Predictors of the onset of manic symptoms and a (hypo)manic episode in patients with major depressive disorder

[Early intervention in bipolar affective disorders: Why, when and how]

OBJECTIVES

Bipolar disorder (BD) is a chronic and severe psychiatric disease. There are often significant delays prior to diagnosis, and only 30 to 40 % of patients will experience complete remission. Since BD occurs most often at a young age, the disorder can seriously obstruct future socio-professional development and integration. Vulnerability-stress model of BD is considered to be the result of an interaction between vulnerability genes and environmental risk factors, which leads to the onset of the disorder most often in late adolescence or early adulthood. The clinical "staging" model of BD situates the subject in a clinical continuum of varying degrees of severity (at-risk status, first episode, full-blown BD). Given the demonstrated effectiveness of early intervention in the early stages of psychotic disorder, we posit that early intervention for early stages of BD (i.e. at-risk status and first episode mania or hypomania) would reduce the duration of untreated illness and optimize the chances of therapeutic response and recovery.

METHODS

We conducted a narrative review of the literature to gather updated data on: (1) features of early stages: risk factors, at-risk symptoms, clinical specificities of the first manic episode; (2) early screening: targeted populations and psychometric tools; (3) early treatment: settings and therapeutic approaches for the early stages of BD.

RESULTS

(1) Features of early stages: among genetic risk factors, we highlighted the diagnosis of BD in relatives and affective temperament including as cyclothymic, depressive, anxious and dysphoric. Regarding prenatal environmental risk, we identified peripartum factors such as maternal stress, smoking and viral infections, prematurity and cesarean delivery. Later in the neurodevelopmental course, stressful events and child psychiatric disorders are recognized as increasing the risk of developing BD in adolescence. At-risk symptoms could be classified as "distal" with early but aspecific expressions including anxiety, depression, sleep disturbance, decreased cognitive performance, and more specific "proximal" symptoms which correspond to subsyndromic hypomanic symptoms that increase in intensity as the first episode of BD approaches. Specific clinical expressions have been described to assess the risk of BD in individuals with depression. Irritability, mixed and psychotic features are often observed in the first manic episode. (2) Early screening: some individuals with higher risk need special attention for screening, such as children of people with BD. Indeed, it is shown that children with at least one parent with BD have around 50 % risk of developing BD during adolescence or early adulthood. Groups of individuals presenting other risk factors, experiencing an early stage of psychosis or depressive disorders should also be considered as targeted populations for BD screening. Three questionnaires have been validated to screen for the presence of at-risk symptoms of BD: the Hypomanic Personality Scale, the Child Behavior Checklist-Paediatric Bipolar Disorder, and the General Behavior Inventory. In parallel, ultra-high risk criteria for bipolar affective disorder ("bipolar at-risk") distinguishing three categories of at-risk states for BD have been developed. (3) Early treatment: clinical overlap between first psychotic and manic episode and the various trajectories of the at-risk status have led early intervention services (EIS) for psychosis to reach out for people with an early stage of BD. EIS offers complete biopsychosocial evaluations involving a psychiatric examination, semi-structured interviews, neuropsychological assessments and complementary biological and neuroimaging investigations. Key components of EIS are a youth-friendly approach, specialized and intensive care and client-centered case management model. Pharmaceutical treatments for at-risk individuals are essentially symptomatic, while guidelines recommend the use of a non-antipsychotic mood stabilizer as first-line monotherapy for the first manic or hypomanic episode. Non-pharmacological approaches including psychoeducation, psychotherapy and rehabilitation have proven efficacy and should be considered for both at-risk and first episode of BD.

CONCLUSIONS

EIS for psychosis might consider developing and implementing screening and treatment approaches for individuals experiencing an early stage of BD. Several opportunities for progress on early intervention in the early stages of BD can be drawn. Training first-line practitioners to identify at-risk subjects would be relevant to optimize screening of this population. Biomarkers including functional and structural imaging measures of specific cortical regions and inflammation proteins including IL-6 rates constitute promising leads for predicting the risk of transition to full-blown BD. From a therapeutic perspective, the use of neuroprotective agents such as folic acid has shown particularly encouraging results in delaying the emergence of BD. Large-scale studies and long-term follow-up are still needed to achieve consensus in the use of screening and treatment tools. The development of specific recommendations for the early stages of BD is warranted.

