Predominant polarity in bipolar disorders: refining or redefining diagnosis?

The progression trajectory of Bipolar Disorder: results from the application of a staging model over a ten-year observation

BACKGROUND

Trying to better define Bipolar Disorder (BD) progression, different staging models have been conceptualized, each one emphasizing different aspects of illness. In a previous article we retrospectively applied the main staging models to a sample of 100 bipolar patients at four time points over a ten-year observation. In the present study, focusing on Kupka & Hillegers's model, we aimed to assess the transition of the same sample through the different stages of illness and to explore the potential role of clinical variables on the risk of progression.

METHODS

Multistate Model using the mstate package in R and Markov model with stratified hazards were used for statistical analysis.

RESULTS

A high hazard of transition from stage 2 to 3 emerged, with a probability of staying in stage 2 decreasing to 14 % after 3 years. BD II was significantly associated with transition from stage 1 to 2, whereas the number of lifetime episodes >3 and the elevated predominant polarity with transition from stage 3 to 4.

CONCLUSION

Our results corroborated the evidence on BD progression and contributed to outline its trajectory over time. Further effort may help to define a standardized staging approach towards ever increasing tailored interventions.

Prevalence and correlates of manic/hypomanic and depressive predominant polarity in bipolar disorder: systematic review and meta-analysis

BACKGROUND

Identification of the predominant polarity, i.e. hypomanic/manic (mPP) or depressive predominant polarity (dPP), might help clinicians to improve personalised management of bipolar disorder.

AIMS

We performed a systematic review and meta-analysis to estimate prevalence and correlates of mPP and dPP in bipolar disorder.

METHOD

The protocol was registered in the Open Science Framework Registries (https://doi.org/10.17605/OSF.IO/8S2HU). We searched main electronic databases up to December 2023 and performed random-effects meta-analyses of weighted prevalence of mPP and dPP. Odds ratios and weighted mean differences (WMDs) were used for relevant correlates.

RESULTS

We included 28 studies, providing information on rates and/or correlates of mPP and dPP. We estimated similar rates of mPP (weighted prevalence = 30.0%, 95% CI: 23.1 to 37.4%) and dPP (weighted prevalence = 28.5%, 95% CI: 23.7 to 33.7%) in bipolar disorder. Younger age (WMD = -3.19, 95% CI: -5.30 to -1.08 years), male gender (odds ratio = 1.39, 95% CI: 1.10 to 1.76), bipolar-I disorder (odds ratio = 4.82, 95% CI: 2.27 to 10.24), psychotic features (odds ratio = 1.56, 95% CI: 1.01 to 2.41), earlier onset (WMD = -1.57, 95% CI: -2.88 to -0.26 years) and manic onset (odds ratio = 13.54, 95% CI: 5.83 to 31.46) were associated with mPP (P < 0.05). Depressive onset (odds ratio = 12.09, 95% CI: 6.38 to 22.90), number of mood episodes (WMD = 0.99, 95% CI: 0.28 to 1.70 episodes), history of suicide attempts (odds ratio = 2.09, 95% CI: 1.49 to 2.93) and being in a relationship (odds ratio = 1.98, 95% CI: 1.22 to 3.22) were associated with dPP (P < 0.05). No differences were estimated for other variables.

CONCLUSIONS

Despite some limitations, our findings support the hypothesis that predominant polarity might be a useful specifier of bipolar disorder. Evidence quality was mixed, considering effects magnitude, consistency, precision and publication bias. Different predominant polarities may identify subgroups of patients with specific clinical characteristics.

