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Bohnen JLB, Wigstrom TP, Griggs AM, Roytman S, Paalanen RR, Andrews HA, Bohnen NI, Franklin JJH, McInnis MG. Ketogenic-Mimicking Diet as a Therapeutic Modality for Bipolar Disorder: Biomechanistic Rationale and Protocol for a Pilot Clinical Trial. Nutrients 2023; 15:3068. [PMID: 37447394 PMCID: PMC10346691 DOI: 10.3390/nu15133068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
There is growing interest in the investigation of ketogenic diets as a potential therapy for bipolar disorder. The overlapping pharmacotherapies utilized for both bipolar disorder and seizures suggest that a mechanistic overlap may exist between these conditions, with fasting and the ketogenic diet representing the most time-proven therapies for seizure control. Recently, preliminary evidence has begun to emerge supporting a potential role for ketogenic diets in treating bipolar disorder. Notably, some patients may struggle to initiate a strict diet in the midst of a mood episode or significant life stressors. The key question addressed by this pilot clinical trial protocol is if benefits can be achieved with a less restrictive diet, as this would allow such an intervention to be accessible for more patients. Recent development of so-called ketone esters, that once ingested is converted to natural ketone bodies, combined with low glycemic index dietary changes has the potential to mimic two foundational components of therapeutic ketosis: high levels of ketones and minimal spiking of glucose/insulin. This pilot clinical trial protocol thus aims to investigate the effect of a 'ketogenic-mimicking diet' (combining supplementation of ketone esters with a low glycemic index dietary intervention) on neural network stability, mood, and biomarker outcomes in the setting of bipolar disorder. Positive findings obtained via this pilot clinical trial protocol may support future target engagement studies of ketogenic-mimicking diets or related ketogenic interventions. A lack of positive findings, in contrast, may justify a focus on more strict dietary interventions for future research.
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Affiliation(s)
| | | | - Alexis M. Griggs
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
- Neurology Service and GRECC, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA
| | - Stiven Roytman
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
| | | | | | - Nicolaas I. Bohnen
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
- University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Neurology Service and GRECC, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson’s Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Melvin G. McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, USA
- Heinz C. Prechter Bipolar Research Program, University of Michigan, Ann Arbor, MI 48109, USA
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2
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Montano CB, Jackson WC, Vanacore D, Weisler R. Considerations when selecting an antidepressant: a narrative review for primary care providers treating adults with depression. Postgrad Med 2023:1-17. [PMID: 36912037 DOI: 10.1080/00325481.2023.2189868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Major depressive disorder (MDD) is a debilitating mental disorder that can be treated with a number of different antidepressant therapies, each with its own unique prescribing considerations. Complicating the selection of an appropriate antidepressant for adults with MDD is the heterogeneity of clinical profiles and depression subtypes. Additionally, patient comorbidities, preferences, and likelihood of adhering to treatment must all be considered when selecting an appropriate therapy. With the majority of prescriptions being written by primary care practitioners, it is appropriate to review the unique characteristics of all available antidepressants, including safety considerations. Prior to initiating antidepressant treatment and when patients do not respond adequately to initial therapy and/or exhibit any hypomanic or manic symptoms, bipolar disorder must be ruled out, and evaluation for psychiatric comorbidities must be considered as well. Patients with an inadequate response may then require a treatment switch to another drug with a different mechanism of action, combination, or augmentation strategy. In this narrative review, we propose that careful selection of the most appropriate antidepressant for adult patients with MDD based on their clinical profile and comorbidities is vital for initial treatment selection.Strategies must be considered for addressing partial and inadequate responses as well to help patients achieve full remission and sustained functional recovery. This review also highlights data for MDD clinical outcomes for which gaps in the literature have been identified, including the effects of antidepressants on functional outcomes, sleep disturbances, emotional and cognitive blunting, anxiety, and residual symptoms of depression.
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Affiliation(s)
- C Brendan Montano
- Montano Wellness LLC, CT Clinical Research, University of Connecticut Medical School, Farmington, CT, USA
| | - W Clay Jackson
- West Cancer Center, Department of Family Medicine and Department of Psychiatry, University of Tennessee College of Medicine, Memphis, TN, USA
| | | | - Richard Weisler
- P.A. & Associates; Department of Psychiatry, Duke University, Durham, NC, USA.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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3
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Montano CB, Jackson WC, Vanacore D, Weisler RH. Practical Advice for Primary Care Clinicians on the Safe and Effective Use of Vortioxetine for Patients with Major Depressive Disorder (MDD). Neuropsychiatr Dis Treat 2022; 18:867-879. [PMID: 35440869 PMCID: PMC9013418 DOI: 10.2147/ndt.s337703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 03/04/2022] [Indexed: 01/10/2023] Open
Abstract
Primary care clinicians have a vital role to play in the diagnosis and management of patients with major depressive disorder (MDD). This includes screening for MDD as well as identifying other possible psychiatric disorders including bipolar disorder and/or other comorbidities. Once MDD is confirmed, partnering with patients in the shared decision-making process while considering different treatment options and best management of MDD over the course of their illness is recommended. Vortioxetine has been approved for the treatment of adults with MDD since 2013, and subsequent US label updates indicate that vortioxetine may be particularly beneficial for specific populations of patients with MDD, including those with treatment-emergent sexual dysfunction and patients experiencing certain cognitive symptoms. Given these recent label updates, this prescribing guide for vortioxetine aims to provide clear and practical guidance for primary care clinicians on the safe and effective use of vortioxetine for the treatment of MDD, including how to identify appropriate patients for treatment.
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Affiliation(s)
- C Brendan Montano
- Montano Wellness LLC, Cromwell, CT, USA.,Department of Family Medicine, University of Connecticut Medical School, Farmington, CT, USA
| | - W Clay Jackson
- Department of Psychiatry and Family Medicine, West Cancer Center, Germantown, TN, USA.,Department of Psychiatry and Family Medicine, University of Tennessee College of Medicine, Memphis, TN, USA
| | - Denise Vanacore
- Department of Nursing, Messiah University, Mechanicsburg, PA, USA
| | - Richard H Weisler
- Richard H. Weisler MD, P.A. & Associates, Raleigh, NC, USA.,Department of Psychiatry, Duke University and the University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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4
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Buoli M, Cesana BM, Bolognesi S, Fagiolini A, Albert U, Di Salvo G, Maina G, de Bartolomeis A, Pompili M, Palumbo C, Bondi E, Steardo L, De Fazio P, Amore M, Altamura M, Bellomo A, Bertolino A, Di Nicola M, Di Sciascio G, Fiorillo A, Sacchetti E, Sani G, Siracusano A, Di Lorenzo G, Tortorella A, Altamura AC, Dell'Osso B. Factors associated with lifetime suicide attempts in bipolar disorder: results from an Italian nationwide study. Eur Arch Psychiatry Clin Neurosci 2022; 272:359-370. [PMID: 34652488 PMCID: PMC8938374 DOI: 10.1007/s00406-021-01343-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 10/04/2021] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Massimiliano Buoli
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Bruno Mario Cesana
- Department of Clinical Sciences and Community Health, Unit of Medical Statistics, Biometry and Bioinformatics "Giulio A. Maccacaro", Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | | | | | - Umberto Albert
- Department of Medicine, Surgery and Health Sciences, Department of Mental Health, UCO Clinica Psichiatrica, ASUGI-Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Trieste, Italy
| | | | - Giuseppe Maina
- San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
| | - Andrea de Bartolomeis
- Laboratory of Molecular Psychiatry and Translational Psychiatry, Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Odontostomatology, University School of Medicine of Napoli Federico II, Naples, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sapienza University of Rome, Rome, Italy
| | - Claudia Palumbo
- Department of Psychiatry, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Emi Bondi
- Department of Psychiatry, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Steardo
- Psychiatric Unit, Department of Health Sciences, University Magna Graecia, Catanzaro, Italy
| | - Pasquale De Fazio
- Psychiatric Unit, Department of Health Sciences, University Magna Graecia, Catanzaro, Italy
| | - Mario Amore
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Mario Altamura
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Antonello Bellomo
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Alessandro Bertolino
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Marco Di Nicola
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Andrea Fiorillo
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Emilio Sacchetti
- Department of Mental Health and Addiction Services, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Gabriele Sani
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alberto Siracusano
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Unit of Psychiatry and Clinical Psychology, Policlinico Tor Vergata Foundation, Rome, Italy
| | - Giorgio Di Lorenzo
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Unit of Psychiatry and Clinical Psychology, Policlinico Tor Vergata Foundation, Rome, Italy
| | | | - A Carlo Altamura
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Bernardo Dell'Osso
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Psychiatry Unit 2, ASST-Fatebenefratelli-Sacco, via G.B.Grassi 74, 20157, Milan, Italy
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
- CRC "Aldo Ravelli" for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Milan, Italy
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5
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Pisanu C, Vitali E, Meloni A, Congiu D, Severino G, Ardau R, Chillotti C, Trabucchi L, Bortolomasi M, Gennarelli M, Minelli A, Squassina A. Investigating the Role of Leukocyte Telomere Length in Treatment-Resistant Depression and in Response to Electroconvulsive Therapy. J Pers Med 2021; 11:jpm11111100. [PMID: 34834452 PMCID: PMC8622097 DOI: 10.3390/jpm11111100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022] Open
Abstract
Psychiatric disorders seem to be characterized by premature cell senescence. However, controversial results have also been reported. In addition, the relationship between accelerated aging and treatment-resistance has scarcely been investigated. In the current study, we measured leukocyte telomere length (LTL) in 148 patients with treatment-resistant depression (TRD, 125 with major depressive disorder, MDD, and 23 with bipolar disorder, BD) treated with electroconvulsive therapy (ECT) and analyzed whether LTL was associated with different response profiles. We also compared LTL between patients with TRD and 335 non-psychiatric controls. For 107 patients for which genome-wide association data were available, we evaluated whether a significant overlap among genetic variants or genes associated with LTL and with response to ECT could be observed. LTL was negatively correlated with age (Spearman’s correlation coefficient = −0.25, p < 0.0001) and significantly shorter in patients with treatment-resistant MDD (Quade’s F = 35.18, p < 0.0001) or BD (Quade’s F = 20.84, p < 0.0001) compared to controls. Conversely, baseline LTL was not associated with response to ECT or remission. We did not detect any significant overlap between genetic variants or genes associated with LTL and response to ECT. Our results support previous findings suggesting premature cell senescence in patients with severe psychiatric disorders and suggest that LTL could not be a predictive biomarker of response to ECT.
