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Zimmerman M, Mackin D. Identifying the DSM-5 mixed features specifier in depressed patients: A comparison of measures. J Affect Disord 2023; 339:854-859. [PMID: 37490969 DOI: 10.1016/j.jad.2023.07.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/09/2023] [Accepted: 07/19/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND A commonly used measure to assess mixed features in depressed patients is the Young Mania Rating Scale (YMRS), which only partially aligns with the DSM-5 criteria. Different algorithms on the YMRS have been used to approximate the DSM-5 mixed features criteria. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the agreement and validity of different approaches towards assessing the mixed features specifier. METHODS Three hundred nine depressed psychiatric patients were interviewed with the Structured Clinical Interview for DSM-IV, the DSM-5 Mixed Features Specifier Interview (DMSI) and the YMRS. Seven definitions of mixed features were examined, two based on the DMSI and five from the YMRS. RESULTS The prevalence of mixed features varied 8-fold amongst the 7 definitions. The level of agreement between the YMRS definitions and the DMSI was poor. For each definition, mixed features were significantly more common in patients with bipolar disorder than major depressive disorder. A family history of bipolar disorder was significantly associated with the DMSI assessment of mixed features but none of the YMRS approaches. LIMITATIONS The ratings on the measures were not independent of each other. The sample size was too small to compare the patients with bipolar I and bipolar II disorder. CONCLUSIONS While there was evidence of validity for both the DSM-5 and YMRS approaches towards identifying mixed features, the 2 approaches are not interchangeable. The algorithm on the YMRS used to classify patients has a significant impact on prevalence.
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Affiliation(s)
- Mark Zimmerman
- Department of Psychiatry and Human Behavior, Brown Medical School, South County Psychiatry, Providence, RI, United States.
| | - Daniel Mackin
- Department of Psychiatry and Human Behavior, Brown Medical School, South County Psychiatry, Providence, RI, United States
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2
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Wu CL, Yek CW, Wang TY, Lu TH, Chang WH, Chen PS. Comparative efficacy of rTMS add-on treatment for bipolar depression versus unipolar depression. Brain Stimul 2023; 16:1102-1104. [PMID: 37442367 DOI: 10.1016/j.brs.2023.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/07/2023] [Accepted: 07/07/2023] [Indexed: 07/15/2023] Open
Affiliation(s)
- Chien-Lin Wu
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chin Wei Yek
- Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tzu-Yun Wang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsung-Hua Lu
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei Hung Chang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan
| | - Po See Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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3
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Mansur RB. Antidepressants in Bipolar Depression: Still Controversial After All These Years. Psychiatr Ann 2023. [DOI: 10.3928/00485713-20230119-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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4
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Goldberg JF. Perspectives on the success rate of current antidepressant pharmacotherapy. Expert Opin Pharmacother 2022; 23:1781-1791. [PMID: 36259350 DOI: 10.1080/14656566.2022.2138333] [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: 11/04/2022]
Abstract
INTRODUCTION There has been growing debate about the effectiveness of traditional antidepressants for the treatment of depression, and whether the clinical trials literature overstates the value of existing agents. Antidepressant efficacy is limited by suboptimal remission rates, lack of robust efficacy across diverse depressed subgroups, slow onset, and challenges managing tolerability. Clinicians can better navigate uncertainties in this area by recognizing patient-specific clinical and prognostic factors that influence the likelihood of antidepressant drug response. AREAS COVERED The author summarizes pertinent literature regarding drug-placebo differences in antidepressant outcome as well as patient-specific factors that influence antidepressant drug responsivity across subtypes of depressive disorders. EXPERT OPINION Standardized effect sizes for most monoaminergic antidepressants are relatively modest. At least one-third of treatment response derives from nonspecific (yet substantial) placebo effects, limiting the ability to compare antidepressant medication effects to that of "no treatment." Patients with high baseline depressive symptom severity are less likely to respond to placebo but may be more responsive to antidepressant pharmacotherapy than is the case in mild forms of depression. Patient satisfaction with antidepressant response must take into consideration not only efficacy for reducing symptoms but also drug tolerability/acceptability and tangible improvement in functional outcome and quality of life.
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Affiliation(s)
- Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY
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Masi G. Controversies In The Pharmacotherapy Of Adolescent Depression. Curr Pharm Des 2022; 28:1975-1984. [PMID: 35619257 DOI: 10.2174/1381612828666220526150153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/08/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although fluoxetine and, in the USA, escitalopram are approved for depression in adolescence, substantial concern surrounds antidepressant use in youth. Major controversies regarding efficacy and safety (increased suicidality). INTRODUCTION The cathegory of depression is very broad and overinclusive, in terms of etiology, role of psychosocial adversities severity, episodicity, presentation, relationship with bipolarity. This heterogeneity, not fully controlled considered in Randomized Controlled Trials (RCTs), may account for the disappointing results on both efficacy and safety. METHOD Based on the available literature, we will address the following topics: a) controversies regarding the definition of depression as a unique homogeneous condition with a unique type of pharmacological treatment; b) controversies about the interpretation of data from Randomized Controlled Trials (RCTs) on the efficacy of pharmacological treatments in adolescent depression; c) the interpretation of data regarding the safety of antidepressant treatment in adolescent depression, particularly in terms of increased suicidal risk. RESULTS According to RCTs, antidepressants are minimally to moderately more effective than placebo, principally based on very high placebo responses, and only fluoxetine showed more evidence of efficacy. These differences in meta-analyses are sometimes statistically, but not clinically significant. Depression is a heterogeneous condition in terms of etiology, role of psychosocial adversities severity, episodicity, presentation, relationship with bipolarity. This heterogeneity may partly explain the low drug-placebo difference and the high placebo response (possibly related to a high level of natural recovery of the adolescent depression). In the National Institute of Mental Health (NIMH)-funded studies, including a lower number of study sites and more reliable enrollment procedures, lower placebo response rates and greater group differences between medication and placebo were found. Robust evidence supports an increased risk of emergent suicidality after starting antidepressants. A clear age effect on suicidal risk after antidepressants is supported by a comprehensive meta-analysis, showing that suicidal risk increased with decreasing age, being markedly greater in subjects aged between 18 and 25 years. However, the term suicidality is too broad, as it includes suicidal ideation, suicidal attempts, and completed suicide, with a hugely wide range of severity and pervasiveness. If emergent suicidality should be actively and carefully explored, empirical evidence, albeit weak, suggests that combined pharmacotherapy (antidepressant and/or lithium) associated with psychotherapy may be helpful in reducing pretreatment suicidal ideation and suicidal risk. DISCUSSION Moderate to severe depression should be treated with psychotherapy and/or fluoxetine, the best-supported medication, and treatment-resistant adolescents should always receive combined treatment with psychotherapy. Suicidal ideation, particularly with a plan, should be actively explored before starting an antidepressant, as a reason for the closest monitoring. Emergent suicidality after starting antidepressants, as well as antidepressant-related activation, should also be closely monitored and may lead to antidepressant discontinuation. Although no response to pharmacotherapy and psychotherapy may occur in up to 40% of depressed adolescents, possible predictors or mediators of poorer response in adolescents are uncertain, and only a few studies support possible treatment strategies. Finally, studies exploring the efficacy of antidepressants in specific depression subtypes, i.e., based on prevalent psychopathological dimensions (apathy, withdrawal, impulsivity), are warranted.
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Affiliation(s)
- Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
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6
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Fei Y, Liu L, Zheng D, Li X, Li W, Yang H, Yang B, Yi Z, Huang L, Wang Y, Wang P, Li Z, Wang Z. Reliability and validity of the Chinese version of the CUDOS-M in patients with mood disorders: A multicenter study across China. J Affect Disord 2021; 294:723-729. [PMID: 34343931 DOI: 10.1016/j.jad.2021.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/20/2021] [Accepted: 07/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND A useful scale for identification of mixed features in major depressive episodes (MDE) patients is urgent in China. This study aimed to evaluate the reliability and validity of the Chinese version of the Clinically Useful Depression Outcome Scale supplemented with questions for the DSM-5 mixed features specifier (Chinese-CUDOS-M) in MDE patients. METHODS A total of 152 MDE patients were recruited and assessed using Chinese-CUDOS-M, Patient Health Questionnaire-9 (PHQ-9) and 32-item Hypomania Checklist (HCL-32). Principal component analysis (PCA) and exploratory factor analysis (EFA) were conducted. The predictive validity was calculated by the area under the receiver operating characteristic curve (AUROC). RESULTS The Cronbach's alpha of Chinese-CUDOS-M was 0.85. PCA showed three common factors with eigenvalue greater than 1; the eigenvalue of factor I was 4.96, with 38.1% of variance explanation. Chinese-CUDOS-M depression subscale was associated with PHQ-9 (r = 0.83, p<0.01), and manic subscale was associated with HCL-32 (r = 0.73, p< 0.01). AUROC of the Chinese-CUDOS-M for patients with mixed depression was 0.90 (95%CI: 0.85-0.95), with a cut-off value of 7, sensitivity of 0.95, and specificity of 0.73. Furthermore, AUROC was 0.88 in patients with major depressive disorder (MDD), with a cut-off value of 7, sensitivity of 0.96, and specificity of 0.71. AUROC was 0.92 in bipolar disorder (BD) depression patients, with a cut-off value of 9, sensitivity of 0.89, and specificity of 0.87. CONCLUSION Our study shows that the Chinese-CUDOS-M can identify mixed features in both MDD and BD depression with satisfactory reliability and validity.
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Affiliation(s)
- Yue Fei
- Division of Mood Disorders, Hongkou District Mental Health Center, Shanghai, China
| | - Lei Liu
- Qingdao Mental Health Center, Qingdao University, Qingdao, China
| | - Denise Zheng
- McGovern Medical School, Houston, Texas, United States of America
| | - Xujuan Li
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, China
| | - Wenfei Li
- Anhui Mental Health Center, Hefei, China
| | | | | | - Zhenghui Yi
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Leping Huang
- Division of Mood Disorders, Hongkou District Mental Health Center, Shanghai, China
| | - Yu Wang
- Division of Mood Disorders, Hongkou District Mental Health Center, Shanghai, China
| | - Ping Wang
- Division of Mood Disorders, Hongkou District Mental Health Center, Shanghai, China
| | - Zezhi Li
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Zuowei Wang
- Division of Mood Disorders, Hongkou District Mental Health Center, Shanghai, China; School of Medicine, Shanghai University, Shanghai, China.
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Diagnosing and treating major depressive episodes that lie along the mood disorders spectrum: focus on depression with mixed features. CNS Spectr 2021. [PMID: 33715657 DOI: 10.1017/s1092852921000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Growing evidence indicates that historical descriptions of mixed depression-broadly defined as major depressive episodes with subthreshold manic or hypomanic (hypo/manic) symptoms-are incredibly clinically relevant in this day-and-age. However, the first operational definition of mixed depression did not occur in the modern nomenclature until 2013 with publication of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), and there has not been enough time to evaluate these criteria empirically. Thus, the most valid operational definition of a mixed depressive episode is still unknown, widely accepted treatment guidelines are not available, and no treatment has regulatory approval for mixed depression-whether associated with bipolar I disorder, bipolar II disorder, or major depressive disorder. This is despite seven drugs having regulatory indications for mixed episodes, defined as the co-occurrence of syndromal depression and syndromal mania, and now recognized as mania with mixed features by DSM-5. Indeed, we found only two randomized, placebo-controlled trials in patients with protocol defined mixed depression, one with ziprasidone and one with lurasidone. Both studies were positive, suggesting treatment with second-generation antipsychotics may be helpful for mixed depressive episodes associated with bipolar II or unipolar disorder. We found no randomized control trial of antidepressant monotherapy in mixed depression and many clinical reports that such treatment may worsen mixed depression Randomized, placebo-controlled trials of antidepressants, antipsychotics, and mood stabilizers-alone and in combination-in individuals with carefully defined mixed depression are needed before firm treatment guidelines can be produced.
