1
|
Barbuti M, Menculini G, Verdolini N, Pacchiarotti I, Kotzalidis GD, Tortorella A, Vieta E, Perugi G. A systematic review of manic/hypomanic and depressive switches in patients with bipolar disorder in naturalistic settings: The role of antidepressant and antipsychotic drugs. Eur Neuropsychopharmacol 2023; 73:1-15. [PMID: 37119556 DOI: 10.1016/j.euroneuro.2023.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 03/13/2023] [Accepted: 04/13/2023] [Indexed: 05/01/2023]
Abstract
The present systematic review was aimed at critically summarizing the evidence about treatment-emergent manic/hypomanic and depressive switches during the course of bipolar disorder (BD). A systematic search of the MEDLINE, EMBASE, CINAHL, Web of Science, and PsycInfo electronic databases was conducted until March 24th, 2021, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Observational studies clearly reporting data regarding the prevalence of treatment-emergent mood switches in patients with BD were considered for inclusion. Thirty-two original studies met the inclusion criteria. In the majority of cases, manic switches were analyzed; only 3 papers investigated depressive switches in type I BD. Treatment-emergent mania/hypomania in BD subjects ranged from 17.3% to 48.8% and was more frequent with antidepressant monotherapy compared to combination treatment with mood stabilizers, especially lithium, or second-generation antipsychotics. A higher likelihood of mood switch has been reported with tricyclics and a lower rate with bupropion. Depressive switches were detected in 5-16% of type I BD subjects and were associated with first-generation antipsychotic use, the concomitant use of first- and second-generation antipsychotics, and benzodiazepines. The included studies presented considerable methodological heterogeneity, small sample sizes and comparability flaws. In conclusion, many studies, although heterogeneous and partly discordant, have been conducted on manic/hypomanic switches, whereas depressive switches during treatment with antipsychotics are poorly investigated. In BD subjects, both antidepressant and antipsychotic medications seems to play a role in the occurrence of mood switches, although the effects of different pharmacological compounds have yet to be fully investigated.
Collapse
Affiliation(s)
- Margherita Barbuti
- Psychiatry Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, PI, Italy
| | - Giulia Menculini
- Section of Psychiatry, Department of Medicine and Surgery, University of Perugia, Piazzale Lucio Severi 1, 06132 Perugia, Italy
| | - Norma Verdolini
- Bipolar and Depressive Disorders Unit, Hospital Clinic, Institute of Neurosciences, University of Barcelona, IDIBAPS, CIBERSAM, 170 Villarroel, 08036, Barcelona, Catalonia, Spain
| | - Isabella Pacchiarotti
- Bipolar and Depressive Disorders Unit, Hospital Clinic, Institute of Neurosciences, University of Barcelona, IDIBAPS, CIBERSAM, 170 Villarroel, 08036, Barcelona, Catalonia, Spain
| | - Georgios D Kotzalidis
- Centro Lucio Bini, Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza University, Via Crescenzio 42, Via di Grottarossa 1035-1039, 00189, 00193, Rome, Italy
| | - Alfonso Tortorella
- Section of Psychiatry, Department of Medicine and Surgery, University of Perugia, Piazzale Lucio Severi 1, 06132 Perugia, Italy
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Hospital Clinic, Institute of Neurosciences, University of Barcelona, IDIBAPS, CIBERSAM, 170 Villarroel, 08036, Barcelona, Catalonia, Spain
| | - Giulio Perugi
- Psychiatry Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, PI, Italy.
| |
Collapse
|
2
|
Miranda ASD, Miranda ASD, Teixeira AL. Lamotrigine as a mood stabilizer: insights from the pre-clinical evidence. Expert Opin Drug Discov 2018; 14:179-190. [PMID: 30523725 DOI: 10.1080/17460441.2019.1553951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Lamotrigine (LTG) is a well-established anticonvulsant that is also approved for the prevention of mood relapses in bipolar disorder. However, the mechanisms underlying LTG mood stabilizing effects remain unclear. Areas covered: Herein, the pre-clinical evidence concerning LTG's' mode of action in depression and mania is reviewed. Bottlenecks and future perspectives for this expanding and promising field are also discussed. Pre-clinical studies have indicated that neurotransmitter systems, especially serotoninergic, noradrenergic and glutamatergic, as well as non-neurotransmitter pathways such as inflammation and oxidative processes might play a role in LTG's antidepressant effects. The mechanisms underlying LTG's anti-manic properties remain to be fully explored, but the available pre-clinical evidence points out to the role of glutamatergic neurotransmission, possibly through AMPA-receptors. Expert opinion: A major limitation of current pre-clinical investigations is that there are no experimental models that recapitulate the complexity of bipolar disorder. Significant methodological differences concerning time and dose of LTG treatment, administration route, animal strains, and behavioral paradigms also hamper the reproducibility of the findings, leading to contradictory conclusions. Moreover, the role of other mechanisms (e.g. inositol phosphate and GSK3β pathways) implicated in the mode of action of different mood-stabilizers must also be consolidated with LTG.
