Special considerations in treating bipolar disorder in women

Effect of social media on body image of pregnant and postpartum women in India

In the present times, there is a high influence caused by social media platforms in case of body image issues faced by an individual. Pregnancy is a stage for women where they go through several mental and physical changes. Realizing the inseparable role played by social media in this aspect, it is an attempt here to determine the effect caused by social media on the body image of pregnant women as well for those in their post-partum stages. The PRISMA method is used by the authors to arrive at 55 research papers from the Scopus databases that are systematically reviewed. The authors' review reveals that social media can have both negative and positive effects on women's perception of body image during pregnancy and the postpartum period.

"Women as Troublemakers": The Hard Sociopolitical Context of Soft Bipolar Disorder in Iran

Gender differences in the prevalence of psychiatric disorders, with higher prevalence of mood and anxiety disorders among women, have been the focus of much debate. In Iran, the adoption of the construct of Bipolar Spectrum Disorder (BSD) and of the concept of "soft bipolarity" has been associated with a large gender difference in rates of diagnosis. This paper discusses the gendered meanings of the diagnosis of BSD in Iran. In this qualitative study, we conducted 25 in-depth semi-structured interviews with prominent psychiatrists and university professors (7 female and 18 male) at six different universities in Iran and 37 in-depth semi-structured interviews with patients (23 female and 14 male, 18-55 years of age) who had received bipolar spectrum disorder diagnosis and treatment, excluding Bipolar I. Findings suggest that the high rate of diagnosis of bipolar spectrum disorder (i.e., subthreshold or soft bipolar disorder) among women in Iran is influenced by gender, sociocultural, political, and economic factors, as well as the diagnostic practices of biomedical psychiatry. The dominant biological psychiatry system in Iran has led many psychiatrists to frame sociopolitically and culturally rooted forms of distress in terms of biomedical categories like soft bipolarity and to limit their interventions to medication. This bioreductionist approach silences the voices of vulnerable groups, including those of women, and marginalizes discussions of problematic institutional and social power. To understand the preference for biomedical explanations, we need to consider not only the economic interests at play in the remaking of human identity in terms of biological being and the globalization of biological psychiatry, but also the resistance to addressing the sociocultural, political, and economic determinants of women's mental suffering in particular contexts.

Self-Reported Low Lithium Adherence Among Chinese Patients with Bipolar Disorder in Shenzhen: A Cross-Sectional Study

BACKGROUND

Lithium has been widely used to treat bipolar disorder (BD), although its adherence is rarely reported in China. This study aimed to explore the rate of lithium adherence and its associated factors in patients with BD, which has rarely been reported in China.

METHODS

We conducted a cross-sectional study among patients in Shenzhen Mental Health Center (Shenzhen Kangning Hospital), who were aged 12 years or above, were diagnosed with BD based on the International Classification of Diseases, tenth edition (ICD-10), and had been on lithium for at least 1 month. We collected information on sociodemographic and clinical characteristics and on knowledge about and attitudes toward lithium. We also investigated patients' concerns while taking lithium and where they can and wish to obtain information on lithium.

RESULTS

Of the 244 enrolled patients and 221 patients aged 18 years or older, 52% and 50% disclosed low adherence to lithium, respectively. Factors associated with poor lithium adherence were a younger age (odds ratio (OR): 0.962, 95% confidence interval (CI): 0.933-0.992), female sex (OR: 2.171, 95% CI: 1.146-4.112), and no hospitalization history (OR: 0.389, 95% CI: 0.217-0.689) for the full sample, and more years of education (OR: 4.086, 95% CI: 1.397-11.946) and fewer hospitalizations (OR: 0.615, 95% CI: 0.467-0.809) for patients aged 18 years or older. Less knowledge of periodic tests conducted during lithium treatment played a critical role in low lithium adherence (regression analysis of the full sample: OR: 0.642, 95% CI: 0.532-0.775, regression analysis of subgroups: OR: 0.609, 95% CI: 0.500-0.742). The treatment duration was a major concern among patients on lithium, and patients preferred obtaining lithium-associated information through health services and WeChat.

CONCLUSION

The rate of lithium adherence was low in this study. Psychoeducation to increase lithium compliance should mainly focus on patients who are young and provide thorough background information on lithium. Health services should actively provide lithium-associated information. A greater need for medication information based on WeChat was observed, implying its potential role in adherence-related psychoeducation.

Feasibility and acceptability of integrated psychological therapy versus treatment as usual for people with bipolar disorder and co-morbid alcohol use: A single blind randomised controlled trial

BACKGROUND

Alcohol use is a common problem in bipolar disorder (BD) and evidence indicates more promising outcomes for alcohol use than other substances. No trials have evaluated individual integrated motivational interviewing and cognitive behaviour therapy (MI-CBT) for problematic alcohol use in BD. We therefore assessed the feasibility and acceptability of a novel MI-CBT intervention for alcohol use in BD.

METHODS

A single blind RCT was conducted to compare MI-CBT plus treatment as usual (TAU) with TAU only. MI-CBT was delivered over 20 sessions with participants followed up at 3, 6, 9 and 12 months post-randomisation. Primary outcomes were the feasibility and acceptability of MI-CBT (recruitment to target, retention to follow-up and therapy, acceptability of therapy and absence of adverse events). We also conducted preliminary analyses of alcohol and mood outcomes (frequency and severity of alcohol use and time to mood relapse).

RESULTS

44 participants were recruited with 75% retention to 6 and 12 months follow-up. Therapy participants attended a mean of 17.6 (SD 4.5) sessions. Therapy alliance and treatment fidelity were acceptable. Qualitative interviews indicated the intervention was experienced as collaborative, and helpful, in addressing mood and alcohol issues, although risk of overconfidence following therapy was also identified. Clinical outcomes did not differ between arms at 12 months follow-up.

LIMITATIONS

As a feasibility and acceptability trial any secondary results should be treated with caution.

CONCLUSIONS

Integrated MI-CBT is feasible and acceptable, but lack of clinical impact, albeit in a feasibility study, suggests need for further development. Potential adaptations are discussed.

The impact of postpartum psychosis on partners

Background

Postpartum Psychosis is a severe mental health condition following childbirth, with a psychosis and associated mood disturbance. Research to date has primarily focused on mothers’ experiences, and on identifying risk factors, aetiology, and intervention efficacy. Within both research and clinical communities, there has been little acknowledgement of partners’ experiences of Postpartum Psychosis, nor the important support role that partners can provide. The aim of this study was to consider the lived experiences of partners of women who have had Postpartum Psychosis, and the impact that it has had on their lives and relationships.

Methods

Participants (N = 8) were partners recruited through the charity Action on Postpartum Psychosis. Partners completed an in-depth, semi-structured interview regarding their experiences of Postpartum Psychosis. Interpretative Phenomenological Analysis was used to analyse the interview transcripts.

Results

Seven superordinate themes emerged from the interview data: loss; powerlessness; united vs. individual coping; hypothesising and hindsight; barriers to accessing care and unmet needs; managing multiple roles; and positive changes from Postpartum Psychosis.

