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Basquin L, Maruani J, Leseur J, Mauries S, Bazin B, Pineau G, Henry C, Lejoyeux M, Geoffroy PA. Study of the different sleep disturbances during the prodromal phase of depression and mania in bipolar disorders. Bipolar Disord 2024. [PMID: 38653574 DOI: 10.1111/bdi.13429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND One of the challenges in bipolar disorder (BD) lies in early detection of the illness and its recurrences, to improve prognosis. Sleep disturbances (SD) have been proposed as reliable predictive markers of conversion. While preliminary studies have explored the relationship between SD and the onset of mood episodes, the results remain heterogeneous and a few have specifically examined patients' perception of prodromal symptoms and their progression until the episode occurs. Identifying prodromes represents a crucial clinical challenge, as it enables early intervention, thereby reducing the severity of BD. Therefore, the objective of this study is to better characterize and evaluate the progressive nature of SD as prodromal symptoms of mood episodes, and patients' perception of it. METHODS Patients diagnosed with BD, either hospitalized or seeking treatment for a (hypo)manic or depressive episode benefited from standardized questionnaires, structured interviews, and self-report questionnaires to evaluate SD prior to the current episode, as well as sociodemographic and clinical information. RESULTS Out of the 41 patients included, 59% spontaneously reported SD prior to the episode, appearing 90 days before depression and 35 days before mania (pre-indexed/spontaneous reports: 51.22% insomnia complaints, 4.88% hypersomnolence complaints, 7.32% parasomnias, 2.44% sleep movements). After inquiry about specific SD, the percentage of patients reporting prodromal SD increased significantly to 83%, appearing 210 days before depression and 112.5 days before mania (post-indexed reports: 75.61% presented with insomnia complaints appearing 150 days before depression and 20 days before mania, 46.34% had hypersomnolence complaints appearing 60 days before depression, 43.9% had parasomnias appearing 210 days before depression and 22.5 days before mania, 36.59% had sleep movements appearing 120 days before depression and 150 days before mania). Of note, bruxism appeared in 35% of patients before mania, and restless legs syndrome in 20% of patients before depression. CONCLUSION This study highlights the very high prevalence of SD prior to a mood episode in patients with BD with differences between depressive and manic episodes. The more systematic screening of sleep alterations of the prodromal phase improved the recognition and characterization of different symptoms onset by patients. This underscores the need for precise questioning regarding sleep patterns in patients, to better identify the moment of transition toward a mood episode, referred to as "Chronos syndrome". The study emphasizes the importance of educating patients about the disorder and its sleep prodromal symptoms to facilitate early intervention and prevent recurrences.
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Affiliation(s)
- Louise Basquin
- Département de Psychiatrie et d'addictologie, AP-HP, GHU Paris Nord, DMU Neurosciences, Hôpital Bichat - Claude Bernard, Paris, France
- NeuroDiderot, Inserm, FHU I2-D2, Université Paris Cité, Paris, France
| | - Julia Maruani
- Département de Psychiatrie et d'addictologie, AP-HP, GHU Paris Nord, DMU Neurosciences, Hôpital Bichat - Claude Bernard, Paris, France
- NeuroDiderot, Inserm, FHU I2-D2, Université Paris Cité, Paris, France
- GHU Paris - Psychiatrie & Neurosciences, Paris, France
| | - Jeanne Leseur
- Département de Psychiatrie et d'addictologie, AP-HP, GHU Paris Nord, DMU Neurosciences, Hôpital Bichat - Claude Bernard, Paris, France
| | - Sibylle Mauries
- Département de Psychiatrie et d'addictologie, AP-HP, GHU Paris Nord, DMU Neurosciences, Hôpital Bichat - Claude Bernard, Paris, France
- NeuroDiderot, Inserm, FHU I2-D2, Université Paris Cité, Paris, France
- GHU Paris - Psychiatrie & Neurosciences, Paris, France
| | | | - Guillaume Pineau
- Département de Psychiatrie et d'addictologie, AP-HP, GHU Paris Nord, DMU Neurosciences, Hôpital Bichat - Claude Bernard, Paris, France
| | - Chantal Henry
- GHU Paris - Psychiatrie & Neurosciences, Paris, France
- Department of Psychiatry, Service Hospitalo-Universitaire, GHU Paris Psychiatrie & Neurosciences, Paris, France
- Université de Paris, Paris, France
| | - Michel Lejoyeux
- Département de Psychiatrie et d'addictologie, AP-HP, GHU Paris Nord, DMU Neurosciences, Hôpital Bichat - Claude Bernard, Paris, France
- NeuroDiderot, Inserm, FHU I2-D2, Université Paris Cité, Paris, France
- GHU Paris - Psychiatrie & Neurosciences, Paris, France
| | - Pierre A Geoffroy
- Département de Psychiatrie et d'addictologie, AP-HP, GHU Paris Nord, DMU Neurosciences, Hôpital Bichat - Claude Bernard, Paris, France
- NeuroDiderot, Inserm, FHU I2-D2, Université Paris Cité, Paris, France