Collapse
Affiliation(s)
- Aline Silva de Miranda
- a Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil.,b Laboratório de Neurobiologia, Departamento de Morfologia, Instituto de Ciências Biológicas , Universidade Federal de Minas Gerais , Belo Horizonte , Brasil
| | - Amanda Silva de Miranda
- c Departamento de Química , Instituto de Ciências Exatas, Universidade Federal de Minas Gerais , Belo Horizonte , Brasil
| | - Antônio Lúcio Teixeira
- a Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil.,d Neuropsychiatry Program & Immuno-Psychiatry Lab, Department of Psychiatry & Behavioral Sciences, McGovern Medical School , University of Texas Health Science Center at Houston , Houston , USA
| |
Collapse
|
3
|
Abstract
SummaryFor many patients with bipolar disorder there is a long delay between the onset of illness and receiving a diagnosis and the initiation of treatment. This may have an adverse effect on the clinical outcome. Early intervention in bipolar disorder has received less attention than in schizophrenia, and there are relatively few specialist services in this area. This article reviews the literature on the early detection of bipolar disorder and on the effectiveness of pharmacological, psychological and psychosocial interventions in the early phase of the disorder.
Collapse
|
4
|
Miranda ASD, Moreira FA, Teixeira AL. The preclinical discovery and development of quetiapine for the treatment of mania and depression. Expert Opin Drug Discov 2017; 12:525-535. [PMID: 28271741 DOI: 10.1080/17460441.2017.1304378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Bipolar disorder is a chronic disabling condition characterized by alternating manic and depressive episodes. Bipolar disorder has been associated with functional impairment, poor quality of life, morbidity and mortality. Despite its significant clinical, social and economic burden, treatment options for bipolar disorder are still limited. Several clinical trials have shown efficacy of the atypical antipsychotic quetiapine (QTP) in the treatment of this condition. However, the mechanisms underlying the antidepressant and anti-manic effects of QTP remain poorly understood. Areas covered: The article provides the emerging evidence from pre-clinical studies regarding the antidepressant and anti-manic mechanisms of action of QTP. In combination with its primary active metabolite norquetiapine, QTP modulates several neurotransmitter systems, including serotonin, dopamine, noradrenaline and histamine. QTP also seems to influence mediators of the immune system. Expert opinion: Pre-clinical studies have provided valuable information on the potential antidepressant mechanisms of action of QTP, but pre-clinical studies on QTP's anti-manic effects are still scarce. A major problem refers to the lack of valid experimental models for bipolar disorder. Additionally, immune and genetic based studies are largely descriptive. The role of the QTP metabolite norquetiapine in modulating non-neurotransmitter systems also needs to be further addressed.