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Affiliation(s)
- Claudia Pisanu
- Department of Biomedical Science, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy; (C.P.); (A.M.); (D.C.); (G.S.)
| | - Erika Vitali
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy; (E.V.); (M.G.); (A.M.)
- Genetics Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125 Brescia, Italy
| | - Anna Meloni
- Department of Biomedical Science, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy; (C.P.); (A.M.); (D.C.); (G.S.)
| | - Donatella Congiu
- Department of Biomedical Science, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy; (C.P.); (A.M.); (D.C.); (G.S.)
| | - Giovanni Severino
- Department of Biomedical Science, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy; (C.P.); (A.M.); (D.C.); (G.S.)
| | - Raffaella Ardau
- Unit of Clinical Pharmacology, University Hospital Agency of Cagliari, 09123 Cagliari, Italy; (R.A.); (C.C.)
| | - Caterina Chillotti
- Unit of Clinical Pharmacology, University Hospital Agency of Cagliari, 09123 Cagliari, Italy; (R.A.); (C.C.)
| | - Luigi Trabucchi
- Psychiatric Hospital “Villa Santa Chiara”, 37142 Verona, Italy; (L.T.); (M.B.)
| | - Marco Bortolomasi
- Psychiatric Hospital “Villa Santa Chiara”, 37142 Verona, Italy; (L.T.); (M.B.)
| | - Massimo Gennarelli
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy; (E.V.); (M.G.); (A.M.)
- Genetics Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125 Brescia, Italy
| | - Alessandra Minelli
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy; (E.V.); (M.G.); (A.M.)
- Genetics Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125 Brescia, Italy
| | - Alessio Squassina
- Department of Biomedical Science, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy; (C.P.); (A.M.); (D.C.); (G.S.)
- Correspondence: ; Tel.: +39-070-675-4323
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6
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Antolín-Concha D, Lähteenvuo M, Vattulainen P, Tanskanen A, Taipale H, Vieta E, Tiihonen J. Suicide mortality and use of psychotropic drugs in patients hospitalized due to bipolar disorder: A Finnish nationwide cohort study. J Affect Disord 2020; 277:885-892. [PMID: 33065830 DOI: 10.1016/j.jad.2020.09.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/16/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Knowledge on the comparative effectiveness of pharmacological treatments to prevent suicide mortality in bipolar disorder is still lacking. METHODS We studied the risk of suicide mortality during 1996-2012 among all patients who had been hospitalized due to bipolar disorder in Finland (n = 18,018; mean follow-up time 7.2 years) using nation-wide databases. We used a Cox proportional hazards model. Analyses were adjusted for the effects of time since diagnosis, order of treatments, current use of other treatments, polypharmacy, number of suicidal hospitalizations within 2 year (indicator of inherent risk of relapse), age at index date, sex, and calendar year of index date. In secondary analysis, the first 30 days were omitted from analysis after initiation of a psychopharmacological treatment to control for protopathic bias. RESULTS In comparison between use and no use among specific agents, only lithium (HR 0.33, 95%CI 0.24-0.47, p<0.0001) and valproic acid (HR 0.61, 95%CI 0.48-0.79, p=0.0002) were associated with a significantly decreased risk of suicide in bipolar disorder. Lithium showed a 42% lower risk for suicide mortality compared to valproic acid (HR 0.58, 95% CI 0.39-0.86, p = 0.007). Hypnotics were associated with a significantly (HR 1.52, 95%CI 1.22-1.90, p=0.0002) higher risk of suicide. LIMITATIONS Only hospitalized patients were included. CONCLUSIONS Lithium should be considered as treatment of choice for patients with bipolar disorder who are at high risk for suicide. Hypnotic use among suicidal patients indicates need for close monitoring of these patients.
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Affiliation(s)
- Diego Antolín-Concha
- University of Eastern Finland, Department of Forensic Psychiatry, Niuvanniemi Hospital, Finland (Antolín-Concha, Lähteenvuo, Tanskanen, Taipale, Tiihonen)
| | - Markku Lähteenvuo
- University of Eastern Finland, Department of Forensic Psychiatry, Niuvanniemi Hospital, Finland (Antolín-Concha, Lähteenvuo, Tanskanen, Taipale, Tiihonen).
| | | | - Antti Tanskanen
- University of Eastern Finland, Department of Forensic Psychiatry, Niuvanniemi Hospital, Finland (Antolín-Concha, Lähteenvuo, Tanskanen, Taipale, Tiihonen); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (Tanskanen, Taipale, Tiihonen); National Institute for Health and Welfare, Impact Assessment Unit, Helsinki, Finland (Tanskanen)
| | - Heidi Taipale
- University of Eastern Finland, Department of Forensic Psychiatry, Niuvanniemi Hospital, Finland (Antolín-Concha, Lähteenvuo, Tanskanen, Taipale, Tiihonen); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (Tanskanen, Taipale, Tiihonen); School of Pharmacy, University of Eastern Finland, Kuopio, Finland (Taipale)
| | - Eduard Vieta
- Institute of Neurosience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Vieta)
| | - Jari Tiihonen
- University of Eastern Finland, Department of Forensic Psychiatry, Niuvanniemi Hospital, Finland (Antolín-Concha, Lähteenvuo, Tanskanen, Taipale, Tiihonen); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (Tanskanen, Taipale, Tiihonen); Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden (Tiihonen)
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7
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Tokumitsu K, Yasui-Furukori N, Adachi N, Kubota Y, Watanabe Y, Miki K, Azekawa T, Edagawa K, Katsumoto E, Hongo S, Goto E, Ueda H, Kato M, Yoshimura R, Nakagawa A, Kikuchi T, Tsuboi T, Shimoda K, Watanabe K. Real-world clinical features of and antidepressant prescribing patterns for outpatients with bipolar disorder. BMC Psychiatry 2020; 20:555. [PMID: 33228573 PMCID: PMC7686705 DOI: 10.1186/s12888-020-02967-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/17/2020] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Several evidence-based practice guidelines have been developed to better treat bipolar disorder. However, the articles cited in these guidelines were not sufficiently based on real-world clinical practice. METHODS The MUlticenter treatment SUrvey on BIpolar disorder in Japanese psychiatric clinics (MUSUBI) is a study conducted to accumulate evidence on the real-world practical treatment of bipolar disorder. Psychiatrists were asked to complete a questionnaire about patients with bipolar disorder by performing a retrospective medical record survey. The questionnaire included patient characteristics (age, gender, height, weight, academic background, and occupational status), comorbidities, mental status, treatment period, Global Assessment of Functioning (GAF) score, and details of pharmacological treatment. RESULTS Data on 2705 patients were included in this study. The proportion of patients receiving antidepressant prescriptions was 40.9%. The most commonly used antidepressant was duloxetine, and the most frequently used antidepressant class was selective serotonin reuptake inhibitors (SSRIs). Binomial logistic regression analysis and bivariate analysis revealed that the usage of antidepressants was correlated with low prescription rates for mood stabilizers, high prescription rates for anxiolytics and hypnotics, and low GAF scores. In addition, patients in a depressive state had a significantly higher rate of antidepressant prescriptions than patients with other mental states. CONCLUSIONS Approximately 40% of patients in Japan with a diagnosis of bipolar disorder have received antidepressants. Antidepressants were most often prescribed in combination with mood stabilizers, antipsychotics or both. Patients who were prescribed antidepressants received fewer mood stabilizers, more anxiolytics, and more hypnotics than those who did not receive antidepressant prescriptions.
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Affiliation(s)
- Keita Tokumitsu
- grid.255137.70000 0001 0702 8004Department of Psychiatry, Dokkyo Medical University, School of Medicine, Mibu, Shimotsuga, Tochigi 321-0293 Japan
| | - Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Mibu, Shimotsuga, Tochigi, 321-0293, Japan. .,The Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan.
| | - Naoto Adachi
- The Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Yukihisa Kubota
- The Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | | | - Kazuhira Miki
- The Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Takaharu Azekawa
- The Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Koji Edagawa
- The Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Eiichi Katsumoto
- The Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Seiji Hongo
- The Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Eiichiro Goto
- The Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Hitoshi Ueda
- The Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Masaki Kato
- grid.469781.50000 0004 5897 9100The Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan ,grid.410783.90000 0001 2172 5041Department of Neuropsychiatry, Kansai Medical University, Osaka, Japan
| | - Reiji Yoshimura
- grid.469781.50000 0004 5897 9100The Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan ,grid.271052.30000 0004 0374 5913Department of Psychiatry, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Atsuo Nakagawa
- grid.469781.50000 0004 5897 9100The Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan ,grid.26091.3c0000 0004 1936 9959Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Toshiaki Kikuchi
- grid.469781.50000 0004 5897 9100The Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan ,grid.26091.3c0000 0004 1936 9959Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Tsuboi
- grid.469781.50000 0004 5897 9100The Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan ,grid.411205.30000 0000 9340 2869Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Kazutaka Shimoda
- grid.255137.70000 0001 0702 8004Department of Psychiatry, Dokkyo Medical University, School of Medicine, Mibu, Shimotsuga, Tochigi 321-0293 Japan
| | - Koichiro Watanabe
- grid.469781.50000 0004 5897 9100The Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan ,grid.411205.30000 0000 9340 2869Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
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9
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Tondo L, Vazquez GH, Baldessarini RJ. Suicidal Behavior Associated with Mixed Features in Major Mood Disorders. Psychiatr Clin North Am 2020; 43:83-93. [PMID: 32008690 DOI: 10.1016/j.psc.2019.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Mixed features of the opposite nominal mood-polarity are increasingly recognized in both depressive and [hypo]manic phases of major affective disorders. They are associated with major increases of risk of suicidal behaviors. The authors reviewed the association of suicidal behavior with mixed features in both major depressive and bipolar disorders, as well as potentially relevant adverse effects of antidepressant treatment and use of alternative treatments aimed at minimizing agitation and suicidal risk.