- GHU Paris - Psychiatrie & Neurosciences, Paris, France
- CNRS UPR 3212, Institute for Cellular and Integrative Neurosciences, Strasbourg, France
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Visioli C, Tondo L, Miola A, Pinna M, Contu M, Baldessarini RJ. Early sexual or physical abuse in female and male mood disorder patients. J Psychiatr Res 2023; 167:125-131. [PMID: 37866326 DOI: 10.1016/j.jpsychires.2023.10.015] [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: 04/22/2023] [Revised: 09/08/2023] [Accepted: 10/13/2023] [Indexed: 10/24/2023]
Abstract
Early abuse has been associated with psychiatric morbidity but comparisons of bipolar (BD) and major depressive (MDD) disorder subjects with versus without early sexual or physical abuse are rare. Patients (n = 684) diagnosed with a DSM-5-TR major mood disorder were evaluated and followed for several years at mood disorder centers to compare details of history and clinical status in participants with versus without early sexual or physical abuse. Early history of sexual (16.2%) or physical abuse (11.9%) was prevalent; 5.15% reported both. Both types of abuse were much more prevalent with BD than MDD. Sexual abuse was associated with younger illness-onset and somewhat younger menarche in females; both abuse-types were associated with familial mood disorders, especially BD. Prospective, long-term illness episode-frequency, depressions or [hypo]manias/year and %-time [hypo]manic all were greater following sexual abuse but morbidity measures did not differ following physical abuse. Prevalence of suicidal behavior ranked: double (48.5%) > physical (32.1%) > sexual (30.3%) abuse, and with BD > MDD (OR = 2.31). Recall bias and not using psychometric instruments to define abuse severity or type may limit interpretation of findings. Early sexual (more than physical) abuse, led to greater morbidity and both abuses were strongly associated with familial mood disorders and greater suicidal risk, especially with double-abuse and BD diagnosis. We support a bilateral relationship between abuse and diagnosis of BD: abuse may facilitate early appearance of BD but also may result from the actions of abusive BD family members.
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Affiliation(s)
| | - Leonardo Tondo
- Lucio Bini Mood Disorder Centers, Cagliari, Rome, Italy; International Consortium for Mood & Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Alessandro Miola
- International Consortium for Mood & Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, MA, USA; Department of Neuroscience, University of Padova, Padua, Italy.
| | - Marco Pinna
- Lucio Bini Mood Disorder Centers, Cagliari, Rome, Italy; Section on Psychiatry, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Martina Contu
- Lucio Bini Mood Disorder Centers, Cagliari, Rome, Italy
| | - Ross J Baldessarini
- International Consortium for Mood & Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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3
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Álvarez-Cadenas L, García-Vázquez P, Ezquerra B, Stiles BJ, Lahera G, Andrade-González N, Vieta E. Detection of bipolar disorder in the prodromal phase: A systematic review of assessment instruments. J Affect Disord 2023; 325:399-412. [PMID: 36623571 DOI: 10.1016/j.jad.2023.01.012] [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: 11/03/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early detection of prodromal symptoms may contribute to improving the prognosis of patients with bipolar disorder (BD). The main objective of this systematic review is to present the different procedures for the identification of initial and relapse prodromes in these patients. METHODS PsycINFO, Web of Science and PubMed databases were searched using a predetermined strategy, until January 4, 2022. Then, by means of a regulated process, studies that used a BD prodrome detection procedure, in English-language and all ages participants were selected. Quantitative and qualitative studies were assessed using a modified version of the Newcastle-Ottawa Scale and by Critical Appraisals Skills Programme checklist, respectively. RESULTS Forty-five studies were selected. Of these, 26 used procedures for identifying initial prodromes (n = 8014) and 19 used procedures for detecting relapse prodromes (n = 1136). The interview was the most used method in the detection of both types of prodromes (k = 30 papers, n = 4068). It was variable in its degree of structure. Mobile applications and digital technologies are gaining importance in the detection of the relapse prodromes. LIMITATIONS A retrospective design in most papers, small samples sizes, existence of persistent subsyndromal symptoms and difficulty to identify the end of the prodrome and the onset of the disorder. CONCLUSIONS There is a wide variety of assessment instruments to detect prodromes in BD, among which the clinical interview is most frequently used. Future research should consider development of a brief tool to be applied in different formats to patients and family members.