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Köhler-Forsberg O, Sylvia LG, Fung V, Overhage L, Thase M, Calabrese JR, Deckersbach T, Tohen M, Bowden CL, McInnis M, Kocsis JH, Friedman ES, Ketter TA, McElroy SL, Shelton RC, Ostacher MJ, Iosifescu DV, Nierenberg AA. Adjunctive antidepressant treatment among 763 outpatients with bipolar disorder: Findings from the Bipolar CHOICE and LiTMUS trials. Depress Anxiety 2021; 38:114-123. [PMID: 32598093 DOI: 10.1002/da.23069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/12/2020] [Accepted: 06/03/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Adjunctive antidepressants are frequently used for bipolar depression but their clinical efficacy has been studied in few trials and little is known about how co-occurring manic symptoms affect treatment response. METHODS Bipolar Clinical Health Outcomes Initiative in Comparative Effectiveness (N = 482) and Lithium Treatment Moderate-Dose Use Study (N = 281) were similar comparative effectiveness trials on outpatients with bipolar disorder comparing four different randomized treatment arms with adjunctive personalized guideline-based treatment for 24 weeks. Adjunctive antidepressant treatment could be used if clinically indicated and was assessed at every study visit. Adjusted mixed effects linear regression analyses compared users of antidepressants to nonusers overall and in different subcohorts. RESULTS Of the 763 patients, 282 (37.0%) used antidepressant drugs during the study. Antidepressant users had less improvement compared to nonusers on the Clinical Global Impression Scale for Bipolar Disorder and on measures of depression. This was particularly true among patients with co-occurring manic symptoms. Exclusion of individuals begun on antidepressants late in the study (potentially due to overall worse response) resulted in no differences between users and nonusers. We found no differences in treatment effects on mania scales. CONCLUSIONS In this large cohort of outpatients with bipolar disorder, clinically indicated and guideline-based adjunctive antidepressant treatment was not associated with lower depressive symptoms or higher mania symptoms. The treatment-by-indication confounding due to the nonrandomized design of the trials complicates causal interpretations, but no analyses indicated better treatment effects of adjunctive antidepressants.
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Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit and the Department of Affective Disorders, Aarhus University Psychiatry Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Louisa G Sylvia
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Vicki Fung
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Lindsay Overhage
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio
| | - Thilo Deckersbach
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, Texas
| | - Melvin McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, New York
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Susan L McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Psychiatry, Lindner Center of HOPE, Mason, Ohio
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael J Ostacher
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Dan V Iosifescu
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Andrew A Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Goldwaser EL, Daddario K, Aaronson ST. A retrospective analysis of bipolar depression treated with transcranial magnetic stimulation. Brain Behav 2020; 10:e01805. [PMID: 33169946 PMCID: PMC7749511 DOI: 10.1002/brb3.1805] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/22/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Treatment options are limited for patients with bipolar depression. Antidepressants added to mood stabilizers even carry risks of precipitating mixed/manic episodes. Transcranial magnetic stimulation (TMS) may provide a safe and effective option for these patients. METHODS Database analysis of the TMS Service at Sheppard Pratt Health System identified patients with bipolar disorder type I (BD1) or II (BD2) in a pure depressive phase at initiation of TMS. Records were reviewed for response and remission rates based on MADRS scores, time to effect, and adverse events, notably treatment-emergent affective switching. All had failed at least two prior treatments for depression, were currently on at least one mood stabilizer and off antidepressants. Stimulation parameters targeted left dorsolateral prefrontal cortex: 120% motor threshold, 10 pulses per second (pps) × 4s, intertrain interval (ITI) 26s, 75 trains (37.5 min/session) for 3,000 pps total, 5 sessions/week for 30 total treatments, or until remission criteria were met. RESULTS A total of 44 patients with BD were identified, representing 15% of the total TMS population. 77% of those who completed a course of TMS met response criteria, and 41% of subjects who completed at least 25 treatments met remission criteria. Subjects with BD1 were more likely to respond, remit, or suffer an adverse event than those with BD2. No patient met clinical criteria for a manic/mixed episode, but four (10%) discontinued due to concerns of activation. CONCLUSIONS TMS is effective in the bipolar depressed population where episode focused intervention can be specifically offered. Risk of psychomotor agitation must be closely monitored.
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Affiliation(s)
- Eric L Goldwaser
- Department of Psychiatry, University of Maryland Medical Center and Sheppard Pratt Health System, Baltimore, Maryland, USA
| | - Kathy Daddario
- Clinical Research, Sheppard Pratt Health System, Baltimore, Maryland, USA
| | - Scott T Aaronson
- Clinical Research, Sheppard Pratt Health System, Baltimore, Maryland, USA
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Cuéllar-Barboza AB, McElroy SL, Veldic M, Singh B, Kung S, Romo-Nava F, Nunez NA, Cabello-Arreola A, Coombes BJ, Prieto M, Betcher HK, Moore KM, Winham SJ, Biernacka JM, Frye MA. Potential pharmacogenomic targets in bipolar disorder: considerations for current testing and the development of decision support tools to individualize treatment selection. Int J Bipolar Disord 2020; 8:23. [PMID: 32632502 PMCID: PMC7338319 DOI: 10.1186/s40345-020-00184-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 03/07/2020] [Indexed: 12/13/2022] Open
Abstract
Background Treatment in bipolar disorder (BD) is commonly applied as a multimodal therapy based on decision algorithms that lack an integrative understanding of molecular mechanisms or a biomarker associated clinical outcome measure. Pharmacogenetics/genomics study the individual genetic variation associated with drug response. This selective review of pharmacogenomics and pharmacogenomic testing (PGT) in BD will focus on candidate genes and genome wide association studies of pharmacokinetic drug metabolism and pharmacodynamic drug response/adverse event, and the potential role of decision support tools that incorporate multiple genotype/phenotype drug recommendations. Main body We searched PubMed from January 2013 to May 2019, to identify studies reporting on BD and pharmacogenetics, pharmacogenomics and PGT. Studies were selected considering their contribution to the field. We summarize our findings in: targeted candidate genes of pharmacokinetic and pharmacodynamic pathways, genome-wide association studies and, PGT platforms, related to BD treatment. This field has grown from studies of metabolizing enzymes (i.e., pharmacokinetics) and drug transporters (i.e., pharmacodynamics), to untargeted investigations across the entire genome with the potential to merge genomic data with additional biological information. Conclusions The complexity of BD genetics and, the heterogeneity in BD drug-related phenotypes, are important considerations for the design and interpretation of BD PGT. The clinical applicability of PGT in psychiatry is in its infancy and is far from reaching the robust impact it has in other medical disciplines. Nonetheless, promising findings are discovered with increasing frequency with remarkable relevance in neuroscience, pharmacology and biology.
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Affiliation(s)
- Alfredo B Cuéllar-Barboza
- Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.,Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Susan L McElroy
- Lindner Center of HOPE and Department of Psychiatry, University of Cincinnati, Cincinnati, OH, USA
| | - Marin Veldic
- Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Balwinder Singh
- Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Simon Kung
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Francisco Romo-Nava
- Lindner Center of HOPE and Department of Psychiatry, University of Cincinnati, Cincinnati, OH, USA
| | - Nicolas A Nunez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Alejandra Cabello-Arreola
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Miguel Prieto
- Department of Psychiatry, Universidad de los Andes, Santiago, Chile
| | - Hannah K Betcher
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Katherine M Moore
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Stacey J Winham
- Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Joanna M Biernacka
- Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico.,Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Mark A Frye
- Department of Psychiatry, University Hospital, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico. .,Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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O'Donovan C, Alda M. Depression Preceding Diagnosis of Bipolar Disorder. Front Psychiatry 2020; 11:500. [PMID: 32595530 PMCID: PMC7300293 DOI: 10.3389/fpsyt.2020.00500] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022] Open
Abstract
This paper focuses on depression that precedes an onset of manifest bipolar disorder as early stage bipolar disorder. First, we review how to pragmatically identify the clinical characteristics of patients presenting with an episode of depression who subsequently go on to develop episodes of mania or hypomania. The existing literature shows a strong consensus: accurate identification of depression with early onset and recurrent course with multiple episodes, subthreshold hypomanic and/or mixed symptoms, and family history of bipolar disorder or completed suicide have been shown by multiple authors as signs pointing to bipolar diagnosis. This contrasts with relatively limited information available to guide management of such "pre-bipolar" (pre-declared bipolar) patients, especially those in the adult age range. Default assumption of unipolar depression at this stage carries significant risk. Antidepressants are still the most common pharmacological treatment used, but clinicians need to be aware of their potential harm. In some patients with unrecognized bipolar depression, antidepressants can not only produce switch to (hypo)mania, but also mixed symptoms, or worsening of depression with an increased risk of suicide. We review pragmatic management strategies in the literature beyond clinical guidelines that can be considered for this at-risk group encompassing the more recent child and adolescent literature. In the future, genetic research could make the early identification of bipolar depression easier by generating informative markers and polygenic risk scores.
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Affiliation(s)
| | - Martin Alda
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
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13
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Grover S, Chakrabarti S, Sahoo S. Prevalence and clinical correlates of residual symptoms in remitted patients with bipolar disorder: An exploratory study. Indian J Psychiatry 2020; 62:295-305. [PMID: 32773873 PMCID: PMC7368443 DOI: 10.4103/psychiatry.indianjpsychiatry_760_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/30/2020] [Accepted: 04/10/2020] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE This cross-sectional study aimed to evaluate the prevalence and factors associated with residual symptoms (both depressive and manic) in subjects with bipolar disorder (BD). MATERIALS AND METHODS A total of 844 subjects diagnosed BD with an illness of 2 years' duration and minimum of two lifetime episodes and in clinical remission were evaluated for residual symptoms using Hamilton Depression Rating Scale (HAM-D) and Young Mania Rating Scale (YMRS). Based on the severity of residual symptoms, the study groups were divided into four groups. RESULTS Sixty-nine percent of the subjects had residual depressive symptoms (i.e., HAM-D score in the range of 1-7) and 59% had residual manic symptoms (i.e., YMRS score in the range of 1-7). The most common residual depressive symptom was psychic anxiety (34%) followed by impaired insight (29%). The most common manic symptom was poor insight (31%) followed by sleep disturbances (25%). Subjects with both sets of residual symptoms had onset of BD at a relatively young age, when compared to those with only residual depressive symptoms. Presence of any comorbid physical illness and substance abuse disorder was significantly higher in those with both sets of residual symptoms. CONCLUSIONS The present study suggests that a substantial proportion of patients with BD have residual symptoms of both types. Comorbid physical illness and substance use were associated with residual symptoms. Identification and management of residual symptoms are highly essential to improve the overall outcome of patients with BD.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Swapnajeet Sahoo
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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14
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Abstract
PURPOSE OF REVIEW Mixed presentations in bipolar disorder have long posed clinical and nosological challenges. The DSM-5 mixed features specifier was developed to provide a more flexible and clinically relevant definition of mixed presentations compared with narrowly defined DSM-IV mixed episodes. However, there is little guidance on treating such presentations. Here, we summarize the evidence for biological treatments of DSM-5 and similarly defined mixed features (MFs). RECENT FINDINGS The literature on treating MFs is almost exclusively based on post hoc analyses. Within this limited evidence base is preliminary positive data for aripiprazole, asenapine, cariprazine, olanzapine, risperidone, and ziprasidone in treating acute mania with MFs, and cariprazine, lurasidone, olanzapine, and ziprasidone for depressive symptoms in depression with MFs. Divalproex may also be efficacious for acute mania with MFs. The few extant maintenance studies suggest that divalproex and olanzapine may have long-term efficacy in those with index MFs or for the prevention of MFs, respectively. The existing evidence suggests that clinicians consider atypical antipsychotics and divalproex for treating acute mixed presentations. However, adequately powered treatment trials-and studies of maintenance and neurostimulation therapies-are needed. Additionally, data-driven techniques to identify relevant symptom clusters may help improve our conceptualization of mixed presentations.