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Affiliation(s)
- Leonardo Tondo
- International Consortium for Research on Mood & Psychotic Disorders, McLean Hospital, Belmont, MA, USA; Mailman Research Center 3, McLean Hospital, 115 Mill Street, Belmont, MA 02478-9106, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Lucio Bini Mood Disorders Center, Cagliari, Italy.
| | - Gustavo H Vazquez
- International Consortium for Research on Mood & Psychotic Disorders, McLean Hospital, Belmont, MA, USA; Mailman Research Center 3, McLean Hospital, 115 Mill Street, Belmont, MA 02478-9106, USA; Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Ross J Baldessarini
- International Consortium for Research on Mood & Psychotic Disorders, McLean Hospital, Belmont, MA, USA; Mailman Research Center 3, McLean Hospital, 115 Mill Street, Belmont, MA 02478-9106, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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10
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Stübner S, Grohmann R, Greil W, Zhang X, Müller-Oerlinghausen B, Bleich S, Rüther E, Möller HJ, Engel R, Falkai P, Toto S, Kasper S, Neyazi A. Suicidal Ideation and Suicidal Behavior as Rare Adverse Events of Antidepressant Medication: Current Report from the AMSP Multicenter Drug Safety Surveillance Project. Int J Neuropsychopharmacol 2018; 21:814-821. [PMID: 29939264 PMCID: PMC6119288 DOI: 10.1093/ijnp/pyy048] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 06/15/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Suicidal ideations, suicide attempts, and fatal suicides are rare adverse drug reactions to antidepressant drugs, but they essentially are clinically relevant. Drawing on a larger dataset of the European drug surveillance program, the present naturalistic study updates a previous contribution (Stübner et al., 2010). METHODS First an analysis of the comprehensive data collected in 81 psychiatric hospitals from 1993 to 2014 by the European drug surveillance program Arzneimittelsicherheit in der Psychiatrie was made. All documented single cases of suicidal ideations or behavior judged as adverse drug reactions to antidepressant drugs were carefully assessed as to their clinical features and drug prescriptions. RESULTS Among 219,635 adult hospitalized patients taking antidepressant drugs under surveillance, 83 cases of suicidal adverse drug reactions occurred (0.04%): 44 cases of suicidal ideation, 34 attempted suicides, and 5 committed suicides were documented. Restlessness was present in 42 patients, ego-dystonic intrusive suicidal thoughts or urges in 39 patients, impulsiveness in 22 patients, and psychosis in 7 patients. Almost all adverse drug reactions occurred shortly after beginning antidepressant drug medication or increasing the dosage. Selective serotonin reuptake inhibitors caused a higher incidence of suicidal ideation and suicidal behavior as adverse drug reactions than noradrenergic and specific serotonergic antidepressants or tricyclic antidepressants, as did monotherapy consisting of one antidepressant drug, compared to combination treatments. CONCLUSIONS The study supports the view that antidepressant drug-triggered suicidal ideation and suicidal behavior (primarily with selective serotonin reuptake inhibitors) are rare. Special clinical features (restlessness, ego-dystonic thoughts or urges, impulsiveness) may be considered as possible warning signs. A combination therapy might be preferable to antidepressant drug monotherapy when beginning treatment.
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Affiliation(s)
- Susanne Stübner
- Department of Psychiatry, Kbo-IAK, Academic Teaching Hospital of the Ludwig-Maximilian University, Haar/ Munich, Germany,Department of Psychiatry, Ludwig-Maximilian University, Munich, Germany,Correspondence: Susanne Stübner, PD Dr, Department of Psychiatry, Kbo-IAK, Academic teaching hospital of the Ludwig-Maximilian, University, School of Medicine, Vockestraße 72, 85540 Haar/ Munich ()
| | - Renate Grohmann
- Department of Psychiatry, Ludwig-Maximilian University, Munich, Germany
| | - Waldemar Greil
- Department of Psychiatry, Ludwig-Maximilian University, Munich, Germany,Psychiatric Hospital Kilchberg /Zurich, Switzerland
| | - Xueqiong Zhang
- Department of Psychiatry, Ludwig-Maximilian University, Munich, Germany,Psychiatric Hospital Kilchberg /Zurich, Switzerland
| | | | - Stefan Bleich
- Department of Psychiatry, Hannover Medical School, Hannover, Germany
| | - Eckart Rüther
- Department of Psychiatry, Ludwig-Maximilian University, Munich, Germany,Department of Psychiatry, Georg August University, Göttingen, Germany
| | | | - Rolf Engel
- Department of Psychiatry, Ludwig-Maximilian University, Munich, Germany
| | - Peter Falkai
- Department of Psychiatry, Ludwig-Maximilian University, Munich, Germany
| | - Sermin Toto
- Department of Psychiatry, Hannover Medical School, Hannover, Germany
| | | | - Alexandra Neyazi
- Department of Psychiatry, Hannover Medical School, Hannover, Germany
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11
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Bellivier F, Belzeaux R, Scott J, Courtet P, Golmard JL, Azorin JM. Anticonvulsants and suicide attempts in bipolar I disorders. Acta Psychiatr Scand 2017; 135:470-478. [PMID: 28190254 DOI: 10.1111/acps.12709] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To identify risk factors for suicide attempts (SA) in individuals commencing treatment for a manic or mixed episode. METHOD A total of 3390 manic or mixed cases with bipolar disorder (BD) type I recruited from 14 European countries were included in a prospective, 2-year observational study. Poisson regression models were used to identify individual and treatment factors associated with new SA events. Two multivariate models were built, stratified for the presence or absence of prior SA. RESULTS A total of 302 SA were recorded prospectively; the peak incidence was 0-12 weeks after commencing treatment. In cases with a prior history of SA, risk of SA repetition was associated with younger age of first manic episode (P = 0.03), rapid cycling (P < 0.001), history of alcohol and/or substance use disorder (P < 0.001), number of psychotropic drugs prescribed (P < 0.001) and initiation of an anticonvulsant at study entry (P < 0.001). In cases with no previous SA, the first SA event was associated with rapid cycling (P = 0.02), lifetime history of alcohol use disorder (P = 0.02) and initiation of an anticonvulsant at study entry (P = 0.002). CONCLUSION The introduction of anticonvulsants for a recent-onset manic or mixed episode may be associated with an increased risk of SA. Further BD studies must determine whether this link is causal.
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Affiliation(s)
- F Bellivier
- Inserm, U1144, Paris, France.,Department of Psychiatry and Addition Medicine, Assistance Publique - Hôpitaux de Paris (APHP), GH Saint-Louis - Lariboisière - F. Widal, Paris, France.,Paris Diderot University, Sorbonne Paris Cité, UMR-S 1144, Paris, France.,Fondation FondaMental, Créteil, France
| | - R Belzeaux
- Fondation FondaMental, Créteil, France.,Department of Psychiatry, Assistance Publique Hôpitaux de Marseille (APHM), Marseille, France
| | - J Scott
- Academic Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle, UK.,Centre for Affective Disorders, IPPN, Kings College, London, UK
| | - P Courtet
- Fondation FondaMental, Créteil, France.,INSERM U1061, University of Montpellier UM1, Montpellier, France.,Department of Emergency Psychiatry & Acute Care, Lapeyronie Hospital, CHU Montpellier, Montpellier, France
| | - J-L Golmard
- ER4/EA3974, Biostatistics Department, Université Paris 6 et APHP, UF de biostatistique, GH Pitié-Salpêtrière, Paris, France
| | - J-M Azorin
- Fondation FondaMental, Créteil, France.,Department of Psychiatry, Assistance Publique Hôpitaux de Marseille (APHM), Marseille, France
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12
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Beyer JL, Weisler RH. Suicide Behaviors in Bipolar Disorder: A Review and Update for the Clinician. Psychiatr Clin North Am 2016; 39:111-23. [PMID: 26876322 DOI: 10.1016/j.psc.2015.09.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Suicide behaviors (ideation, attempts, and completions) are unfortunately common in patients with bipolar disorder. It is estimated that 25 to 50% attempt suicide at least once during their lifetime, and 6% to 19% complete suicide. Risk factors include a family history of suicide, previous suicide attempts, younger age of onset, comorbid psychiatric illnesses, and psychological constructs like hopelessness. Pharmacologic treatment may impact suicidal behaviors, either increasing vulnerability or resilience. Clinicians need to be particularly sensitive to their patient's thoughts and beliefs about death, particularly during stressful times of life or when in a depressive/mixed episode of bipolar disorder.
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Affiliation(s)
- John L Beyer
- Duke University Medical Center, Box 3519, Durham, NC 27710, USA.
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13
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El-Mallakh RS, Elmaadawi AZ, Loganathan M, Lohano K, Gao Y. Bipolar Disorder: An Update. Postgrad Med 2015; 122:24-31. [DOI: 10.3810/pgm.2010.07.2172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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Costa LDS, Alencar ÁP, Nascimento Neto PJ, dos Santos MDSV, da Silva CGL, Pinheiro SDFL, Silveira RT, Bianco BAV, Pinheiro RFF, de Lima MAP, Reis AOA, Rolim Neto ML. Risk factors for suicide in bipolar disorder: a systematic review. J Affect Disord 2015; 170:237-54. [PMID: 25261630 DOI: 10.1016/j.jad.2014.09.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 08/18/2014] [Accepted: 09/02/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Bipolar disorder confers the highest risk of suicide among major psychological disorders. The risk factors associated with bipolar disorder and suicide exist and are relevant to clinicians and researchers. OBJECTIVE The aim of the present study was to conduct a systematic review of articles regarding the suicide risk factors in bipolar disorder. METHODS A systematic review of articles on suicide risk factors in bipolar disorder, published from January 1, 2010 to April 05, 2014, on SCOPUS and PUBMED databases was carried out. Search terms were "Suicide" (medical subject headings [MeSH]), "Risk factors" (MeSH), and "Bipolar" (keyword). Of the 220 retrieved studies, 42 met the eligibility criteria. RESULTS Bipolar disorder is associated with an increased rate death by suicide which contributes to overall mortality rates. Studies covered a wide range of aspects regarding suicide risk factors in bipolar disorder, such as risk factors associated to Sociodemographic conditions, Biological characteristics, Drugs Relationships, Psychological Factors, Genetic Compound, Religious and Spirituals conditions. Recent scientific literature regarding the suicide risk factors in bipolar disorder converge to, directly or indirectly, highlight the negative impacts of risk factors to the affected population quality of life. CONCLUSION This review demonstrated that Bipolar disorders commonly leads to other psychiatric disorders and co-morbidities involving risk of suicide. Thus the risk factors are relevant to have a better diagnosis and prognosis of BD cases involving risk of suicide.