Combining predominant polarity and affective spectrum concepts in bipolar disorder: towards a novel theoretical and clinical perspective

This is an overview of recent advances on predominant polarity conceptualization in bipolar disorder (BD). Current evidence on its operationalized definitions, possible contextualization within the affective spectrum, along with its epidemiological impact, and treatment implications, are summarized. Predominant polarity identifies three subgroups of patients with BD according to their mood recurrencies: (i) those with depressive or (ii) manic predominance as well as (iii) patients without any preponderance ('nuclear' type). A predominant polarity can be identified in approximately half of patients, with similar rates for depressive and manic predominance. Different factors may influence the predominant polarity, including affective temperaments. More generally, affective disorders should be considered as existing on a spectrum ranging from depressive to manic features, also accounting for disorders with 'ultrapredominant' polarity, i.e., unipolar depression and mania. While mixed findings emerge on its utility in clinical practice, it is likely that the construct of predominant polarity, in place of conventional differentiation between BD-I and BD-II, may be useful to clarify the natural history of the disorder and select the most appropriate interventions. The conceptualization of predominant polarity seems to reconcile previous theoretical views of both BD and affective spectrum into a novel perspective. It may provide useful information to clinicians for the early identification of possible trajectories of BD and thus guide them when selecting interventions for maintenance treatment. However, further research is needed to clarify the specific role of predominant polarity as a key determinant of BD course, outcome, and treatment response.

Undetermined predominant polarity in a cohort of bipolar disorder patients: Prevalent, severe, and overlooked

OBJECTIVES

Predominant polarity (PP) is a concept used to define patients with bipolar disorder (BD) as presenting a tendency to manifest depressive (DPP) or manic (MPP) episodes. Still, the high percentage of patients with an undetermined PP (UPP), has been overlooked in most studies. Thus, we aimed to study UPP and outline its socio-demographic, clinical, and treatment-related features.

METHODS

Patients were recruited from a BD specialized unit. The sample was divided into three groups according to PP and socio-demographic and clinical variables were compared. Significant variables at univariate comparisons were included in multivariate logistic regression with UPP as the dependent variable.

RESULTS

A total of 708 BD patients were included, of which 437 with UPP (61.7%). UPP was associated with a higher number of affective relapses, when compared with DPP or MPP (χ2= 28.704, p<0.001). Mixed episodes (OR=1.398; CI=1.118-1.749), aggressive behaviour (OR=1.861; CI=1.190-2.913), seasonality (OR=2.025; CI= 1.289-3.501) and treatment with lamotrigine (OR= 2.101; CI=1.244-3.550) were significantly associated with UPP at the logistic regression.

LIMITATIONS

Recall bias may have occurred due to mixed episode diagnostic criteria change over the years. No data on the patients' follow-up has been reported on predominant polarity changes.

CONCLUSIONS

UPP is associated with a higher number of relapses, and different clinical variables related to a severe course of illness. Considering PP in patients with BD may guide the choice for differential treatment approaches having an impact on BD course of illness and patients' prognosis and recovery.

Structural neuroimaging and predominant polarity in patients with type 1 bipolar disorder from Antioquia

INTRODUCTION

Predominant polarity (PP) has been proposed as a specifier of bipolar disorder (BD) due to its relationship with clinical and prognostic variables. It is possible that this is due to a different underlying neurobiology, in such a way that the changes found by structural nuclear magnetic resonance imaging (sMRI) in BD are different and specific.

OBJECTIVES

To explore findings of structural neuroimaging in patients with BD type I (BD-I) according to PP.

METHODS

Cross-sectional study that evaluated 77 patients with BD-I using the DIGS interview. PP was established using the operative definition of two-thirds of all affective episodes throughout life to classify PP as manic (MPP), depressive (DPP) or indeterminate (IPP). MRI was performed during the euthymia phase to measure intracranial structures. The data obtained was analysed using a linear regression model adjusted for confounding variables (drug use, alcohol use, psychoactive substance use) and were compared between the three groups finding the standardised mean difference (SMD).

RESULTS

Differences with adequate effect size were found in three brain structures after adjusting for confounding variables, specifically in the right fusiform gyrus and the left lingual gyrus, which were greater in the DPP group than in the MPP group (SMD = 0.92; 95% CI = 0.34-1.49 and SMD = 0.78; 95% CI = 0.21-1.35). Likewise, in the right thalamus, it was shown to be greater in the IPP group compared to MPP group (SMD 0.89, 95% CI = 0.31-1.46).

CONCLUSIONS

A reduction in the thickness of the right fusiform gyrus and the left lingual gyrus, as well as the right thalamic volume was observed in patients with BD-I with PPM, which supports the hypothesis that PP has a plausible neurobiological correlate and could have potential utility as a BD specifier.