Collapse
Affiliation(s)
- Aline Silva de Miranda
- a Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil.,b Laboratório de Neurobiologia, Departamento de Morfologia, Instituto de Ciências Biológicas , Universidade Federal de Minas Gerais , Belo Horizonte , Brasil
| | - Fabrício A Moreira
- c Laboratório de Neuropsicofarmacologia, Departamento de Farmacologia, Instituto de Ciências Biológicas , Universidade Federal de Minas Gerais , Belo Horizonte , Brasil
| | - Antônio Lúcio Teixeira
- a Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil.,d Neuropsychiatry Program, Department of Psychiatry & Behavioral Sciences, McGovern Medical School , University of Texas Health Science Center at Houston , Houston , TX , USA
| |
Collapse
|
5
|
Investigating the mechanism(s) underlying switching between states in bipolar disorder. Eur J Pharmacol 2015; 759:151-62. [PMID: 25814263 DOI: 10.1016/j.ejphar.2015.03.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 03/03/2015] [Accepted: 03/12/2015] [Indexed: 12/12/2022]
Abstract
Bipolar disorder (BD) is a unique disorder that transcends domains of function since the same patient can exhibit depression or mania, states with polar opposite mood symptoms. During depression, people feel helplessness, reduced energy, and risk aversion, while with mania behaviors include grandiosity, increased energy, less sleep, and risk preference. The neural mechanism(s) underlying each state are gaining clarity, with catecholaminergic disruption seen during mania, and cholinergic dysfunction during depression. The fact that the same patient cycles/switches between these states is the defining characteristic of BD however. Of greater importance therefore, is the mechanism(s) underlying cycling from one state - and its associated neural changes - to another, considered the 'holy grail' of BD research. Herein, we review studies investigating triggers that induce switching to these states. By identifying such triggers, researchers can study neural mechanisms underlying each state and importantly how such mechanistic changes can occur in the same subject. Current animal models of this switch are also discussed, from submissive- and dominant-behaviors to kindling effects. Focus however, is placed on how seasonal changes can induce manic and depressive states in BD sufferers. Importantly, changing photoperiod lengths can induce local switches in neurotransmitter expression in normal animals, from increased catecholaminergic expression during periods of high activity, to increased somatostatin and corticotrophin releasing factor during periods of low activity. Identifying susceptibilities to this switch would enable the development of targeted animal models. From animal models, targeted treatments could be developed and tested that would minimize the likelihood of switching.
Collapse
|
6
|
Pacchiarotti I, Nivoli AMA, Mazzarini L, Kotzalidis GD, Sani G, Koukopoulos A, Scott J, Strejilevich S, Sánchez-Moreno J, Murru A, Valentí M, Girardi P, Vieta E, Colom F. The symptom structure of bipolar acute episodes: in search for the mixing link. J Affect Disord 2013; 149:56-66. [PMID: 23394711 DOI: 10.1016/j.jad.2013.01.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 01/11/2013] [Accepted: 01/11/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The nature of mixed mood episodes is still a matter of controversy amongst experts. Currently, the approach to this syndrome is mainly categorical and very restrictive. The factor-structure of bipolar mood episodes has not been studied yet. We performed a dimensional analysis of the structure of bipolar episodes aimed at identifying a factor deconstructing mixed episodes; furthermore, we analyzed correlations of factors emerging from the factorial analysis of the Brief Psychiatric Rating Scale (BPRS) with Temperament Evaluation of Memphis-Pisa-Paris-San Diego (TEMPS-A) and predominant polarity. METHOD 187 consecutive bipolar I inpatients hospitalized for DSM-IV-TR acute mood episodes (depressive, manic or mixed) underwent a standardized assessment, including the 24-item Brief Psychiatric Rating Scale (BPRS 4.0), the 21-item Hamilton Depression Rating Scale (HDRS-21), the Young Mania Rating Scale (YMRS) and the TEMPS-A. Principal factor analysis was performed on BPRS-24 items. RESULTS This analysis revealed five factors corresponding to "psychosis", "euphoric mania", "mixity", "dysphoria" and "inhibited depression", capturing 71.89% of the rotated variance. The mixity factor was characterized by higher rates of suicidal ideation, more mixed episodes, higher frequencies of antidepressant (AD) use, depressive predominant polarity and anxious temperament. DISCUSSION The factor-structure of the BPRS in inpatients with bipolar I disorder with an acute episode of any type is pentafactorial; one factor identified is the mixity factor, which is independent from other factors and characterized by anxiety and motor hyperactivity and by the absence of motor retardation. Our results should prompt reconsideration of proposals for DSM-5 diagnostic criteria for the mixed features specifier. Limitations of the study include the relative small sample, the absence of drug-naïve patients and the use of rating scales no specific for mixed states.
