, antidepressants are not robustly effective and are poorly tolerated.

LIMITATIONS

The main limitation of this review is that none of the individual studies were designed to test our primary hypothesis.

CONCLUSIONS

This review provides at least moderate support to the hypothesis that BD is a contributor to apparent TRD. Thus, clinicians treating MDD are urged to search for "soft" signs of bipolarity and to be prepared to alter diagnosis and treatment strategies accordingly.

Mania possibly induced by desvenlafaxine

A case is presented of the occurrence of an episode of mania apparently induced by desvenlafaxine, in a patient with a history of major depressive disorder and no apparent history of previous mania or hypo-mania. To our knowledge, this is the first such documented case with this new antidepressant. The discussion focuses on the concept of the bipolar spectrum, and how to view patients who have only become manic while taking antidepressants.

Where should bipolar disorder appear in the meta-structure?

BACKGROUND

The extant major psychiatric classifications, DSM-IV and ICD-10, are purportedly atheoretical and largely descriptive. Although this achieves good reliability, the validity of a medical diagnosis is greatly enhanced by an understanding of both risk factors and clinical history. In an effort to group mental disorders on the basis of risk factors and clinical manifestations, five clusters have been proposed. The purpose of this paper is to consider the position of bipolar disorder (BPD), which could be either with the psychoses, or with emotional disorders, or in a separate cluster.

METHOD

We reviewed the literature on BPD, unipolar depression (UPD) and schizophrenia in relation to 11 validating criteria proposed by the DSM-V Task Force Study Group, and then summarized similarities and differences between BPD and schizophrenia on the one hand, and UPD on the other.

RESULTS

There are differences, often substantial and never trivial, for 10 of the 11 validators between BPD and UPD. There are also important differences between BPD and schizophrenia.

CONCLUSION

BPD has previously been classified together with UPD, but this is the least justifiable place for it. If it is to be recruited to a 'psychotic cluster', there are several important respects in which it differs from schizophrenia, so the cluster would have a division within it. The alternative would be to allow it to be in an intermediate position in a cluster of its own.

Duloxetine-induced hypomania: case report and brief review of the literature on SNRIs-induced mood switching

Manic switching during antidepressant treatment has been reported with every class of antidepressant drugs. Serotonin-noradrenaline reuptake inhibitors (SNRIs) have been increasingly used for the treatment of unipolar and bipolar depression and are well tolerated and sufficiently effective because of their dual mechanism of action. A case of duloxetine-induced hypomania in a non-bipolar patient is presented, and a brief review of all cases of SNRIs' induced mania and hypomania has been carried out. The available data suggest that SNRIs, especially venlafaxine, can induce mood switching in patients with bipolar depression and in certain patients with unipolar depression, but the potential of duloxetine and milnacipran to induce manic or hypomanic symptoms cannot be disregarded. Switching appears to be dose-related and treatment initiation with lower doses and upward titration when needed may be preferable in selected cases and may help minimizing the risk of mood switching.

Sub-threshold manic symptoms in recurrent major depressive disorder are a marker for poor outcome

OBJECTIVE

A small but significant proportion of patients with major depressive disorder (MDD) report mild manic symptoms which are below the diagnostic threshold for a hypomanic episode.

METHOD

We tested for an association between sub-threshold manic symptoms and clinical outcome in almost 600 patients with recurrent MDD who also had no known family history of bipolar disorder.

RESULTS

9.6% of this large sample had a life-time history of sub-threshold manic symptoms. These patients were significantly more likely to have a history of poor response to antidepressants (OR 2.84; 95% CI 1.23-6.56; P < 0.02) and more likely to have experienced psychosis (OR 2.07; 95% CI 1.05-4.09; P < 0.04). They had also experienced more depressive episodes on average (P = 0.006) and were more likely to have been admitted to hospital (P < 0.03).

CONCLUSION

Sub-threshold manic symptoms in patients with recurrent MDD may be a useful clinical marker for poor response to antidepressants and a more morbid long-term clinical course.