Conclusions

These findings provide a rich illustration of the experiences of partners, including some previously unidentified findings relating to partner hypervigilance to signs of relapse and positive changes in their attitudes and relationships. Areas where support could be provided for partners are also highlighted.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2055-z) contains supplementary material, which is available to authorized users.

Reducing relapse and suicide in bipolar disorder: practical clinical approaches to identifying risk, reducing harm and engaging service users in planning and delivery of care – the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation and Suicidality) programme

Background

Bipolar disorder (BD) costs £5.2B annually, largely as a result of incomplete recovery after inadequate treatment.

Objectives

A programme of linked studies to reduce relapse and suicide in BD.

Design

There were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users’ (SUs) and psychiatrists’ experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5).

Setting

Participants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)].

Participants

Aged ≥ 18 years. In WS1–3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for theDiagnostic and Statistical Manual of Mental Disorders.

Interventions

In WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively.

Main outcome measures

In WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation.

Results

Group PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio testp = 0.217). The interaction between the number of previous bipolar episodes (1–7 and 8–19, relative to 20+) and treatment arm was significant (χ2 = 6.80, degrees of freedom = 2;p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of £37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive–behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD:n = 72, 72% retention to follow-up; MI-CBT:n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans.

Limitations

Inferences for routine clinical practice from WS1 were limited by the absence of a ‘treatment as usual’ group.

Conclusion

The programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support.

Future work

Future work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated.

Trial registration

Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.

Integrated psychological therapy for people with bipolar disorder and co-morbid alcohol use: A feasibility and acceptability randomised controlled trial

BACKGROUND

Co-morbid substance misuse, particularly alcohol, is common in bipolar disorder (BD) and associated with worse treatment outcomes. Research into psychological interventions for substance misuse in BD is at an early stage and no studies have specifically targeted problematic alcohol use. This paper describes the context and protocol for a feasibility and acceptability randomised controlled trial (RCT) evaluating a novel intervention combining motivational interviewing and cognitive behavioural therapy (MI-CBT) for participants with BD and problematic alcohol use, developed in collaboration with people with lived experience of both issues.

METHODS AND DESIGN

An RCT will assess the feasibility and acceptability of MI-CBT in addition to treatment as usual (TAU) compared with TAU alone. Participants will be recruited from across the North West of England through NHS services and self-referral. The primary outcomes will be the feasibility and acceptability of the intervention assessed by recruitment to target, adherence to intervention, retention rate at follow-up, absence of adverse events and qualitative analysis of participants' reported experiences of intervention. The effect size of the impact of the intervention on alcohol use and mood outcomes will also be estimated. In addition, we will explore a number of potential process variables in therapy.

DISCUSSION

This is the first RCT evaluating MI-CBT for BD and problematic alcohol use. Given the prevalence and impact of alcohol problems in BD this novel integrated intervention may have potential to offer important improvements in clinical and functional outcomes.

The International College of Neuro-Psychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 3: The Clinical Guidelines

Background

The current paper introduces the actual International College of Neuro-Psychopharmacology clinical guidelines for the treatment of bipolar disorder.

Concept and structure of the guidelines

The current clinical guidelines are based on evidence-based data, but they also intend to be clinically useful, while a rigid algorithm was developed on the basis of firm evidence alone. Monotherapy was prioritized over combination therapy. There are separate recommendations for each of the major phases of bipolar disorder expressed as a 5-step algorithm.

Discussion

The current International College of Neuro-Psychopharmacology clinical guidelines for the treatment of bipolar disorder are the most up-to-date guidance and are as evidence based as possible. They also include recommendations concerning the use of psychotherapeutic interventions, again on the basis of available evidence. This adherence of the workgroup to the evidence in a clinically oriented way helped to clarify the role of specific antidepressants and traditional agents like lithium, valproate, or carbamazepine. The additional focus on specific clinical characteristics, including predominant polarity, mixed features, and rapid cycling, is also a novel approach. Many issues need further studies, data are sparse and insufficient, and many questions remain unanswered. The most important and still unmet need is to merge all the guidelines that concern different phases of the illness into a single one and in this way consider BD as a single unified disorder, which is the real world fact. However, to date the research data do not permit such a unified approach.

Gender by onset age interaction may characterize distinct phenotypic subgroups in bipolar patients

OBJECTIVE

Although bipolar disorder (BD) is a common recurrent condition with highly heterogeneous illness course, data are limited regarding clinical implications of interactions between gender and onset age. We assessed relationships between onset age and demographic/illness characteristics among BD patients stratified by gender.

METHODS

Demographic and unfavorable illness characteristics, descriptive traits, and clinical correlates were compared in 502 patients from Stanford University BD Clinic patients enrolled in the Systematic Treatment Enhancement Program for BD between 2000 and 2011, stratified by gender, across pre-, peri-, and post-pubertal (<12, 13-16, and >17 years, respectively) onset-age subgroups.

RESULTS

Among 502 BD patients, 58.2% were female, of whom 21.9% had pre-pubertal, 30.7% peri-pubertal, and 47.4% post-pubertal onset. Between genders, although demographics, descriptive characteristics, and most clinical correlates were statistically similar, there were distinctive onset-age related patterns of unfavorable illness characteristics. Among females, rates of 6/8 primary unfavorable illness characteristics were significantly higher in pre-pubertal and peri-pubertal compared to post-pubertal onset patients. However, among males, rates of only 3/8 unfavorable illness characteristics were significantly higher in only pre-pubertal versus post-pubertal onset patients, and none between peri-pubertal versus post-pubertal onset patients.

LIMITATIONS

Caucasian, insured, suburban, American specialty clinic-referred sample limits generalizability, onset age based on retrospective recall.

DISCUSSION

We describe different phenotypic presentations across age at illness onset groups according to gender. Among females and males, peri-pubertal and post-pubertal onset age groups were more different and more similar, respectively. Further investigation is warranted to assess implications of gender-by-onset-age interactions to more accurately delineate distinctive BD phenotypes.

Bipolar Depression: Pregnancy, Postpartum, and Lactation

Medication management of bipolar depression in pregnancy and lactation is best done by assessing each patient's and family's needs in detail. Keeping pregnant patients as psychiatrically stable as possible is the most important principle for clinicians. Unfortunately, there is no risk-free situation for patients with psychiatric illness. This is often the most difficult and hard to accept reality for these patients, families, and clinicians. Clinicians serve these patients best by being as transparent as possible about the risk/benefit analysis of each patient's situation with the realization that ultimately the decisions are made by the patient and family.

Gender differences in mood stabilizer medications prescribed to Veterans with serious mental illness

BACKGROUND

Mood stabilizer medications (MSMs) can induce significant weight gain and other metabolic side effects. Research suggests that women are more susceptible to psychotropic medication-induced metabolic side effects than men. We examined gender differences in the likelihood of receiving an MSM with a lower liability for weight gain using data from the U.S. Department of Veterans Affairs (VA) healthcare system.

METHODS

We identified 3823 VA patients with a schizophrenia or bipolar disorder diagnosis who initiated treatment with a MSM between 10/2006 and 9/2011. We used multivariable logistic regression analysis to examine gender differences in the likelihood of incident prescription of MSMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and demographic, mental health, and physical health characteristics.