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Affiliation(s)
- Lucas da Silva Costa
- Laboratório de Escrita Científica, Faculdade de Medicina, Universidade Federal do Cariri, UFCA, Barbalha, Ceará, Brazil.
| | - Átila Pereira Alencar
- Laboratório de Escrita Científica, Faculdade de Medicina, Universidade Federal do Cariri, UFCA, Barbalha, Ceará, Brazil
| | | | | | | | | | - Regiane Teixeira Silveira
- Programa de Pós-Graduação em Ciências da Saúde, Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil
| | - Bianca Alves Vieira Bianco
- Programa de Pós-Graduação em Ciências da Saúde, Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil
| | | | | | - Alberto Olavo Advincula Reis
- Programa de Pós-Graduação em Saúde Pública, Faculdade de Saúde Pública, Universidade de São Paulo, USP, São Paulo, São Paulo, Brazil
| | - Modesto Leite Rolim Neto
- Líder de Grupo de Pesquisa em Suicidologia, Universidade Federal do Ceará, UFC/Conselho Nacional de Desenvolvimento Científico e Tecnológico, CNPq, Faculdade de Medicina, Universidade Federal do Cariri, UFCA, Barbalha, Ceará, Brazil
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15
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Clinical subtypes of severe bipolar mixed states. J Affect Disord 2013; 151:1076-82. [PMID: 24074482 DOI: 10.1016/j.jad.2013.08.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aim of the present study was to identify different clinical subtypes in severe, treatment resistant bipolar mixed state (MS). METHOD The sample comprised 202 Bipolar I patients currently in MS referred for an Electro-convulsive Therapy (ECT) trial and evaluated in the first week of hospitalization and one week after the ECT course. Principal component factor analysis (PCA) followed by Varimax rotation was performed on 21 non-overlapping items selected from Hamilton rating-scale for depression (HAMD) and from Young mania rating-scale (YMRS) at baseline evaluation. Cluster subtypes derived from the factor scores were compared in clinical variables and final HAMD, YMRS, Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression (CGI) scores. RESULTS The principal-component analysis extracted 6 interpretable factors explaining 55.9% of the total variance. Cluster analysis identified four groups, including respectively 63 (31.2%) subjects with Agitated-Irritable Mixed-Depression, 59 (29.2%) with Psychotic Mixed-Mania, 17 (8.5%) with Anxious-Irritable-Psychotic Mixed-Mania, and 63 (31.2%) with Retarded-Psychotic Mixed-Depression. The four clusters were statistically distinct and did not show significant overlap in the main symptomatological presentation. Cluster subtypes reported differences in number of past mood episodes, duration of the current episode, suicide attempts, lifetime comorbidity with panic and eating disorders, baseline and final rating-scale scores and rate of remission after ECT trial. CONCLUSIONS Our study indicates that, at least in severe treatment resistant MS, multiple depressive and manic subtypes can be observed with substantial differences in terms of clinical presentation, course, associated comorbidities and treatment response.
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16
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Cerimele JM, Chwastiak LA, Chan YF, Harrison DA, Unützer J. The presentation, recognition and management of bipolar depression in primary care. J Gen Intern Med 2013; 28:1648-56. [PMID: 23835789 PMCID: PMC3832714 DOI: 10.1007/s11606-013-2545-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.
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Affiliation(s)
- Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Box 356560, Seattle, WA, 98195-6560, USA,
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17
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18
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Saunders KEA, Hawton K. Clinical assessment and crisis intervention for the suicidal bipolar disorder patient. Bipolar Disord 2013; 15:575-83. [PMID: 23565916 DOI: 10.1111/bdi.12065] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 10/27/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Suicidal behaviour is common in people suffering with bipolar disorder, and suicide is a leading cause of death in this group. Our aim in this review is to provide an overview of key assessment and management strategies, highlight research findings relevant to suicide prevention, and identify important areas for future research. METHODS We reviewed the published literature regarding the risk factors for and management of suicida\l behaviour in individuals with bipolar disorder using the Pubmed and PsychINFO databases. Where available, we focused our search on systematic reviews. RESULTS Suicide is usually associated with a depressive phase, although mixed affective states also convey increased risk. All individuals with bipolar disorder should have an up-to-date crisis management plan which outlines the action to be taken should suicidal behaviour emerge. Timely clinical assessment is essential in ensuring that those at high risk are identified. This should include mental state examination, consideration of risk factors, and evaluation of issues such as access to means, preparatory acts before suicide, and also protective factors. While pharmacological approaches are the mainstay of management, less specific measures, such as the removal of access to means, are also important in ensuring safety in the acute situation. Intensifying the clinical support of both patients and relatives, and the sharing of risk information with other health agencies are essential in management. Specific psychological treatments are likely to be helpful in preventing crises, although the evidence base is limited. CONCLUSIONS The aetiology of suicidal behaviour in bipolar disorder is multifactorial and requires proactive crisis planning and management. A range of issues need to be addressed in the assessment of at-risk patients. Determining the efficacy of interventions specific to reducing suicidality in bipolar disorder should be a research priority.
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Affiliation(s)
- Kate E A Saunders
- Centre for Suicide Research, Department of Psychiatry, Oxford University, Warneford Hospital, Oxford, UK
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19
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Yerevanian BI, Choi YM. Impact of psychotropic drugs on suicide and suicidal behaviors. Bipolar Disord 2013; 15:594-621. [PMID: 23869907 DOI: 10.1111/bdi.12098] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 03/25/2013] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine the impact of psychotropic drugs on suicide and suicidal behaviors in bipolar disorders. METHODS A Medline search of articles published from January 1960 to January 2013 was performed using relevant keywords to identify studies examining the relationship of psychotropic drugs to suicidal behaviors. The publications were further reviewed for relevant references and information. Additionally, the US Food and Drug Administration Center for Drug Evaluation Research website was searched. RESULTS The available studies used differing methodologies, making interpretation of the findings difficult. Studies suggest that antidepressants may increase suicidal risk in bipolar disorder, this possibly being related to the induction of broadly defined mixed states. There is no evidence that antiepileptic drugs as a class increase suicidal risk in patients with bipolar disorder. Only lithium provides convincing data that it reduces the risk of suicide over the long term. There is little known regarding the effects of antipsychotics, as well as anti-anxiety and hypnotic drugs, on suicidal behavior. CONCLUSIONS The available evidence for the impact of psychotropics on suicidal risk in patients with bipolar disorder is largely methodologically flawed and, except for a few instances, clinically not useful at this point. Adequately powered, prospective randomized controlled studies are needed to assess the impact of each class of psychotropic and each psychotropic as well as common combination therapies. Until such studies have been carried out, clinicians are urged to exercise caution in using these drugs and rely on the traditional means of carefully assessing and monitoring patients with bipolar disorder who are at high risk for suicide.
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Affiliation(s)
- Boghos I Yerevanian
- Department of Psychiatry, Greater Los Angeles VA Healthcare System, Sepulveda Ambulatory Care Center, North Hills, CA 91343, USA.
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20
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Ahearn EP, Chen P, Hertzberg M, Cornette M, Suvalsky L, Cooley-Olson D, Swanlund J, Eickhoff J, Becker T, Krahn D. Suicide attempts in veterans with bipolar disorder during treatment with lithium, divalproex, and atypical antipsychotics. J Affect Disord 2013; 145:77-82. [PMID: 22871534 PMCID: PMC4174317 DOI: 10.1016/j.jad.2012.07.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 06/26/2012] [Accepted: 07/17/2012] [Indexed: 11/17/2022]
Abstract
Suicide attempt rates were assessed in 1306 subjects in this 6 year retrospective study of Bipolar disorder. Participants were Veterans from 5 different Veterans Administration Hospitals who met criteria for bipolar type 1 or 2 and who had at least one prescription for lithium or divalproex or both during the study period. This study focused on the impact of atypical antipsychotics on the suicide attempt rate when used in addition to or in place of lithium or divalproex. Medication exposure was calculated using computerized pharmacy records. Suicide attempts were established through chart review including emergency room records, inpatient records, and outpatient records. There were a total of 117 suicide attempts and 2 suicide completions during the study period. Most attempts (59%) occurred when patients were on no medications. Nearly 90% of subjects spent an average of 45 months during the 6 year period on none of the aforementioned medications. The lowest percentage of suicide attempts (15%) occurred while on lithium, 21% while on divalproex and 24% while on atypical antipsychotics. When total months of exposure were taken into account, the lowest attempt rate occurred on lithium plus divalproex (6.3 attempts per 10,000 months of exposure), followed by divalproex alone (7.0 attempts/10,000 months of exposure), and lithium alone (7.7 attempts per 10,000 months of exposure). Patients on atypical antipsychotics alone had an attempt rate of 26.1 attempts per 10,000 months of exposure. In this study, lithium and divalproex provided protection against suicide attempts. Results need to be replicated in future prospective studies and clearly strategies for improving medication compliance among veterans are warranted.
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Affiliation(s)
- Eileen P Ahearn
- William S. Middleton Memorial Veterans Hospital, Madison, WI 53705-2286, United States.