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Affiliation(s)
- Trisha Chakrabarty
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada
| | - Kamyar Keramatian
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada
| | - Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada.
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15
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Abstract
Objective: We reviewed important clinical aspects of bipolar depression, a progressive psychiatric condition that is commonly treated in primary care. Bipolar depression is associated with considerable burden of illness, high suicide risk, and greater morbidity and mortality than bipolar mania. Methods: We identified articles relevant to our narrative review using a multistep search of the literature and applying terms that were relevant to bipolar depression or bipolar disorder. Results: Bipolar depression accounts for the majority of time spent unwell for patients with bipolar disorder; high rates of morbidity and mortality arise from full symptomatic episodes and interepisode subsyndromal symptoms. Bipolar depression is an important contributor to long-term dysfunction for patients with bipolar disorder due to psychosocial impairment, loss of work productivity and high rates of substance abuse. Missed and delayed diagnosis is prevalent due to overlapping symptoms with unipolar depression and other diagnoses. Medical comorbidities (i.e. cardiovascular disease, hypertension, obesity, metabolic syndrome) and psychiatric comorbidities (i.e. anxiety disorder, personality disorder, eating disorder, attention-deficit/hyperactivity disorder) are common. Currently, only three treatments are FDA-approved for bipolar depression; monotherapy antidepressants are not a recommended treatment option. Conclusions: Bipolar disorder is common among primary care patients presenting with depression; it is often treated exclusively in primary care. Clinicians should be alert for symptoms of bipolar disorder in undiagnosed patients, know what symptoms probabilistically suggest bipolar versus unipolar depression, have expertise in providing ongoing treatment to diagnosed patients, and be knowledgeable about managing common medication-related side effects and comorbidities. Prompt and accurate diagnosis is critical.
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Affiliation(s)
- Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network , Toronto , Canada
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16
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Takeshima M. Early recognition and appropriate pharmacotherapy for mixed depression: the key to resolving complex or treatment-refractory clinical cases. ACTA ACUST UNITED AC 2019. [DOI: 10.5234/cnpt.10.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Minoru Takeshima
- Meishinkai Shibata Hospital, Takaoka City, Japan
- Department of Psychiatry, Tokyo Medical University, Tokyo, Japan
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17
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Goldberg JF. Personalized Pharmacotherapy for Bipolar Disorder: How to Tailor Findings From Randomized Trials to Individual Patient-Level Outcomes. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2019; 17:206-217. [PMID: 32047366 PMCID: PMC6999206 DOI: 10.1176/appi.focus.20190005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The quest for "personalized medicine" in psychiatry has focused mainly on pursuing potential biomarkers such as pharmacogenetic predictors of drug response. However, the collective randomized trial database across phases of bipolar disorder allows one to identify clinical characteristics that inform the likelihood of desired treatment outcomes. In turn, those characteristics, termed moderators and mediators of drug response, enable those who administer treatment to construct clinical profiles that can help them tailor pharmacotherapies to the features of a given patient rather than simply to an overall diagnosis. Bipolar disorder typically involves more heterogeneous than uniform clinical presentations, partly because of its highly prevalent psychiatric and medical comorbid conditions. Further clinical diversity arises from characteristics such as bipolar I versus II disorder subtype, rapid cycling, mixed versus pure affective episodes, psychosis, anxiety, chronicity, cognitive dysfunction, and suicidality, among other distinguishing features. By coupling such profiles with an awareness of the psychotropic breadth of spectrum held by particular medications, clinicians can devise strategic combination therapy regimens, capitalizing on synergies and using drugs that exert multiple relevant effects, addressing comorbid conditions, incorporating medications that could offset adverse effects of other agents, and avoiding or deprescribing medication options that lack known evidence to target symptoms within the clinical profile of a given patient.
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Affiliation(s)
- Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City
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18
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Martinotti G, Montemitro C, Pettorruso M, Viceconte D, Alessi MC, Di Carlo F, Lucidi L, Picutti E, Santacroce R, Di Giannantonio M. Augmenting pharmacotherapy with neuromodulation techniques for the treatment of bipolar disorder: a focus on the effects of mood stabilizers on cortical excitability. Expert Opin Pharmacother 2019; 20:1575-1588. [PMID: 31150304 DOI: 10.1080/14656566.2019.1622092] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Mood stabilizers and antipsychotics have been demonstrated to be effective in Bipolar Disorder, with lithium as the gold standard. However, the presence of adverse events and treatment-resistance is still a relevant issue. To this respect, the use of brain stimulation techniques may be considered as an augmentation strategy, with both Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS) having shown some level of efficacy in bipolar patients although clinical trials are still not sufficient to draw any conclusion. Areas covered: The authors have conducted a systematic review of the literature, in order to evaluate the role of mood stabilizers on neural activity and cortical excitability. Furthermore, the article reviews neuromodulation techniques and highlights the potential of integrating pharmacological first-line therapies with these techniques to treat BD patients. Expert opinion: The combination of neuromodulation techniques and available pharmacotherapies is a valuable opportunity which is not undermined by specific effects on cortical excitability and could improve BD patient outcome. Neurostimulation techniques may be considered safer than antidepressant treatments in BD, with a lower level of manic switches and may represent a new treatment strategy in BD depressive episodes.
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Affiliation(s)
- G Martinotti
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" of Chieti , Chieti , Italy.,Department of Pharmacy, Pharmacology, Clinical Science, University of Hertfordshire , Herts , UK
| | - C Montemitro
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" of Chieti , Chieti , Italy
| | - M Pettorruso
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" of Chieti , Chieti , Italy
| | - D Viceconte
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" of Chieti , Chieti , Italy
| | - M C Alessi
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" of Chieti , Chieti , Italy
| | - F Di Carlo
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" of Chieti , Chieti , Italy
| | - L Lucidi
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" of Chieti , Chieti , Italy
| | - E Picutti
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" of Chieti , Chieti , Italy
| | - R Santacroce
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" of Chieti , Chieti , Italy
| | - M Di Giannantonio
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio" of Chieti , Chieti , Italy
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19
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Abstract
Our current conceptualisation of mixed states, defined as co-occurring manic and depressive symptoms, is unlikely to advance our knowledge or inform clinical practice. Episodes of mixed states can no longer be coded in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the 'mixed features specifier' fails to capture the most common mixed state presentations. This reflects a lack of understanding of both the importance of mixed states and their underlying pathophysiology. Indeed, research into the nature of mixed states is scarce and uninformative, and most clinical practice guidelines fail to provide advice regarding their management. In this paper, we proffer a reconceptualisation of mixed states that provides a framework for informing clinical practice and research. It is based on the ACE model, which deconstructs mood disorders into three domains of symptoms: activity, cognition, and emotion. Symptoms within each domain vary independently over time and in different directions (towards either excitation or inhibition). By deconstructing mood disorders into component domains, mixed states can be explained as the product of different domains varying 'out of sync'. In most cases, the aetiology of mixed states is unknown. Alongside such idiopathic mixed states, we describe three potential causes of mixed states that are important to consider when formulating management: transitions, ultradian cycling, and treatment-emergent affective switches. In addition to providing guidance on the identification of various kinds of mixed states, we discuss practical strategies for their management, including the monitoring of ACE domains and functioning, to inform the use of psychoeducation and lifestyle changes, psychotherapy, pharmacology, and electroconvulsive therapy.
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Affiliation(s)
- Gin S Malhi
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, 2000, Australia.
- Department of Academic Psychiatry, Northern Syndey Local Health District, St Leonards, NSW, 2065, Australia.
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.
| | - Kristina Fritz
- Department of Psychology, California State University, Northridge, CA, USA
| | - Preeya Elangovan
- Department of Academic Psychiatry, Northern Syndey Local Health District, St Leonards, NSW, 2065, Australia
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Lauren Irwin
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, 2000, Australia
- Department of Academic Psychiatry, Northern Syndey Local Health District, St Leonards, NSW, 2065, Australia
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
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20
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Hooshmand F, Do D, Shah S, Gershon A, Park DY, Yuen LD, Dell'Osso B, Wang PW, Miller S, Ketter TA. Antidepressants have complex associations with longitudinal depressive burden in bipolar disorder. J Affect Disord 2019; 246:836-842. [PMID: 30795488 DOI: 10.1016/j.jad.2018.12.074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/12/2018] [Accepted: 12/23/2018] [Indexed: 10/27/2022]
Abstract
AIMS Antidepressants are common in bipolar disorder (BD), but controversial due to questionable efficacy/tolerability. We assessed baseline antidepressant use/depression associations in BD. METHODS Stanford BD Clinic outpatients, enrolled during 2000-2011, assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, were monitored up to two years with the STEP-BD Clinical Monitoring Form while receiving naturalistic expert treatment. Prevalence/correlates of baseline antidepressant use in recovered (euthymic ≥8 weeks)/depressed patients were assessed. Kaplan-Meier survival analyses assessed times to depressive recurrence/recovery in patients with/without baseline antidepressant use, and Cox Proportional Hazard regression analyses assessed covariate effects. RESULTS Baseline antidepressant use was significantly (albeit without Bonferroni multiple comparison correction) less among 105 recovered (31.4%) versus 153 depressed (44.4%) patients, and among recovered patients (again without Bonferroni correction), associated with Caucasian race, earlier onset, worse Clinical Global Impression scores, and hastened depressive recurrence (only if mood elevation episodes were not censored), driven by lifetime anxiety disorder, and more (even with Bonferroni correction) bipolar II disorder, lifetime anxiety and eating disorders, and core psychotropics. Baseline antidepressant use among depressed patients was associated with significantly (again without Bonferroni correction) older age, female gender, and more (even with Bonferroni correction) anxiolytics/hypnotics, complex pharmacotherapy, and core psychotropics, but no other unfavorable illness characteristic/current mood symptom, and not time to depressive recovery. LIMITATIONS Tertiary BD clinic referral sample receiving open naturalistic expert treatment. Analyses without/with Bonferroni correction. CONCLUSIONS Additional research is required to assess the complex associations between baseline antidepressant use and longitudinal depressive burden in BD.
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Affiliation(s)
- Farnaz Hooshmand
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Dennis Do
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Saloni Shah
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Anda Gershon
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Dong Yeon Park
- Department of Psychiatry, Seoul National Hospital, Seoul, South Korea
| | - Laura D Yuen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Bernardo Dell'Osso
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA; Department of Psychiatry, University of Milan, Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Po W Wang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Shefali Miller
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA.