Factors associated with lifetime suicide attempts in bipolar disorder: results from an Italian nationwide study

The purpose of the present study was to detect demographic and clinical factors associated with lifetime suicide attempts in Bipolar Disorder (BD). A total of 1673 bipolar patients from different psychiatric departments were compared according to the lifetime presence of suicide attempts on demographic/clinical variables. Owing to the large number of variables statistically related to the dependent variable (presence of suicide attempts) at the univariate analyses, preliminary multiple logistic regression analyses were realized. A final multivariable logistic regression was then performed, considering the presence of lifetime suicide attempts as the dependent variable and statistically significant demographic/clinical characteristics as independent variables. The final multivariable logistic regression analysis showed that an earlier age at first contact with psychiatric services (odds ratio [OR] = 0.97, p < 0.01), the presence of psychotic symptoms (OR = 1.56, p < 0.01) or hospitalizations (OR = 1.73, p < 0.01) in the last year, the attribution of symptoms to a psychiatric disorder (no versus yes: OR = 0.71, partly versus yes OR = 0.60, p < 0.01), and the administration of psychoeducation in the last year (OR = 1.49, p < 0.01) were all factors associated with lifetime suicide attempts in patients affected by BD. In addition, female patients resulted to have an increased association with life-long suicidal behavior compared to males (OR: 1.02, p < 0.01). Several clinical factors showed complex associations with lifetime suicide attempts in bipolar patients. These patients, therefore, require strict clinical monitoring for their predisposition to a less symptom stabilization. Future research will have to investigate the best management strategies to improve the prognosis of bipolar subjects presenting suicidal behavior.

Hair cortisol, social support, personality traits, and clinical course: differences in schizophrenia and bipolar disorder

OBJECTIVE

This study aimed to investigate the differences in the relationship between hair cortisol concentration (HCC) and psychosocial stress, social support, clinical features, clinical course, and outcome in schizophrenia and bipolar disorder.

METHODS

A total of 109 schizophrenia patients, 93 bipolar disorder patients and 86 healthy controls between 18 and 60 years old were enrolled in the study. Linear regression and factor analysis were employed to examine and compare the relationship between HCC and childhood trauma, the number of stressful life events, the amount of social support in the three months before the hair cortisol assessment, clinical fearures, clinical course, and outcome in schizophrenia and bipolar disorder.

RESULTS

HCC is significantly associated with clinical syndromes, including depression-anxiety factor of Positive and Negative Syndrome Scale in schizophrenia patients, and thought disorder in bipolar disorder patients. However, HCC is positively related to social support and personality traits only in schizophrenia patients but not in bipolar disorder patients. Factor analysis indicates schizophrenia and bipolar disorder share a very similar but somewhat different structure in terms of HCC, psychosocial stress, social support, clinical features, clinical course, and outcome.

CONCLUSION

Findings support that schizophrenia and bipolar disoder have a significant overlap in both clinical characteristics and enviromental risk factors. Aberrant HCC contributes to the complexity of clinical characteristics mainly in schizophrenia.

Predominant polarity in bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

AIM

This cross-sectional study aimed to assess the predominant polarity (PP) in patients with bipolar disorder (BD) and the factors associated with PP.

METHODOLOGY

For this study, 773 participants with at least 10 years of illness, were recruited from 14 centres, were evaluated using the National Institute of Mental Health- Retrospective Life Charts to assess the course of illness and PP was determined by both Barcelona proposal and the Harvard Index.

RESULTS

According to Barcelona proposal for PP, 20.6% of the patients belonged to depressive PP, 45.8% belonged to manic PP and 33.6% belonged to indeterminate polarity. According to Harvard index of PP, 31.6% of the patients belonged to depressive PP, 56.1% belonged to manic polarity and 12.3% of the patients could not be categorized into any of these categories and hence, were considered to have indeterminate polarity. Those with depressive PP were more often having BD-II, had later age of onset, spent more time in episodes, had higher residual depressive symptoms, had lower residual manic symptoms, more often had depression as the first lifetime episode, and less often had at least one psychotic episode.