Collapse
Affiliation(s)
- Isabella Pacchiarotti
- Bipolar Disorders Programme, Institute of Clinical Neuroscience, Hospital Clínic, Universitat de Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalunya, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Salvadore G, Quiroz JA, Machado-Vieira R, Henter ID, Manji HK, Zarate CA. The neurobiology of the switch process in bipolar disorder: a review. J Clin Psychiatry 2010; 71:1488-501. [PMID: 20492846 PMCID: PMC3000635 DOI: 10.4088/jcp.09r05259gre] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 06/09/2009] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The singular phenomenon of switching from depression to its opposite state of mania or hypomania, and vice versa, distinguishes bipolar disorder from all other psychiatric disorders. Despite the fact that it is a core aspect of the clinical presentation of bipolar disorder, the neurobiology of the switch process is still poorly understood. In this review, we summarize the clinical evidence regarding somatic interventions associated with switching, with a particular focus on the biologic underpinnings presumably involved in the switch process. DATA SOURCES Literature for this review was obtained through a search of the MEDLINE database (1966-2008) using the following keywords and phrases: switch, bipolar disorder, bipolar depression, antidepressant, SSRIs, tricyclic antidepressants, norepinephrine, serotonin, treatment emergent affective switch, mania, hypomania, HPA-axis, glucocorticoids, amphetamine, dopamine, and sleep deprivation. STUDY SELECTION All English-language, peer-reviewed, published literature, including randomized controlled studies, naturalistic and open-label studies, and case reports, were eligible for inclusion. DATA SYNTHESIS Converging evidence suggests that certain pharmacologic and nonpharmacologic interventions with very different mechanisms of action, such as sleep deprivation, exogenous corticosteroids, and dopaminergic agonists, can trigger mood episode switches in patients with bipolar disorder. The switch-inducing potential of antidepressants is unclear, although tricyclic antidepressants, which confer higher risk of switching than other classes of antidepressants, are a possible exception. Several neurobiological factors appear to be associated with both spontaneous and treatment-emergent mood episode switches; these include abnormalities in catecholamine levels, up-regulation of neurotrophic and neuroplastic factors, hypothalamic-pituitary-adrenal axis hyperactivity, and circadian rhythms. CONCLUSIONS There is a clear need to improve our understanding of the neurobiology of the switch process; research in this field would benefit from the systematic and integrated assessment of variables associated with switching.
Collapse
Affiliation(s)
- Giacomo Salvadore
- Mood and Anxiety Disorders Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Jorge A. Quiroz
- Johnson & Johnson Pharmaceutical Research and Development, L.L.C., Titusville, NJ
| | - Rodrigo Machado-Vieira
- Experimental Therapeutics, Mood and Anxiety Disorders Program, National Institute of Mental Health, Bethesda, Maryland, USA
| | - Ioline D. Henter
- Mood and Anxiety Disorders Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Husseini K. Manji
- Mood and Anxiety Disorders Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA,Johnson & Johnson Pharmaceutical Research and Development, L.L.C., Titusville, NJ
| | - Carlos A. Zarate
- Experimental Therapeutics, Mood and Anxiety Disorders Program, National Institute of Mental Health, Bethesda, Maryland, USA
| |
Collapse
|
8
|
A review of the preclinical and clinical evidence for protein kinase C as a target for drug development for bipolar disorder. Curr Psychiatry Rep 2008; 10:510-9. [PMID: 18980735 PMCID: PMC2727597 DOI: 10.1007/s11920-008-0081-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In this article, we review preclinical studies investigating the role of protein kinase C (PKC) as it pertains to mania and effective antimanic agents. We then discuss clinical studies conducted with tamoxifen, a relatively selective PKC inhibitor, in acute bipolar mania. We conclude that PKC is an important target-arguably the first mechanistically distinct drug target for bipolar disorder. PKC holds considerable promise as a novel target for developing a new line of treatments for bipolar disorder.
Collapse
|
9
|
Goetz I, Tohen M, Reed C, Lorenzo M, Vieta E. Functional impairment in patients with mania: baseline results of the EMBLEM study. Bipolar Disord 2007; 9:45-52. [PMID: 17391349 DOI: 10.1111/j.1399-5618.2007.00325.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) is a large-scale prospective observational multicentre study to evaluate the longitudinal course of bipolar disorder and its associations with pharmacological treatment following an acute manic or mixed episode. We present an overview of the study design and patient characteristics at baseline while focusing on factors influencing work performance in the year prior to enrollment. METHODS A total of 530 investigators across 14 European countries enrolled 3,681 patients with acute mania between December 2002 and June 2004. Longitudinal observations are ongoing until July 2006. Socio-demographic variables, psychiatric history, clinical status and information on pharmacological treatment for bipolar disorder were recorded. Items from the SLICE of LIFE were applied, including a measure of work impairment during the previous year. The distribution of the baseline characteristics was analysed with descriptive statistics. Eighteen variables were investigated as hypothesized risk factors for work impairment applying logistic regression models. RESULTS In the previous year, 28 and 68% of patients were classified as having 'low' and 'high' work impairment, respectively. Clinical Global Impression - Bipolar Disorder (CGI-BP) overall, CGI-BP depression at baseline, rapid cycling during the previous 12 months, age between 35 and 64 years, substance abuse other than alcohol and cannabis and living without a partner or as dependent household member were significantly associated with work impairment during the previous year. CONCLUSIONS EMBLEM is to our knowledge the largest prospective observational study assessing patients during and after an acute episode of mania. Work impairment is significant in the year prior to an acute episode of mania.