Risk factors for new-onset bipolar disorder in a community cohort: A five-year follow up study

The aim of this study was to assess the risk factors for new-onset Bipolar Disorder (BD) in a community sample of young adults. This is a prospective cohort study including a population-based sample of young adults aged between 18-24 years. The baseline took place from 2007 to 2009, and 1560 subjects were included. Five years after, 1244 individuals were re-evaluated (79.7% retention). Substance abuse/dependence was assessed using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), and mental disorders were assessed using the Mini International Neuropsychiatric Interview 5.0 (MINI) at both waves. The cumulative incidence of BD in five years was 4.6%. There was no significant association between sociodemographic factors and BD incidence. Tobacco, cannabis, cocaine/crack, other substances abuse/dependence increased the relative risk for BD. Depressive, anxiety, post-traumatic stress disorders, and the suicide risk increased the relative risk to BD. Depressive episode was the strongest risk factor for BD, followed by other mental disorders and substance abuse/dependence in a probabilistic community sample of young adults. Preventive actions in mental health directed at the non-clinical population are needed for early detection and better management of BD.

Clinical characteristic of prodromal symptoms between bipolar I and II disorder among Chinese patients: a retrospective study

BACKGROUND

This study aimed to identify the clinical characteristic of prodromal symptoms in Chinese patients with bipolar disorder (BD), prior to the first affective episode. It further aimed to characterize the prodromal traits between bipolar disorder type I (BD-I) and type II (BD-II).

METHODS

120 individuals with BD-I (n = 92) and BD- II (n = 28) were recruited to the study. Semi-structured interviews were then administered to evaluate prodromal symptoms in patients, within 3 years of BD onset, by using the Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R).

RESULTS

In the prodromal phase of the first depressive episode, patients with BD-II experienced more prodromal symptoms (p = 0.0028) compared to BD-I. Additionally, more frequent predictors were reported in patients with BD-II than BD-I including educational and occupational dysfunction (p = 0.0023), social isolation (p < 0.001), difficulty making decisions (p = 0.0012), oppositionality (p = 0.012), and suspiciousness/persecutory ideas (p = 0.017). There were also differences in the duration of the precursors. The duration of "weight loss or decrease in appetite" (p = 0.016) lasted longer in patients with BD-I, while "obsessions and compulsions" (p = 0.023) started earlier in patients with BD-II and occurred during the pre-depressive period. The prevalence and duration of each reported prodrome, preceding a first (hypo) manic episode, showed no difference between patients with BD-I and BD-II.

CONCLUSIONS

Specific affective, general, or psychotic symptoms occurred prior to both affective episodes. The characteristic of prodromal symptoms were key predictors for later episodes of BD including attenuated mania-like symptoms, subthreshold depressed mood, mood swings/lability, and anxiety. In the pre-depressive state, when compared to BD-II, BD-I presented with more prodromal symptoms in nonspecific dimensions, which indicated the substantial burden of BD-II. In conclusion, this study extends the understanding of the characteristics of prodromes of BD-I and BD-II.

The Management of Prodromal Symptoms of Bipolar Disorder: Available Options and Future Perspectives

The onset of prodromal symptoms in subjects who are at familial or clinical risk for bipolar disorder could be considered as an important alarm bell for the development of the disease and should be carefully detected. The management of prodromes in bipolar high-risk patients appears to be an important means of prevention; nevertheless, at the moment, there aren’t clear and widely shared treatment indications. The aim of this review is to summarize the available treatment options (pharmacological, psychosocial and nutraceutical) for the management of prodromal symptoms in subjects who are at familial or clinical risk for bipolar disorder.

Research Review: Brain network connectivity and the heterogeneity of depression in adolescence - a precision mental health perspective

BACKGROUND

Adolescence is a period of high risk for the onset of depression, characterized by variability in symptoms, severity, and course. During adolescence, the neurocircuitry implicated in depression continues to mature, suggesting that it is an important period for intervention. Reflecting the recent emergence of 'precision mental health' - a person-centered approach to identifying, preventing, and treating psychopathology - researchers have begun to document associations between heterogeneity in features of depression and individual differences in brain circuitry, most frequently in resting-state functional connectivity (RSFC).

METHODS

In this review, we present emerging work examining pre- and post-treatment measures of network connectivity in depressed adolescents; these studies reveal potential intervention-specific neural markers of treatment efficacy. We also review findings from studies examining associations between network connectivity and both types of depressive symptoms and response to treatment in adults, and indicate how this work can be extended to depressed adolescents. Finally, we offer recommendations for research that we believe will advance the science of precision mental health of adolescence.