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21
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Bruschi A, Mazza M, Camardese G, Calò S, Palumbo C, Mandelli L, Callea A, Gori A, Di Nicola M, Marano G, Berk M, di Sciascio G, Janiri L. Psychopathological Features of Bipolar Depression: Italian Validation of the Bipolar Depression Rating Scale (I-BDRS). Front Psychol 2018; 9:1047. [PMID: 29977223 PMCID: PMC6022061 DOI: 10.3389/fpsyg.2018.01047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 06/04/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Aim of the study was the validation of the Bipolar Disorder Rating Scale (BDRS) in an Italian population. Secondary aim was the evaluation of differences between unipolar and bipolar depression and between bipolar I and II depressed patients. Method: 125 Bipolar Disorder and 60 Major Depressive Disorder patients were administered an Italian translation of the BDRS (I-BDRS), Hamilton Depression Rating Scale (HDRS), Montgomery-Asberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS) and Temperament and Character Inventory-Revised (TCI-R). Results: I-BDRS showed considerable validity and reliability. Factor analysis found 3 subscales, two linked to depressive symptoms and one to mixed symptoms. Measures concerning depression (MADRS and HAM-D) were positively related to the I-BDRS's subscales, but mostly to the two subscales measuring depression. In mixed symptoms, the mean of the bipolar group was significantly higher than the unipolar group suggesting that the BDRS was able to distinguish between unipolar and bipolar depressed patients. Conclusion: I-BDRS is a valid scale for the measurement of depression in BD patients, with a notable internal consistency (Cronbach's α 0.82), a significant consistency between items/total (Cronbach's α from 0.80 to 0.82) and positive correlation with other scales (MADRS r = 0.67, p < 0.001; HDRS r = 0.81, p < 0.001; YMRS r = 0.46 p < 0.0001). The mixed state sub-scale shows usefulness in differentiating bipolar from unipolar patients. I-BDRS could be a sensitive tool, both in pure depression and in mixed states, and could be used in the everyday screening and treatment of Bipolar Disorder.
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Affiliation(s)
- Angelo Bruschi
- Institute of Psychiatry and Psychology, Department of Geriatrics, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Rome, Italy.,Istituto di Psicopatologia, Rome, Italy.,Department of Mental Health, ASL Viterbo, Rome, Italy
| | - Marianna Mazza
- Institute of Psychiatry and Psychology, Department of Geriatrics, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Rome, Italy
| | - Giovanni Camardese
- Institute of Psychiatry and Psychology, Department of Geriatrics, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Rome, Italy
| | - Salvatore Calò
- Department of Psychiatry, Policlinico Hospital Bari, Bari, Italy.,Department of Mental Health, ASL Lecce, Lecce, Italy
| | - Claudia Palumbo
- Department of Psychiatry, Policlinico Hospital Bari, Bari, Italy.,Esine Hospital, ASST Valcamonica, Esine, Italy
| | - Laura Mandelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | | | - Alessio Gori
- Department of Human Science, LUMSA University, Rome, Italy.,Department of Education and Psychology, University of Florence, Florence, Italy
| | - Marco Di Nicola
- Institute of Psychiatry and Psychology, Department of Geriatrics, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Rome, Italy
| | - Giuseppe Marano
- Institute of Psychiatry and Psychology, Department of Geriatrics, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Rome, Italy
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia.,Orygen Youth Health Research Centre, Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | | | - Luigi Janiri
- Institute of Psychiatry and Psychology, Department of Geriatrics, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Rome, Italy
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22
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McIntyre RS, Young AH, Haddad PM. Rethinking the spectrum of mood disorders: implications for diagnosis and management - Proceedings of a symposium presented at the 30th Annual European College of Neuropsychopharmacology Congress, 4 September 2017, Paris, France. Ther Adv Psychopharmacol 2018; 8:1-16. [PMID: 29977518 PMCID: PMC6022880 DOI: 10.1177/2045125318762911] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/09/2018] [Indexed: 12/17/2022] Open
Abstract
The simultaneous occurrence of manic and depressive features has been recognized since classical times, but the term 'mixed state' was first used by Kraepelin at the end of the 19th century. From the 1980s, until the advent of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), psychiatric disorders were classified using a categorical approach. However, it was recognized that such an approach was too rigid to encompass the range of symptomatology encountered in clinical practice. Therefore, a dimensional approach was adopted in DSM-5, in which affective states are considered to be distributed across a continuum ranging from pure mania to pure depression. In addition, the copresence of symptoms of the opposite pole are captured using a 'with mixed features' specifier, applied when three or more nonoverlapping subthreshold symptoms of the opposite pole are present. Mixed features are common in patients with mood episodes, complicating the course of illness, reducing treatment response and worsening outcomes. However, research in this area is scarce and treatment options are limited. Current evidence indicates that antidepressants should be avoided for the treatment of bipolar mixed states. Evidence for bipolar mixed states supports the use of several second-generation antipsychotics, valproate and electroconvulsive therapy. One randomized controlled trial has demonstrated the efficacy of lurasidone, compared with placebo, in patients with major depressive disorder with mixed features, and there is limited evidence supporting the use of ziprasidone in such patients. Further research is required to determine whether other antipsychotic agents, or additional therapeutic approaches, might also be effective in this setting.
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Affiliation(s)
- Roger S McIntyre
- UHN-Toronto Western Hospital, Mood Disorders Psychopharmacology Unit, University of Toronto, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
| | - Allan H Young
- Department of Psychological Medicine, King's College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - Peter M Haddad
- Neuroscience and Psychiatry Unit, University of Manchester, Manchester, UK
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23
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Olsufka W, Abraham MA. Treatment-emergent hypomania possibly associated with over-the-counter supplements. Ment Health Clin 2018; 7:160-163. [PMID: 29955516 PMCID: PMC6007531 DOI: 10.9740/mhc.2017.07.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The use of complementary and alternative medicine (CAM) is gaining popularity in the Western world. Among the general public, CAM is often perceived to be associated with less stigma, fewer adverse effects, and may be more affordable. A number of patients utilize CAM for the treatment of depression; however, as there is limited scientific evidence, the safety profile of these supplements are largely unknown. In this case, a 42-year-old man developed hypomania approximately 1 week after S-adenosylmethionine (SAMe) and 5-hydroxytryptophan (5-HTP) therapy was initiated for depression. The combination of SAMe and 5-HTP can potentially induce hypomanic episodes.
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Affiliation(s)
- William Olsufka
- Assistant Professor of Pharmacy Practice, Mount Sinai Beth Israel/Touro College of Pharmacy, New York, New York,
| | - Mary-Ann Abraham
- PGY1 Psychiatric Resident, Mount Sinai Beth Israel, New York, New York
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24
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Shvartzman Y, Krivoy A, Valevski A, Gur S, Weizman A, Hochman E. Adjunctive antidepressants in bipolar depression: A cohort study of six- and twelve-months rehospitalization rates. Eur Neuropsychopharmacol 2018; 28:353-360. [PMID: 29449055 DOI: 10.1016/j.euroneuro.2018.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 12/04/2017] [Accepted: 01/26/2018] [Indexed: 12/16/2022]
Abstract
Although antidepressants (ADs) are widely used in bipolar depression, there is weak evidence for their effectiveness and safety in this condition. Furthermore, there is a paucity of studies on the risk-benefit ratio of AD maintenance treatment in bipolar disorder (BD). We compared rehospitalization rates of patients with BD-I depressive episode who were discharged with mood stabilizers (MSs) and/or atypical antipsychotics (AAPs) with or without adjunctive AD. Ninety-eight patients with BD-I who were hospitalized with a depressive episode between 2005 and 2013 were retrospectively followed for 6-months and 1-year rehospitalization rates, as well as time to rehospitalization, according to treatment at discharge: MSs and/or AAPs with or without AD. Multivariable survival models adjusted for covariates known to influence rehospitalization were conducted. Six-months and 1-year rehospitalization rates were significantly lower in the adjunctive-AD treatment group compared to the no-AD group (9.2% vs. 36.4%, P = .001, power = 0.87 and 12.3% vs. 42.4%, P = .001, power = 0.89, respectively). Time to rehospitalization within 6-months and 1-year was significantly longer in the adjunctive-AD treatment group (169.9 vs 141 days, P = .001 and 335.6 vs 252.3 days, P = .001, respectively). Adjunctive-AD treatment at discharge reduced significantly the adjusted risk of rehospitalization within 6-months (HR = 0.081, 95% CI: 0.016-0.412, P = 0.002) and 1-year (HR = 0.149, 95% CI: 0.041-0.536, P = 0.004). Moreover, adjunctive-AD treatment did not increase rehospitalization rates of manic episode. In conclusion, adjunctive-AD therapy to MS/AAP at discharge from BD-I depressive episode hospitalization is associated with a lower rate of and a longer time to rehospitalization during a 1-year follow up period.
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Affiliation(s)
- Yahav Shvartzman
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Amir Krivoy
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel; Geha Mental Health Center, Petach-Tikva, Israel; Laboratory of Biological Psychiatry, Felsenstein Medical Research Center, Petach-Tikva, Israel
| | - Avi Valevski
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel; Geha Mental Health Center, Petach-Tikva, Israel
| | - Shay Gur
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel; Geha Mental Health Center, Petach-Tikva, Israel
| | - Abraham Weizman
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel; Geha Mental Health Center, Petach-Tikva, Israel; Laboratory of Biological Psychiatry, Felsenstein Medical Research Center, Petach-Tikva, Israel
| | - Eldar Hochman
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel; Geha Mental Health Center, Petach-Tikva, Israel; Laboratory of Biological Psychiatry, Felsenstein Medical Research Center, Petach-Tikva, Israel
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25
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Antidepressants and Mood Stabilizers: Novel Research Avenues and Clinical Insights for Bipolar Depression. Int J Mol Sci 2017; 18:ijms18112406. [PMID: 29137178 PMCID: PMC5713374 DOI: 10.3390/ijms18112406] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/06/2017] [Accepted: 11/09/2017] [Indexed: 12/31/2022] Open
Abstract
The concept of the bipolar-spectrum and of mixed features being a bridge between major depressive disorders and bipolar disorders (BDs) has become increasingly important in mood-disorder diagnoses. Under these circumstances, antidepressants (ADs) and mood stabilizers (MSs) should be used with caution in the treatment of major depressive episodes (MDEs) and to obtain long-term stability in BDs. Before treating MDEs, screening tools, specific symptom evaluation and medical history should be used to distinguish between bipolarity and mixed features in patients for whom AD monotherapy may present a risk. In these patients, a combination of ADs plus MSs or atypical antipsychotics is recommended, rather than AD monotherapy. Studies evaluating MSs for bipolar depression suggest that lamotrigine is the most reliable treatment and lithium has modest effects; there is a lack of clear evidence regarding the efficacy of valproate and carbamazepine. Recently, significant progress has been made with respect to the pathophysiology of mood disorders and the application of potential biomarkers. There is an opportunity to study novel drug mechanisms through the rediscovery of fast-acting drugs such as ketamine. It is anticipated that future research developments will involve the discovery of potential targets for new drugs and their application to personalized treatments.