RESULTS

Overall, 47% of women were prescribed a low metabolic risk MSM compared to 26% of men (p<0.0001). In multivariable analysis, women were 2.19 times as likely as men to be prescribed a low metabolic risk MSM (95% CI: 1.84-2.60, p<0.0001). Several demographic and clinical covariates were also independently related to prescribing of MSMs by level of metabolic risk.

LIMITATIONS

This study used retrospective administrative data collected from a VA healthcare system database, which does not allow us to understand the context in which MSM treatment decisions were made.

CONCLUSIONS

Prescribing choices for MSMs by VA mental health prescribers and female Veterans may reflect a growing awareness of the potential adverse health consequences of these treatments in women.

Postmenopausal syndrome

Menopause is one of the most significant events in a woman's life and brings in a number of physiological changes that affect the life of a woman permanently. There have been a lot of speculations about the symptoms that appear before, during and after the onset of menopause. These symptoms constitute the postmenopausal syndrome; they are impairing to a great extent to the woman and management of these symptoms has become an important field of research lately. This chapter attempts to understand these symptoms, the underlying pathophysiology and the management options available.

Gender differences in thyroid system function: relevance to bipolar disorder and its treatment

OBJECTIVES

Thyroid hormones play a critical role in the functioning of the adult brain, and thyroid diseases impair both mood and cognition. This paper reviews gender differences in thyroid system function that are relevant to the diagnosis and treatment of bipolar disorder.

METHODS

The study comprised a comprehensive literature review of gender differences in thyroid disease that are pertinent to mood disorders.

RESULTS

The prevalence of thyroid disease was found to be much higher in females than males, and to increase with age. The most commonly detected abnormality was subclinical hypothyroidism, which was found to occur in up to 20% of postmenopausal women. Females also had higher rates of thyroid autoimmunity. Individuals at risk for thyroid disease, such as adult females, may have had less ability to compensate for additional challenges to thyroid metabolism, including lithium treatment. Thyroid abnormalities were associated with a poorer response to standard treatments for mood disorders. Females with treatment-resistant mood disorders may have responded better than males to adjunctive therapy with thyroid hormones.

CONCLUSIONS

Disturbances of thyroid system function, which occur commonly in females, may complicate the diagnosis and treatment of mood disorders. In particular, this is clinically relevant during lithium treatment because lithium may impair vital thyroid metabolic pathways secondary to its anti-thyroid activity.

Risks associated with gender differences in bipolar I disorder

BACKGROUND

Previous studies have demonstrated that bipolar patients may differ in several features according to gender, but a number of the differences found remain controversial.

METHODS

The demographic, illness course, clinical, comorbidity and temperament characteristics of a total of 1090 consecutive DSM-IV bipolar I manic inpatients were compared according to gender.

RESULTS

Bipolar illness in women was characterised by the predominance of depression, as indicated by a depressive polarity at onset, higher rates of mixed mania, more suicidal behaviour, and a greater number of temperaments with depressive propensities. In contrast, the manic component was found to predominate in men. Men also had an earlier onset of their illness. Women displayed more comorbidities with eating, anxiety, and endocrine/metabolic disorders, whereas men were more comorbid with alcoholism and other forms of substance abuse, neurological, and cancer disorders. The following independent variables were associated with male gender: being single (+), depressive temperament (-), excessive alcohol use (+), cyclothymic temperament (-), excessive other substance use (+), mood congruent psychotic features (+), and manic polarity at onset (+).

LIMITATIONS

The retrospective design and the sample being potentially not representative of the bipolar disorder population are limitations.

CONCLUSIONS

Findings from this study tend to confirm most of the differences previously observed among bipolar men and women. Furthermore, these results draw attention to the risks that may be specifically linked to gender differences in bipolar I patients.

Bipolar disorder with seasonal pattern: clinical characteristics and gender influences

Bipolar disorder (BD) has a multifactorial etiology with heterogeneous clinical presentations. Around 25% of BD patients may present with a depressive seasonal pattern (SP). However, there are limited scientific data on the prevalence of SP, its clinical manifestations, and any gender influence. Four hundred and fifty-two BD I and II cases (62% female), recruited from three French university-affiliated psychiatric departments, were assessed for SP. Clinical, treatment, and sociodemographic variables were obtained from structured interviews. One hundred and two (23%) cases met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria for SP, with similar frequency according to gender. Multivariate analysis showed a significant association between SP and BD II (odds ratio [OR] = 1.99, p = 0.01), lifetime history of rapid cycling (OR = 2.05, p = 0.02), eating disorders (OR = 2.94, p = 0.003), and total number of depressive episodes (OR = 1.13, p = 0.002). Seventy-one percent of cases were correctly classified by this analysis. However, when stratifying the analyses by gender, SP was associated with BD II subtype (OR = 2.89, p = 0.017) and total number of depressive episodes (OR = 1.21, p = 0.0018) in males but with rapid cycling (OR = 3.02, p = 0.0027) and eating disorders (OR = 2.60, p = 0.016) in females. This is the first study to identify different associations between SP and clinical characteristics of BD according to gender. The authors suggest that SP represents a potentially important specifier of BD. These findings indicate that seasonality may reflect increased severity or complexity of disorder.

A randomised controlled trial of time limited CBT informed psychological therapy for anxiety in bipolar disorder

BACKGROUND

Anxiety comorbidity is common in bipolar disorder and is associated with worse treatment outcomes, greater risk of self harm, suicide and substance misuse. To date however there have been no psychological interventions specifically designed to address this problem. The primary objective of this trial is to establish the acceptability and feasibility of a new integrated intervention for anxiety in bipolar disorder designed in collaboration with individuals with personal experience of both problems.

METHODS AND DESIGN

Single blind randomised controlled trials to assess the feasibility and acceptability of a time limited CBT informed psychological intervention for anxiety in bipolar disorder (AIBD) compared with treatment as usual. Participants will be recruited from across the North West of England from specialist mental health services and through primary care and self referral. The primary outcome of the study is the feasibility and acceptability of AIBD assessed by recruitment to target and retention to follow-up, as well as absence of untoward incidents associated with AIBD. We will also estimate the effect size of the impact of the intervention on anxiety and mood outcomes, as well as calculate preliminary estimates of cost-effectiveness and investigate potential mechanisms for this (stigma, self appraisal and stability of social rhythms).

DISCUSSION

This is the first trial of an integrated intervention for anxiety in bipolar disorder. It is of interest to researchers involved in the development of new therapies for bipolar disorder as well as indicating the wider potential for evaluating approaches to the treatment of comorbidity in severe mental illness.

Women and the DSM-5: a clinician's response to the question of invisibility

Diagnosis of psychiatric conditions is a topic that is currently receiving significant attention in light of the release of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders in 2013. The process of the revisions is complex and involves political, social, and economic influences, all of which are amplified in an evolving corporate health care system in the United States. Of particular concern in the development of the revised nosology is the representation of gender-specific diagnoses and course specifiers to reflect the distinct manifestations of the psychiatric symptoms of women. Based on a growing body of psychobiological evidence related to gender differences in symptom manifestation, gender specific diagnoses remain palpably absent from the taxonomy. This article explores the issue of invisibility of women-specific diagnosis from the perspective of a women's health advanced practice nurse.

