Adding Increased Energy or Activity to Criterion (A) of the DSM-5 Definition of Hypomania and Mania: Effect on the Diagnoses of 907 Patients From the Bipolar Collaborative Network

The state of (mis) trust: Human-centered technology development & implementation in intensive mental health settings

Innovative technology-based solutions in mental healthcare promise significant improvements in care quality and clinical outcomes. However, their successful implementation is profoundly influenced by the levels of trust patients hold toward their treatment providers, organizations, and the technology itself. This paper delves into the complexities of building and assessing patient trust within the intensive mental health care context, focusing on inpatient settings. We explore the multifaceted nature of trust, including interpersonal, institutional, and technological trust. We highlight the crucial role of therapeutic trust, which comprises both interpersonal trust between patients and providers, and institutional trust in treatment organizations. The manuscript identifies potential key barriers to trust, from sociocultural background to a patient's psychopathology. Furthermore, it examines the concept of technological trust, emphasizing the influence of digital literacy, socio-economic status, and user experience on patients' acceptance of digital health innovations. By emphasizing the importance of assessing and addressing the state of trust among patients, the overarching goal is to leverage digital innovations to enhance mental healthcare outcomes within intensive mental health settings.

Can daily actigraphic profiles distinguish between different mood states in inpatients with bipolar disorder? An observational study

Background

Criterion A changes for bipolar disorder (BD) in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition yield new difficulties in diagnosis. Actigraphy has been used to capture the activity features of patients with BD. However, it remains unclear whether long-term actigraphic data could distinguish between different mood states in hospitalized patients with BD.

Methods

In this observational study, 30 hospitalized patients with BD were included. Wrist-worn actigraphs were used to monitor motor activity. The patients were divided into bipolar disorder-depression (BD-D), bipolar disorder-mania (BD-M), and bipolar disorder-mixed state (BD-MS) groups. Motor activity differences were estimated using non-parametric analyses between and within the three groups.

Results

The mean 24 h activity level differed between the groups. In the between-group analysis, the intra-individual fluctuation and minute-to-minute variability in the morning and the mean activity level and minute-to-minute variability in the evening significantly differed between the BD-M and BD-MS groups. In the within-group analysis, the BD-M group showed a disrupted rhythm and reduced activity complexity at night. Both the BD-D and BD-MS groups demonstrated significant differences between several parameters obtained in the morning and evening.

Conclusion

The mean activity levels during the relatively long monitoring period and the intra-day variation within the groups could reflect the differences in motor activity. Sustained activity monitoring may clarify the emotional states and provide information for clinical diagnosis.

Bipolar disorder in the International Classification of Diseases-Eleventh version: A review of the changes, their basis, and usefulness

The World Health Organization’s 11^th revision of the International Classification of Diseases (ICD-11) including the chapter on mental disorders has come into effect this year. This review focuses on the “Bipolar or Related Disorders” section of the ICD-11 draft. It describes the benchmarks for the new version, particularly the foremost principle of clinical utility. The alterations made to the diagnosis of bipolar disorder (BD) are evaluated on their scientific basis and clinical utility. The change in the diagnostic requirements for manic and hypomanic episodes has been much debated. Whether the current criteria have achieved an optimum balance between sensitivity and specificity is still not clear. The ICD-11 definition of depressive episodes is substantially different, but the lack of empirical support for the changes has meant that the reliability and utility of bipolar depression are relatively low. Unlike the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5), the ICD-11 has retained the category of mixed episodes. Although the concept of mixed episodes in the ICD-11 is not perfect, it appears to be more inclusive than the DSM-5 approach. Additionally, there are some uncertainties about the guidelines for the subtypes of BD and cyclothymic disorder. The initial results on the reliability and clinical utility of BD are promising, but the newly created diagnostic categories also appear to have some limitations. Although further improvement and research are needed, the focus should now be on facing the challenges of implementation, dissemination, and education and training in the use of these guidelines.