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26
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Betzler F, Stöver LA, Sterzer P, Köhler S. Mixed states in bipolar disorder - changes in DSM-5 and current treatment recommendations. Int J Psychiatry Clin Pract 2017; 21:244-258. [PMID: 28417647 DOI: 10.1080/13651501.2017.1311921] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Mixed states in affective disorders represent a particular challenge in clinical routine, characterized by a complicated course of treatment and a worse treatment response. METHODS Clinical features of mixed states and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria are presented and critical discussed. We then performed a systematic review using the terms 'bipolar', 'mixed' and 'randomized' to evaluate current treatment options. RESULTS For pharmacological treatment of mixed states in total, there is still insufficient data from RCTs. However, there is some evidence for efficacy in mixed states from RCTs for atypical antipsychotics, especially olanzapine, aripiprazole and asenapine as well as mood stabilizers as valproate and carbamazepine. CONCLUSIONS Mixed states are of a high clinical relevance and the DSM-5 criteria substantially reduced the diagnostic threshold. Besides advantages of a better characterization of patients with former DSM-IV-defined mixed episodes, disadvantages arise for example differential diagnoses with a substantial overlap in symptoms such as borderline personality disorders. Atypical antipsychotics, valproate and carbamazepine demonstrated efficacy in a limited sample of RCTs. LIMITATIONS The number of RCTs in the treatment of mixed states is highly limited. Furthermore, nearly all studies were funded by pharmaceutical companies which may lead to an underestimation of classical mood stabilizers such as lithium.
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Affiliation(s)
- Felix Betzler
- a Department of Psychiatry and Psychotherapy , Clinic for Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin , Campus Mitte , Berlin , Germany
| | - Laura Apollonia Stöver
- a Department of Psychiatry and Psychotherapy , Clinic for Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin , Campus Mitte , Berlin , Germany
| | - Philipp Sterzer
- a Department of Psychiatry and Psychotherapy , Clinic for Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin , Campus Mitte , Berlin , Germany
| | - Stephan Köhler
- a Department of Psychiatry and Psychotherapy , Clinic for Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin , Campus Mitte , Berlin , Germany
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Barbuti M, Pacchiarotti I, Vieta E, Azorin JM, Angst J, Bowden CL, Mosolov S, Young AH, Perugi G. Antidepressant-induced hypomania/mania in patients with major depression: Evidence from the BRIDGE-II-MIX study. J Affect Disord 2017; 219:187-192. [PMID: 28558366 DOI: 10.1016/j.jad.2017.05.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/12/2017] [Accepted: 05/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The issue of antidepressant-induced mood switches to hypomania, mania, or mixed states within the course of mayor depressive disorder (MDD) has been a controversial topic. The present post-hoc analysis of the BRIDGE-II-MIX study focuses on the clinical features of patients with history of antidepressant-induced hypomania/mania (AIHM) in a large international sample of patients with major depressive episode (MDE). METHODS 2811 subjects with major depression were enrolled in this multicentre cross-sectional study. Current mixed symptoms, socio-demographic and other clinical variables were collected and compared among MDD-AIHM, MDD and BD patients. RESULTS 475 patients out of 2811 had history of AIHM (16.90%). In the MDD-AIHM group, familiarity for BD and rates of atypical features and comorbid anxiety, eating and borderline personality disorders were similar to BD and significantly more frequent compared to MDD group. MDD-AIHM patients had more frequently more than 3 episodes and reported higher rates of treatment resistance, mood lability and irritability following treatment with antidepressants. Frequencies of depression with mixed features and (hypo)manic symptoms were similar in patients of MDD-AIHM and BD groups and significantly higher in both groups than in MDD. LIMITATIONS there were widely varying rates of hospitalized patients across countries and the participating centres were not randomly selected. CONCLUSIONS Our results strongly support the DSM-5 inclusion of MDD patients with AIHM within the rubric of bipolar disorder. Differences with other MDD and BD were also observed suggesting the possibility that MDD-AIHM may represent a specific sub-population, particularly sensitive to exogenous input from antidepressants.
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Affiliation(s)
- Margherita Barbuti
- University of Pisa, Pisa, Italy; Barcelona Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Isabella Pacchiarotti
- Barcelona Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Eduard Vieta
- Barcelona Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | | | - Jules Angst
- Psychiatric Hospital, University of Zurich, Switzerland
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Lima AF, Miguel SR, Cohen M, Zimmermann JJ, Shansis FM, Cruz LN, Ziegelmann PK, Polanczyk CA, Fleck MP. Effectiveness evaluation of mood disorder treatment algorithms in Brazilian public healthcare patients. ACTA ACUST UNITED AC 2017; 40:26-34. [PMID: 28832750 PMCID: PMC6899428 DOI: 10.1590/1516-4446-2016-2147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/06/2017] [Indexed: 11/30/2022]
Abstract
Objective: To assess the effectiveness of three mood disorder treatment algorithms in a sample of patients seeking care in the Brazilian public healthcare system. Methods: A randomized pragmatic trial was conducted with an algorithm developed for treating episodes of major depressive disorder (MDD), bipolar depressive episodes and mixed episodes of bipolar disorder (BD). Results: The sample consisted of 259 subjects diagnosed with BD or MDD (DSM-IV-TR). After the onset of symptoms, the first treatment occurred ∼6 years and the use of mood stabilizers began ∼12 years. All proposed algorithms were effective, with response rates around 80%. The majority of the subjects took 20 weeks to obtain a therapeutic response. Conclusions: The algorithms were effective with the medications available through the Brazilian Unified Health System. Because therapeutic response was achieved in most subjects by 20 weeks, a follow-up period longer than 12 weeks may be required to confirm adequate response to treatment. Remission of symptoms is still the main desired outcome. Subjects who achieved remission recovered more rapidly and remained more stable over time. Clinical trial registration: NCT02901249, NCT02870283, NCT02918097
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Affiliation(s)
- Ana F Lima
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Sandro R Miguel
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Mírian Cohen
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Jacques J Zimmermann
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil
| | | | - Luciane N Cruz
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Patrícia K Ziegelmann
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil.,Departamento de Estatística, Instituto de Matemática, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Ciências da Saúde: Cardiologia e Ciências Cardiovasculares, UFRGS, Porto Alegre, RS, Brazil
| | - Carisi A Polanczyk
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Ciências da Saúde: Cardiologia e Ciências Cardiovasculares, UFRGS, Porto Alegre, RS, Brazil
| | - Marcelo P Fleck
- Departamento de Psiquiatria e Medicina Legal, Faculdade de Medicina, UFRGS, Porto Alegre, RS, Brazil
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Diler RS, Goldstein TR, Hafeman D, Rooks BT, Sakolsky D, Goldstein BI, Monk K, Hickey MB, Axelson D, Iyengar S, Birmaher B. Characteristics of depression among offspring at high and low familial risk of bipolar disorder. Bipolar Disord 2017; 19:344-352. [PMID: 28612977 PMCID: PMC5901748 DOI: 10.1111/bdi.12508] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/28/2017] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Having a parent with bipolar disorder (BP) is a very strong risk factor for developing BP. Similarly, depression among youth is a clinical risk factor for subsequent BP. We evaluated whether mood symptomatology in depressed youth is different between those at high and low familial risk to develop BP. METHODS The most severe major depressive episode in BP offspring (N=61) and community control offspring (N=20) was evaluated using expanded depression and mania rating scales derived from the Schedule for Affective Disorders and Schizophrenia for Children Present Version. The results were adjusted for any between-group significant demographic differences and for multiple comparisons. RESULTS The severity of depressive symptoms and the percentage of offspring with severe depressive symptoms, especially atypical depressive features, were significantly higher in the depressed offspring of BP parents compared to the depressed controls (Ps <.05). The depressive symptoms were helpful to identify a high-risk group (e.g., odds ratio [OR] for hypersomnia: 22.4, 95% confidence interval [CI]: 1.3-404, P=.04). In addition, there were significantly more depressed offspring of BP parents with subsyndromal manic symptoms than controls (52.5% vs 20%, OR: 4.2, 95% CI: 1.2-14.7, P<.01). CONCLUSIONS Depressed BP offspring had more severe depression including atypical depressive symptoms, and were more likely to have subsyndromal mixed manic symptoms than depressed control offspring. Prospective studies to evaluate whether these youth are at high risk to develop BP are warranted. If replicated, the results of this study have important clinical (e.g., treatment of depression in depressed offspring of BP parents) and research implications.
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Affiliation(s)
- Rasim Somer Diler
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O’Hara St., Pittsburgh, PA, 15213, USA
| | - Tina R. Goldstein
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O’Hara St., Pittsburgh, PA, 15213, USA
| | - Danella Hafeman
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O’Hara St., Pittsburgh, PA, 15213, USA
| | - Brian Thomas Rooks
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O’Hara St., Pittsburgh, PA, 15213, USA
| | - Dara Sakolsky
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O’Hara St., Pittsburgh, PA, 15213, USA
| | - Benjamin I. Goldstein
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, 2075 Bayview Ave., FG-53, Toronto, ON, M4N-3M5, Canada
| | - Kelly Monk
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O’Hara St., Pittsburgh, PA, 15213, USA
| | - Mary Beth Hickey
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O’Hara St., Pittsburgh, PA, 15213, USA
| | - David Axelson
- Department of Psychiatry, Nationwide Children’s Hospital and The Ohio State College of Medicine, 1670 Upham Dr., Columbus, OH, 43210, USA
| | - Satish Iyengar
- Department of Statistics, University of Pittsburgh, 2717 Cathedral of Learning, Pittsburgh, PA, 15260, USA
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O’Hara St., Pittsburgh, PA, 15213, USA
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Grunebaum MF, Ellis SP, Keilp JG, Moitra VK, Cooper TB, Marver JE, Burke AK, Milak MS, Sublette ME, Oquendo MA, Mann JJ. Ketamine versus midazolam in bipolar depression with suicidal thoughts: A pilot midazolam-controlled randomized clinical trial. Bipolar Disord 2017; 19:176-183. [PMID: 28452409 DOI: 10.1111/bdi.12487] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/12/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To evaluate feasibility and effects of a sub-anesthetic infusion dose of ketamine versus midazolam on suicidal ideation in bipolar depression. Neurocognitive, blood and saliva biomarkers were explored. METHODS Sixteen participants with bipolar depression and a Scale for Suicidal Ideation (SSI) score of ≥4 were randomized to ketamine (0.5 mg/kg) or midazolam (0.02 mg/kg). Current pharmacotherapy was maintained excluding benzodiazepines within 24 hours. The primary clinical outcome was SSI score on day 1 post-infusion. RESULTS Results supported feasibility. Mean reduction of SSI after ketamine infusion was almost 6 points greater than after midazolam, although this was not statistically significant (estimate=5.84, SE=3.01, t=1.94, P=.074, 95% confidence interval ([CI)]=-0.65 to 12.31). The number needed to treat for response (SSI <4 and at least 50% below baseline) was 2.2, and for remission (SSI=0) was 3.2. The strongest neurocognitive correlation was between memory improvement on the Selective Reminding Test (SRT) and reduction in SSI score on day 1 after ketamine (ρ=-.89, P=.007). Pre- to post-infusion decrease in serum brain derived neurotrophic factor (BDNF) correlated with reduction in SSI from baseline to day 1 after ketamine (n=5, ρ=0.90, P=.037) but not midazolam (P=.087). CONCLUSIONS The study demonstrated feasibility. Suicidal thoughts were lower after ketamine than after midazolam at a trend level of significance, likely due to the small pilot sample. Memory improvement and BDNF are promising biomarkers. Replication is needed in an adequately powered full-scale trial.