The genetic association of DUSP6 with bipolar disorder and its effect on ERK activity

The dual-specificity phosphatase 6 (DUSP6) gene resides at chromosome location 12q22-23, which is one of the candidate loci for susceptibility to bipolar disorder and which encodes a phosphatase selective for extracellular signal-regulated kinase (ERK). Previously, we reported a positive association between the functional Leu114Val polymorphism (rs2279574) in DUSP6 and bipolar disorder. Given that the association between DUSP6 and the reported down-regulation of DUSP6 transcript in bipolar postmortem brains were sex-dimorphic, showing significance in women but not men, we performed two independent analyses in homogenous samples of male and female Korean patients with bipolar disorder or schizophrenia using samples enlarged from our previous report. Among the examined DUSP6 SNPs, five (rs769700, rs704076, rs770087, rs808820, and rs2279574) showed positive allelic associations, with the frequency of minor alleles (C, T, G, G, and G) in each SNP significantly increased in women with BD. Consequently, the "C-T-G-G-G" haplotype was significantly over-represented (P=0.016; OR=3.242), whereas the "T-G-T-A-T" haplotype was significantly under-represented (P=0.014; OR=0.697). We found no significant associations with DUSP6 SNPs in men with bipolar disorder or schizophrenia. We also investigated the functions of the functional SNPs' positive associations and found that Leu114Val (rs2279574; T/G) and Ser144Ala (rs770087; T/G) mutations in DUSP6 proteins reduced lithium-induced ERK1/2 phosphorylation in vitro, implicating the dominant active functions. Thus, DUSP6 may not only play important roles in the pathogenesis of bipolar disorder, particularly in women, but also affect the therapeutic response to lithium through modulating lithium's effects on intracellular signaling.

Gender differences in a cohort study of 604 bipolar patients: the role of predominant polarity

BACKGROUND

Some clinical differences between gender regarding the course and outcome of bipolar disorders have already been described and some others remain still controversial.

AIMS

To explore gender differences regarding clinical and socio-demographic characteristics amongst bipolar patients with particular attention to predominant polarity and depressive symptoms.

METHOD

Data were collected from DSM-IV type I and II bipolar patients (n=604), resulting from the systematic follow-up of the Bipolar Disorders Program, Hospital Clinic of Barcelona, over an average follow-up of 10 years. Socio-demographic and clinical variables were collected in order to detect gender-related differences.

RESULTS

Bipolar women are more likely than men to show a predominance of depressive polarity as well as a depressive onset whilst men would be more likely to suffer from comorbid substance use disorders. Women significantly have a higher lifetime prevalence of psychotic depression and a higher prevalence of axis II comorbid disorders. Bipolar women are also more likely to have a family history of suicide and a lifetime history of attempted suicide. Suicide attempts are more often violent amongst bipolar men. In a backward logistic regression model, two variables were responsible for most gender-related clinical differences: type of predominant polarity - more likely to be depressive amongst women - (B=-0.794, p=0.027, Exp(B)=0.452; CI= 0.223-0.915), alcohol abuse (B=-1.095, p=0.000, Exp(B)=2990; CI= 1.817-4.919) and cocaine abuse (B=0.784, p=0.033, Exp(B)=2.189; CI= 1.066-4.496) - more prevalent amongst men.

CONCLUSION

The main characteristic featuring bipolar women is depression, both at illness onset and as a predominant polarity all along the illness course. This may have important diagnostic and therapeutic implications.

Suicidal mothers

Background:

Epidemiological research has demonstrated that suicidal ideation is a relatively frequent complication of pregnancy in both developed and developing countries. Hence, the aims of this study are: to assess whether or not pregnancy may be considered a period highly susceptible to suicidal acts; to recognize potential contributing factors to suicidal behaviors; to describe the repercussions of suicide attempts on maternal, fetal, and neonatal outcome; to identify a typical profile of women at high risk of suicide during pregnancy.

Methods:

Medical literature information published in any language since 1950 was identified using MEDLINE/PubMed, Scopus, and Google Scholar databases. Search terms were: "pregnancy", (antenatal) "depression", "suicide". Searches were last updated on 28 September 2010. Forty-six articles assessing the suicidal risk during pregnancy and obstetrical outcome of pregnancies complicated by suicide attempts were analyzed, without methodological limitations.

Results:

Worldwide, frequency of suicidal attempts and the rate of death by suicidal acts are low. Although this clinical event is rare, the consequences of a suicidal attempt are medically and psychologically devastating for the mother-infant pair. We also found that common behaviors exist in women at high risk for suicide during pregnancy. Review data indeed suggest that a characteristic profile can prenatally identify those at highest risk for gestational suicide attempts.

Conclusions:

Social and health organizations should make all possible efforts to identify women at high suicidal risk, in order to establish specific programs to prevent this tragic event. The available data informs health policy makers with a typical profile to screen women at high risk of suicide during pregnancy. Those women who have a current or past history of psychiatric disorders, are young, unmarried, unemployed, have incurred an unplanned pregnancy (eventually terminated with an induced abortion), are addicted to illicit drugs and/or alcohol, lack effective psychosocial support, have suffered from episodes of sexual or physical violence are particularly vulnerable.

Gender differences in outcomes of acute mania: a 12-month follow-up study

This study aimed to assess short-term (12 weeks) and long-term (12 months) gender differences in the outcomes of patients experiencing an episode of mania in the course of bipolar disorder. European Mania in Bipolar Longitudinal Evaluation of Medication was a 2-year, prospective, observational study of the outcomes of patients with a manic or mixed episode conducted in 14 European countries. Data were collected during the acute phase (12 weeks) and during a follow-up period (up to 12 months). Analyses were carried out in the subgroup of patients identified with a pure manic episode at baseline. Kaplan-Meier survival analysis estimated time to first occurrence of mania improvement, worsening, recovery and depressive episode, and Cox's proportional hazards models were used to analyse factors associated with these outcomes. Overall, 2,485 patients (46.6% men, 53.4% women) were included in the analysis. Frequency of substance abuse was higher in men than women. No significant gender differences were found in the severity of manic symptoms at baseline. There were no gender differences in assessment of mania improvement, worsening or recovery over 12 weeks, but more women than men showed mania improvement over 12 months (95.4% vs. 89.2%; p < 0.01). Significantly more women developed a depressive episode over 12 weeks (14.9% vs. 9.7%; p < 0.01) and over 12 months (27.7% vs. 21.5%; p < 0.001). In conclusion, the results show that there are small gender differences in the course of patients experiencing a pure manic episode. Women had a faster time to mania improvement and a higher risk of developing a depressive episode during the 12-month follow-up period.

[Treatment of bipolar disorder during pregnancy and in the postpartum period]

BACKGROUND

Pharmacological treatment and prophylaxis of bipolar disorders during pregnancy and in the postpartum period imply complicated clinical assessments.

MATERIAL AND METHOD

This article is based on a non-systematic search in PubMed and the authors' clinical experience.

RESULTS

If a woman is already using a prophylactic drug at the time of pregnancy, she can in general continue to do so during pregnancy, with the exception of valproate. If the disorder starts during pregnancy; lithium, lamotrigine or second generation antipsychotic drugs are suitable alternatives. In general, drugs used during pregnancy can also be used in the postpartum period, although some require special precautions if the mother wishes to breast-feed. If treatment is initiated after delivery, the mother's wish to breast-feed should be taken into consideration when choosing a drug.