Early intervention in bipolar disorders: clinical, biochemical and neuroimaging imperatives

In the absence of clear targets for primary prevention of many psychiatric illnesses, secondary prevention becomes the most feasible therapeutic target, and is best encompassed by the concept of early intervention. This construct encompasses the goals of minimising diagnostic delay and the prompt initiation of clinically appropriate therapy. This paper develops the rationale for early intervention in bipolar disorder. Three interrelated themes are discussed; the clinical data supporting the value of prompt diagnosis and treatment in bipolar disorder, the putative biochemical mechanisms underlying the pathophysiological processes, and the parallel concept of neuroprotection, and the developing neuroimaging data that supports early intervention. Early initiation of appropriate therapy may potentially facilitate improved clinical outcomes, and further might allow the secondary prevention of the sequelae of untreated illness, which include the deleterious impact on family relationships, psychosexual and vocational development, identity and self-concept and self-stigma.

The role of 5-HTTLPR polymorphism in antidepressant-associated mania in bipolar disorder

BACKGROUND

The occurrence of mania during antidepressant treatment is a key issue in the clinical management of bipolar disorder (BD). The serotonin transporter gene is a candidate to be associated with antidepressant-associated mania (AAM) in some patients. This gene has a polymorphism within the promoter region (5-HTTLPR) with two allelic forms, the long (L) and the short (S) variants.

METHODS

We performed a case-control study to compare 5-HTTLPR genotype and allelic frequencies between 43 patients with a DSM-IV diagnosis of BD, with at least one manic/hypomanic episode associated with treatment with proserotonergic antidepressants (AAM+) and 69 unrelated, matched bipolar patients, who had been exposed to proserotonergic antidepressants without development of manic symptoms (AAM-(*)). Furthermore, we performed this comparison between a subgroup of 23 AAM+ patients that, when they presented AAM, were not using mood stabilizer (AAM+(*)) and 25 AAM- patients who used antidepressant without the concomitant use of a mood stabilizer (AAM-(*)). 5-HTTLPR genotyping was performed using PCR.

RESULTS

No significant differences were found between AAM+ and AAM-. Within the subgroups, our results show that S-carriers (LS+SS Genotypes) are more prone to make a manic/hypomanic episode associated with antidepressant (P=0.017).

LIMITATIONS

Our study is retrospective.

CONCLUSIONS

The 5-HTTLPR polymorphism may be considered a predictor of abnormal response to antidepressant in patients with BP, but this action is influenced by the presence of a mood stabilizer. Such observations reinforce that a correct diagnosis of bipolarity before the beginning of the treatment is essential, mainly for S-carriers patients.

Treatment-emergent mania/hypomania during antidepressant monotherapy in patients with rapid cycling bipolar disorder

OBJECTIVE

To study treatment-emergent mania/hypomania (TEM) associated with second-generation antidepressant monotherapy in patients with rapid cycling bipolar disorder (RCBD).

METHODS

Data of patients with RCBD (n = 180) enrolled into two clinical trials were used to study the risk for TEM during second-generation antidepressant monotherapy. History of TEM was retrospectively determined at the initial assessment by asking patients whether they were exposed to second-generation antidepressants and if a hypomania/mania episode emerged during the first four weeks of treatment. Data were analyzed using t-test, chi-square, and logistic regression.

RESULTS

Of the 180 patients (bipolar I disorder, n = 128; bipolar II disorder, n = 52) with RCBD, 85% (n = 153) had at least one antidepressant treatment. Among these patients, 94.1% (144/153) had at least one antidepressant monotherapy treatment. Overall, 49.3% of patients had at least one TEM and 29.1% (116/399) of treatment trials were associated with TEM. In regression analysis, an inverse association between the number of mood episodes in the last 12 months and TEM was observed with an odds ratio of 0.9. However, gender, bipolar subtype, a lifetime history of comorbid anxiety disorder, substance use disorder, or psychosis, and age of mood disorder onset were not associated with TEM. For individual antidepressants, the rates of TEM varied from 42.1% for fluoxetine to 0% for fluvoxamine and mirtazapine. As a group, there was no difference between selective serotonin reuptake inhibitors and venlafaxine or bupropion in the incidence of TEM.

CONCLUSIONS

Use of second-generation antidepressants as monotherapy in RCBD is accompanied by clinically relevant rates of TEM. Even in patients with RCBD, differential vulnerabilities to antidepressant TEM may exist.