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Affiliation(s)
- Michael F Grunebaum
- Molecular Imaging and Neuropathology Division, Department of Psychiatry, Columbia University Medical Center (CUMC) and New York State Psychiatric Institute, New York, NY, USA
| | - Steven P Ellis
- Molecular Imaging and Neuropathology Division, Department of Psychiatry, Columbia University Medical Center (CUMC) and New York State Psychiatric Institute, New York, NY, USA
| | - John G Keilp
- Molecular Imaging and Neuropathology Division, Department of Psychiatry, Columbia University Medical Center (CUMC) and New York State Psychiatric Institute, New York, NY, USA
| | | | - Thomas B Cooper
- Analytical Psychopharmacology Laboratory, Nathan Kline Institute, Research Foundation for Mental Hygiene of New York State, Orangeburg, NY, USA
| | - Julia E Marver
- Molecular Imaging and Neuropathology Division, Department of Psychiatry, Columbia University Medical Center (CUMC) and New York State Psychiatric Institute, New York, NY, USA
| | - Ainsley K Burke
- Molecular Imaging and Neuropathology Division, Department of Psychiatry, Columbia University Medical Center (CUMC) and New York State Psychiatric Institute, New York, NY, USA
| | - Matthew S Milak
- Molecular Imaging and Neuropathology Division, Department of Psychiatry, Columbia University Medical Center (CUMC) and New York State Psychiatric Institute, New York, NY, USA
| | - M Elizabeth Sublette
- Molecular Imaging and Neuropathology Division, Department of Psychiatry, Columbia University Medical Center (CUMC) and New York State Psychiatric Institute, New York, NY, USA
| | - Maria A Oquendo
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - J John Mann
- Molecular Imaging and Neuropathology Division, Department of Psychiatry, Columbia University Medical Center (CUMC) and New York State Psychiatric Institute, New York, NY, USA
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What is the role of conventional antidepressants in the treatment of major depressive episodes with Mixed Features Specifier? CNS Spectr 2017; 22:120-125. [PMID: 27831463 DOI: 10.1017/s1092852916000493] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The newly introduced Mixed Features Specifier of Major Depressive Episode and Disorder (MDE/MDD) is especially challenging in terms of pharmacological management. Prior to the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the symptoms of the mixed features specifier were intradepressive hypomanic symptoms, always and only associated with bipolar disorder (BD). Intradepressive hypomanic symptoms, mostly referred to as depressive mixed states (DMX), have been poorly characterized, and their treatment offers significant challenges. To understand the diagnostic context of DMX, we trace the nosological changes and collocation of intradepressive hypomanic symptoms, and examine diagnostic and prognostic implications of such mixed features. One of the reasons so little is known about the treatment of DMX is that depressed patients with rapid cycling, substance abuse disorder, and suicidal ideation/attempts are routinely excluded from clinical trials of antidepressants. The exclusion of DMX patients from clinical trials has prevented an assessment of the safety and tolerability of short- and long-term use of antidepressants. Therefore, the generalization of data obtained in clinical trials for unipolar depression to patients with intradepressive hypomanic features is inappropriate and methodologically flawed. A selective review of the literature shows that antidepressants alone have limited efficacy in DMX, but they have the potential to induce, maintain, or worsen mixed features during depressive episodes in BD. On the other hand, preliminary evidence supports the effective use of some atypical antipsychotics in the treatment of DMX.
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Abstract
Mixed states address the relationships between episodes and the course of an illness, presenting significant clinical challenges. Recurrent affective disorders were described thousands of years ago as dimensional disturbances of the basic elements of behavior, combining the characteristics of what we would now consider manic and depressive episodes. It was recognized from the beginning that combinations of depressive and manic features are associated with a severe illness course, including increased suicide risk. Early descriptions of affective disorders formulated them as systemic illnesses, a concept supported by more recent data. Descriptions of affective disorders and their course, including mixed states, became more systematic during the 19th century. Structured criteria achieved importance with evidence that, in addition to early onset, frequent recurrence, and comorbid problems, mixed states had worse treatment outcomes than other episodes. In contrast to 2000 years of literature on recurrent affective episodes and mixed states, the unipolar-bipolar disorder distinction was formalized in the mid-20th century. Mixed-state criteria, initially developed for bipolar disorder, ranged from fully combined depression and mania to the DSM-5 criteria, no longer limited to bipolar disorder, of a primary depressive or manic episode with at least three symptoms of the other episode type. The challenges involved in understanding and identifying mixed states center largely on what drives them, including (1) their formulation as either categorical or dimensional constructs, (2) the specificity of their relationships to depressive or manic episodes, and (3) specificity for bipolar versus major depressive disorder. Their existence challenges the distinction between bipolar and major depressive disorders. The challenges involved in identifying the underlying physiological mechanisms go to the heart of these questions.
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Remission and recovery associated with lurasidone in the treatment of major depressive disorder with subthreshold hypomanic symptoms (mixed features): post-hoc analysis of a randomized, placebo-controlled study with longer-term extension. CNS Spectr 2017; 22:220-227. [PMID: 28264739 DOI: 10.1017/s1092852917000025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE This post-hoc analysis assessed rates of symptomatic and functional remission, as well as recovery (combination of symptomatic and functional remission), in patients treated with lurasidone for major depressive disorder (MDD) associated with subthreshold hypomanic symptoms (mixed features). METHOD Patients with MDD plus two or three manic symptoms (defined as per the DSM-5 mixed-features specifier) were randomly assigned to flexible-dose lurasidone 20-60 mg/day (n=109) or placebo (n=100) for 6 weeks, followed by a 3-month open-label, flexible-dose extension study for U.S. sites only (n=48). Cross-sectional recovery was defined as the presence of both symptomatic remission (Montgomery-Åsberg Depression Rating Scale score ≤ 12) and functional remission (all Sheehan Disability Scale [SDS] domain scores ≤3) at week 6, and at both months 1 and 3 of the extension study ("sustained recovery"). RESULTS A significantly higher proportion of lurasidone-treated patients (31.3%) achieved recovery (assessed cross-sectionally) compared to placebo (12.2%, p=0.002) at week 6. The number of manic symptoms at baseline moderated the effect size for attaining cross-sectional recovery for lurasidone treatment (vs. placebo) (p=0.028). Sustained recovery rates were higher in patients initially treated with lurasidone (20.8%) versus placebo (12.5%). CONCLUSIONS In this post-hoc analysis of a placebo-controlled study with open-label extension that involved patients with MDD and mixed features, lurasidone was found to significantly improve the rate of recovery at 6 weeks (vs. placebo) that was sustained at month 3 of the extension study. The presence of two (as opposed to three) manic symptoms moderated recovery at the acute study endpoint.
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Clinical Use of Mood Stabilizers With Antidepressants in Asia: Report From the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD) Projects in 2004 and 2013. J Clin Psychopharmacol 2017; 37:255-259. [PMID: 28146001 DOI: 10.1097/jcp.0000000000000670] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE As most reports concerning treatment with combinations of mood stabilizer (MS) with antidepressant (AD) drugs are based in the West, we surveyed characteristics of such cotreatment in 42 sites caring for the mentally ill in 10 Asian countries. METHODS This cross-sectional, pharmacoepidemiologic study used 2004 and 2013 data from the REAP-AD (Research Study on Asian Psychotropic Prescription Patterns for Antidepressants) to evaluate the rates and doses of MSs given with ADs and associated factors in 4164 psychiatric patients, using standard bivariate methods followed by multivariable logistic regression modeling. RESULTS Use of MS + AD increased by 104% (5.5% to 11.2%) between 2004 and 2013 and was much more associated with diagnosis of bipolar disorder than major depression or anxiety disorder, as well as with hospitalization > outpatient care, psychiatric > general-medical programs, and young age (all P < 0.001), but not with country, sex, or AD dose. CONCLUSIONS The findings provide a broad picture of contemporary use of MSs with ADs in Asia, support predictions that such treatment increased in recent years, and was associated with diagnosis of bipolar disorder, treatment in inpatient and psychiatric settings, and younger age.
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Abstract
During the past two decades, a number of studies have found that depressed patients frequently have manic symptoms intermixed with depressive symptoms. While the frequency of mixed syndromes are more common in bipolar than in unipolar depressives, mixed states are also common in patients with major depressive disorder. The admixture of symptoms may be evident when depressed patients present for treatment, or they may emerge during ongoing treatment. In some patients, treatment with antidepressant medication might precipitate the emergence of mixed states. It would therefore be useful to systematically inquire into the presence of manic/hypomanic symptoms in depressed patients. We can anticipate that increased attention will likely be given to mixed depression because of changes in the DSM-5. In the present article, I review instruments that have been utilized to assess the presence and severity of manic symptoms and therefore could be potentially used to identify the DSM-5 mixed-features specifier in depressed patients and to evaluate the course and outcome of treatment. In choosing which measure to use, clinicians and researchers should consider whether the measure assesses both depression and mania/hypomania, assesses all or only some of the DSM-5 criteria for the mixed-features specifier, or assesses manic/hypomanic symptoms that are not part of the DSM-5 definition. Feasibility, more so than reliability and validity, will likely determine whether these measures are incorporated into routine clinical practice.
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Abstract
A significant minority of people presenting with a major depressive episode (MDE) experience co-occurring subsyndromal hypo/manic symptoms. As this presentation may have important prognostic and treatment implications, the DSM-5 codified a new nosological entity, the "mixed features specifier," referring to individuals meeting threshold criteria for an MDE and subthreshold symptoms of (hypo)mania or to individuals with syndromal mania and subthreshold depressive symptoms. The mixed features specifier adds to a growing list of monikers that have been put forward to describe phenotypes characterized by the admixture of depressive and hypomanic symptoms (e.g., mixed depression, depression with mixed features, or depressive mixed states [DMX]). Current treatment guidelines, regulatory approvals, as well the current evidentiary base provide insufficient decision support to practitioners who provide care to individuals presenting with an MDE with mixed features. In addition, all existing psychotropic agents evaluated in mixed patients have largely been confined to patient populations meeting the DSM-IV definition of "mixed states" wherein the co-occurrence of threshold-level mania and threshold-level MDE was required. Toward the aim of assisting clinicians providing care to adults with MDE and mixed features, we have assembled a panel of experts on mood disorders to develop these guidelines on the recognition and treatment of mixed depression, based on the few studies that have focused specifically on DMX as well as decades of cumulated clinical experience.
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Kim H, Kim W, Citrome L, Akiskal HS, Goffin KC, Miller S, Holtzman JN, Hooshmand F, Wang PW, Hill SJ, Ketter TA. More inclusive bipolar mixed depression definition by permitting overlapping and non-overlapping mood elevation symptoms. Acta Psychiatr Scand 2016; 134:199-206. [PMID: 27137894 DOI: 10.1111/acps.12580] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this study was to assess the strengths and limitations of a mixed bipolar depression definition made more inclusive than that of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) by counting not only 'non-overlapping' mood elevation symptoms (NOMES) as in DSM-5, but also 'overlapping' mood elevation symptoms (OMES, psychomotor agitation, distractibility, and irritability). METHODS Among bipolar disorder (BD) out-patients assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, we assessed prevalence, demographics, and clinical correlates of mixed vs. pure depression, using more inclusive (≥3 NOMES/OMES) and less inclusive DSM-5 (≥3 NOMES) definitions. RESULTS Among 153 depressed BD, counting not only NOMES but also OMES yielded a three-fold higher mixed depression rate (22.9% vs. 7.2%) and important statistically significant clinical correlates for mixed compared to pure depression (more lifetime anxiety disorder comorbidity, more current irritability, and less current antidepressant use), which were not significant using the DSM-5 threshold. CONCLUSION To conclude, further studies with larger numbers of patients with DSM-5 bipolar mixed depression assessing strengths and limitations of more inclusive mixed depression definitions are warranted, including efforts to ascertain whether or not OMES should count toward mixed depression.