INTERPRETATION

Although existing studies have weaknesses, there is sufficient evidence to give qualified advice regarding choice of medication for bipolar disorder during pregnancy and in the postpartum period.

Neurodevelopmental effects of prenatal exposure to psychotropic medications

Until now, studies on the reproductive safety of psychotropics have typically assessed the risk of congenital malformations and perinatal complications associated with in utero exposure to such medications. However, little is known of their inherent potential neurobehavioral teratogenicity. The objective is to analyze available data from studies investigating developmental outcome of children exposed prenatally to psychotropics. A computerized Medline/PubMed/TOXNET/ENBASE search (1960-2010) was conducted using the following keywords: pregnancy, child/infant development/neurodevelopment, antidepressants, benzodiazepines, mood stabilizers, and antipsychotics. A separate search was also run to complete the safety profile of single specific medications. Resultant articles were cross-referenced for other relevant articles not identified in the initial search. A noncomputerized review of pertinent journals and textbooks was also performed. All studies published in English and reporting primary data on the developmental outcome of infants exposed in utero to psychotropics and born without malformations were collected. As regards antiepileptic drugs, only studies that provided data on specific medications approved for psychiatric practice use (carbamazepine, lamotrigine, and valproate) were considered. Data were extracted from 41 articles (38 identified electronically and 3 nonelectronically), which met the inclusion criteria. Despite reviewed studies showing relevant methodological limitations, concordant, albeit preliminary, information seems to exclude that prenatal exposure to both selective serotonin reuptake inhibitors and tricyclic antidepressants may interfere with the infants' psychological and cognitive development. Conversely, information on valproate strongly discourages its use in pregnant women. Moreover, although data on carbamazepine remain controversial, information on whole classes of drugs and single medications is either absent (second-generation antipsychotics) or too limited (first-generation antipsychotics, benzodiazepines, lithium, and lamotrigine) to inform the decision-making process. For all classes of psychotropics, new and/or further studies are warranted to answer definitively the urgent question about the impact of prenatal exposure to such medications on infant development.

Differential modulation of intracellular Ca2+ responses in B lymphoblasts by mood stabilizers

Irregularities of intracellular calcium (Ca2+) homeostasis have been implicated in the pathophysiology of bipolar disorder (BD). Findings that chronic ex-vivo treatment with lithium modifies lysophosphatidic acid (LPA)-stimulated Ca2+ responses in B lymphoblast cell lines (BLCLs) from BD-I patients and healthy controls, and differentially decreases levels of the type-3 canonical transient receptor potential Ca2+-permeable channel in BLCLs from BD-I patients, support the view that the amelioration of these abnormalities is important in the therapeutic action of lithium. To determine whether other clinically efficacious mood stabilizers share these effects, LPA (100 mum)- and thapsigargin (TG, 200 nm)-stimulated Ca2+ responses were determined in BLCLs from BD-I patients and healthy controls treated acutely (24 h) and chronically (7 d) ex vivo with therapeutically relevant concentrations of lithium (0.75 mm), valproate (0.5 mm), lamotrigine (15 mum) or respective vehicles. Chronic treatment with valproate significantly attenuated LPA-stimulated Ca2+ responses ([downward arrow]8%: F's=9.1-9.4, d.f.=1, 9, p's<0.05) compared to vehicle in BLCLs from BD-I patients and healthy controls, similar to chronic lithium treatment ([downward arrow]8%: F=6.2, d.f.=1, 21, p<0.05), but also attenuated TG-evoked Ca2+ responses ([downward arrow]10% to [downward arrow]19%: F's=5.5-15.5, d.f.=1, 12, p's<0.05). However, chronic lamotrigine treatment did not affect LPA- or TG-stimulated Ca2+ responses. These results suggest that chronic lithium and valproate treatments act differently from lamotrigine in respect of modulation of receptor- and/or capacitance-mediated Ca2+ flux. These differential effects on Ca2+ responses may be relevant to the distinctive clinical profiles of these mood stabilizers.

Screening for bipolar disorder during pregnancy and the postpartum period

Bipolar disorder is a significant mental health problem among perinatal women; however, little attention has been devoted to methods of screening for bipolar disorder during this phase of women's life cycle. There is a need for reliable and valid screening instruments for perinatal women. This paper presents a review of 11 self-report measures used to screen bipolar disorder in the general population and discusses their applicability to screening among perinatal women. Published psychometric data, including reliability, sensitivity, specificity, and positive predictive value of each self-report instrument, is presented and critiqued. We make recommendations for screening in clinical practice and highlights priorities for future research. The need for more research in this area is emphasized.

Antipsychotic therapy during early and late pregnancy. A systematic review

OBJECTIVE

Both first- (FGAs) and second-generation antipsychotics (SGAs) are routinely used in treating severe and persistent psychiatric disorders. However, until now no articles have analyzed systematically the safety of both classes of psychotropics during pregnancy. DATA SOURCES AND SEARCH STRATEGY: Medical literature information published in any language since 1950 was identified using MEDLINE/PubMed, TOXNET, EMBASE, and The Cochrane Library. Additional references were identified from the reference lists of published articles. Bibliographical information, including contributory unpublished data, was also requested from companies developing drugs. Search terms were pregnancy, psychotropic drugs, (a)typical-first-second-generation antipsychotics, and neuroleptics. A separate search was also conducted to complete the safety profile of each reviewed medication. Searches were last updated on July 2008.

DATA SELECTION

All articles reporting primary data on the outcome of pregnancies exposed to antipsychotics were acquired, without methodological limitations.

CONCLUSIONS

Reviewed information was too limited to draw definite conclusions on structural teratogenicity of FGAs and SGAs. Both classes of drugs seem to be associated with an increased risk of neonatal complications. However, most SGAs appear to increase risk of gestational metabolic complications and babies large for gestational age and with mean birth weight significantly heavier as compared with those exposed to FGAs. These risks have been reported rarely with FGAs. Hence, the choice of the less harmful option in pregnancy should be limited to FGAs in drug-naive patients. When pregnancy occurs during antipsychotic treatment, the choice to continue the previous therapy should be preferred.

Understanding and treating premenstrual dysphoric disorder: an update for the women's health practitioner

Up to 7% of women report premenstrual symptoms severe enough to impair daily function, and are said to suffer from premenstrual dysphoric disorder (PMDD). Although PMDD is predominately regarded as a biologically based condition, sociocultural factors, and particularly life stress, past sexual abuse, and cultural socialization, likely interact with hormonal changes. This integrative model has implications for etiology and treatment of PMDD.