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21
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Finseth PI, Morken G, Andreassen OA, Malt UF, Vaaler AE. Risk factors related to lifetime suicide attempts in acutely admitted bipolar disorder inpatients. Bipolar Disord 2012; 14:727-34. [PMID: 22998124 DOI: 10.1111/bdi.12004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The main aim of this study was to assess possible clinical characteristics of acutely admitted bipolar I disorder (BD-I) and bipolar II disorder (BD-II) inpatients at high risk of suicide by comparing patients who had made one or several serious suicide attempts with patients who had not. METHODS A total of 206 consecutive patients (mean age 42 ± 15 years; 54.9% women) with DSM-IV diagnosed BD-I (n = 140) and BD-II (n= 66) acutely admitted to a single psychiatric hospital department from November 2002 through June 2009 were included. Using a detailed retrospective questionnaire, patients with a history of a serious suicide attempt were compared to those with no history of a suicide attempt. RESULTS Ninety-three patients (45.1%) had a history of one or more serious suicide attempts. These constituted 60 (42.9%) of the BD-I patients and 33 (50%) of the BD-II patients (no significant difference). Lifetime suicide attempt was associated with a higher number of hospitalizations due to depression (p < 0.0001), antidepressant (AD)-induced hypomania/mania (p = 0.033), AD- and/or alcohol-induced affective episodes (p = 0.009), alcohol and/or substance use (p = 0.002), and a family history of alcohol abuse and/or affective disorder (p = 0.01). Suicide attempt was negatively associated with a higher Positive and Negative Syndrome Scale for Schizophrenia (PANSS) Positive Subscale score (p = 0.022) and more hospitalizations due to mania (p = 0.006). CONCLUSIONS The lifetime suicide attempt rate in BD inpatients is high. Risk factors of suicide attempts were: (i) a predominant depressive course of illness, (ii) comorbid alcohol and substance use disorders, and (iii) a history of AD- and/or alcohol-induced affective episodes. Risk-reducing factors were a preponderant manic or psychotic course of the illness. These risk factors may be signs of a clinical subgroup at risk of suicidal behaviour, and seem to be important for suicide risk assessment in acutely admitted BD patients.
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Affiliation(s)
- Per I Finseth
- Department of Neuroscience, Trondheim Norwegian University of Science and Technology (NTNU), Oslo, Norway.
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22
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Hodgkin D, Volpe-Vartanian J, Merrick EL, Horgan CM, Nierenberg AA, Frank RG, Lee S. Customization in prescribing for bipolar disorder. HEALTH ECONOMICS 2012; 21:653-668. [PMID: 21506194 PMCID: PMC3164906 DOI: 10.1002/hec.1737] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 02/18/2011] [Accepted: 03/14/2011] [Indexed: 05/30/2023]
Abstract
For many disorders, patient heterogeneity requires physicians to customize their treatment to each patient's needs. We test for the existence of customization in physicians' prescribing for bipolar disorder, using data from a naturalistic clinical effectiveness trial of bipolar disorder treatment (STEP-BD), which did not constrain physician prescribing. Multinomial logit is used to model the physician's choice among five combinations of drug classes. We find that our observed measure of the patient's clinical status played only a limited role in the choice among drug class combinations, even for conditions such as mania that are expected to affect class choice. However, treatment of a patient with given characteristics differed widely depending on which physician was seen. The explanatory power of the model was low. There was variation within each physician's prescribing, but the results do not suggest a high degree of customization in physicians' prescribing, based on our measure of clinical status.
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Affiliation(s)
- Dominic Hodgkin
- Institute for Behavioral Health, Heller School of Social Policy & Management, Brandeis University, Waltham, MA 02454, USA.
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23
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Biernacka JM, McElroy SL, Crow S, Sharp A, Benitez J, Veldic M, Kung S, Cunningham JM, Post RM, Mrazek D, Frye MA. Pharmacogenomics of antidepressant induced mania: a review and meta-analysis of the serotonin transporter gene (5HTTLPR) association. J Affect Disord 2012; 136:e21-e29. [PMID: 21680025 DOI: 10.1016/j.jad.2011.05.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 05/18/2011] [Indexed: 01/30/2023]
Abstract
BACKGROUND Antidepressants can trigger a rapid mood switch from depression to mania. Identifying genetic risk factors associated with antidepressant induced mania (AIM) may enable individualized treatment strategies for bipolar depression. This review and meta-analysis evaluates the evidence for association between the serotonin transporter gene promoter polymorphism (5HTTLPR) and AIM. METHODS Medline up to November 2009 was searched for key words bipolar, antidepressant, serotonin transporter, SLC6A4, switch, and mania. RESULTS Five studies have evaluated the SLC6A4 promoter polymorphism and AIM in adults (total N=340 AIM+ cases, N=543 AIM- controls). Although a random effects meta-analysis showed weak evidence of association of the S allele with AIM+ status, a test of heterogeneity indicated significant differences in estimated genetic effects between studies. A similar weak association was observed in a meta-analysis based on a subset of three studies that excluded patients on mood stabilizers; however the result was again not statistically significant. LIMITATIONS Few pharmacogenomic studies of antidepressant treatment of bipolar disorder have been published. The completed studies were underpowered and often lacked important phenotypic information regarding potential confounders such as concurrent use of mood stabilizers or rapid cycling. CONCLUSIONS There is insufficient published data to confirm an association between 5HTTLPR and antidepressant induced mania. Pharmacogenomic studies of antidepressant induced mania have high potential clinical impact provided future studies are of adequate sample size and include rigorously assessed patient characteristics (e.g. ancestry, rapid cycling, concurrent mood stabilization, and length of antidepressant exposure).
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Affiliation(s)
- Joanna M Biernacka
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States.
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, United States; University of Cincinnati College of Medicine, Cincinnati, OH, United States; The Bipolar Collaborative Network, Bethesda, MD, United States
| | - Scott Crow
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, United States
| | - Alexis Sharp
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Joachim Benitez
- Department of Psychiatry, Austin Medical Center, Mayo Health System, Austin, MN, United States
| | - Marin Veldic
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Simon Kung
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Julie M Cunningham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Robert M Post
- The Bipolar Collaborative Network, Bethesda, MD, United States
| | - David Mrazek
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Mark A Frye
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States; The Bipolar Collaborative Network, Bethesda, MD, United States
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[Management, needs and expectations of patients suffering from bipolar I disorders (The ECHO study - France)]. Encephale 2011; 37:332-8. [PMID: 21981895 DOI: 10.1016/j.encep.2011.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 07/23/2011] [Indexed: 11/22/2022]
Abstract
AIM The ECHO study is the first French study directly asking patients with bipolar I disorders on the history and experiences of their disease, their perceptions of care, their sociofamilial relationships, and their expectations regarding what should be done by healthcare professionals and their environment. METHOD Three hundred euthymic patients suffering from bipolar disorder I were interviewed using a semi-standardized evaluation through telephone interviews. These patients were selected according to the quota method of nationally representative INSEE 99 to be representative of the French population. RESULTS Ninety-nine percent of patients consulted at least once for psychological signs before the correct diagnosis was established. The average age at the time of diagnosis was of 30.1 years (± 11.3). The average time between first consultation for psychological symptoms and diagnosis is about 5 years. In 92% of cases, the psychiatrist is the health professional that made the diagnosis; 74% of patients were also followed by a general practitioner. One hundred percent of participants had been hospitalized for manic episodes (criterion for inclusion in the study) and 86% were also hospitalized for depressive symptoms. The experience of hospitalization is positive (feeling of security for 84% of the sample, feelings of being helped for 81% of the sample), although these experiences are also associated with the perception of confinement (52% of the sample). At the time of the interview, 97% of these patients were followed by one or more health professionals. Only 34% of these patients were taking a mood stabilizer (lithium, anticonvulsant or atypical antipsychotic with indications in France for bipolar disorder), while 44% were taking an antidepressant and 38% were taking anxiolytics; 84% of patients had experienced side effects related to their current treatment. Acceptance of the disease is difficult and only 56% of patients personally feel they suffer from bipolar disorders. Patients believe that their mental health problems have a significant impact on their lives, including impact on their self-esteem and happiness. Relationships with family, friends but also sexual relations are affected. Even in the euthymic phase, 44% of patients have difficulties in their daily tasks. Three quarters of patients said they had already experienced rejection or discrimination related to their disease. Finally, patients gave a score of 6.4 out of 10 to assess the impact of the disorder on their quality of life. Patients request more dialogue with health professionals and a more personalized treatment, taking into account side effects. They also want more information on the treatment. They would also like to be supported, together with their families, and advised on how to cope with the disease.
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Tundo A, Cavalieri P, Navari S, Marchetti F. Treating bipolar depression - antidepressants and alternatives: a critical review of the literature. Acta Neuropsychiatr 2011; 23:94-105. [PMID: 26952895 DOI: 10.1111/j.1601-5215.2011.00542.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Although depressive symptoms are preponderant in the course of bipolar (BP) disorders, the treatment of BP depression remains a controversial issue with different clinical approaches available. This review addresses the issues of whether antidepressants (ADs) are effective in treating acute and long-term BP depression, risks linked to ADs and what alternatives to ADs are available. METHODS We searched the MEDLINE databases using the following syntax: [bipolar depression AND unipolar depression AND (antidepressants OR anticonvulsants OR lithium OR antipsychotics OR dopamine-agonists OR psychoeducation OR psychotherapy OR electroconvulsive therapy OR transcranial magnetic stimulation)]. The search included studies published up to 31 May 2009 and conducted on adults. RESULTS In the acute treatment of BP depression ADs are effective with no differences among drug classes. However, neither the switch into (hypo)mania induction rate nor the suicide risk linked to AD use are definitely established. The effectiveness of long-term AD use is limited to highly selected samples of patients with positive acute response. The risk of long-term ADs causing cycle acceleration and rapid cycling induction concerns a subpopulation of patients. Valid alternatives to ADs in treating acute BP depression are quetiapine, an olanzapine-fluoxetine combination, and electroconvulsive therapy for more severe patients. Lamotrigine is effective and safe in preventing depressive relapses. Psychotherapy and psychoeducation represent effective adjunctive treatments. CONCLUSION In the treatment of BP depression there is not a specific effective treatment for all the patients. Interventions should therefore be personalised and the scientific evidence should be adapted to each patient's clinical features.
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Tondo L, Vázquez G, Baldessarini RJ. Mania associated with antidepressant treatment: comprehensive meta-analytic review. Acta Psychiatr Scand 2010; 121:404-14. [PMID: 19958306 DOI: 10.1111/j.1600-0447.2009.01514.x] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review available data pertaining to risk of mania-hypomania among bipolar (BPD) and major depressive disorder (MDD) patients with vs. without exposure to antidepressant drugs (ADs) and consider effects of mood stabilizers. METHOD Computerized searching yielded 73 reports (109 trials, 114 521 adult patients); 35 were suitable for random effects meta-analysis, and multivariate-regression modeling included all available trials to test for effects of trial design, AD type, and mood-stabilizer use. RESULTS The overall risk of mania with/without ADs averaged 12.5%/7.5%. The AD-associated mania was more frequent in BPD than MDD patients, but increased more in MDD cases. Tricyclic antidepressants were riskier than serotonin-reuptake inhibitors (SRIs); data for other types of ADs were inconclusive. Mood stabilizers had minor effects probably confounded by their preferential use in mania-prone patients. CONCLUSION Use of ADs in adults with BPD or MDD was highly prevalent and moderately increased the risk of mania overall, with little protection by mood stabilizers.