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Affiliation(s)
- H Kim
- Department of Psychiatry, Ilsan Paik Hospital, Inje University School of Medicine, Goyang, South Korea
| | - W Kim
- Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine, Seoul, South Korea
| | - L Citrome
- New York Medical College, Valhalla, NY, USA
| | - H S Akiskal
- International Mood Centre, University of California and Veterans Administration Hospital, San Diego, CA, USA
| | - K C Goffin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S Miller
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - J N Holtzman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - F Hooshmand
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - P W Wang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S J Hill
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - T A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Kim W, Kim H, Citrome L, Akiskal HS, Goffin KC, Miller S, Holtzman JN, Hooshmand F, Wang PW, Hill SJ, Ketter TA. More inclusive bipolar mixed depression definitions by requiring fewer non-overlapping mood elevation symptoms. Acta Psychiatr Scand 2016; 134:189-98. [PMID: 26989836 DOI: 10.1111/acps.12563] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Assess strengths and limitations of mixed bipolar depression definitions made more inclusive than that of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) by requiring fewer than three 'non-overlapping' mood elevation symptoms (NOMES). METHOD Among bipolar disorder (BD) out-patients assessed with Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, we assessed prevalence, demographics, and clinical correlates of mixed vs. pure depression, using less inclusive (≥3 NOMES, DSM-5), more inclusive (≥2 NOMES), and most inclusive (≥1 NOMES) definitions. RESULTS Among 153 depressed BD, compared to less inclusive DSM-5 threshold, our more and most inclusive thresholds, yielded approximately two- and five-fold higher mixed depression rates (7.2%, 15.0%, and 34.6% respectively), and important statistically significant clinical correlates for mixed compared to pure depression (e.g. more lifetime anxiety disorder comorbidity, more current irritability), which were not significant using the DSM-5 threshold. CONCLUSION Further studies assessing strengths and limitations of more inclusive mixed depression definitions are warranted, including assessing the extent to which enhanced statistical power vs. other factors contributes to more vs. less inclusive mixed bipolar depression thresholds having more statistically significant clinical correlates, and whether 'overlapping' mood elevation symptoms should be counted.
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Affiliation(s)
- W Kim
- Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine, Seoul, South Korea
| | - H Kim
- Department of Psychiatry, Ilsan Paik Hospital, Inje University School of Medicine, Goyang, South Korea
| | - L Citrome
- New York Medical College, Valhalla, NY, USA
| | - H S Akiskal
- International Mood Centre, University of California and Veterans Administration Hospital, San Diego, CA, USA
| | - K C Goffin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S Miller
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - J N Holtzman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - F Hooshmand
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - P W Wang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S J Hill
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - T A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Panza F, Lozupone M, Stella E, Lofano L, Gravina C, Urbano M, Daniele A, Bellomo A, Logroscino G, Greco A, Seripa D. Psychiatry meets pharmacogenetics for the treatment of revolving door patients with psychiatric disorders. Expert Rev Neurother 2016; 16:1357-1369. [DOI: 10.1080/14737175.2016.1204913] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Francesco Panza
- a Geriatric Unit and Geriatric Research Laboratory, Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza , Foggia , Italy.,b Neurodegenerative Diseases Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy.,c Neurodegenerative Diseases Unit, Department of Clinical Research in Neurology , University of Bari "Aldo Moro" at "Pia Fondazione Card. G. Panico" , Lecce , Italy
| | - Madia Lozupone
- b Neurodegenerative Diseases Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy.,d Psychiatric Unit, Department of Clinical and Experimental Medicine , University of Foggia , Foggia , Italy
| | - Eleonora Stella
- d Psychiatric Unit, Department of Clinical and Experimental Medicine , University of Foggia , Foggia , Italy
| | - Lucia Lofano
- e Psychiatric Unit, Department of Basic Medicine Sciences, Neuroscience, and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy
| | - Carolina Gravina
- a Geriatric Unit and Geriatric Research Laboratory, Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Maria Urbano
- a Geriatric Unit and Geriatric Research Laboratory, Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Antonio Daniele
- f Institute of Neurology , Catholic University of Sacred Heart , Rome , Italy
| | - Antonello Bellomo
- d Psychiatric Unit, Department of Clinical and Experimental Medicine , University of Foggia , Foggia , Italy
| | - Giancarlo Logroscino
- b Neurodegenerative Diseases Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , University of Bari "Aldo Moro" , Bari , Italy.,c Neurodegenerative Diseases Unit, Department of Clinical Research in Neurology , University of Bari "Aldo Moro" at "Pia Fondazione Card. G. Panico" , Lecce , Italy
| | - Antonio Greco
- a Geriatric Unit and Geriatric Research Laboratory, Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Davide Seripa
- a Geriatric Unit and Geriatric Research Laboratory, Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
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Major depressive disorder with subthreshold hypomania (mixed features): Clinical characteristics of patients entered in a multiregional, placebo-controlled study. Prog Neuropsychopharmacol Biol Psychiatry 2016; 68:9-14. [PMID: 26908089 DOI: 10.1016/j.pnpbp.2016.02.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/17/2016] [Accepted: 02/19/2016] [Indexed: 11/20/2022]
Abstract
Major depressive disorder (MDD) associated with subthreshold hypomanic symptoms (mixed features), has been identified as a distinct nosological entity in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). We identified the predominant manic symptoms present at baseline in a multiregional, placebo-controlled trial involving 211 patients with MDD with mixed features (Clinicaltrials.govNCT01421134). Patients with 2 or 3 DSM-5 criteria defined manic symptoms were eligible for the study. At study baseline, increased talkativeness (pressure to keep talking) and flight of ideas (racing thoughts) were endorsed by approximately 65% of patients and a decreased need for sleep was endorsed by 40% of patients. Approximately 60% of patients also endorsed irritability and distractibility at baseline although these symptoms are not generally counted as part of the "mixed" depression diagnosis as they may overlap with criteria for MDD. Thus, five clinical symptoms characterized the manic presentation in the majority of patients diagnosed as having MDD with "mixed" features in this first placebo-controlled trial examining the use of a psychotropic medication (lurasidone) in this population. Our findings support the designation of MDD with mixed features specifier and suggest that this subpopulation of depressed patients may warrant additional medication beyond antidepressants.
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Abstract
Bipolar disorder is a common mental disorder which is relapsing and remitting in nature. Subsyndromal symptoms are common and associated with poorer outcomes. Management of the disorder can be challenging and depends on the polarity and severity of the mood episode.
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Affiliation(s)
- Kate E A Saunders
- Clinical Researcher and Honorary Consultant Psychiatrist in the Oxford University Department of Psychiatry, Warneford Hospital, Oxford
| | - John R Geddes
- Head of Department and Professor of Epidemiological Psychiatry in the Oxford University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX
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Hasselmann H. Interaction of Ketamine and Cannabis in Bipolar Disorder. Biol Psychiatry 2016; 79:e73-e74. [PMID: 26382597 DOI: 10.1016/j.biopsych.2015.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/16/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Helge Hasselmann
- Clinic for Psychiatry and Psychotherapy and NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany.
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43
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Jeon HJ, Baek JH, Ahn YM, Kim SJ, Ha TH, Cha B, Moon E, Kang HJ, Ryu V, Cho CH, Heo JY, Kim K, Lee HJ. Review of Cohort Studies for Mood Disorders. Psychiatry Investig 2016; 13:265-76. [PMID: 27247592 PMCID: PMC4878960 DOI: 10.4306/pi.2016.13.3.265] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/23/2015] [Accepted: 12/23/2015] [Indexed: 12/28/2022] Open
Abstract
This paper aimed to review currently available cohort studies of subjects with mood disorders such as major depressive disorder (MDD) and bipolar disorder (BD). Using the PubMed and KoreaMed databases, we reviewed eight major cohort studies. Most studies recruited participants with MDD and BD separately, so direct comparison of factors associated with diagnostic changes was difficult. Regular and frequent follow-up evaluations utilizing objective mood ratings and standardized evaluation methods in a naturalistic fashion are necessary to determine detailed clinical courses of mood disorders. Further, biological samples should also be collected to incorporate clinical findings in the development of new diagnostic and therapeutic approaches. An innovative cohort study that can serve as a platform for translational research for treatment and prevention of mood disorders is critical in determining clinical, psychosocial, neurobiological and genetic factors associated with long-term courses and consequences of mood disorders in Korean patients.
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Affiliation(s)
- Hong Jin Jeon
- Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Health Sciences & Technology, Department of Clinical Research Design and Evaluation, and Department of Medical Device Management and Research, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Seoul, Republic of Korea
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ji Hyun Baek
- Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong-Min Ahn
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Se Joo Kim
- Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Hyun Ha
- Department of Psychiatry, Seoul National University Bundang Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Boseok Cha
- Department of Psychiatry, Gyeongsang National University College of Medicine, Jinju, Republic of Korea
| | - Eunsoo Moon
- Department of Psychiatry, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Hee-Ju Kang
- Department of Psychiatry, Chonnam National University College of Medicine, Gwangju, Republic of Korea
| | - Vin Ryu
- Department of Psychiatry, Seoul National Hospital, Seoul, Republic of Korea
| | - Chul-Hyun Cho
- Department of Psychiatry, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jung-Yoon Heo
- Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kiwon Kim
- Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Heon-Jeong Lee
- Department of Psychiatry, Korea University College of Medicine, Seoul, Republic of Korea
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Coulombe S, Radziszewski S, Meunier S, Provencher H, Hudon C, Roberge P, Provencher MD, Houle J. Profiles of Recovery from Mood and Anxiety Disorders: A Person-Centered Exploration of People's Engagement in Self-Management. Front Psychol 2016; 7:584. [PMID: 27199819 PMCID: PMC4844930 DOI: 10.3389/fpsyg.2016.00584] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/08/2016] [Indexed: 12/21/2022] Open
Abstract
Context: A shift toward person-centered care has been occurring in services provided to people with mood and anxiety disorders. Recovery is recognized as encompassing personal aspects in addition to clinical ones. Guidelines now recommend supporting people's engagement in self-management as a complementary recovery avenue. Yet the literature lacks evidence on how individualized combinations of self-management strategies used by people relate to their clinical and personal recovery indicators. Objectives: The aims of this study were to identify profiles underlying mental health recovery, describe the characteristics of participants corresponding to each profile, and examine the associations of profiles with criterion variables. Method: 149 people recovering from anxiety, depressive, or bipolar disorders completed questionnaires on self-management, clinical recovery (symptom severity), personal recovery (positive mental health), and criterion variables (personal goal appraisal, social participation, self-care abilities, coping). Results: Latent profile analysis (LPA) revealed three profiles. The Floundering profile included participants who rarely used self-management strategies and had moderately severe symptoms and the lowest positive mental health. The Flourishing profile was characterized by frequent use of self-empowerment strategies, the least severe symptoms, and the highest positive mental health. Participants in the Struggling profile engaged actively in several self-management strategies focused on symptom reduction and healthy lifestyle. They concomitantly reported high symptom severity and moderately high positive mental health. The study revealed that Floundering was associated with higher probabilities of being a man, being single, and having a low income. People in the Flourishing profile had the most favorable scores on criterion variables, supporting the profiles' construct validity. Discussion: The mixed portrait of Struggling participants on recovery indicators suggests the relationship between health engagement and recovery is more intricate than anticipated. Practitioners should strive for a holistic understanding of their clients' self-management strategies and recovery indicators to provide support personalized to their profile. While people presenting risk factors would benefit from person-centered support, societal efforts are needed in the long term to reduce global health inequalities. The integration of constructs from diverse fields (patient-centered care, chronic illness, positive psychology) and the use of person-oriented analysis yielded new insights into people's engagement in their health and well-being.