RESULTS

Nascent studies suggest that linking RSFC-based pathophysiological variation with effects of different types of treatment and changes in mood following specific interventions will strengthen predictions of prognosis and treatment response. Studies with larger sample sizes and direct comparisons of treatments are required to determine whether RSFC patterns are reliable neuromarkers of treatment response for depressed adolescents. Although we are not yet at the point of using RSFC to guide clinical decision-making, findings from research examining the stability and reliability of RSFC point to a favorable future for network-based clinical phenotyping.

CONCLUSIONS

Delineating the correspondence between specific clinical characteristics of depression (e.g., symptoms, severity, and treatment response) and patterns of network-based connectivity will facilitate the development of more tailored and effective approaches to the assessment, prevention, and treatment of depression in adolescents.

Antidepressant Withdrawal and Rebound Phenomena

BACKGROUND

Antidepressants are among the most commonly prescribed drugs worldwide. They are often discontinued, frequently without the knowledge of the prescribing physician. It is, therefore, important for physicians to be aware of the withdrawal and rebound phenomena that may arise, in order to prevent these phenomena, treat them when necessary, and counsel patients appropriately.

METHODS

This review is based on a comprehensive, structured literature search on antidepressant withdrawal phenomena that we carried out in the CENTRAL, PubMed (Medline), and Embase databases. We classified the relevant publications and reports by their methodological quality.

RESULTS

Out of a total of 2287 hits, there were 40 controlled trials, 38 cohort studies and retrospective analyses, and 271 case reports that met the inclusion criteria. Withdrawal manifestations are usually mild and self-limiting; common ones include dizziness, headache, sleep disturbances, and mood swings. More serious or pro- longed manifestations rarely arise. There is an increased risk with MAO inhibitors, tricyclic antidepressants, venlafaxine, and paroxetine; on the other hand, for agome- latine and fluoxetine, abrupt discontinuation seems to be unproblematic. There is also some evidence of rebound phenomena, i.e., of higher relapse rates or especially severe relapses of depression after the discontinuation of an anti- depressant.

CONCLUSION

A robust evidence base now indicates that there can be acute with- drawal phenomena when antidepressants are discontinued. Putative rebound phenomena have not been adequately studied to date. It is recommended that antidepressants should be tapered off over a period of more than four weeks.

Incidence of and factors associated with manic episodes and bipolar disorder in the decade following depression onset in Germany

AIM

The goal of this retrospective cohort study was to analyze the incidence of and factors associated with manic episodes and bipolar disorder in the decade following a depression diagnosis in patients from Germany.

METHODS

This study included adults who were diagnosed with depression for the first time in one of 199 neuropsychiatric practices in Germany between 2007 and 2017 (index date). The cumulative incidence of a manic episode or bipolar disorder was estimated for up to 10 years after the index date using Kaplan-Meier curves. Multivariate Cox regression models were further used to investigate the association between demographic, clinical, and pharmaceutical variables and the incidence of manic episodes and bipolar disorder.

RESULTS

This study included 162,689 patients [mean (standard deviation) age 51.6 (14.9) years; 63.2% women]. Ten years after a depression diagnosis, the incidence of manic episodes and bipolar disorder ranged from 2.9% to 5.1%. Young age, severe depression, and the prescription of venlafaxine were identified as variables positively associated with manic episodes and bipolar disorder, while several clinical (e.g., somatoform disorders, extrapyramidal and movement disorders) and pharmaceutical variables (e.g., hypericum perforatum, amitriptyline) were negatively associated with bipolarity.

CONCLUSIONS

The incidence of manic episodes and bipolar disorder was relatively low in the decade following a depression diagnosis in Germany. Young age, depression severity, and several clinical and pharmaceutical variables were significantly associated with bipolarity in patients with depression.

Personality traits and the risk of incident (hypo)mania among subjects initially suffering from depressive and anxiety disorders in a 9-year cohort study

BACKGROUND

Bipolar disorder (BD) is characterized by the alternating occurrence of (hypo)manic and depressive episodes. The aim of the current study was to determine whether personality traits independently predicted the subsequent development of (hypo)manic episodes within a group of patients who were initially diagnosed with depressive and anxiety disorders.

METHODS

The Netherlands Study of Depression and Anxiety is a cohort study with measurements taken at baseline and at 2-, 4-, 6-, and 9-year follow-up. Development of a (hypo)manic episode during follow-up was assessed with the Composite International Diagnostic Interview and (hypo)manic symptoms were evaluated with the Mood Disorder Questionnaire. The Big Five personality traits were the independent variables in multivariable Cox regression analyses.