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Affiliation(s)
- L Tondo
- Department of Psychiatry and Neuroscience Program, Harvard Medical School and McLean Division of Massachusetts General Hospital, Boston, MA, USA.
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Novick DM, Swartz HA, Frank E. Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence. Bipolar Disord 2010; 12:1-9. [PMID: 20148862 PMCID: PMC4536929 DOI: 10.1111/j.1399-5618.2009.00786.x] [Citation(s) in RCA: 208] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The prevalence of suicide attempts (SA) in bipolar II disorder (BPII), particularly in comparison to the prevalence in bipolar I disorder (BPI), is an understudied and controversial issue with mixed results. To date, there has been no comprehensive review of the published prevalence data for attempted suicide in BPII. METHODS We conducted a literature review and meta-analysis of published reports that specified the proportion of individuals with BPII in their presentation of SA data. Systematic searching yielded 24 reports providing rates of SA in BPII and 21 reports including rates of SA in both BPI and BPII. We estimated the prevalence of SA in BPII by combining data across reports of similar designs. To compare rates of SA in BPII and BPI, we calculated a pooled odds ratio (OR) and 95% confidence interval (CI) with random-effect meta-analytic techniques with retrospective data from 15 reports that detailed rates of SA in both BPI and BPII. RESULTS Among the 24 reports with any BPII data, 32.4% (356/1099) of individuals retrospectively reported a lifetime history of SA, 19.8% (93/469) prospectively reported attempted suicide, and 20.5% (55/268) of index attempters were diagnosed with BPII. In 15 retrospective studies suitable for meta-analysis, the prevalence of attempted suicide in BPII and BPI was not significantly different: 32.4% and 36.3%, respectively (OR = 1.21, 95% CI: 0.98-1.48, p = 0.07). CONCLUSION The contribution of BPII to suicidal behavior is considerable. Our findings suggest that there is no significant effect of bipolar subtype on rate of SA. Our findings are particularly alarming in concert with other evidence, including (i) the well-documented predictive role of SA for completed suicide and (ii) the evidence suggesting that individuals with BPII use significantly more violent and lethal methods than do individuals with BPI. To reduce suicide-related morbidity and mortality, routine clinical care for BPII must include ongoing risk assessment and interventions targeted at risk factors.
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Affiliation(s)
- Danielle M Novick
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Biffin F, Tahtalian S, Filia K, Fitzgerald PB, de Castella AR, Filia S, Berk M, Dodd S, Callaly P, Berk L, Kelin K, Smith M, Montgomery W, Kulkarni J. The impact of age at onset of bipolar I disorder on functioning and clinical presentation. Acta Neuropsychiatr 2009; 21:191-6. [PMID: 25384633 DOI: 10.1111/j.1601-5215.2009.00399.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Recent studies have proposed the existence of three distinct subgroups of bipolar 1 disorder based on age at onset (AAO). The present study aims to investigate potential clinical and functional differences between these subgroups in an Australian sample. METHODS Participants (n = 239) were enrolled in the Bipolar Comprehensive Outcomes Study (BCOS), a 2-year longitudinal, observational, cross-sectional study. Assessment measures included the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAMD21), Clinical Global Impressions Scale (CGI-BP), SF-36, SLICE/Life Scale, and the EuroQol (EQ-5D). Participants were also asked about their age at the first major affective episode. RESULTS Three AAO groups were compared: early (AAO < 20, mean = 15.5 ± 2.72; 44.4% of the participants); intermediate (AAO 20-39, mean = 26.1 ± 4.8; 48.14% of the participants) and late (AAO > 40, mean = 50.6 ± 9.04; 7.4% of the participants). Higher rates of depression, suicidal ideation and binge drinking were reported by the early AAO group. This group also reported poorer quality of life in a number of areas. The early AAO group had a predominant depressive initial polarity and the intermediate group had a manic predominance. CONCLUSION Early AAO is associated with an adverse outcome.
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Affiliation(s)
- Frances Biffin
- 1Alfred Psychiatry Research Centre, The Alfred and Monash University, School of Psychology, Psychiatry & Psychological Medicine, Commercial Road, Melbourne Australia
| | - Steven Tahtalian
- 1Alfred Psychiatry Research Centre, The Alfred and Monash University, School of Psychology, Psychiatry & Psychological Medicine, Commercial Road, Melbourne Australia
| | - Kate Filia
- 1Alfred Psychiatry Research Centre, The Alfred and Monash University, School of Psychology, Psychiatry & Psychological Medicine, Commercial Road, Melbourne Australia
| | - Paul B Fitzgerald
- 1Alfred Psychiatry Research Centre, The Alfred and Monash University, School of Psychology, Psychiatry & Psychological Medicine, Commercial Road, Melbourne Australia
| | - Anthony R de Castella
- 1Alfred Psychiatry Research Centre, The Alfred and Monash University, School of Psychology, Psychiatry & Psychological Medicine, Commercial Road, Melbourne Australia
| | - Sacha Filia
- 1Alfred Psychiatry Research Centre, The Alfred and Monash University, School of Psychology, Psychiatry & Psychological Medicine, Commercial Road, Melbourne Australia
| | - Michael Berk
- 2Department of Clinical and Biomedical Sciences: Barwon Health, The University of Melbourne, Geelong, Australia
| | - Seetal Dodd
- 2Department of Clinical and Biomedical Sciences: Barwon Health, The University of Melbourne, Geelong, Australia
| | - Pam Callaly
- 2Department of Clinical and Biomedical Sciences: Barwon Health, The University of Melbourne, Geelong, Australia
| | - Lesley Berk
- 2Department of Clinical and Biomedical Sciences: Barwon Health, The University of Melbourne, Geelong, Australia
| | - Katarina Kelin
- 3Eli Lilly Australia Pty Ltd, 112 Wharf Road, West Ryde, Australia
| | - Meg Smith
- 4School of Social Sciences, University of Western Sydney, Penrith South Dc, Australia
| | | | - Jayashri Kulkarni
- 1Alfred Psychiatry Research Centre, The Alfred and Monash University, School of Psychology, Psychiatry & Psychological Medicine, Commercial Road, Melbourne Australia
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Cha B, Kim JH, Ha TH, Chang JS, Ha K. Polarity of the first episode and time to diagnosis of bipolar I disorder. Psychiatry Investig 2009; 6:96-101. [PMID: 20046381 PMCID: PMC2796048 DOI: 10.4306/pi.2009.6.2.96] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Revised: 04/29/2009] [Accepted: 05/11/2009] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The current study explored the relationship between the polarity of the first episode and the timing of eventual diagnosis of bipolar I disorder, and associated clinical implications. METHODS Twelve years of clinical data from the medical records of 258 inpatients meeting DSM-III-R or DSM-IV criteria for bipolar I disorder were analyzed. Subjects were divided into two groups according to the polarity of the first episode: those with depressive polarity (FE-D), and those with manic polarity (FE-M). Comparisons were made between the two groups on variables associated with the timing of diagnosis and related outcomes. RESULTS In population with bipolar I disorder, a significant longer time lapse from the first major mood episode to the confirmed diagnosis was associated with the FE-D group compared to the FE-M group [5.6 (+/-6.1) vs. 2.5 (+/-5.5) years, p<0.001]. FE-D subjects tended to have prior diagnoses of schizophrenia and major depressive disorder while FE-M subjects tended to have prior diagnoses of bipolar disorder and schizophrenia. A significantly higher rate of suicide attempts was associated with the FE-D group compared to the FE-M group (12.7 vs. 1.7%, p<0.001). CONCLUSION The results of this study indicate that first-episode depressive polarity is likely to be followed by a considerable delay until an eventual confirmed diagnosis of bipolar I disorder. Given that first-episode depressive patients are particularly vulnerable to unfavorable clinical outcomes such as suicide attempts, a more systematic approach is needed to differentiate bipolar disorder among depressed patients in their early stages.
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Affiliation(s)
- Boseok Cha
- Mood Disorders Clinic and Clinical Affective Neuroscience Laboratory, Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong Hyun Kim
- Mood Disorders Clinic and Clinical Affective Neuroscience Laboratory, Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tae Hyon Ha
- Mood Disorders Clinic and Clinical Affective Neuroscience Laboratory, Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Seung Chang
- Mood Disorders Clinic and Clinical Affective Neuroscience Laboratory, Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyooseob Ha
- Mood Disorders Clinic and Clinical Affective Neuroscience Laboratory, Department of Psychiatry, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Psychiatry and Behavioral Science, Seoul National University College of Medicine, Seoul, Korea
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Eppel AB. Antidepressants in the treatment of bipolar disorder: decoding contradictory evidence and opinion. Harv Rev Psychiatry 2008; 16:205-9. [PMID: 18569041 DOI: 10.1080/10673220802160381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Alan Brian Eppel
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 50 Charlton Ave. East, Hamilton, Ontario L8N 4A6, Canada.
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Shaltiel G, Maeng S, Malkesman O, Pearson B, Schloesser RJ, Tragon T, Rogawski M, Gasior M, Luckenbaugh D, Chen G, Manji HK. Evidence for the involvement of the kainate receptor subunit GluR6 (GRIK2) in mediating behavioral displays related to behavioral symptoms of mania. Mol Psychiatry 2008; 13:858-72. [PMID: 18332879 PMCID: PMC2804880 DOI: 10.1038/mp.2008.20] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2007] [Revised: 12/17/2007] [Accepted: 12/20/2007] [Indexed: 01/15/2023]
Abstract
The glutamate receptor 6 (GluR6 or GRIK2, one of the kainate receptors) gene resides in a genetic linkage region (6q21) associated with bipolar disorder (BPD), but its function in affective regulation is unknown. Compared with wild-type (WT) and GluR5 knockout (KO) mice, GluR6 KO mice were more active in multiple tests and super responsive to amphetamine. In a battery of specific tests, GluR6 KO mice also exhibited less anxious or more risk-taking type behavior and less despair-type manifestations, and they also had more aggressive displays. Chronic treatment with lithium, a classic antimanic mood stabilizer, reduced hyperactivity, aggressive displays and some risk-taking type behavior in GluR6 KO mice. Hippocampal and prefrontal cortical membrane levels of GluR5 and KA-2 receptors were decreased in GluR6 KO mice, and chronic lithium treatment did not affect these decreases. The membrane levels of other glutamatergic receptors were not significantly altered by GluR6 ablation or chronic lithium treatment. Together, these biochemical and behavioral results suggest a unique role for GluR6 in controlling abnormalities related to the behavioral symptoms of mania, such as hyperactivity or psychomotor agitation, aggressiveness, driven or increased goal-directed pursuits, risk taking and supersensitivity to psychostimulants. Whether GluR6 perturbation is involved in the mood elevation or thought disturbance of mania and the cyclicity of BPD are unknown. The molecular mechanism underlying the behavioral effects of lithium in GluR6 KO mice remains to be elucidated.