Reproductive and metabolic abnormalities associated with bipolar disorder and its treatment

Women with mood disorders, especially bipolar disorder (BD), have been shown to have high rates of reproductive and metabolic dysfunction. The available data on the functional, anatomic, and clinical neuroendocrine abnormalities in women with BD suggest a two-tiered relationship with mood pathology. First, many of the medications commonly used in the treatment of BD can have deleterious effects on blood levels of reproductive hormones and consequently on the hypothalamic-pituitary-gonadal (HPG) axis and reproductive function. Studies that have specifically addressed the association between psychotropic medications and menstrual abnormalities, polycystic ovary syndrome, and overall reproductive endocrine function in women with BD have found high rates of HPG irregularities in women with BD. Second, there is evidence of reproductive dysfunction in women with BD prior to treatment. In addition, many of the psychotropic medications used in the treatment of BD are associated with weight gain, insulin resistance, and dyslipidemia. These metabolic side effects further compound the neuroendocrine system dysregulation in women with BD. Current understanding of the reproductive and metabolic function in women with BD points to vulnerability, which in turn increases the risk of later-life cardiovascular disease and diabetes, among other morbidities, for women with BD.

Emergent research in the cause of mental illness in women across the lifespan

PURPOSE OF REVIEW

In recent years, there has been an increased appreciation of gender and sex differences in mental illness. This perspective has included attention to sex differences in neurobiology, neurochemistry, sex steroids, endocrine sex reactivity and psychosocial stressors. However, emerging research investigating gene-environment interactions presents another layer of complexity in understanding sex differences in epidemiology, clinical features and treatment of mental disorders across the lifespan.

RECENT FINDINGS

The main themes in the current literature point to gene-environment interactions underlying sex-specific differences in the psychiatric sequelae of both early childhood and current life stress. Evidence related to the serotonin-linked polymorphic region (5HTTLPR) polymorphism is strongest, but evidence exists for other candidate genes. There is also emerging support for genetic factors that increase susceptibility of some women to hormonal changes of the reproductive life cycle. The interaction of these genetic factors with various environmental stressors, many of which are more common in women, may increase the risk of mental illness, especially mood disorders.

SUMMARY

Further research into sex-specific gene-environment interactions across the lifespan is needed with the goal of improving preventive efforts and optimizing treatment in women's mental health.

Special gender issues in psychiatry

Significant gender differences exist in the course, manifestation and treatment of mental illness. Regardless of specific diagnosis age is one of the key factors in gender differences. Such differences between the sexes exist not only concerning origin and perpetuation of specific psychiatric diseases, they are also available and notable in specific fields of pharmacological and psychotherapeutically treatment. That review should sensitize clinicians for their responsibility to provide individualized, optimally effective, gender-specific care to patients suffering from mental diseases in some special topics. It should be a short overview considering some important gender details illustrated in concern with the epidemiological background, the symptoms and general used psychiatric treatment strategies of some frequent psychiatric diagnoses.

Increased depressive symptoms in menopausal age women with bipolar disorder: age and gender comparison

OBJECTIVE

Emerging data suggest the menopausal transition may be a time of increased risk for depression. This study examines the course of bipolar disorder focusing on depressive symptoms in menopausal transition age women, compared to similar-aged men as well as younger adult women and men.

METHODS

Outpatients with bipolar disorder were assessed with the systematic treatment enhancement program for bipolar disorder (STEP-BD) affective disorders evaluation and longitudinally monitored during naturalistic treatment with the STEP-BD clinical monitoring form. Clinical status (syndromal/subsyndromal depressive symptoms, syndromal/subsyndromal elevation or mixed symptoms, and euthymia) was compared between menopausal transition age women (n=47) and pooled similar-aged men (n=30) 45-55 years old, younger women (n=48) and men (n=39) 30-40 years old.

RESULTS

Subjects included 164 bipolar disorder patients (67 type I, 82 type II, and 15 not otherwise specified), 34% were rapid cycling and 58% women. Bipolar II disorder/bipolar NOS was more common in women. Monitoring averaged 30+/-22 months, with an average of 0.9+/-0.5 clinic visits/month. Menopausal age women had a significantly greater proportion of visits with depressive symptoms (p<0.05), significantly fewer euthymic visits (p<0.05) and no difference in proportion of visits with elevated/mixed symptoms compared to pooled comparison group.

CONCLUSIONS

Menopausal transition age women with bipolar disorder experience a greater proportion of clinic visits with depressive symptoms compared to similarly aged men, and younger women and men with bipolar disorder. Further systematic assessment on the influence of the menopausal transition and reproductive hormones upon mood is needed to better inform clinical practice in treating women with bipolar disorder.

Gender-sensitive mental health care

OBJECTIVE

The aim of this paper is to examine aspects of mental health and mental health care through a gender lens.

CONCLUSION

Gender differences have an impact on mental health and the experience and course of women's mental illness. Comprehensive gender-sensitive mental health care requires the planning, delivery, monitoring and quality improvement initiatives of mental health care to be informed by a knowledge and understanding of gender differences in women and men and their inter-relationship with respect to childhood and adult life experiences (e.g. violence and abuse); day-to-day social, cultural, and family realities; expression and experience of mental ill health and treatment needs and responses.

Estradiol and lithium chloride specifically alter NMDA receptor subunit NR1 mRNA and excitotoxicity in primary cultures

Glutamate facilitates calcium influx via NMDAR, and excess calcium influx increases excitotoxicity--a pathological characteristic of neurological diseases. Both 17beta-estradiol (E2) and lithium influence NMDAR expression/signaling and excitotoxicity. This led us to hypothesize that combined E2 and lithium will alter NMDAR expression and excitotoxicity. We tested this hypothesis using primary cell cultures from the cortex and hippocampus of C57BL/6J fetal mice pretreated with E2, lithium chloride (LiCl) and combined E2/LiCl for 12, 24 or 48 h. We examined cultures for brain cell type and changes in cell type caused by experimental procedures using glia and neuron gene specific primers. These cultures expressed increased glial fibrillary acidic protein (GFAP) mRNA with low neurofilament-heavy chain (NF-H) mRNA expression. Subsequent analysis of cortical cell cultures indicated that combined E2/LiCl decreased NR1 mRNA expression after a 12 and 48 h treatment period. Combined E2/LiCl also reduced NR1 mRNA expression in hippocampal cultures but only after a 48 h treatment period. LiCl-treated hippocampal cultures also reduced NR1 mRNA expression after a 24 and 48 h treatment. We next examined the response of 48 h pretreated cultures to a toxic level of glutamate. Excitotoxicity was measured using fluorescein diacetate/propidium iodide (FDA/PI) cell viability assay. Results from FDA/PI assay revealed that LiCl pretreatment increased viability for cortical cultures while E2 and combined E2/LiCl reduced viability. All pretreatments for hippocampal cultures failed to increase viability. Our results showed combined E2/LiCl reduced NR1 mRNA and prevented protection against glutamate excitotoxicity in glial primary cultures.

[Specific aspects of treatment for women with bipolar affliction]

This manuscript summarizes specific issues in the disease course and pharmacological treatment of women with bipolar disorders. Gender differences relevant to the female biology manifest in symptoms, outcome, and course. The preponderance of depressive symptoms is typical, and the risk of rapid cycling is estimated to be eight times higher for women than for men. Comorbid anxiety and eating disorders occur more frequently in female patients. In planning treatment it is important to take fertility, contraception, and pregnancy into consideration and adjust the pharmacotherapy to harmonize with the patient's current phase of life. Little is known about potential sexual dysfunctions of bipolar women. Further research should include clinical and observational studies focusing on gender-specific differences in symptomatology, treatment, and long-term outcome of bipolar disorders.