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Affiliation(s)
- Simon Coulombe
- Department of Psychology, Université du Québec à Montréal, Montréal QC, Canada
| | | | - Sophie Meunier
- Department of Psychology, Université du Québec à Montréal, Montréal QC, Canada
| | | | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke Sherbrooke, QC, Canada
| | - Pasquale Roberge
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke Sherbrooke, QC, Canada
| | | | - Janie Houle
- Department of Psychology, Université du Québec à Montréal, MontréalQC, Canada; Research Centre, Institut universitaire en santé mentale de Montréal, MontréalQC, Canada
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Abstract
Bipolar depression is the most common and difficult-to-treat phase of bipolar disorder. Antidepressants for unipolar depression are among the most widely used drugs, but recent data and meta-analyses indicate a lack of efficacy. Many of the drugs discussed here are graded provisionally for the strength of the findings in the literature, safety and tolerability, and likely utility of use in patients with bipolar disorder. Successful long-term treatment of bipolar depression is critical to preventing illness-related morbidity, disability, cognitive decline, suicide, and premature loss of years of life expectancy largely from the excess medical mortality associated with cardiovascular disorders.
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Affiliation(s)
- Robert M Post
- Bipolar Collaborative Network, 5415 West Cedar Lane, Suite 201-B, Bethesda, MD 20814, USA.
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46
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Sánchez-Iglesias S, García-Solaesa V, García-Berrocal B, Sanchez-Martín A, Lorenzo-Romo C, Martín-Pinto T, Gaedigk A, González-Buitrago JM, Isidoro-García M. Role of Pharmacogenetics in Improving the Safety of Psychiatric Care by Predicting the Potential Risks of Mania in CYP2D6 Poor Metabolizers Diagnosed With Bipolar Disorder. Medicine (Baltimore) 2016; 95:e2473. [PMID: 26871771 PMCID: PMC4753865 DOI: 10.1097/md.0000000000002473] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
One of the main concerns in psychiatric care is safety related to drug management. Pharmacogenetics provides an important tool to assess causes that may have contributed the adverse events during psychiatric therapy. This study illustrates the potential of pharmacogenetics to identify those patients for which pharmacogenetic-guided therapy could be appropriate. It aimed to investigate CYP2D6 genotype in our psychiatric population to assess the value of introducing pharmacogenetics as a primary improvement for predicting side effects.A broad series of 224 psychiatric patients comprising psychotic disorders, depressive disturbances, bipolar disorders, and anxiety disorders was included. The patients were genotyped with the AmpliChip CYP450 Test to analyzing 33 allelic variants of the CYP2D6 gene.All bipolar patients with poor metabolizer status showed maniac switching when CYP2D6 substrates such as selective serotonin reuptake inhibitors were prescribed. No specific patterns were identified for adverse events for other disorders.We propose to utilize pharmacogenetic testing as an intervention to aid in the identification of patients who are at risk of developing affective switching in bipolar disorder treated with selective serotonin reuptake inhibitors, CYP2D6 substrates, and inhibitors.
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Affiliation(s)
- Santiago Sánchez-Iglesias
- From the Servicio de Psiquiatría, Hospital Universitario de Salamanca (SS-I, CL-R, TM-P); Instituto Biosanitario de Salamanca, IBSAL (VG-S, BG-B, AS-M, JML-R, MI-G); Servicio de Bioquímica Clínica, Hospital Universitario de Salamanca (BG-B, JMG-B, MI-G); Servicio de Farmacia, Hospital Universitario de Salamanca, Spain (AS-M); Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Hospital (AG); Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA (AG); and Departamento de Medicina, Universidad de Salamanca, Spain (MI-G)
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Onset polarity and illness course in bipolar I and II disorders: The predictive role of broadly defined mixed states. Compr Psychiatry 2015; 63:15-21. [PMID: 26555487 DOI: 10.1016/j.comppsych.2015.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 06/05/2015] [Accepted: 07/27/2015] [Indexed: 11/20/2022] Open
Abstract
Several studies investigating bipolar disorders have shown that polarity of onset can predict differences in symptomatology, course, and prognosis. Frequently, however, research on the topic has examined only bipolar I inpatients and has not included patients with mixed onset. The aim of the present naturalistic study was to evaluate the clinical characteristics and illness course of a consecutive sample (407 outpatients, 58.7% with bipolar I (BD-I) and 41.3% with bipolar II (BD-II) disorder) according to polarity of onset: depressive (DP-o); manic/hypomanic (HM-o); or mixed--broadly defined to include agitated depression for BD-II--onset (MX-o). As compared with patients in the other two groups: a) DP-o patients (67.3%) were more frequently affected by BD-II and had lower ratings for psychotic symptoms; b) HM-o patients (17%) had a higher rate of family history for psychosis and a lower rate of suicide attempts; and c) patients in the MX-o group (15.7%) more frequently showed substance abuse and had a higher number of mixed recurrences per year. In the BD-II group, MX-o patients more frequently attempted suicide. The present study's main limitations are those of retrospective assessment of onset polarity and lack of treatment-impact evaluations over illness course. In conclusion, we confirm clinical expression differences in bipolar disorder in function of polarity of onset and underscore the importance of carefully considering broadly defined mixed state when examining polarity of onset. Further investigations are required to confirm the present study's results.
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Antidepressant dose and treatment response in bipolar depression: Reanalysis of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) data. J Psychiatr Res 2015; 68:151-6. [PMID: 26228414 DOI: 10.1016/j.jpsychires.2015.06.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 06/17/2015] [Accepted: 06/19/2015] [Indexed: 01/02/2023]
Abstract
UNLABELLED The aim of this study is to evaluate whether an adjunct antidepressant therapy at a higher dose to a mood stabilizer would make a difference in the treatment of bipolar depression. This is a post-hoc analysis of the data from the randomized treatment for acute depression of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), in which patients with bipolar depression were randomly assigned to treatment with a mood stabilizer plus adjunctive antidepressant drugs or placebo. According to the highest dose received in the course of treatment, the subjects were divided into one of the following three groups: high-dose, low-dose and placebo groups. The primary and secondary outcomes were durable recovery (which was operationally defined as eight consecutive weeks with </ = 2 symptoms) and treatment-emergent affective switch (i.e. transition to mania or hypomania), respectively. In the evaluable 333 subjects, subjects in both the high-dose (n = 102) and placebo groups (n = 169) more significantly achieved durable recovery than the low-dose group (n = 62) (odds ratio = 3.013 [p = 0.009], 2.899 [p = 0.008], respectively). No significant association was found between the dose status and treatment-emergent affective switch (p = 0.614). The allocation to either high- and low-dose antidepressants was not randomized and the dose was guided by a case-by-case decision, which hampers to draw a firm conclusion on dose-response issues and renders the findings as preliminary. Nevertheless, higher doses of adjunctive antidepressant drugs seem to have potential for yielding greater clinical improvement without increasing any risk of manic switch compared to lower doses, at least in carefully selected patients. THE CLINICALTRIALS. GOV IDENTIFIER NCT00012558.
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Sani G, Napoletano F, Vöhringer PA, Sullivan M, Simonetti A, Koukopoulos A, Danese E, Girardi P, Ghaemi N. Mixed depression: clinical features and predictors of its onset associated with antidepressant use. PSYCHOTHERAPY AND PSYCHOSOMATICS 2015; 83:213-21. [PMID: 24970376 DOI: 10.1159/000358808] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 01/16/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mixed depression (MxD) is narrowly defined in the DSM-IV and somewhat broader in the DSM-5, although both exclude psychomotor agitation as a diagnostic criterion. This article proposes a clinical description for defining MxD, which emphasizes psychomotor excitation. METHODS Two hundred and nineteen consecutive outpatients were diagnosed with an MxD episode using criteria proposed by Koukopoulos et al. [Acta Psychiatr Scand 2007;115(suppl 433):50-57]; we here report their clinical features and antidepressant-related effects. RESULTS The most frequent MxD symptoms were: psychic agitation or inner tension (97%), absence of retardation (82%), dramatic description of suffering or weeping spells (53%), talkativeness (49%), and racing or crowded thoughts (48%). MxD was associated with antidepressants in 50.7% of patients, with similar frequency for tricyclic antidepressants (45%) versus selective serotonin reuptake inhibitors (38.5%). Positive predictors of antidepressant-associated MxD were bipolar disorder type II diagnosis, higher index depression severity, and higher age at index episode. Antipsychotic or no treatment was protective against antidepressant-associated MxD. CONCLUSIONS MxD, defined as depression with excitatory symptoms, can be clinically identified, is common, occurs in both unipolar depression and bipolar disorder, and is frequently associated with antidepressant use. If replicated, this view of MxD could be considered a valid alternative to the DSM-5 criteria for depression with mixed features.
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Affiliation(s)
- Gabriele Sani
- NESMOS Department (Neuroscience, Mental Health, and Sensory Organs), Sapienza University, School of Medicine and Psychology, Sant'Andrea Hospital, Rome, Italy
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Tundo A, Calabrese JR, Proietti L, de Fillippis R. Variation in response to short-term antidepressant treatment between patients with continuous and non-continuous cycling bipolar disorders. J Affect Disord 2015; 174:126-30. [PMID: 25497468 DOI: 10.1016/j.jad.2014.11.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 11/18/2014] [Accepted: 11/19/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The study aimed to compare effectiveness and safety of short-term antidepressant treatment between patients with continuous (CCC) and non-continuous (N-CCC) cycling bipolar disorders. METHODS The study sample included 101 patients with bipolar disorder, 22 (21.8%) CCC and 79 (78.2%) N-CCC. Response was defined as a HDRS21 total score <7 at 12 weeks of treatment and remission as a ≥50% reduction of baseline HDRS21 total score sustained for 8 weeks. RESULTS Compared with N-CCC patients, CCC patients achieved a significantly lower percentage of response (respectively 50% vs. 82.3%, χ²=9.6, p=0.002) and remission (respectively 40.9% vs. 69.6%, χ²=6.11, p=0.013). Adjusted logistic regression analysis indicated that CCC patients were 4.3 times more likely to be non-responders and 3.3 times more likely to be non-remitters than N-CCC patients. CONCERNING AD safety, 1 (5.0%) CCC patient committed a suicide attempt and AD-emerging switch was observed in 2 patients with N-CCC (2.5%) and in 1 with CCC (4.5%). LIMITATIONS The observational nature of the study, retrospective assessment of course, and unblinded outcomes assessment. CONCLUSIONS Our findings indicate that the presence or absence of a free interval identifies two different forms of bipolar disorders with different response not only to prophylactic treatment, as previously reported, but also to short-term ADs. We submit that clinicians should take into consideration their patients׳ pattern of cycling when prescribing short-term AD treatment. Moreover, subtypes of bipolar disorders might be used as moderators of treatment response in studies assessing the efficacy or the effectiveness of antidepressant treatment.
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Affiliation(s)
| | - Joseph R Calabrese
- Department of Psychiatry, University Hospital Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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