DSM-5 and ICD-11 criteria for bipolar disorder: Implications for the prevalence of bipolar disorder and validity of the diagnosis - A narrative review from the ECNP bipolar disorders network

This narrative review summarizes and discusses the implications of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 and the upcoming International Classification of Diseases (ICD)-11 classification systems on the prevalence of bipolar disorder and on the validity of the DSM-5 diagnosis of bipolar disorder according to the Robin and Guze criteria of diagnostic validity. Here we review and discuss current data on the prevalence of bipolar disorder diagnosed according to DSM-5 versus DSM-IV, and data on characteristics of bipolar disorder in the two diagnostic systems in relation to extended Robin and Guze criteria: 1) clinical presentation, 2) associations with para-clinical data such as brain imaging and blood-based biomarkers, 3) delimitation from other disorders, 4) associations with family history / genetics, 5) prognosis and long-term follow-up, and 6) treatment effects. The review highlights that few studies have investigated consequences for the prevalence of the diagnosis of bipolar disorder and for the validity of the diagnosis. Findings from these studies suggest a substantial decrease in the point prevalence of a diagnosis of bipolar with DSM-5 compared with DSM-IV, ranging from 30-50%, but a smaller decrease in the prevalence during lifetime, corresponding to a 6% reduction. It is concluded that it is likely that the use of DSM-5 and ICD-11 will result in diagnostic delay and delayed early intervention in bipolar disorder. Finally, we recommend areas for future research.

Impact of modification to DSM-5 criterion A for hypomania/mania in newly diagnosed bipolar patients: findings from the prospective BIO study

Background

DSM-IV states that criterion A for diagnosing hypomania/mania is mood change. The revised DSM-5 now states that increased energy or activity must be present alongside mood changes to diagnose hypomania/mania, thus raising energy/activity to criterion A. We set out to investigate how the change in criterion A affects the diagnosis of hypomanic/manic visits in patients with a newly diagnosed bipolar disorder.

Results

In this prospective cohort study, 373 patients were included (median age = 32; IQR, 27–40). Women constituted 66% (n = 245) of the cohort and 68% of the cohort (n = 253) met criteria for bipolar type II, the remaining patients were diagnosed bipolar type I. Median number of contributed visits was 2 per subject (IQR, 1–3) and median follow-up time was 3 years (IQR, 2–4). During follow-up, 127 patients had at least one visit with fulfilled DSM-IV criterion A. Applying DSM-5 criterion A reduced the number of patients experiencing a hypomanic/manic visit by 62% at baseline and by 50% during longitudinal follow-up, compared with DSM-IV criterion A. Fulfilling DSM-5 criterion A during follow-up was associated with higher modified young mania rating scale score (OR = 1.51, CL [1.34, 1.71], p < 0.0001) and increased number of visits contributed (OR = 1.86, CL [1.52, 2.29], p < 0.0001).

Conclusion

Applying the stricter DSM-5 criterion A in a cohort of newly diagnosed bipolar patients reduced the number of patients experiencing a hypomanic/manic visit substantially, and was associated with higher overall young mania rating scale scores, compared with DSM-IV criterion A. Consequently, fewer hypomanic/manic visits may be detected in newly diagnosed bipolar patients with applied DSM-5 criterion A, and the upcoming ICD-11, which may possibly result in longer diagnostic delay of BD as compared with the DSM-IV.

Comorbid Bipolar and Alcohol Use Disorder-A Therapeutic Challenge

Comorbidity rates in Bipolar disorder rank highest among major mental disorders, especially comorbid substance use. Besides cannabis, alcohol is the most frequent substance of abuse as it is societally accepted and can be purchased and consumed legally. Estimates for lifetime comorbidity of bipolar disorder and alcohol use disorder are substantial and in the range of 40-70%, both for Bipolar I and II disorder, and with male preponderance. Alcohol use disorder and bipolarity significantly influence each other's severity and prognosis with a more complicated course of both disorders. Modern treatment concepts acknowledge the interplay between these disorders using an integrated therapy approach where both disorders are tackled in the same setting by a multi-professional team. Motivational interviewing, cognitive behavioral and socio- therapies incorporating the family and social environment are cornerstones in psychotherapy whereas the accompanying pharmacological treatment aims to reduce craving and to optimize mood stability. Adding valproate to lithium may reduce alcohol consumption whereas studies with antipsychotics or naltrexone and acamprosate did not affect mood fluctuations or drinking patterns. In summary, there is a continuous need for more research in order to develop evidence-based approaches for integrated treatment of this frequent comorbidity.

How Does Adding the DSM-5 Criterion Increased Energy/Activity for Mania Change the Bipolar Landscape?