Antidepressant-induced hypomania in treatment-resistant depression

OBJECTIVE

The authors propose that isolated treatment-associated hypomanic episodes in patients with chronic treatment-resistant major depressive disorder are not indicative of true bipolar depression. This proposal is in contrast to most studies that support the notion that antidepressant-induced hypomania reflects an underlying bipolar condition in such depressed patients. However, the patients described in the literature have not had treatment-resistant depression.

METHOD

Records of 146 patients with treatment-resistant major depression seen at a university-based tertiary referral center were reviewed for evidence of treatment-associated mania or hypomania. Treatment histories, clinical characteristics, and family histories of these patients were assessed.

RESULTS

Of the 146 patients, 16 patients had evidenced treatment-induced hypomania or hypomanic-like episodes. The number of antidepressant trials these patients had received ranged from 2 to 13. The hypomanic episodes did not occur with the first antidepressant treatment trial except in one patient. All of the 16 patients had antidepressant treatment trials subsequent to the trial during which they experienced hypomania, but only one of them experienced further episodes of hypomania. In addition, only 1 of the 16 patients had a family history of bipolar disorder, a rate of bipolar family history that is considerably less than we have found among bipolar patients.

CONCLUSION

These findings support the concept of antidepressant-induced hypomania presented in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, revised (DSM-IV-TR). However, we argue that this term should be restricted to patients with chronic treatment-resistant major depression who infrequently evidence mania or hypomania.

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

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

The interface between borderline personality disorder and bipolar spectrum disorders

OBJECTIVE

This review examines whether borderline personality disorder (BPD) should be considered part of the bipolar spectrum.

METHODS

A literature review examined studies of co-occurrence, phenomenology, family prevalence, medication response, longitudinal course, and etiology.

RESULTS

Borderline personality disorder and bipolar disorder co-occur, but their relationship is not consistent or specific. There are overlaps but important differences in phenomenology and in medication response. Family studies suggest clear distinctions, and it is unusual for BPD to evolve into bipolar disorder. Research is insufficient to establish whether these disorders have a common etiology.

CONCLUSIONS

Existing data fail to support the conclusion that BPD and bipolar disorders exist on a spectrum but allows for the possibility of partially overlapping etiologies.

Manic/hypomanic switch during acute antidepressant treatment for unipolar depression

A significant proportion of patients with unipolar depression clinically develop manic or hypomanic switch during acute antidepressant treatment. Elucidation of its prevalence and predicting factors is of clinical relevance during acute antidepressant treatment of such patients. We retrospectively studied patients with unipolar depression who were admitted to our department during the 6-year period from 1997 to 2002 and who had fewer than 3 previous episodes before admission. The clinical background of the consecutive patients with manic/hypomanic switch (n = 37) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria was compared with that of patients without manic/hypomanic switch (n = 245). The prevalence rate of manic/hypomanic switch was 13.1%. The switch group was composed of 23 men and 14 women, whose average age was 48.8 +/- 12.3 years (range, 26-78 years). Manic/hypomanic switch was most frequently observed between 2 and 3 weeks after the antidepressant was increased to the ongoing dose. Antidepressants were decreased in 13 patients and discontinued in 23. Manic/hypomanic episodes lasted from 1 to 8 weeks. The patients in the switch group included a greater proportion of male subjects and had a higher frequency of family history of bipolar disorders than those in the nonswitch group. The mean doses of antidepressants were not significantly different between these groups. The higher frequency of manic/hypomanic switch occurring around the period when antidepressants begin to show clinical effects and the higher frequency of family history of bipolar disorders might suggest a biological susceptibility to antidepressants in patients of the switch group.