Collapse
Affiliation(s)
- I Goetz
- European Health Outcomes, Lilly Research Centre, Windlesham, Surrey, UK.
| | | | | | | | | |
Collapse
|
10
|
Carlson GA. Trouble bipolaire à début précoce : considérations cliniques et de recherche. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.neurenf.2006.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
11
|
Mansell W, Colom F, Scott J. The nature and treatment of depression in bipolar disorder: A review and implications for future psychological investigation. Clin Psychol Rev 2005; 25:1076-100. [PMID: 16140444 DOI: 10.1016/j.cpr.2005.06.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2005] [Revised: 05/26/2005] [Accepted: 06/13/2005] [Indexed: 10/25/2022]
Abstract
Bipolar depression is poorly understood and researched, yet it is has a huge impact on functioning in bipolar disorder. This review explores the current status of research regarding the phenomenology, natural history, neuropsychology, psychosocial predictors and cognitive style of bipolar depression. The current status of pharmacotherapy and psychological treatment of bipolar depression is also described. In particular, the manner in which cognitive behaviour therapy for bipolar depression has been adapted from CBT for unipolar depression is critically evaluated. It is concluded that there appears to be a considerable overlap between the features of unipolar and bipolar depression, yet there is also emerging evidence for specific elements. The ability of current psychological theories of bipolar disorder to account for the findings are compared, and as a consequence, a new preliminary integrative model is proposed to direct future hypothesis-led research, which will need to incorporate more suitable populations and utilise more objective methods of assessment.
Collapse
Affiliation(s)
- Warren Mansell
- Psychological Treatments PO96, Department of Psychological Medicine, Institute of Psychiatry, London SE5 8AF, UK.
| | | | | |
Collapse
|
12
|
Sato T, Bottlender R, Kleindienst N, Möller HJ. Irritable psychomotor elation in depressed inpatients: a factor validation of mixed depression. J Affect Disord 2005; 84:187-96. [PMID: 15708416 DOI: 10.1016/s0165-0327(02)00172-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2002] [Accepted: 05/06/2002] [Indexed: 10/25/2022]
Abstract
BACKGROUND Early authors described hypomanic symptoms as mixed features in depressive episode, but this syndrome has not been sufficiently explored in previous studies. METHODS 958 consecutive depressed patients were assessed by using a standardized method in terms of 43 psychiatric symptoms at hospitalization. RESULTS A principal component analysis, followed by varimax rotation, extracted six interpretable factors: typical vegetative symptoms, depressive retardation/loss of feeling, hypomanic syndrome, anxiety, psychosis, and depressive mood/hopelessness. The extracted factor structure was relatively stable among several patient groups. There was no evidence that the hypomanic factor was exaggerated by antidepressant pretreatments before hospitalization. Bipolar diagnoses were associated with higher scores on depressive retardation and hypomanic symptoms, and a lower score on anxiety. LIMITATIONS Psychiatric syndromes and their interrelationships, found in the present study, may be strongly influenced by the rating instrument used. The sample of this study was depressed inpatients. The results should not be generalized for depressed outpatients or epidemiological depressed populations. CONCLUSIONS Hypomanic symptoms, as characterized by the flight of ideas, racing thought, increased drive, excessive social contact, irritability, and aggression are a salient syndrome in acutely ill depressed patients, lending support to the factor validity of mixed depression. The symptoms may not be related to pretreatments with antidepressants, or comorbidity of substance abuse, suggesting that they reflect various natural phenomenological manifestations of depressive episodes. Anxiety is unlikely to play a major role in the core phenomenological features of mixed depression. Hypomanic symptoms during a depressive episode were more represented in bipolar disorders, which may serve for further clarifications of latent bipolarity in unipolar depression, and prediction of switch into maniform states under biological depression treatments.