According to DSM-IV, the criterion (A) for diagnosing hypomanic/manic episodes is mood change (i.e., elevated, expansive or irritable mood). Criterion (A) was redefined in DSM-5 in 2013, adding increased energy/activity in addition to mood change. This paper examines a potential change of prevalence data for bipolar I or II when adding increased energy/activity to the criterion (A) for the diagnosis of hypomania/mania. Own research suggests that the prevalence of manic/hypomanic episodes drops by at least one third when using DSM-5 criteria. Whether this has positive or negative impact on clinical practice and research still needs further evaluation.

Smartphone-based activity measurements in patients with newly diagnosed bipolar disorder, unaffected relatives and control individuals

BACKGROUND

In DSM-5 activity is a core criterion for diagnosing hypomania and mania. However, there are no guidelines for quantifying changes in activity. The objectives of the study were (1) to investigate daily smartphone-based self-reported and automatically-generated activity, respectively, against validated measurements of activity; (2) to validate daily smartphone-based self-reported activity and automatically-generated activity against each other; (3) to investigate differences in daily self-reported and automatically-generated smartphone-based activity between patients with bipolar disorder (BD), unaffected relatives (UR) and healthy control individuals (HC).

METHODS

A total of 203 patients with BD, 54 UR, and 109 HC were included. On a smartphone-based app, the participants daily reported their activity level on a scale from -3 to + 3. Additionally, participants owning an android smartphone provided automatically-generated data, including step counts, screen on/off logs, and call- and text-logs. Smartphone-based activity was validated against an activity questionnaire the International Physical Activity Questionnaire (IPAQ) and activity items on observer-based rating scales of depression using the Hamilton Depression Rating scale (HAMD), mania using Young Mania Rating scale (YMRS) and functioning using the Functional Assessment Short Test (FAST). In these analyses, we calculated averages of smartphone-based activity measurements reported in the period corresponding to the days assessed by the questionnaires and rating scales.

RESULTS

(1) Smartphone-based self-reported activity was a valid measure according to scores on the IPAQ and activity items on the HAMD and YMRS, and was associated with FAST scores, whereas the majority of automatically-generated smartphone-based activity measurements were not. (2) Daily smartphone-based self-reported and automatically-generated activity correlated with each other with nearly all measurements. (3) Patients with BD had decreased daily self-reported activity compared with HC. Patients with BD had decreased physical (number of steps) and social activity (more missed calls) but a longer call duration compared with HC. UR also had decreased physical activity compared with HC but did not differ on daily self-reported activity or social activity.

CONCLUSION

Daily self-reported activity measured via smartphone represents overall activity and correlates with measurements of automatically generated smartphone-based activity. Detecting activity levels using smartphones may be clinically helpful in diagnosis and illness monitoring in patients with bipolar disorder. Trial registration clinicaltrials.gov NCT02888262.

Hypomania/Mania by DSM-5 definition based on daily smartphone-based patient-reported assessments

INTRODUCTION

The DSM-5 has introduced elevated/irritable mood and increased activity/ energy as equal and necessary criterion A symptoms for a diagnosis of (hypo)mania. The impact of these changes is poorly elucidated. The aim of the study was to investigate differences in the prevalence of elevated/irritable mood with and without co-occurring increased activity, and the associations between these, in patients with an ICD-10 and DSM-IV diagnosis of BD, using real life daily smartphone-based patient-reported measures of mood, irritability and activity.

METHODS

Data from two RCTs investigating the effect of smartphone-based treatment in patients with BD were combined. Patients with BD (N = 117) evaluated mood, irritability and activity level daily for six to nine months via a smartphone-based system. Analyses in this study are exploratory post hoc analyses based on previously published data.

RESULTS

During the follow-up period, patients reported elevated mood 8.0% of the time, irritability 28.4% of the time and increased activity 20.6% of the time. Co-occurring elevated/irritable mood and activity were prevalent 0.12% of the time for four consecutive days (duration criteria for a hypomanic episode) compared to 24% of the time with elevated/irritable mood without co-occurring increased activity. In linear mixed effect models accommodating for inter-individual and intra-individual variation, there was a statistically significant positive association between mood and activity (B: 0.14, 95% CI: 0.046; 0.24, p = 0.004). There was no association between irritability and activity (p = 0.23).

CONCLUSION

Based on real life daily assessments, the prevalence of (hypo)manic episodes is substantial reduced as a result of the introduction of DSM-5 and with potentially clinical consequences.