CONCLUSION

In the Indian subcontinent, although the prevalence of PP is influenced by the definition used, the most common PP is that of mania.

Medication adherence in bipolar disorder: Exploring the role of predominant polarity

OBJECTIVES

Medication non-adherence is one important reason behind sub-optimal outcome from treatment of bipolar affective disorder (BPAD). Though various reasons behind medication non-adherence have been identified, little is known about the medication adherence patterns across various predominant polarities (PP) in BPAD.

METHODS

100 euthymic patients of BPAD were purposively recruited and the PP were determined. Subsequently, Morisky Medication adherence scale (MMAS); Global Assessment of Functioning (GAF); Oslo Social Support Scale and World Health Organization Quality of Life scale- Brief version (WHOQOL-Bref) were administered. Analysis of covariance (ANCOVA) was done to estimate the difference of scores of MMAS after adjusting for any potential confounders.

RESULTS

Overall, 44 patients with manic PP (MPP), 17 with depressive PP (DPP) and 39 with indeterminate PP (IPP) were recruited. It was found that patients who presented with DPP showed significantly higher medication adherence as compared to MPP.

CONCLUSION

Knowledge of PP of a patient of BPAD can be useful in anticipating medication adherence and treatment outcome. The major limitations included non-probability sampling, cross-sectional design and limited generalizability of the results.

Structural Neuroimaging and Predominant Polarity in Patients with Type 1 Bipolar Disorder from Antioquia

INTRODUCTION

Predominant polarity (PP) has been proposed as a specifier of bipolar disorder (BD) due to its relationship with clinical and prognostic variables. It is possible that this is due to a different underlying neurobiology, in such a way that the changes found by structural nuclear magnetic resonance imaging (sMRI) in BD are different and specific.

OBJECTIVES

To explore findings of structural neuroimaging in patients with BD type I (BD-I) according to PP.

METHODS

Cross-sectional study that evaluated 77 patients with BD-I using the DIGS interview. PP was established using the operative definition of two-thirds of all affective episodes throughout life to classify PP as manic (MPP), depressive (DPP) or indeterminate (IPP). MRIwas performed during the euthymia phase to measure intracranial structures. The data obtained was analysed using a linear regression model adjusted for confounding variables (drug use, alcohol use, psychoactive substance use) and were compared between the three groups finding the standardised mean difference (SMD).

RESULTS

Differences with adequate effect size were found in three brain structures after adjusting for confounding variables, specifically in the right fusiform gyrus and the left lingual gyrus, which were greater in the DPP group than in the MPP group (SMD = 0.92; 95% CI = 0.34 to 1.49 and SMD = 0.78; 95% CI = 0.21 to 1.35). Likewise, in the right thalamus, it was shown to be greater in the IPP group compared to MPP group (SMD 0.89, 95% CI = 0.31 to 1.46).

CONCLUSIONS

A reduction in the thickness of the right fusiform gyrus and the left lingual gyrus, as well as the right thalamic volume was observed in patients with BD-I with PPM, which supports the hypothesis that PP has a plausible neurobiological correlate and could have potential utility as a BD specifier.

Paliperidone LAI and Aripiprazole LAI Plasma Level Monitoring in the Prophylaxis of Bipolar Disorder Type I with Manic Predominance

Introduction The objective of this study was the evaluation of utility of plasma level monitoring in the clinical stabilizing efficacy and tolerability of paliperidone palmitate (PP) vs. aripiprazole monohydrate (AM) in bipolar disorder I (BD I) with manic predominance.

Methods Fifty-six outpatients of both sexes, age ranging from 18 to 65 years, affected by BD I with manic predominance, orally treated and stabilized after acute episode for at least 2 weeks with paliperidone or aripiprazole (n=31, paliperidone; n=25, aripiprazole) underwent a prospective observational study of switching to the corresponding long-acting injection (LAI) on the basis of clinical evaluation. The efficacy and tolerability of the 2 treatments were assessed by BPRS, PANSS, HAMD21, and MRS rating scales and a check list every month for 12 months. Drug plasma levels determinations (PLs) were performed at the same times.