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Affiliation(s)
- Laura Álvarez-Cadenas
- Central University Hospital of Asturias, Health Service of Principality of Asturias, Oviedo, Spain.
| | - Paula García-Vázquez
- Central University Hospital of Asturias, Health Service of Principality of Asturias, Oviedo, Spain
| | - Berta Ezquerra
- Rey Juan Carlos University Hospital, Móstoles, Madrid, Spain
| | - Bryan J Stiles
- Department of Psychology and Neuroscience, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Guillermo Lahera
- Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain; IRyCIS, CIBERSAM, Madrid, Spain; Príncipe de Asturias University Hospital, Alcalá de Henares, Madrid, Spain
| | - Nelson Andrade-González
- Psychiatry and Mental Health Research Group, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain; Faculty of Medicine, Alfonso X el Sabio University, Villanueva de la Cañada, Madrid, Spain
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
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Lippard ETC, Nemeroff CB. Going beyond risk factor: Childhood maltreatment and associated modifiable targets to improve life-long outcomes in mood disorders. Pharmacol Biochem Behav 2022; 215:173361. [PMID: 35219755 DOI: 10.1016/j.pbb.2022.173361] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 02/17/2022] [Accepted: 02/20/2022] [Indexed: 01/26/2023]
Abstract
Childhood maltreatment increases risk for mood disorders and is associated with earlier onset-and more pernicious disease course following onset-of mood disorders. While the majority of studies to date have been cross-sectional, longitudinal studies are emerging and support the devastating role(s) childhood maltreatment has on development of, and illness course in, mood disorders. This manuscript extends prior reviews to emphasize more recent work, highlighting longitudinal data, and discusses treatment studies that provide clues to mechanisms that mediate disease risk, course, relapse, and treatment response. Evidence suggesting systemic inflammation, alterations in hypothalamic-pituitary-adrenal (HPA) axis function and corticotropin-releasing factor (CRF) neural systems, genetic and other familial factors as mechanisms that mediate risk and onset of, and illness course in, mood disorders following childhood maltreatment is discussed. Risky behaviors following maltreatment, e.g., substance use and unhealthy lifestyles, may further exacerbate alterations in the HPA axis, CRF neural systems, and systematic inflammation to contribute to a more pernicious disease course. More research on sex differences and the impact of maltreatment in vulnerable populations is needed. Future research needs to be aimed at leveraging knowledge on modifiable targets, going beyond childhood maltreatment as a risk factor, to inform prevention and treatment strategies and foster trauma-informed care.
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Affiliation(s)
- Elizabeth T C Lippard
- Department of Psychiatry and Behavioral Sciences, Dell Medical School, University of Texas, Austin, TX, USA; Institute of Early Life Adversity Research, Dell Medical School, University of Texas, Austin, TX, USA; Waggoner Center for Alcohol and Addiction Research, University of Texas, Austin, TX, USA; Department of Psychology, University of Texas, Austin, TX, USA; Mulva Clinic for Neuroscience, Dell Medical School, University of Texas, Austin, TX, USA.
| | - Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences, Dell Medical School, University of Texas, Austin, TX, USA; Institute of Early Life Adversity Research, Dell Medical School, University of Texas, Austin, TX, USA; Waggoner Center for Alcohol and Addiction Research, University of Texas, Austin, TX, USA; Mulva Clinic for Neuroscience, Dell Medical School, University of Texas, Austin, TX, USA
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Primary prevention of depression: An umbrella review of controlled interventions. J Affect Disord 2021; 294:957-970. [PMID: 34375224 DOI: 10.1016/j.jad.2021.07.101] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/14/2021] [Accepted: 07/26/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Primary prevention has the potential to modify the course of depression, but the consistency and magnitude of this effect are currently undetermined. METHODS PRISMA and RIGHT compliant (PROSPERO:CRD42020179659) systematic meta-review, PubMed/Web of Science, up to June 2020. Meta-analyses of controlled interventions for the primary prevention of depressive symptoms [effect measures: standardized mean difference (SMD)] or depressive disorders [effect measure: relative risk (RR)] were carried out. Results were stratified by: (i) age range; (ii) target population (general and/or at-risk); (iii) intervention type. Quality (assessed with AMSTAR/AMSTAR-PLUS content) and credibility (graded as high/moderate/low) were assessed. USPSTF grading system was used for recommendations. RESULTS Forty-six meta-analyses (k=928 individual studies, n=286,429 individuals, mean age=22.4 years, 81.1% female) were included. Effect sizes were: SMD=0.08-0.53; for depressive symptoms; RR=0.90-0.28 for depressive disorders. Sensitivity analyses including only RCTs did not impact the findings. AMSTAR median=9 (IQR=8-9); AMSTAR-PLUS content median=4.25 (IQR=4-5). Credibility of the evidence was insufficient/low in 43 (93.5%) meta-analyses, moderate in two (4.3%), and high in one (2.2%): reduction of depressive symptoms using psychosocial interventions for young adults only, and a combination of psychological and educational interventions in primary care had moderate credibility; preventive administration of selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in individuals with a stroke had high credibility. LIMITATIONS Intervention heterogeneity and lack of long-term efficacy evaluation. CONCLUSIONS Primary preventive interventions for depression might be effective. Among them, clinicians may offer SSRIs post-stroke to prevent depressive disorders, and psychosocial interventions for children/adolescents/young adults with risk factors or during the prenatal/perinatal period.