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Affiliation(s)
- G Shaltiel
- Laboratory of Molecular Pathophysiology, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - S Maeng
- Laboratory of Molecular Pathophysiology, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - O Malkesman
- Laboratory of Molecular Pathophysiology, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - B Pearson
- Laboratory of Molecular Pathophysiology, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - RJ Schloesser
- Laboratory of Molecular Pathophysiology, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - T Tragon
- Laboratory of Molecular Pathophysiology, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - M Rogawski
- Epilepsy Research Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - M Gasior
- Epilepsy Research Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - D Luckenbaugh
- Laboratory of Molecular Pathophysiology, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - G Chen
- Laboratory of Molecular Pathophysiology, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - HK Manji
- Laboratory of Molecular Pathophysiology, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Tondo L, Lepri B, Baldessarini RJ. Suicidal status during antidepressant treatment in 789 Sardinian patients with major affective disorder. Acta Psychiatr Scand 2008; 118:106-15. [PMID: 18397362 DOI: 10.1111/j.1600-0447.2008.01178.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Relationships between antidepressant treatment and suicidality remain uncertain in major depressive disorder (MDD), and rarely evaluated in bipolar disorder (BPD). METHOD We evaluated changes in suicidality ratings (Hamilton Depression Rating Scale item-3) at the start and after 3.59 +/- 2.57 months of sustained antidepressant treatment in a systematically assessed clinical sample (n = 789) of 605 patients with MDD, 103 patients with BPD-II and 81 patients with BPD-I (based on DSM-IV; 68.1% women; aged 44.3 +/- 16.1 years), comparing suicidal vs. non-suicidal and recovered vs. unrecovered initially suicidal patients. RESULTS Suicidal patients (103/789, 16.5%; BPD/MDD risk: 2.2) were more depressed and were ill longer. During treatment, 81.5% of suicidal patients became non-suicidal; 0.46% of 656 initially non-suicidal patients reported new suicidal thoughts, with no new attempts. Becoming non-suicidal was associated with greater depression severity and greater improvement. CONCLUSION Suicidal ideation was prevalent in patients with depressed major affective disorder, but most of the initially suicidal patients became non-suicidal with antidepressant treatment, independent of diagnosis, treatment type or dose.
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Affiliation(s)
- L Tondo
- Department of Psychiatry and Neuroscience Program, Harvard Medical School and McLean Division of Massachusetts General Hospital, Boston, MA, USA
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O'Donovan C, Garnham JS, Hajek T, Alda M. Antidepressant monotherapy in pre-bipolar depression; predictive value and inherent risk. J Affect Disord 2008; 107:293-8. [PMID: 17850879 DOI: 10.1016/j.jad.2007.08.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 07/24/2007] [Accepted: 08/08/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify specific treatment-emergent symptoms in response to antidepressant therapy in depression preceding bipolar disorder. METHODS Retrospective chart review of response to antidepressants in "pre-bipolar" depression, compared to a matched unipolar sample. RESULTS Family history of completed suicide (p=0.0003) and bipolar disorder (p=0.004) were more common in the pre-bipolar subgroup. Earlier age of onset of diagnosed depression (p=0.005) as well as even earlier episodes of untreated retrospectively diagnosed major depression (p<0.0001) were associated with a future bipolar course. The pre-bipolar group was less likely to respond to antidepressant treatment (p=0.009). Treatment-emergent "mixed" symptoms (two or more symptoms of DSM IV mania, mood lability, irritability/rage with co-existing depression) and in particular, "serious symptoms" (treatment emergent or increased agitation, rage or suicidality) occurred more commonly in the bipolar group. The two variables that best accounted for the between-group differences in logistic regression, were early age at first symptoms of depression and treatment-emergent agitation. CONCLUSIONS Family history of completed suicide and/or bipolar disorder, early onset of depressive symptoms as well as treatment-emergent "mixed" symptoms are common in depression preceding the diagnosis of bipolar disorder.
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Affiliation(s)
- Claire O'Donovan
- Queen Elizabeth II Health Sciences Centre, Mood Disorders Program, Department of Psychiatry, Abbie J. Ln. Memorial Bldg., 3rd floor, Veterans Memorial Lane, Dalhousie University, Halifax, Nova Scotia, Canada.
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McIntyre RS, Muzina DJ, Kemp DE, Blank D, Woldeyohannes HO, Lofchy J, Soczynska JK, Banik S, Konarski JZ. Bipolar disorder and suicide: research synthesis and clinical translation. Curr Psychiatry Rep 2008; 10:66-72. [PMID: 18269897 DOI: 10.1007/s11920-008-0012-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Attempted suicide and suicide are prevalent in individuals with bipolar disorder (BD). Extant evidence indicates that history of suicide attempts, percentage of time spent in a depressed state, and hostility are factors associated with suicide attempts and completed suicide. Childhood adversity (eg, sexual and physical abuse) is emerging as a risk factor for suicide attempts in adults with BD. The pertinacity of medical comorbidity (eg, obesity, metabolic syndrome) in the bipolar population is further underscored by its preliminary association with suicidality. Biomarkers such as cerebrospinal fluid monoamine metabolite levels may be predictive of suicide attempts and lethality in BD. Compelling evidence supports an antisuicide effect of long-term lithium prophylaxis; lithium's salutary effect is mediated primarily by reduced lethality of suicidal acts. Conventional unimodal antidepressants may engender or exacerbate suicidality in susceptible individuals with BD. A nascent database suggests that adjunctive psychosocial interventions may further reduce suicide risk in bipolar individuals.
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Affiliation(s)
- Roger S McIntyre
- Department of Psychiatry and Pharmacology, University of Toronto, Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.
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Abstract
The bipolar spectrum model suggests that several patient presentations not currently recognized by the DSM warrant consideration as part of a mood disorders continuum. These include hypomania or mania associated with antidepressants; manic symptoms which fall short of the current DSM threshold for hypomania; and depression attended by multiple non-manic markers that are associated with bipolar course. Evidence supporting the inclusion of these groups within the realm of bipolar disorder (BP) is examined. Several diagnostic tools for detecting and characterizing these patient groups are described. Finally, options for altering DSM-IV criteria to allow some of the above patient presentations to be recognized as bipolar are considered. More data on the validity and utility of these alterations would be useful, but limited changes appear warranted now. We describe an additional BP Not Otherwise Specified (BP NOS) example which creates a subthreshold hypomanic analogue to cyclothymia, consistent with existing BP NOS criteria. This change should be accompanied by additional requirements for the assessment and reporting of non-manic bipolar markers.
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Affiliation(s)
- James Phelps
- Corvallis Psychiatric Clinic, Corvallis, OR 97330, USA.
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Benazzi F. A tetrachoric factor analysis validation of mixed depression. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32:186-92. [PMID: 17804137 DOI: 10.1016/j.pnpbp.2007.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 08/06/2007] [Accepted: 08/06/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Mixed depression, i.e. a Major Depressive Episode plus co-occurring manic/hypomanic symptoms, has recently become the focus of research. However, its diagnostic validity and bipolar nature are still not firmly supported. A bipolar nature could have significant treatment impacts. STUDY AIM The aim was to psychometrically validate the concept of, and the bipolar nature, of mixed depression, by using (for the first time) tetrachoric factor analysis of its hypomanic symptoms. METHODS Consecutive 441 Bipolar II Disorder (BP-II), and 289 Major Depressive Disorder (MDD) outpatients were cross-sectionally assessed for Major Depressive Episode (MDE) and concurrent hypomanic symptoms (as binary variables) when presenting for treatment of depression, by a mood disorder specialist psychiatrist (FB), using the Structured Clinical Interview for DSM-IV (as modified by [Akiskal HS, Benazzi F. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J Clin Psychiatry 2005; 66: 914-921.]) in a private practice. Consecutive 275 remitted BP-II were also assessed for past hypomania. Mixed depression was defined as co-occurrence of MDE and 3 or more, usually subthreshold, hypomanic symptoms. RESULTS In multivariable logistic regression, BP-II independent predictor variables were young onset age, MDE recurrences, mixed depression, and bipolar family history. Factor analysis of past hypomania symptoms found three factors: an "irritable mental overactivity" factor, an "elevated mood" factor, and a "motor overactivity" factor. Factor analysis of intradepression hypomanic symptoms in BP-II, and in MDD, found two similar mental and motor overactivity factors. Multivariate regression of the intradepression hypomanic factors versus bipolar validators, such as bipolar family history and young onset age, found significant associations. DISCUSSION Findings could support the diagnostic validity, and the bipolar nature, of mixed depression, on the basis of the close similarities found between the factor structure of inter-depression hypomania and intra-depression hypomanic symptoms. Impacts on treatment of a bipolar nature of mixed depression may be significant (e.g. more use of mood stabilising agents, less/no use of antidepressants).