Results A good clinical stability and tolerability of both drugs were reported. Lower mean PLs of PP showed a positive effect on depressive symptoms. AM PLs variability was associated with greater instability of manic symptoms whereas intermediate PLs seem to have more influence on depressive symptomatology.

Discussion PLs drug monitoring has been proven to be useful, and further investigations to identify optimal therapeutic ranges for LAI formulations are needed.

Gender-related differences in patients with bipolar disorder: a nationwide study

OBJECTIVE

The possible presence of gender-related differences in patients with bipolar disorder (BD) may have diagnostic and therapeutic implications. This multicenter study aimed to investigate gender differences in BD in the largest Italian database collected to date, on behalf of the Italian Chapter of the International Society of Bipolar Disorders.

METHODS

A total of 1674 patients (males: n = 714; females: n = 960) from different psychiatric departments were compared according to gender on demographic/clinical variables. Owing to the large number of variables statistically related to the dependent variable (gender) at the univariate analyses, preliminary multiple logistic regression analyses were performed. A final multivariable logistic regression was then performed, considering gender as the dependent variable and statistically significant demographic/clinical characteristics as independent variables.

RESULTS

The results of the final multivariable logistic regression analysis with previous statistically significant demographic and clinical variables were the following: female gender was less frequently associated with employment (odds ratio [OR] = 0.7, P < 0.01), lifetime single marital status (OR = 0.45, P < 0.01), and substance abuse in the last year (OR = 0.35, P < 0.01), whereas it was more frequently associated with a major number of lifetime major depressive episodes (OR = 1.78, P < 0.01) and psychiatric visits in the last year (OR = 1.38, P = 0.01).

CONCLUSION

Few significant differences were found between genders in BD, particularly for those clinical features that are associated with poor prognosis (substance abuse for males and number of depressive episodes for females). Transcultural studies are needed to identify cultural versus illness-related variables possibly explaining the different clinical presentation of BD in relation to gender.

Correlates of current rapid-cycling bipolar disorder: Results from the Italian multicentric RENDiBi study

BACKGROUND

we aimed to compare socio-demographic and clinical differences between patients with versus without current RC in order to detect clinical factors that may favor early diagnosis and personalized treatment.

METHODS

A total of 1675 patients (males: n = 714 and females: n = 961; bipolar 1: n = 1042 and bipolar 2: n = 633) from different psychiatric clinics were grouped and compared according to the current presence of RC in terms of socio-demographic and clinical variables. Chi-squared tests for qualitative variables and Student's t tests for quantitative variables were executed for group comparison, and multivariable logistic regressions were performed, considering the current presence of RC as dependent variable, and socio-demographic/clinical factors as independent variables.

RESULTS

Female gender (male versus female: OR = 0.64, p = 0.04), unidentifiable prevalent polarity (versus depressive polarity: OR = 1.76, p = 0.02; versus manic polarity: OR: 2.86, p < 0.01) and hospitalization in the last year (no versus yes: OR = 0.63, p = 0.02) were found to be associated with RC in the final multivariable regression analysis.

CONCLUSIONS

RC in BD seems to be more prevalent in female gender and associated with some unfavorable clinical features, such as an increased risk of hospitalization. These aspects should be taken into account in the management and monitoring of RC versus non-RC patients.

Psychotic versus non-psychotic bipolar disorder: Socio-demographic and clinical profiles in an Italian nationwide study

OBJECTIVE

Psychotic versus non-psychotic patients with bipolar disorder have been traditionally associated with different unfavorable clinical features. In this study on bipolar Italian patients, we aimed to compare clinical and demographic differences between psychotic and non-psychotic individuals, exploring clinical factors that may favor early diagnosis and personalized treatment.

METHODS

A total of 1671 patients (males: n = 712 and females: n = 959; bipolar type 1: n = 1038 and bipolar type 2: n = 633) from different psychiatric departments were compared according to the lifetime presence of psychotic symptoms in terms of socio-demographic and clinical variables. Chi-square tests for qualitative variables and Student's t-tests for quantitative variables were performed for group comparison, and a multivariable logistic regression was performed, considering the lifetime psychotic symptoms as dependent variables and socio-demographic/clinical characteristics as independent variables.