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Impact of Childhood Trauma and Attachment on Resilience in Remitted Patients with Bipolar Disorder. J Affect Disord 2021; 280:219-227. [PMID: 33220557 DOI: 10.1016/j.jad.2020.11.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/22/2020] [Accepted: 11/07/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Childhood trauma has been reported to be associated with severe course of illness, insecure attachment, and lower resilience in bipolar disorder. We aimed to examine the impact of childhood trauma on resilience and possible mediating role of attachment on this impact in bipolar disorder. METHODS The study group comprised of 110 remitted patients with bipolar disorder. Hamilton Depression Rating Scale (HAM-D) and Young Mani Rating Scale (YMRS) are administered to verify remission. Childhood trauma questionnaire (CTQ-SF), Experiences in Close Relationships-revised (ECR-R), and Resilience Scale for Adults (RSA) scales administered to all patients. RESULTS More than half of patients in bipolar disorder group reported childhood trauma. HAM-D scores were positively associated with childhood trauma total scores and emotional abuse scores, negatively associated with resilience, with attachment-related anxiety. Total childhood trauma scores were associated with lower scores of resilience, higher scores of attachment-related anxiety and avoidance. Resilience scores were negatively associated with attachment-related anxiety and avoidance. Impact of childhood trauma on resilience was partly mediated by attachment-related anxiety and avoidance, respectively. LIMITATIONS The cross-sectional design of this study is a limitation in terms of determining causality of the identified relationships. CONCLUSIONS Childhood traumas are associated with lower resilience and higher attachment-related anxiety and avoidance. Attachment-related anxiety and avoidance partly mediated the negative effect of childhood trauma on resilience. Since resilience is associated with increased quality of life in bipolar disorder, it might be helpful to develop attachment-informed psychosocial interventions to ameliorate the detrimental effect of childhood trauma on resilience.
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Quidé Y, Tozzi L, Corcoran M, Cannon DM, Dauvermann MR. The Impact of Childhood Trauma on Developing Bipolar Disorder: Current Understanding and Ensuring Continued Progress. Neuropsychiatr Dis Treat 2020; 16:3095-3115. [PMID: 33364762 PMCID: PMC7751794 DOI: 10.2147/ndt.s285540] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/18/2020] [Indexed: 12/12/2022] Open
Abstract
Childhood trauma (CT) has been repeatedly linked to earlier onset and greater severity of bipolar disorder (BD) in adulthood. However, such knowledge is mostly based on retrospective and cross-sectional studies in adults with BD. The first objective of this selective review is to characterize the short-term effects of CT in the development of BD by focusing on studies in young people. The second objective is to describe the longer-term consequences of CT by considering studies with adult participants. This review first outlines the most prominent hypotheses linking CT exposure and the onset of BD. Then, it summarizes the psychological and biological risk factors implicated in the development of BD, followed by a discussion of original studies that investigated the role of CT in young people with early-onset BD, youths at increased risk of developing BD, or young people with BD with a focus on subclinical and clinical outcome measures. The review considers additional biological and psychological factors associated with a negative impact of CT on the long-term course of BD in later adulthood. Finally, we discuss how the integration of information of CT can improve ongoing early identification of BD and mitigate severe clinical expression in later adulthood.
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Affiliation(s)
- Yann Quidé
- School of Psychiatry, University of New South Wales (UNSW), Sydney, NSW, Australia
- Neuroscience Research Australia, Randwick, NSW, Australia
| | - Leonardo Tozzi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Mark Corcoran
- School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Dara M Cannon
- Centre for Neuroimaging & Cognitive Genomics (NICOG), Clinical Neuroimaging Laboratory, NCBES Galway Neuroscience Centre, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Maria R Dauvermann
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA, USA
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Edmiston EK, Fournier JC, Chase HW, Bertocci MA, Greenberg T, Aslam HA, Lockovich J, Graur S, Bebko G, Forbes EE, Stiffler R, Phillips ML. Assessing Relationships Among Impulsive Sensation Seeking, Reward Circuitry Activity, and Risk for Psychopathology: A Functional Magnetic Resonance Imaging Replication and Extension Study. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2020; 5:660-668. [PMID: 31862347 PMCID: PMC7202969 DOI: 10.1016/j.bpsc.2019.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND High trait impulsive sensation seeking (ISS), the tendency to engage in behavior without forethought and to seek out new or extreme experiences, is a transdiagnostic risk factor for externalizing and mood disorders, particularly bipolar disorder. We published a positive association between trait ISS and reward expectancy-related activity in the left ventrolateral prefrontal cortex (L vlPFC) and the ventral striatum. We aimed to replicate this finding and extend it by testing for mediation effects of ISS on relationships between reward expectancy-related activity and measures denoting hypomania. METHODS A transdiagnostic sample of 127 adults, 18 to 25 years of age, completed a card-guessing functional magnetic resonance imaging task as well as measures of ISS (inattention, motor impulsivity, fun seeking, positive and negative urgency) and the Moods Spectrum as a measure of hypomania. An original sample of 98 was included for confirmatory and mediation analyses. RESULTS We replicated a positive relationship between reward expectancy-related L vlPFC activity and negative urgency, an ISS component (β = .28, t = 2.44, p = .0169). We combined these data with the original sample, confirming this finding (β = .27, t = 2.41, p = .0184). Negative urgency statistically mediated the relationship between reward expectancy-related L vlPFC activity and Moods Spectrum factors associated with hypomania. No other associations between ISS measures and reward expectancy-related activity were replicated. CONCLUSIONS We replicated findings showing that reward expectancy-related L vlPFC activity is a biomarker for negative urgency, the tendency to react with frustration during distressing conditions. Negative urgency also statistically mediated the relationship between L vlPFC activity and measures indicative of hypomanic symptoms.