Teratogenesis associated with antibipolar agents

OBJECTIVE

To review the teratogenic effects associated with the use of Food and Drug Administration-approved agents for bipolar disorder.

METHODS

A PubMed search of all English language articles published from January 1966 to December 2008 was conducted. The key search terms included all major bipolar agents, cross-referenced with: teratogenicity, teratogen, safety, pregnancy, fetus, bipolar disorder, and malformation. The search was augmented with manual reviews of relevant article reference lists as well as http://clinicaltrials.gov and http://www.fda.gov (both last accessed in April 2008). Several pregnancy registries were also reviewed to determine malformation rates as well as teratogenesis attributable to each agent. Articles selected for review were based on author consensus, adequacy of sample size, the use of standardized experimental procedures, validated assessment measures, and overall manuscript quality.

RESULTS

Valproate is associated with the highest rate of major congenital malformations (6.2%-16%). The relative risk of neural tube defects with valproate and carbamazepine is reported as approximately 1%-5% and 0.5%-1%, respectively. Preliminary evidence suggests that the relative risk for oral clefts (cleft lip or palate) is increased with lamotrigine relative to other antiepileptic drugs (AED) (ie, approximately 0.4%). The rate of major congenital malformations is higher in fetuses exposed to AED polytherapy (ie, >or=2 drugs) in comparison with AED monotherapy. Adverse neurobehavioral effects are insufficiently reported for most agents. In-utero exposure to valproate is associated with a greater risk of developmental difficulty requiring special education interventions as well as decreased verbal IQ scores. The risk of Ebstein's anomaly associated with lithium use is increased relative to the general population. The major congenital malformation rate with chlorpromazine and atypical antipsychotics is not established as being higher than a non-exposed group; the teratogenic risks associated with the olanzapine-fluoxetine combination are unknown.

CONCLUSIONS

Well-characterized risks are associated with valproate, carbamazepine, lamotrigine, and lithium. The risks associated with psychotropic drug use need to be understood in the context of significant rates of relapse and associated morbidity when discontinuing bipolar treatment during pregnancy.

More questions than answers! Clinical dilemmas in psychopharmacology in pregnancy and lactation

Women in childbearing age frequently suffer from mental illness. Maternal psychiatric disorders may have a devastating impact on the fetus and the newborn. Thus treating or preventing relapse of these disorders during pregnancy and puerperium is a clinical and ethical duty with the necessity to avoid or minimize fetal or neonatal drug exposure. Though there are many guidelines and comprehensive reviews regarding drug safety in pregnancy and lactation, the application of these recommendations into clinical practice appears to be complex. Hence, we present some clinical questions with answers considering the available literature on safety of psychotropics in pregnancy and lactation.

Current issues: women and bipolar disorder

While the treatment of bipolar disorder (BD) is typically complex, the treatment of women with bipolar disorder is even more challenging because clinicians must also individualize treatment based on the potential for pregnancy, drug interactions with oral contraceptives, and an increased risk of endocrine diseases that can either impact the course of illness or become manifest with some treatments. Women with BD should be checked for hypothyroidism, and if prescribed antidepressants, carefully watched for rapid cycling or a mood switch to mania, hypomania, or a mixed state. Several medications interact with oral contraceptives or increase the risk of developing polycystic ovary syndrome. Consideration of possible pregnancy is essential, and should be planned in advance whenever possible. Rates of recurrence have been shown to be equal in pregnant and nonpregnant women with BD. Risks of medication to the fetus at various points of development must be balanced against the risks of not treating, which is also detrimental to both fetus and mother. The postpartum period is a time of especially high risk; as many as 40% to 67% of women with BD report experiencing a postpartum mania or depression. The decision to breastfeed must also take into account the adverse impact of sleep deprivation in triggering mood episodes. In order to best address these issues, clinicians must be familiar with the data and collaborate with the patient to assess risks and benefits for the individual women and her family.

Increased frequency of depressive episodes during the menopausal transition in women with bipolar disorder: preliminary report

OBJECTIVE

Data are emerging in bipolar disorder regarding mood across phases of the female reproductive life, yet information about mood during the menopausal transition remains limited. The menopausal transition in women without mood disorders is associated with an increase in depression. This study assesses mood course during the menopausal transition in women with bipolar disorder.

METHODS

We monitored mood episodes in 47 women with bipolar disorder ages 45-55 for 17.0+/-14.0 months with systematic treatment enhancement program for bipolar disorder (STEP-BD) standardized evaluations. Charts were additionally reviewed for menstrual status and menstrual history, as well as mood episode type, duration, frequency and history.

RESULTS

During the menopausal transition 68% of women with bipolar disorder experienced at least one depressive episode. Depression (but not mood elevation) episode frequency significantly increased during the menopausal transition compared to reported frequency during patients' reproductive years. History of pre-menstrual and or post-partum mood instability did not predict perimenopausal mood episodes.

CONCLUSIONS

Women with bipolar disorder experience a high frequency of depressive episodes during perimenopausal years and this frequency appears greater than during prior reproductive years. Prospective controlled studies are needed to better understand the course of mood episodes and to enhance the effectiveness of managing bipolar disorder during the menopausal transition.

Prise en charge des femmes souffrant d'un trouble bipolaire de la conception au post-partum

Any plans for pregnancy must be discussed in detail with women with bipolar disorders. They must be informed about the risks related to it and the need for some precautions. Because of the risk of relapse during pregnancy, the risk/benefit ratio of maintaining or starting prophylactic treatment should be assessed, taking into account family history and frequency of recurrences. Lithium may be used during pregnancy under close monitoring. Most anticonvulsants are contraindicated because of their teratogenicity. During the post-partum period, prophylaxis is required in most cases because of the high risk of relapse. If no prophylaxis was given during pregnancy, it must be started quickly after delivery to be effective when the risk is at its highest, i.e., during the first two weeks after delivery. Women with bipolar disorders should be advised against breast-feeding to avoid exposure of the infant to psychotropic medication. Because breast-feeding can be stressful and causes sleep deprivation, it may increase the risk of relapse. Second-generation antipsychotic agents should not be used during pregnancy or breast-feeding because inadequate information is currently available about their safety.

Menopausal transition and depression: who is at risk and how to treat it?

The menopausal transition may impose a challenge to clinicians and health professionals who are invested in improving women's quality of life; after all, this period in life is commonly marked by significant hormone fluctuations accompanied by bothersome vasomotor symptoms (e.g., hot flushes and night sweats) and other somatic complaints. In addition, more recent epidemiologic data demonstrate that some women transitioning to menopause may be at higher risk for developing depression when compared with their risk during premenopausal years; this increased risk appears to be true even among those who had never experienced depression before. In this article, putative contributing factors for this window of vulnerability for depression during the menopausal transition are critically reviewed. Hormonal and nonhormonal factors that may contribute to the occurrence of physical and/or psychiatric complaints during the menopausal transition are discussed. Lastly, existing evidence-based treatment strategies are summarized.