RESULTS

Psychotic versus non-psychotic bipolar subjects resulted to: be more frequently unemployed (p < 0.01) and never married/partnered (p < 0.01); have an earlier age at onset (p < 0.01); more frequently receive a first diagnosis different from a mood disorder (p < 0.01); have a shorter duration of untreated illness (p < 0.01); have a more frequently hypomanic/manic prevalent polarity (p < 0.01) and a prevalent manic-depressive type of cycling (p < 0.01); present a lower lifetime number of depressive episodes (p < 0.01), but have more manic episodes (p < 0.01); and less insight (p < 0.01) and more hospitalizations in the last year (p < 0.01). Multivariable regression analysis showed that psychotic versus non-psychotic bipolar patients received more frequently a first diagnosis different from bipolar disorder (odds ratio = 0.64, 95% confidence interval = [0.46, 0.90], p = 0.02) or major depressive disorder (odds ratio = 0.66, 95% confidence interval = [0.48, 0.91], p = 0.02), had more frequently a prevalent manic polarity (odds ratio = 1.84, 95% confidence interval = [1.14, 2.98], p < 0.01) and had a higher number of lifetime manic episodes (more than six) (odds ratio = 8.79, 95% confidence interval = [5.93, 13.05], p < 0.01).

CONCLUSION

Lifetime psychotic symptoms in bipolar disorder are associated with unfavorable socio-demographic and clinical features as well as with a more frequent initial misdiagnosis.

Predominant polarity in bipolar disorder patients: The COPE bipolar sample

BACKGROUND

The concept of predominant polarity (PP) is defined as presenting more symptoms of one polarity. Previous studies have defined PP as one polarity (either a depression or mania episode) occurring during at least two-thirds of the lifetime.

METHODS

We conducted an observational study with the COPE-BD (Clinical Outcome and Psycho-Education for Bipolar Disorder, Clinical Outcome Measures Section) dataset to identify the diagnostic and treatment differences between bipolar disorder (BD) patients with and without PP.

RESULTS

The final sample included 210 BD-I (59.0%) and 146 BD-II (41.0%) patients. Of these, 28.9% patients presented predominant polarity (PP): 62 (17.4%) of those patients were depressed polarity predominant (DPP), 41 (11.5%) were manic polarity predominant (MPP), and 253 (71.1%) met criteria for bipolar disorders but did not present with PP. In comparison to this group of BD patients with undetermined polarity, the group of BD patients with PP presented more rapid cycling. Furthermore, in the undetermined polarity group, the onset of illness occurred earlier, and the duration of the illness was longer, with more hypomanic/manic and depressive episodes than patients who met the PP criteria.

LIMITATIONS

This study has a naturalistic and retrospective design and does not allow a specific follow-up of polarity over time.

CONCLUSIONS

These different clinical characteristics underline the importance of considering PP in patients with BD, and justify the need for differential treatment approach which could have an impact on patients' prognosis. Yet, more independent and prospective research is needed to confirm these findings, especially with the new classification of DSM-5 concerning mixed states.

Predominant Polarity in Bipolar Affective Disorder: A Scoping Review of Its Relationship with Clinical Variables and Its Implications

BACKGROUND

Bipolar affective disorder (BPAD) is an episodic psychiatric disorder that is associated with considerable morbidity. Psychiatrists have found it difficult to treat the disorder owing to the variety of presentation and variety of challenges in clinical decision-making. To guide the clinicians, the concept of predominant polarity (PP) in BPAD has become important. This review was conducted to understand the definition, epidemiology, relationship with sociodemographic and clinical parameters, and implications of PP in BPAD.

METHODOLOGY

The review was conducted after selecting 17 original research studies from PubMed using appropriate search terms.

RESULTS

There is no consensus definition of PP. Epidemiological data showed varied results, although most common PP demonstrated in most studies was depressive polarity. The relation between sociodemographic and clinical parameters also lacked uniformity, although certain patterns could be identified in their relationships. The implications of PP in diagnostics, treatment, and classificatory system are discussed.