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Affiliation(s)
- E Kale Edmiston
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Jay C Fournier
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Henry W Chase
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michele A Bertocci
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Tsafrir Greenberg
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Haris A Aslam
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jeanette Lockovich
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Simona Graur
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Genna Bebko
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Erika E Forbes
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richelle Stiffler
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mary L Phillips
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Salazar de Pablo G, Guinart D, Cornblatt BA, Auther AM, Carrión RE, Carbon M, Jiménez-Fernández S, Vernal DL, Walitza S, Gerstenberg M, Saba R, Lo Cascio N, Brandizzi M, Arango C, Moreno C, Van Meter A, Correll CU. Demographic and Clinical Characteristics, Including Subsyndromal Symptoms Across Bipolar-Spectrum Disorders in Adolescents. J Child Adolesc Psychopharmacol 2020; 30:222-234. [PMID: 32083495 PMCID: PMC7232658 DOI: 10.1089/cap.2019.0138] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: Bipolar disorder (BD) is a debilitating illness that often starts at an early age. Prevention of first and subsequent mood episodes, which are usually preceded by a period characterized by subthreshold symptoms is important. We compared demographic and clinical characteristics including severity and duration of subsyndromal symptoms across adolescents with three different bipolar-spectrum disorders. Methods: Syndromal and subsyndromal psychopathology were assessed in adolescent inpatients (age = 12-18 years) with a clinical mood disorder diagnosis. Assessments included the validated Bipolar Prodrome Symptom Interview and Scale-Prospective (BPSS-P). We compared phenomenology across patients with a research consensus conference-confirmed DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnoses of BD-I, BD-not otherwise specified (NOS), or mood disorder (MD) NOS. Results: Seventy-six adolescents (age = 15.6 ± 1.4 years, females = 59.2%) were included (BD-I = 24; BD-NOS = 29; MD-NOS = 23) in this study. Median baseline global assessment of functioning scale score was 21 (interquartile range = 17-40; between-group p = 0.31). Comorbidity was frequent, and similar across groups, including disruptive behavior disorders (55.5%, p = 0.27), anxiety disorders (40.8%, p = 0.98), and personality disorder traits (25.0%, p = 0.21). Mania symptoms (most frequent: irritability = 93.4%, p = 0.82) and depressive symptoms (most frequent: depressed mood = 81.6%, p = 0.14) were common in all three BD-spectrum groups. Manic and depressive symptoms were more severe in both BD-I and BD-NOS versus MD-NOS (p < 0.0001). Median duration of subthreshold manic symptoms was shorter in MD-NOS versus BD-NOS (11.7 vs. 20.4 weeks, p = 0.002) and substantial in both groups. The most used psychotropics upon discharge were antipsychotics (65.8%; BD-I = 79.2%; BD-NOS = 62.1%; MD-NOS = 56.5%, p = 0.227), followed by mood stabilizers (43.4%; BD-I = 66.7%; BD-NOS = 31.0%; MD-NOS = 34.8%, p = 0.02) and antidepressants (19.7%; BD-I = 20.8%; BD-NOS = 10.3%; MD-NOS = 30.4%). Conclusions: Youth with BD-I, BD-NOS, and MD-NOS experience considerable symptomatology and are functionally impaired, with few differences observed in psychiatric comorbidity and clinical severity. Moreover, youth with BD-NOS and MD-NOS undergo a period with subthreshold manic symptoms, enabling identification and, possibly, preventive intervention of those at risk for developing BD or other affective episodes requiring hospitalization.