Collapse
Affiliation(s)
- T Sato
- Psychiatrische Klinik, Ludwig-Maximilians-Universität München, Nussbaumstrasse 7 80336 Munich, Germany.
| | | | | | | |
Collapse
|
13
|
Calabrese JR, Vieta E, El-Mallakh R, Findling RL, Youngstrom EA, Elhaj O, Gajwani P, Pies R. Mood state at study entry as predictor of the polarity of relapse in bipolar disorder. Biol Psychiatry 2004; 56:957-63. [PMID: 15601606 DOI: 10.1016/j.biopsych.2004.09.022] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2004] [Revised: 08/05/2004] [Accepted: 09/21/2004] [Indexed: 10/26/2022]
Abstract
Of the placebo-controlled maintenance studies conducted in bipolar disorder, few have enrolled patients who present depressed. In fact, only lithium and lamotrigine have been studied over the long term with placebo-controlled designs in recently manic and recently depressed bipolar patients. Given the magnitude of the unmet medical need and the data suggesting that symptomatic patients with bipolar disorder spend the majority of their time depressed, this is unfortunate. Our review of the pre-lithium literature and more recent publications suggests that mood state at study entry predicts the polarity of relapse and the response to treatment. Accordingly, a need exists to enroll recently depressed patients in maintenance studies to elucidate the complete spectrum of efficacy of putative mood stabilizers and improve the long-term treatment of bipolar depression. Patients presenting depressed for a maintenance study tend to relapse into depression; those presenting manic, into hypomania/mania/mixed states. This is particularly true during the first several months of the randomized treatment. The polarity of the index episode tends to predict the polarity of relapse into a subsequent episode in a ratio of about 2:1 to 3:1. We conclude that putative mood stabilizers must be tested in recently manic and recently depressed patients to determine their spectrum of prophylactic efficacy.
Collapse
Affiliation(s)
- Joseph R Calabrese
- Case University School of Medicine, University Hospitals of Cleveland, 11400 Euclid Avenue, Suite #200, Cleveland, OH 44106, USA.
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Sato T, Bottlender R, Tanabe A, Möller HJ. Cincinnati criteria for mixed mania and suicidality in patients with acute mania. Compr Psychiatry 2004; 45:62-9. [PMID: 14671739 DOI: 10.1016/s0010-440x(03)00145-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The association between suicidality and diagnoses of mixed mania, as defined using both DSM-IV and Cincinnati criteria, was studied in 576 consecutive manic inpatients. Of the whole sample, 51 (8.9%) had suicidal ideation and 13 (2.3%) attempted suicide during the index episode. Suicidality was significantly more frequent in patients with a diagnosis of mixed mania, whether the diagnosis was made by DSM-IV or Cincinnati criteria. A multiple logistic regression analysis revealed that an additive combination of a diagnosis of mixed mania, the depression severity, and the Global Assessment of Functioning (GAF) score was significant in predicting suicidal ideation, when using the DSM-IV criteria. A diagnosis of mixed mania alone was significant in a similar analysis, when using the Cincinnati criteria. The adjusted odds ratio for a diagnosis of mixed mania to having suicidality was much higher when using the latter criteria (4.0 v 14.0). A subsequent logistic regression analysis indicated that the Cincinnati mixed mania alone, rather than an additive combination of the DSM-IV mixed mania and the depression severity, achieved the most appropriate prediction of suicidal ideation in the sample. These findings did not differ, even when suicidality was defined as having a suicide attempt during the index episode. Our finding that suicidality was more strongly associated with Cincinnati mixed mania than with DSM-IV mixed mania is probably due to that suicidal patients who do not meet DSM-IV criteria for mixed mania are classified into mixed mania, or/and that the depressive syndrome, related to suicidality, is more appropriately assessed among manic patients, when using the Cincinnati criteria. There was no evidence that marital status, employment, a lifetime history of alcohol or substance abuse, or a history of suicide attempts before the index episode was significantly associated with suicidality in the sample. Manic patients with suicidality may have a greater severity of residual depressive symptoms at discharge.
Collapse
Affiliation(s)
- Tetsuya Sato
- Psychiatrische Klinik und Poliklinik, Ludwig-Maximilians-Universität, Mūnchen, Germany
| | | | | | | |
Collapse
|