CONCLUSION

PP in BPAD conveys clinically important information that aids a clinician in decision-making. Further studies are required so that we can understand the neurobiological underpinning of the concept.

Modifiable and non-modifiable factors associated with functional impairment during the inter-episodic periods of bipolar disorder

The chronic, long-term evolution of bipolar disorder (BD) requires a careful clinical characterization with prognostic implications in terms of symptom and functional control. The OPTHYMUM multicenter study was conducted in France with the objective of evaluating residual symptoms on overall functioning of BD patients during inter-episodic period. The aims of the present study were to identify the potentially modifiable (e.g., treatable) and non-modifiable variables associated with functional impairment during the inter-episodic periods of BD. Sample was divided into two groups according to level of functioning (adequate vs. impaired), based on the FAST scale total score. FAST cut-off for functional impairment is a score >11. The two subgroups were compared as per sociodemographic and clinical variables with standard univariate analyses, and a logistic regression model was created. The model as a whole contained independent non-modifiable factors (age, gender, BD type, illness duration) and modifiable factors (illness severity, predominant polarity, depressive and manic residual symptoms, comorbidities). The final model was statistically significant (χ ² = 53.89, df = 5, p < 0.001). Modifiable factors most strongly associated with functional impairment were manic predominant polarity (OR = 1.79, CI 95% 1.09-2.96, p = 0.022), residual depressive symptoms (OR = 1.30, CI 95% 1.18-1.43, p < 0.001) and illness severity (OR = 1.24, CI 95% 1.01-1.52, p = 0.037), whilst non-modifiable factor was illness duration (OR = 1.03, CI 95% 1.01-1.05, p = 0.017). Despite intrinsic and non-modifiable illness characteristics, a clinical-wise choice of treatment may help to improve control of manic relapses. Potential improvement of residual depressive symptoms may alleviate the functional burden associated with bipolar disorder.

Impact of predominant polarity on long-term outcome in bipolar disorder: A 7-year longitudinal cohort study

INTRODUCTION

Recent studies suggest that Predominant Polarity (PP) may be an important specifier of Bipolar Disorder (BD), establishing distinct groups of patients and providing a potential tool for tailored treatment. PP has been associated to various clinical variables present in the course of the disorder, including deficits in cognitive functioning, suicide attempts, hospitalizations and response to pharmacological treatment. However, most published studies are retrospective and cross-sectional, frequently relying on patients´ ability to recall past information, which may often be inaccurate.

METHODS

Participants were recruited from the outpatient clinic of the Bipolar Disorder Research Program at the Institute of Psychiatry of the University of São Paulo. Baseline clinical and demographic variables were collected using a semi-structured questionnaire and the SCID-CV. Longitudinal data were collected through medical records, mood charts, and mood symptom scales conducted throughout a 7-year follow-up period.

RESULTS

Manic Predominant Polarity (MPP) was associated with a significantly higher number of hospitalizations, suicide attempts, and episodes with psychotic symptoms throughout the 7-year observed period in comparison to Depressive Predominant Polarity (DPP) and Indefinite Predominant Polarity (IPP) patients. Moreover, baseline PP was significantly associated with 7-year PP, with 67% of patients maintaining their PP both at baseline and after the 7-year follow-up period.

LIMITATIONS

The present study is limited due to the statistically small sample size, although, to our knowledge, it is the largest longitudinal study conducted in this topic, and the unequally distributed frequency of patients´ visitations, which may have created intervals of unobserved periods within the follow-up period.

DISCUSSION

The results revealed PP to be an important specifier for predicting the course of the disorder. Overall, MPP was significantly associated with variables indicative of a worse outcome, suggesting that greater attention to preventive treatment should be addressed to this subgroup. Lastly, baseline PP was significantly associated with 7-year observed PP, suggesting that patients tend to remain within the same PP throughout the course of the disorder.