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Affiliation(s)
- Gonzalo Salazar de Pablo
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain
| | - Daniel Guinart
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, New York, USA
| | - Barbara A. Cornblatt
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York, USA.,Center for Psychiatric Neuroscience, The Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Andrea M. Auther
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York, USA
| | - Ricardo E. Carrión
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York, USA.,Center for Psychiatric Neuroscience, The Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Maren Carbon
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, New York, USA
| | - Sara Jiménez-Fernández
- Child and Adolescent Mental Health Unit, Jaén Medical Center, Jaén, Spain.,Department of Psychiatry, University of Granada, Granada, Spain
| | - Ditte L. Vernal
- Research Unit for Child- and Adolescent Psychiatry, Aalborg University Hospital, Aalborg, Denmark
| | - Susanne Walitza
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Miriam Gerstenberg
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Riccardo Saba
- Department of Mental Health, ASL Roma 6, Rome, Italy
| | - Nella Lo Cascio
- Prevention and Early Intervention Service, Department of Mental Health, ASL Roma 1, Rome, Italy
| | - Martina Brandizzi
- Department of Mental Health, Local Health Agency Rome 1, Inpatient Psychiatric Unit, Santo Spirito in Sassia Hospital, Rome, Italy
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain
| | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain
| | - Anna Van Meter
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York, USA.,Center for Psychiatric Neuroscience, The Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Christoph U. Correll
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, New York, USA.,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York, USA.,Center for Psychiatric Neuroscience, The Feinstein Institutes for Medical Research, Manhasset, New York, USA.,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany.,Address correspondence to: Christoph U. Correll, MD, Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, 75-59 263rd Street, Glen Oaks, NY 11004, USA
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10
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Andrade-González N, Álvarez-Cadenas L, Saiz-Ruiz J, Lahera G. Initial and relapse prodromes in adult patients with episodes of bipolar disorder: A systematic review. Eur Psychiatry 2020; 63:e12. [PMID: 32093795 PMCID: PMC7315869 DOI: 10.1192/j.eurpsy.2019.18] [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] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Distinguishing prodromes of bipolar disorder (BD) specific to children/adolescents, adults, and elderly patients is essential. The primary objective of this systematic review was to determine initial and relapse prodromes identifying adult patients with BD. METHODS PubMed, PsycINFO, and Web of Science databases were searched using a predetermined strategy. A controlled process of study selection and data extraction was performed. RESULTS The 22 articles selected included 1,809 adult patients with BD. Initial prodromes cited most frequently in these studies showed low specificity. Among relapse prodromes cited most frequently, more talkative than usual, increased energy/more goal-directed behavior, thoughts start to race, increased self-esteem, strong interest in sex, increase in activity, and spending too much were identified exclusively before a manic/hypomanic episode, while loss of interest and hypersomnia were detected only before a depressive episode. Initial prodromal phases lasted longer than prodromal relapse phases. In the selected studies, the most used prodrome identification procedure was the clinical interview. CONCLUSIONS For adult patients with BD, initial and relapse prodromes of manic, hypomanic, and depressive episodes were identified. It is proposed that the most frequent prodromes found in this review be incorporated into a smartphone app that monitors the functioning of people at risk of BD and patients who have already been diagnosed. Data from this app would constitute a relevant source of big data.
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Affiliation(s)
- Nelson Andrade-González
- Relational Processes and Psychotherapy Research Group, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain
| | | | - Jerónimo Saiz-Ruiz
- Ramón y Cajal University Hospital, Madrid, Spain.,Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.,IRyCIS, CIBERSAM, Madrid, Spain
| | - Guillermo Lahera
- Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.,IRyCIS, CIBERSAM, Madrid, Spain
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11
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Lippard ET, Nemeroff CB. The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders. Am J Psychiatry 2020; 177:20-36. [PMID: 31537091 PMCID: PMC6939135 DOI: 10.1176/appi.ajp.2019.19010020] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A large body of evidence has demonstrated that exposure to childhood maltreatment at any stage of development can have long-lasting consequences. It is associated with a marked increase in risk for psychiatric and medical disorders. This review summarizes the literature investigating the effects of childhood maltreatment on disease vulnerability for mood disorders, specifically summarizing cross-sectional and more recent longitudinal studies demonstrating that childhood maltreatment is more prevalent and is associated with increased risk for first mood episode, episode recurrence, greater comorbidities, and increased risk for suicidal ideation and attempts in individuals with mood disorders. It summarizes the persistent alterations associated with childhood maltreatment, including alterations in the hypothalamic-pituitary-adrenal axis and inflammatory cytokines, which may contribute to disease vulnerability and a more pernicious disease course. The authors discuss several candidate genes and environmental factors (for example, substance use) that may alter disease vulnerability and illness course and neurobiological associations that may mediate these relationships following childhood maltreatment. Studies provide insight into modifiable mechanisms and provide direction to improve both treatment and prevention strategies.