RESULTS

There were 31 incident cases of (hypo)manic episodes (n = 1888, mean age 42.5 years, 68.3% women), and 233 incident cases of (hypo)manic symptoms (n = 1319, mean age 43.1, 71.9% women). In multivariable analyses, low agreeableness was independently associated with an increased risk of developing a (hypo)manic episode, with a hazard ratio (HR) of 0.54 (p = 0.002, 95% CI [0.37, 0.78]). This finding was consistent with the development of (hypo)manic symptoms (HR 0.77, p = 0.001, 95% CI [0.66, 0.89]).

LIMITATIONS

The 2-year lag-time analysis reduced the number of participants at risk of a (hypo)manic episode.

CONCLUSIONS

We conclude that low agreeableness is a personality-related risk factor for incident (hypo)mania among subjects initially suffering from depressive and anxiety disorders. Increased attention to personality deviances could help to recognize BD at an early stage.

Baseline dimensional psychopathology and future mood disorder onset: findings from the Dutch Bipolar Offspring Study

OBJECTIVE

To identify the early signs of mood disorder development, specifically bipolar disorder (BD), in a population at familial risk for BD.

METHOD

The sample included 107 Dutch adolescent bipolar offspring (age 12-21) followed into adulthood (age 22-32). Lifetime DSM-IV axis I diagnoses were examined at baseline, 1-, 5-, and 12- year follow-up. Symptoms were assessed at baseline on a 3-point Likert scale at baseline with the K-SADS-PL and were analyzed using symptom and sum scores. As observed in previous studies, BD typically starts with other mood disorders. Therefore, the sample was stratified in offspring with a mood diagnosis (n = 29) and without (n = 78) at baseline.

RESULTS

Subthreshold manic experiences proved the strongest predictor of BD conversion (n = 10; HR2.16, CI95% 1.23-3.78). At symptom level, elated mood, decreased need of sleep, racing thoughts, suicidal ideation, and middle insomnia were significantly associated with BD conversion. Depressive symptoms proved the strongest predictor for first mood episode onset (n = 28; HR1.27, CI95% 1.02-1.58).

CONCLUSION

This study extends our knowledge of prodromal manifestations of BD in a high-risk population. Although preliminary, findings of this study provide potential targets for early identification and underscore the importance of detailed assessment of manic symptomatology in bipolar offspring.

Seasonal affective disorder and non-seasonal affective disorders: results from the NESDA study

BACKGROUND

Seasonal affective disorder (SAD) is considered to be a subtype of depression.

AIMS

To compare the clinical picture of SAD to non-seasonal affective disorders (non-SADs).

METHOD

Diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) were established in 2185 participants of the Netherlands Study of Depression and Anxiety. The Seasonal Pattern Assessment Questionnaire was administered to diagnose SAD. Symptoms of depression and anxiety were measured with the Inventory of Depressive Symptoms, the Beck Anxiety Inventory and the Fear Questionnaire.

RESULTS

Participants with SAD, participants with a lifetime bipolar disorder and participants with a lifetime comorbid anxiety and depressive disorder scored highest in terms of psychopathology in the past year. The seasonal distribution of major depressive episodes was not different for participants with or without SAD.

CONCLUSIONS

SAD may be a measure of severity of depression with a subjectively perceived worsening of symptoms in the winter months.

DECLARATION OF INTEREST

Y.M. has received research funding and served as a consultant for Royal Philips Electronics NV and The Litebook Company Ltd. W.A.N. has received grants from the Netherlands Organization for Health Research and Development, the European Union, the Stanley Medical Research Institute, Astra Zeneca, Eli Lilly, GlaxoSmithKline and Wyeth; has received honoraria/speaker's fees from Astra Zeneca, Pfizer, Servier and Wyeth; and has served in advisory boards for Astra Zeneca, Pfizer and Servier.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

A systematic review and meta-analysis of prospective transition from major depression to bipolar disorder

OBJECTIVE

Some people with major depressive disorder (MDD) may be at a pre-onset stage for bipolar disorder (BD), where early identification or prevention efforts may be feasible. We aimed to identify rates and characteristics predictive of transition to BD in prospective follow-up studies of people with MDD.

METHODS

Using a systematic search strategy, we identified studies with a diagnostic ascertainment of MDD and BD of an adequate standard, and where the minimum length of follow-up was 6 months. We examined the incidence and point prevalence of BD and the pooled odds ratios (OR) for baseline predictors.