Ruminative and dampening responses to positive affect in bipolar disorder and major depressive disorder

BACKGROUND

Although previous research has focused on distinguishing cognitive styles between Bipolar Disorder (BD) and Major Depressive Disorder (MDD), little is known about differences in positive affect regulation between these affective groups. The aim of the present study was to extend previous research by investigating such differences between BD and MDD, and between the bipolar subtypes (BD-I vs. BD-II and predominant polarities), using large, clinical, outpatient samples.

METHODS

In total, 298 participants (96 BD-I, 27 BD-II, and 175 MDD) were included. All completed the Responses to Positive Affect (RPA) questionnaire. Mood symptoms in BD patients were clinically assessed by means of the Clinical Global Impression for Bipolar Disorders (CGI-BP), while depressive symptom severity in MDD patients were assessed by means of the Inventory of Depressive Symptomatology (IDS-SR).

RESULTS

Results showed differences between affective groups and bipolar subtypes. The most salient finding was that both BD-I and BD-II patients were more likely to ruminate about positive affect than MDD patients, while MDD patients were more likely to engage in dampening responses to positive affect.

CONCLUSIONS

Differentiation of responses to positive affect between BD and MDD may have relevant clinical implications in terms of symptomatology, course, and treatment.

Socio-demographic and clinical characterization of patients with Bipolar Disorder I vs II: a Nationwide Italian Study

Bipolar disorders (BDs) are prevalent, comorbid and disabling conditions, associated with the highest suicide risk among psychiatric illnesses. In the last few years, new efforts to better characterize the socio-demographic and clinical profiles of BD type I vs II have been documented by several reports, with novel and insightful findings in the field. The present multicenter study aimed to provide a comprehensive and reliable representation of the Italian reality, through the analysis of the largest national sample of bipolar patients collected so far. A total of 1500 patients (BD I n = 963 and BD II n = 537) from different psychiatric departments, participating in the Italian Chapter of the "International Society of Bipolar Disorders" (ISBD), were assessed and divided into two groups on the basis of their diagnostic subtype, and different socio-demographic and clinical variables were compared between the two subgroups. Chi-squared tests for categorical variables and t tests for continuous variables were performed for group comparison. Furthermore, a multivariable logistic regression was performed, considering diagnostic bipolar subtype (type I or II) as dependent variable, and socio-demographic/clinical characteristics as independent variables. BD I vs II patients showed an overall less favorable socio-demographic and clinical profile. In addition, the multivariable logistic regression showed that BD II vs BD I was predicted by the absence of lifetime suicide attempts (OR = 1.58, p = 0.01), a later age of diagnosis (OR = 1.03, p < 0.01), less hypomanic episodes in the last year (OR = 2.29, p < 0.0001) and absence of psycho-educational interventions in the last year (OR = 0.51, p < 0.01). BD I and II patients were found to significantly differ in relation to specific clinical variables, which should be considered within updated diagnostic-therapeutic algorithms.

A study on the bioequivalence of lithium and valproate salivary and blood levels in the treatment of bipolar disorder

Lithium (Li) and valproate (VPA) are used in the treatment of bipolar disorder (BD), with narrow therapeutic window requiring periodic control of serum levels. This prevents intoxication, lack of efficacy due to low serum concentrations, and allows monitoring adherence. We aimed at evaluating the bioequivalence of salivary and blood levels of LI or VPA in a sample of adult BD patients. Secondarily, lithium bioequivalence was evaluated across different patients' lifespans. BD patients treated with either Li or VPA underwent contemporary standard serum and salivary measurements. Blood levels of both drugs were taken according to standard procedures. Li salivary levels were performed by an adapted potentiometric method on the AVL9180 electrolyte analyzer. VPA salivary levels were taken with an immune-assay method with turbidimetric inhibition. A total of 50 patients (38 on Li, 12 on VPA) were enrolled. Blood-saliva bioequivalence for VPA was not found due to a high variability in salivary measures. Li measures resulted in a high correlation (r=0.767, p<0.001), showing no partial correlation with age (r=0.147, p=0.380). Li salivary test is a reliable method of measuring Li availability and is equivalent to serum levels. Potential advantages of Li salivary testing are its non-invasive nature and the possibility of doing the test during the usual appointment with the psychiatrist.