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Affiliation(s)
- Elizabeth T.C. Lippard
- Department of Psychiatry, Dell Medical School, University of Texas, Austin, TX, USA,Institute of Early Life Adversity Research, Dell Medical School, University of Texas, Austin, TX USA,Waggoner Center for Alcohol and Addiction Research, University of Texas, Austin, TX USA,Department of Psychology, University of Texas, Austin, TX, USA,Mulva Clinic for Neuroscience, Dell Medical School, University of Texas, Austin, TX
| | - Charles B. Nemeroff
- Department of Psychiatry, Dell Medical School, University of Texas, Austin, TX, USA,Institute of Early Life Adversity Research, Dell Medical School, University of Texas, Austin, TX USA,Waggoner Center for Alcohol and Addiction Research, University of Texas, Austin, TX USA,Mulva Clinic for Neuroscience, Dell Medical School, University of Texas, Austin, TX
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12
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A systematic review on sleep alterations anticipating the onset of bipolar disorder. Eur Psychiatry 2019; 58:45-53. [DOI: 10.1016/j.eurpsy.2019.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/23/2019] [Accepted: 02/08/2019] [Indexed: 12/14/2022] Open
Abstract
AbstractBackground:Sleep alterations are frequent occurrence in Bipolar Disorder (BD), both in acute and interepisodic phases. Sleep alterations have been also described both long before BD onset, as aspecific risk syndromes, or as immediate prodromes of BD onset. The aim of the present study is to systematically review the relationship between sleep alterations anticipating for the full-blown onset of BD, both in general and according to specific polarities of onset.Methods:A systematic literature research according to PRISMA statement and considering: 1. prospective studies about BD patients’ offspring with sleep alterations who later developed BD. 2. prospective studies assessing patients with sleep disorders who later developed BD. 3. retrospective studies on BD patients where sleep alterations before BD onset of the disease were reported.Results:A total of 16 studies were included in this review. Sleep disturbances may frequently appear 1 year before the onset of BD or more, often during childhood or adolescence. A decreased need for sleep may precede the onset of the illness, specially a manic episode, while insomnia appears to anticipate either a manic or a depressive episode. Hypersomnia seems to precede bipolar depressive episodes.Conclusions:Sleep alterations frequently appear long before the onset of BD, and appear to be related specifically to the polarity of the index episode. The detection and treatment of sleep alterations in special high risk populations may help achieving an earlier detection of the illness.
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13
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Cavicchioli FL, Maes M, Roomruangwong C, Bonifacio KL, Barbosa DS, Anderson G, Vargas HO, Nunes SOV. Associations between severity of anxiety and clinical and biological features of major affective disorders. Psychiatry Res 2018; 260:17-23. [PMID: 29156296 DOI: 10.1016/j.psychres.2017.11.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/25/2017] [Accepted: 11/06/2017] [Indexed: 12/24/2022]
Abstract
Patients with major affective disorders (MAFD) with comorbid anxiety show a greater functional impairment than those without anxiety. The aim of this study is to delineate the associations between severity of anxiety in MAFD, namely bipolar disorder (BD) and major depression (MDD), and MAFD characteristics and serum high-density lipoprotein (HDL)-cholesterol levels. Recruited were 82 participants with anxiety disoders and 83 without anxiety disoders, including 101 MAFD patients and 51 healthy controls. We used the Hamilton Anxiety Rating Scale (HAM-A) to measure severity of anxiety and made the diagnoses of posttraumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), panic disorder (PD), generalized anxiety disorder (GAD) and phobias. The HAM-A score is significantly predicted by higher number of depressive episodes, GAD and phobias, childhood trauma, tobacco use disorder, metabolic syndrome and lowered HDL-cholesterol. Increased HAM-A scores are, independently from severity of depression, associated with lowered quality of life, increased disabilities and suicidal ideation. Lithium treatment significantly lowers HAM-A scores. It is concluded that severity of anxiety significantly worsens the phenomenology of MAFD. Therefore, treatments of MAFD should target increased severity of anxiety and its risk factors including low HDL-cholesterol, metabolic syndrome, childhood trauma and tobacco use disorder.
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Affiliation(s)
| | - Michael Maes
- Health Sciences Graduation Program, Health Sciences Center, State University of Londrina, Brazil; Department of Psychiatry, Chulalongkorn University, Bangkok, Thailand; Impact Strategic Research Center, Deakin University, Geelong, Australia; Department of Psychiatry, Medical University of Plovdiv, Plovdiv, Bulgaria.
| | | | | | - Decio Sabbatini Barbosa
- Health Sciences Graduation Program, Health Sciences Center, State University of Londrina, Brazil
| | | | - Heber Odebrecht Vargas
- Health Sciences Graduation Program, Health Sciences Center, State University of Londrina, Brazil
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14
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Kim JS, Jin MJ, Jung W, Hahn SW, Lee SH. Rumination as a Mediator between Childhood Trauma and Adulthood Depression/Anxiety in Non-clinical Participants. Front Psychol 2017; 8:1597. [PMID: 28993746 PMCID: PMC5622198 DOI: 10.3389/fpsyg.2017.01597] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/31/2017] [Indexed: 11/25/2022] Open
Abstract
Objective: Although there is strong evidence that childhood trauma is associated with the development of depression and anxiety, relatively few studies have explored potential mediating factors for this relationship. The present study aimed to evaluate the mediating role of rumination in the link between childhood trauma and mood status such as depression, anxiety and affective lability. Materials and Methods: Two hundred and seven non-clinical participants completed the Childhood Trauma Questionnaire, the Ruminative Response Scale, the Beck Depression Inventory, the State Anxiety Inventory, and the Affective Lability Scale. Structural equation modeling was used to evaluate the results. Results: Our results supported that rumination is a meaningful mediator between childhood trauma and depression/anxiety in non-clinical participants. The mediation model indicated that childhood trauma and its subtypes are linked to depression and anxiety through three subtypes of rumination, thereby supporting a significant indirect relationship (Standardized coefficient [SC] = 0.56, p < 0.001 for the path from trauma to rumination; SC = 0.67, p < 0.001, from rumination to mood). The direct relationship between childhood trauma and mood symptoms was also significant in a model including rumination (SC = 0.68, p < 0.001). The mediation effect of rumination in the relationship between childhood trauma and mood was more predominant in female participants. Conclusions: The present study found that rumination mediates the influence of childhood trauma on the development of mood symptoms in non-clinical participants. Childhood trauma appears to be a critical determinant for developing symptoms of depression and anxiety.