Association analysis of the chromosome 4p15-p16 candidate region for bipolar disorder and schizophrenia

Several independent linkage studies have identified chromosome 4p15-p16 as a putative region of susceptibility for bipolar disorder (BP), schizophrenia (SCZ) and related phenotypes. Previously, we identified two subregions (B and D) of the 4p15-p16 region that are shared by three of four 4p-linked families examined. Here, we describe a large-scale association analysis of regions B and D (3.8 and 4.5 Mb, respectively). We selected 408 haplotype-tagging single nucleotide polymorphisms (SNPs) on a block-by-block basis from the International HapMap project and tested them in 368 BP, 386 SCZ and 458 control individuals. Nominal significance thresholds were determined using principal component analysis as implemented in the program SNPSpD. In region B, overlapping SNPs and haplotypes met the region-wide threshold (P<or=0.0005) at the global and individual haplotype test level and clustered in two regions. In region D, no individual SNPs were nominally significant, but multiple global and individual haplotypes were associated with BP and/or SCZ (region-wide threshold, P<or=0.0003). These overlapping haplotypes fell into two regions. Within each of these four clusters, at least one globally significant haplotype withstood permutation testing (P(gp)<or=0.05). Five predicted genes were found within these associated regions, while Known/RefSeq genes, including KIAA0746 and PPARGC1A, mapped nearby. There were also nine other clusters within regions B and D with nominally significant haplotypes, but only at the individual haplotype level. KIAA0746, PPARGC1A, GPR125, CCKAR and DKFZp761B107 overlapped with these regions. This study has identified significant associations between BP and SCZ within the chromosome 4p linkage region, resulting in candidate regions worthy of further investigation.

What's new? The clinical epidemiology of bipolar I disorder

The last few decades have seen a rapid change in our understanding of the epidemiology of bipolar disorder, which has only recently started to achieve major research attention. This article reviews recent developments. In addition to electronic searches using MEDLINE and PsycLIT, references from articles were identified, major journals hand searched, and major textbooks of psychiatry and epidemiology reviewed. Studies may have overestimated the prevalence of mania, and underestimated incidence. The incidence of mania may be increasing in recent generations, but the data remain inconclusive. Age at onset of mania is earlier than previously believed, and there are gender differences in epidemiology and clinical course. Ethnic differences in epidemiology and clinical course of bipolar disorder are highlighted. Comorbid alcohol and substance abuse are common in patients suffering from bipolar disorder and are associated with a more severe clinical course and a worse outcome. Urban living and lower socioeconomic and single marital status may be risk factors for developing bipolar disorder.

Serotonin 1a receptor and associated G-protein activation in schizophrenia and bipolar disorder

Abnormalities in the serotonergic signalling system, including the serotonin 1a receptor, have been implicated in the pathogenesis of schizophrenia and bipolar 1 disorder. However, there is no consensus on whether the density of the serotonin 1a receptor and/or the activity of the G-proteins linking the receptor to the intracellular cascade are altered in these disease states. To address these issues, tissue obtained postmortem from four cortical regions was used to measure [3H] 8-hydroxy-2-(dipropylamino)tetralin hydrobromide (8-OH-DPAT) binding and 8-OH-DPAT-stimulated guanosine 5'-[gamma-thio]triphosphate (GTPgammaS) binding to determine if either parameter is altered in schizophrenia or bipolar I disorder. There was an effect of diagnosis on the level of [3H] 8-OH-DPAT binding that may indicate a global change in the density of serotonin 1a receptors, although this effect did not reach significance in any individual brain region. The activation of serotonin 1a receptors did not differ significantly with diagnoses. However, in the outer cortical layers, there appeared to be a dissociation between the number of receptors available and the extent of ligand-induced GTPgammaS binding, suggesting considerable receptor reserve. In addition, comparing gender independent of diagnoses, a decrease in the levels of serotonin 1a receptors was observed in the cortex of female subjects. These data indicates that there may be subtle changes in serotonin 1a receptors across the cortex in schizophrenia or bipolar I disorder and suggests a gender discordance in receptor levels.

Prophylactic treatment of bipolar disorder in pregnancy and breastfeeding: focus on emerging mood stabilizers

OBJECTIVES

Bipolar disorders are reported to have a high incidence during childbearing years and the need may arise to start or continue a pharmacological treatment during pregnancy and the postpartum period. In the last few years several investigations have evaluated the efficacy of emerging mood-stabilizing agents in the treatment of bipolar disorders, such as lamotrigine, olanzapine, risperidone, quetiapine, aripiprazole and ziprasidone. A number of studies, which examined the use of oxcarbazepine, point to its potential usefulness in prophylactic treatment. The aim of this review is to compare information from the literature on the safety of lamotrigine, oxcarbazepine, risperidone, olanzapine, and quetiapine to the safety data on classic mood stabilizers during pregnancy and the postpartum period.

METHODS

A computerized search carried out from 1980 to April 5, 2006 led to the summarization of the results. (References were updated after acceptance and prior to publication.)

RESULTS

Emerging mood stabilizers show uncertain safety parameters in pregnancy and lactation. Limited information on lamotrigine and oxcarbazepine does not suggest a clear increase in teratogenicity, while olanzapine appears to be associated with a higher risk of metabolic complications in pregnant women. Data about risperidone and quetiapine are still inconclusive. Finally, the literature on the safety of these compounds in breastfeeding is anecdotal.

CONCLUSIONS

Untreated pregnant bipolar women are at an increased risk of poor obstetrical outcomes and relapse of affective symptoms. On the other hand, classic antiepileptic drugs are well-known human teratogens, whereas data on lithium are partially ambiguous. The safety of emerging mood stabilizers in pregnancy and breastfeeding has not been examined extensively. Therefore, when approaching bipolar disorder, if possible, each episode must be considered separately.

Open-label lithium for the treatment of adolescents with bipolar depression

OBJECTIVES

To investigate the effectiveness and tolerability of lithium for the treatment of acute depression in adolescents with bipolar disorder. We hypothesized that patients receiving open-label treatment with lithium during a 6-week period would experience a statistically and clinically significant decrease in depressive symptoms and tolerate lithium treatment fairly well.

METHOD

Twenty-seven adolescents (12-18 years old) with an episode of depression associated with bipolar disorder type I received open-label lithium 30 mg/kg (twice-daily dosing), which was adjusted to achieve a therapeutic serum level (1.0-1.2 mEq/L). Effectiveness measures included the Children's Depression Rating Scale-Revised (CDRS-R) and Clinical Global Impressions Scale for Bipolar Disorder (CGI-BP). Adverse events were assessed weekly.

RESULTS

Mean CDRS-R scores significantly decreased from baseline to endpoint (mean [SD] change = -25.5 (20.4); p < .001), resulting in a large effect size of 1.7. Response and remission rates (defined by a > or = 50% reduction in CDRS-R score from baseline to endpoint, and a CDRS-R score < or = 28 and a CGI-BP Improvement score of 1 or 2, respectively) were 48% and 30%. Side effects, which were generally mild to moderate in severity, included headache (74%), nausea/vomiting (67%), stomachache (30%), and abdominal cramps (19%).

CONCLUSIONS

The findings of this study indicate that lithium may be effective and is relatively well tolerated for the treatment of an acute episode of depression in adolescents with bipolar disorder. Controlled studies of lithium in adolescent bipolar depression are needed.