RESULTS

From 5554 unique publications, 56 were included. Nearly a quarter of adults (22.5%) and adolescents with MDD followed up for a mean length of 12-18 years developed BD, with the greatest risk of transition being in the first 5 years. The meta-analysis identified that transition from MDD to BD was predicted by family history of BD (OR = 2.89, 95% CI: 2.01-4.14, N = 7), earlier age of onset of depression (g = -0.33, SE = 0.05, N = 6) and presence of psychotic symptoms (OR = 4.76, 95% CI: 1.79-12.66, N = 5).

CONCLUSIONS

Participants with the identified risk factors merit closer observation and may benefit from prevention efforts, especially if outcomes broader than BD are considered.

Psychiatric comorbidity in adolescent electronic and conventional cigarette use

The popularity of electronic (e-) cigarettes has greatly increased recently, particularly in adolescents. However, the extent of psychiatric comorbidity with adolescent e-cigarette use and dual use of conventional (combustible) and e-cigarettes is unknown. This study characterized psychiatric comorbidity in adolescent conventional and e-cigarette use. Ninth grade students attending high schools in Los Angeles, CA (M age = 14) completed self-report measures of conventional/e-cigarette use, emotional disorders, substance use/problems, and transdiagnostic psychiatric phenotypes consistent with the NIMH-Research Domain Criteria Initiative. Outcomes were compared by lifetime use of: (1) neither conventional nor e-cigarettes (non-use; N = 2557, 77.3%); (2) e-cigarettes only (N = 412, 12.4%); (3) conventional cigarettes only (N = 152, 4.6%); and (4) conventional and e-cigarettes (dual use; N = 189, 5.6%). In comparison to adolescents who used conventional cigarettes only, e-cigarette only users reported lower levels of internalizing syndromes (depression, generalized anxiety, panic, social phobia, and obsessive-compulsive disorder) and transdiagnostic phenotypes (i.e., distress intolerance, anxiety sensitivity, rash action during negative affect). Depression, panic disorder, and anhedonia were higher in e-cigarette only vs. non-users. For several externalizing outcomes (mania, rash action during positive affect, alcohol drug use/abuse) and anhedonia, an ordered pattern was observed, whereby comorbidity was lowest in non-users, moderate in single product users (conventional or e-cigarette), and highest in dual users. These findings: (1) raise question of whether emotionally-healthier ('lower-risk') adolescents who are not interested in conventional cigarettes are being attracted to e-cigarettes; (2) indicate that research, intervention, and policy dedicated to adolescent tobacco-psychiatric comorbidity should distinguish conventional cigarette, e-cigarette, and dual use.

Disturbances in Hypothalamic-Pituitary-Adrenal Axis and Immunological Activity Differentiating between Unipolar and Bipolar Depressive Episodes

INTRODUCTION

Differentiating bipolar depression (BD) from unipolar depression (UD) is difficult in clinical practice and, consequently, accurate recognition of BD can take as long as nine years. Research has therefore focused on the discriminatory capacities of biomarkers, such as markers of the hypothalamic-pituitary-adrenal (HPA) axis or immunological activity. However, no previous study included assessments of both systems, which is problematic as they may influence each other. Therefore, this study aimed to explore whether cortisol indicators and inflammatory markers were a) independently associated with and/or b) showed effect modification in relation to a lifetime (hypo)manic episode in a large sample of depressed patients.

METHODS

Data were derived from the Netherlands Study of Depression and Anxiety and comprised 764 patients with a DSM-IV depressive disorder at baseline, of which 124 (16.2%) had a lifetime (hypo)manic episode at the 2-year assessment, or a more recent episode at the 4-year or 6-year assessment. Baseline cortisol awakening response, evening cortisol and diurnal cortisol slope were considered as cortisol indicators, while baseline C-reactive Protein (CRP), Interleukin-6 (IL-6), and Tumor Necrosis Factor Alpha (TNF-α) were included as inflammatory markers.

RESULTS

In depressed men and women, none of the cortisol indicators and inflammatory markers were (independently) associated with a (hypo)manic episode. However, effect modification was found of diurnal cortisol slope and CRP in relation to a (hypo)manic episode. Further analyses showed that depressed men with high levels of diurnal cortisol slope and CRP had an increased odds (OR=10.99, p=.001) of having a (hypo)manic episode. No significant differences were found in women.

CONCLUSION

Our findings suggest that the combination of high diurnal cortisol slope and high CRP may differentiate between UD and BD. This stresses the importance of considering HPA-axis and immunological activity simultaneously, but more research is needed to unravel their interrelatedness.