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Affiliation(s)
- Ji S Kim
- Clinical Emotion and Cognition Research Laboratory, Inje UniversityGoyang, South Korea.,Department of Psychiatry, Soonchunhyang University of College of MedicineChunan, South Korea
| | - Min J Jin
- Clinical Emotion and Cognition Research Laboratory, Inje UniversityGoyang, South Korea.,Department of Psychology, Chung-Ang UniversitySeoul, South Korea
| | - Wookyoung Jung
- Clinical Emotion and Cognition Research Laboratory, Inje UniversityGoyang, South Korea
| | - Sang W Hahn
- Department of Psychiatry, Soonchunhyang University of College of MedicineSeoul, South Korea
| | - Seung-Hwan Lee
- Clinical Emotion and Cognition Research Laboratory, Inje UniversityGoyang, South Korea.,Department of Psychiatry, Inje University, Ilsan-Paik HospitalGoyang, South Korea
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15
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Brietzke E, Rosa AR, Pedrini M, Noto MN, Kapczinski F, Scott J. Challenges and developments in research of the early stages of bipolar disorder. ACTA ACUST UNITED AC 2016; 38:329-337. [PMID: 27533022 PMCID: PMC7111347 DOI: 10.1590/1516-4446-2016-1975] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/09/2016] [Indexed: 01/02/2023]
Abstract
Recently, attention in the field of bipolar disorder (BD) has focused on prevention, including early detection and intervention, as these strategies have the potential to delay, lessen the severity, or even prevent full-blown episodes of BD. Although knowledge of the neurobiology of BD has advanced substantially in the last two decades, most research was conducted with chronic patients. The objective of this paper is to comprehensively review the literature regarding the early stages of BD, to explore recent discoveries on the neurobiology of these stages, and to discuss implications for research and clinical care. The following databases were searched: PubMed, PsycINFO, Cochrane Library, and SciELO. Articles published in English from inception to December 2015 were retrieved. Several research approaches were used, including examination of offspring studies, retrospective studies, prospective studies of clinical high-risk populations, and exploration of the progression after the first manic episode. Investigations with neuroimaging, cognition assessments, and biomarkers provide promising (although not definitive) evidence of alterations in the neural substrate during the at-risk stage. Research on BD should be expanded to encompass at-risk states and aligned with recent methodological progress in neuroscience.
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Affiliation(s)
- Elisa Brietzke
- Grupo de Pesquisa em Neurociência Comportamental e Molecular do Transtorno Bipolar, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.,Laboratório Interdisciplinar de Neurociências Clínicas (LINC), UNIFESP, São Paulo, SP, Brazil.,Programa de Intervenção em Estados Mentais de Risco (PRISMA), Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil
| | - Adriane R Rosa
- Laboratório de Psiquiatria Molecular, Instituto Nacional de Ciência e Tecnologia - Medicina Translacional (INCT-TM), Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Medicina, Departamento de Psiquiatria, UFRGS, Porto Alegre, RS, Brazil.,Departamento de Farmacologia, UFRGS, Porto Alegre, RS, Brazil
| | - Mariana Pedrini
- Grupo de Pesquisa em Neurociência Comportamental e Molecular do Transtorno Bipolar, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.,Laboratório Interdisciplinar de Neurociências Clínicas (LINC), UNIFESP, São Paulo, SP, Brazil.,Programa de Intervenção em Estados Mentais de Risco (PRISMA), Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil
| | - Mariane N Noto
- Grupo de Pesquisa em Neurociência Comportamental e Molecular do Transtorno Bipolar, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.,Laboratório Interdisciplinar de Neurociências Clínicas (LINC), UNIFESP, São Paulo, SP, Brazil.,Programa de Intervenção em Estados Mentais de Risco (PRISMA), Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil
| | - Flavio Kapczinski
- Laboratório de Psiquiatria Molecular, Instituto Nacional de Ciência e Tecnologia - Medicina Translacional (INCT-TM), Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Medicina, Departamento de Psiquiatria, UFRGS, Porto Alegre, RS, Brazil
| | - Jan Scott
- Academic Psychiatry, Institute of Neuroscience, Newcastle University, UK.,Centre for Affective Disorders, Institute of Psychiatry, King's College London, London, UK
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