Bipolar depression: issues in diagnosis and treatment

Although bipolar affective disorder is defined by the history of manic or hypomanic episodes, depression is arguably a more important facet of the illness. Depressive episodes, on average, are more numerous and last longer than manic or hypomanic episodes, and most suicides occur during these periods. Misdiagnosis of major depressive disorder delays initiation of appropriate therapy, further worsening prognosis. Distinguishing features of bipolar depression include earlier age of onset, a family history of bipolar disorder, presence of psychotic or reverse neurovegetative features, and antidepressant-induced switching. Bipolar I depressions should initially be treated with a mood stabilizer (carbamazapine, divalproex, lamotrigine, lithium, or an atypical antipsychotic); antidepressant monotherapy is contraindicated. More severe or "breakthrough" episodes often require a concomitant antidepressant, such as bupropion or a selective serotonin reuptake inhibitor (SSRI). The first treatment specifically approved for bipolar depression is a combination of the SSRI fluoxetine and the atypical antipsychotic olanzapine. For refractory depressive episodes, venlafaxine, the monoamine oxidase inhibitor tranylcypromine, and ECT are most widely recommended. The optimal duration of maintenance antidepressant therapy has not been established empirically and, until better evidence-based guidelines are established, should be determined on a case-by-case basis.

Is treatment-associated hypomania rare with duloxetine: secondary analysis of controlled trials in non-bipolar depression

BACKGROUND

Selective serotonin (5-HT) and norepinephrine (NE) reuptake inhibitors (SNRIs) like duloxetine have the efficacy of tricyclic antidepressants (TCAs) with a more tolerable side-effect profile. Bipolar disorder is often undetected, with the most common misdiagnosis being unipolar depression. Studies have suggested that treatment of bipolar and unipolar depression with heterocyclic TCAs may increase the risk of switch rate to mania. Studies of antidepressants in unipolar major depression show a small risk of mania or hypomania, presumably because some bipolar depressives were mistakenly studied. This study investigated the rate of hypomania, mania, and hypomanic-like symptoms observed during treatment with duloxetine in patients with major depression.

METHODS

This was a retrospective analysis of data from eight placebo-controlled, double-blind, randomized clinical trials of duloxetine in patients with non-bipolar major depression.

LIMITATIONS

The studies were of limited duration. Manic or hypomanic symptoms were not elicited using standardized mania rating scale instruments.

RESULTS

One case of mania occurred in the placebo group (0.1%), and two cases of hypomania were observed in the duloxetine-treated group (0.2%). Among hypomanic-like symptoms, only insomnia was significantly higher in the duloxetine group than in the placebo group (p<0.05).

CONCLUSIONS

Duloxetine was associated with a low incidence of treatment-emergent hypomania, mania, or hypomanic-like symptoms in patients with major depressive disorder (MDD). The low incidence reported here may be due to greater diagnostic diligence on the part of the investigators. It is possible that the cases reported likely reflect inclusion of misdiagnosed bipolar II patients rather than true unipolar MDD cases. The effect of duloxetine in patients with bipolar depression is not known.

Bipolar II disorder: an overview of recent developments

OBJECTIVE

Recent research on the epidemiology, clinical course, diagnosis, and treatment of bipolar II disorder (BD II) stands to have a considerable impact on clinical practice. This paper reviews these developments.

METHOD

We conducted a Pubmed search, focusing on the period from January 1, 1994, to August 31, 2004. Articles deemed directly relevant to the epidemiology, course, diagnosis, and management of BD II were considered.

RESULTS

The prevalence of BD II is likely higher than previously suggested. Systematic probing for particular clinical features and use of screening tools allow for a more timely and accurate detection of the disorder. There is a paucity of good quality data to guide clinicians treating BD II.

CONCLUSION

Significant progress has been made in clarifying diagnostic and treatment issues in BD II. Neither strong nor broad treatment recommendations can be made; a cautious interpretation of available data suggests that lithium or lamotrigine are fairly reasonable first-line choices. More well-designed studies with larger samples are needed to improve the evidence base for managing this disorder.

Transtorno bipolar de início tardio: uma variedade orgânica do transtorno de humor?

Transtorno bipolar (TB) é comumente associado à fase final da adolescência ou idade adulta jovem, embora em uma proporção substancial dos pacientes a doença comece em fases mais tardias da vida. Os resultados de várias investigações clínicas sugerem que casos de transtorno bipolar com início tardio têm, mais freqüentemente, uma "causa orgânica" e que isso justificaria a subdivisão do transtorno bipolar entre "início precoce" e "início tardio". Este artigo revê a literatura sobre a hipótese orgânica do transtorno bipolar de início tardio e conclui que essa subdivisão é artificial e carece de suporte clínico e epidemiológico.