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Tondo L, Lepri B, Baldessarini RJ. Suicidal risks among 2826 Sardinian major affective disorder patients. Acta Psychiatr Scand 2007; 116:419-28. [PMID: 17997721 DOI: 10.1111/j.1600-0447.2007.01066.x] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We estimated risks of suicidal behaviors in 2826 mood-disorder patients evaluated and followed in a Sardinian mood disorders research center over the past 30 years. METHOD We determined rates of suicidal ideation, attempts, and suicides, with associated risk factors, in men and women with DSM-IV bipolar I (BP-I; n = 529), BP-II; (n = 314), or major depressive disorders (MDD; n = 1983), at risk for an average of 11 years of illness. RESULTS Observed rates (% of patients/year) of suicide ranked: BP-II (0.16) > or = BP-I (0.14) > MDD (0.05); attempts: BP-I (1.52) > BP-II (0.82) > MDD (0.48); ideation: BP-II (42.7) > MDD (33.8) > BP-I (22.7). The ratio of attempts/suicides (lethality index) ranked: BP-II (5.12) < MDD (9.60) < or = BP-I (10.8). Male/female risk-ratios were greater for suicide than attempts or ideation. One-third of all reported acts occurred within the first year of illness, and earliest among MDD patients. Factors associated independently with suicidal acts included BP diagnosis, hospitalizations/person, and early illness-onset; factors associated with suicidal ideation were having an affective temperament, BP-II diagnosis, and higher suicidality-corrected depression score at intake. CONCLUSION Suicidal behaviors were more prevalent among BPD than MDD out-patients.
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Affiliation(s)
- L Tondo
- Department of Psychiatry and Neuroscience Program, Harvard Medical School and McLean Division of Massachusetts General Hospital, Boston, MA, USA
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Yerevanian BI, Koek RJ, Mintz J, Akiskal HS. Bipolar pharmacotherapy and suicidal behavior Part 2. The impact of antidepressants. J Affect Disord 2007; 103:13-21. [PMID: 17617467 DOI: 10.1016/j.jad.2007.05.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 04/26/2007] [Accepted: 05/22/2007] [Indexed: 11/28/2022]
Abstract
UNLABELLED Antidepressant-induced mania and cycle acceleration is a potential risk in bipolar patients. Another serious risk of antidepressants, that of increasing suicidal behavior, has been identified in some affectively ill populations. However, there is a dearth of knowledge about the effects of antidepressants on suicidal behavior specifically in bipolar patients. METHODS Retrospective chart review of 405 veterans with bipolar disorder followed for a mean of three years, with month by month systematic assessment of current pharmacotherapy and suicide completion, attempt or hospitalization for suicidality. Chi-squared comparison of (log) rates of suicidal events during mood stabilizer monotherapy, antidepressant monotherapy, and combination of mood stabilizer and antidepressant. RESULTS Suicidal behavior event rates (per 100 patient years) were greatest during treatment with antidepressant monotherapy (25.92), least during mood stabilizer monotherapy (3.48), and intermediate during mood stabilizer + antidepressant combination treatment (9.75). These differences were statistically significant. LIMITATIONS In a clinical setting, antidepressants may have been prescribed because patients were deemed at greater risk of suicidality. CONCLUSIONS During treatment with antidepressants (even when coupled with mood stabilizers), patients with bipolar disorder have significantly higher rates of non-lethal suicidal behavior compared to those on mood stabilizers without antidepressants, and thus require careful monitoring.
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Affiliation(s)
- Boghos I Yerevanian
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles 16111 Plummer Street, North Hills, CA 91343, United States.
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Abstract
Bipolar II disorder (BP-II) is defined, by DSM-IV, as recurrent episodes of depression and hypomania. Hypomania, according to DSM-IV, requires elevated (euphoric) and/or irritable mood, plus at least three of the following symptoms (four if mood is only irritable): grandiosity, decreased need for sleep, increased talking, racing thoughts, distractibility, overactivity (an increase in goal-directed activity), psychomotor agitation and excessive involvement in risky activities. This observable change in functioning should not be severe enough to cause marked impairment of social or occupational functioning, or to require hospitalisation. The distinction between BP-II and bipolar I disorder (BP-I) is not clearcut. The symptoms of mania (defining BP-I) and hypomania (defining BP-II) are the same, apart from the presence of psychosis in mania, and the distinction is based on the presence of marked impairment associated with mania, i.e. mania is more severe and may require hospitalisation. This is an unclear boundary that can lead to misclassification; however, the fact that hypomania often increases functioning makes the distinction between mania and hypomania clearer. BP-II depression can be syndromal and subsyndromal, and it is the prominent feature of BP-II. It is often a mixed depression, i.e. it has concurrent, usually subsyndromal, hypomanic symptoms. It is the depression that usually leads the patient to seek treatment.DSM-IV bipolar disorders (BP-I, BP-II, cyclothymic disorder and bipolar disorder not otherwise classified, which includes very rapid cycling and recurrent hypomania) are now considered to be part of the 'bipolar spectrum'. This is not included in DSM-IV, but is thought to also include antidepressant/substance-associated hypomania, cyclothymic temperament (a trait of highly unstable mood, thinking and behaviour), unipolar mixed depression and highly recurrent unipolar depression.BP-II is underdiagnosed in clinical practice, and its pharmacological treatment is understudied. Underdiagnosis is demonstrated by recent epidemiological studies. While, in DSM-IV, BP-II is reported to have a lifetime community prevalence of 0.5%, epidemiological studies have instead found that it has a lifetime community prevalence (including the bipolar spectrum) of around 5%. In depressed outpatients, one in two may have BP-II. The recent increased diagnosing of BP-II in research settings is related to several factors, including the introduction of the use of semi-structured interviews by trained research clinicians, a relaxation of diagnostic criteria such that the minimum duration of hypomania is now less than the 4 days stipulated by DSM-IV, and a probing for a history of hypomania focused more on overactivity (increased goal-directed activity) than on mood change (although this is still required for a diagnosis of hypomania). Guidelines on the treatment of BP-II are mainly consensus based and tend to follow those for the treatment of BP-I, because there have been few controlled studies of the treatment of BP-II. The current, limited evidence supports the following lines of treatment for BP-II. Hypomania is likely to respond to the same agents useful for mania, i.e. mood-stabilising agents such as lithium and valproate, and the second-generation antipsychotics (i.e. olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole). Hypomania should be treated even if associated with overfunctioning, because a depression often soon follows hypomania (the hypomania-depression cycle). For the treatment of acute BP-II depression, two controlled studies of quetiapine have not found clearcut positive effects. Naturalistic studies, although open to several biases, have found antidepressants in acute BP-II depression to be as effective as in unipolar depression; however, one recent large controlled study (mainly in patients with BP-I) has found antidepressants to be no more effective than placebo. Results from naturalistic studies and clinical observations on mixed depression, while in need of replication in controlled studies, indicate that antidepressants may worsen the concurrent intradepression hypomanic symptoms. The only preventive treatment for both depression and hypomania that is supported by several, albeit older, controlled studies is lithium. Lamotrigine has shown some efficacy in delaying depression recurrences, but there have also been several negative unpublished studies of the drug in this indication.
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Affiliation(s)
- Franco Benazzi
- Hecker Psychiatry Research Center, a University of California at San Diego (USA) Collaborating Center at Forli, Italy.
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Abstract
Bipolar disorder is a chronic and often devastating illness that may go undiagnosed because of its complex and diverse presentation. Clinicians can provide psychological treatments, in conjunction with pharmacotherapy, that can reduce the frequency, severity, and duration of manic and depressive episodes. Because bipolar disorder is characterized by high degrees of comorbidity and high rates of medical complications, the clinician will frequently need to implement other treatments targeted to comorbid conditions, such as panic, generalized anxiety, substance abuse, and personality disorders. This article introduces the issue of Journal of Clinical Psychology: In Session devoted to the treatment of bipolar disorder. We describe the cognitive styles and personal vulnerabilities that pose greater risk for bipolar disorder. Three evidence-based psychological treatments (interpersonal social rhythm therapy, family-focused treatment, and cognitive-behavioral therapy) and current pharmacological treatments are examined and illustrated. Finally, we review the effectiveness and practice implications of a variety of treatments for this severe and underresearched disorder.
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Affiliation(s)
- Robert L Leahy
- American Institute for Cognitive Therapy, New York, NY 10022, USA.
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Benazzi F. Delineation of the clinical picture of Dysphoric/Mixed Hypomania. Prog Neuropsychopharmacol Biol Psychiatry 2007; 31:944-51. [PMID: 17391823 DOI: 10.1016/j.pnpbp.2007.02.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2006] [Revised: 02/26/2007] [Accepted: 02/27/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND While Mixed Depression (i.e. depression plus subthreshold concurrent manic/hypomanic symptoms) has recently seen a wave of studies, little is known about Dysphoric/Mixed Hypomania (i.e. combination of syndromal hypomania and depression) compared to Bipolar I Disorder Mixed State (i.e. combination of syndromal mania and depression). STUDY AIM To delineate the clinical picture of Dysphoric/Mixed Hypomania. METHODS Consecutive 441 Bipolar II Disorder (BP-II) Major Depressive Episode (MDE) outpatients were cross-sectionally assessed for depression and concurrent hypomanic symptoms when presenting for treatment of depression, by a mood disorder specialist psychiatrist (FB), using the Structured Clinical Interview for DSM-IV, in a private practice. Consecutive 275 remitted BP-II were also assessed for the clinical picture of past (recalled) Hypomania. Dysphoric Hypomania was defined as the co-occurrence of DSM-IV irritable mood Hypomania and MDE. RESULTS Frequency of Dysphoric Hypomania was 17.0%, and it was 66.4% for Mixed Depression. Irritable mood, always present by definition in Dysphoric Hypomania, was present in 65.9% of recalled Hypomania and elevated mood in 81.4%. Dysphoric Hypomania had significantly more racing/crowded thoughts, and much less increased goal-directed activity. Functioning was always impaired in Dysphoric Hypomania (by definition), while it was improved in most recalled Hypomanias. Factor structure was different: recalled Hypomania had three factors ('elevated mood', 'irritability and racing/crowded thoughts', 'goal-directed and risky overactivity'), Dysphoric Hypomania had five factors ('depressive vegetative symptoms', 'low mood and psychomotor agitation', 'risky activities', 'loss of interest', 'racing/crowded thoughts and suicidality'). DISCUSSION Dysphoric Hypomania was uncommon among depressed outpatients (while Mixed Depression was common). Its clinical picture was closer to depression than to hypomania. If it were seen as a simple depression, antidepressants could be used alone (i.e. not protected by mood stabilising agents), risking the worsening of intra-depression irritable hypomania (which was related to suicidality). Systematic assessment of intra-depression hypomanic symptoms is supported.
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Affiliation(s)
- Franco Benazzi
- Hecker Psychiatry Research Center, University of California at San Diego, USA.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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