Current practices of psychoeducation interventions with persons with bipolar disorders: a literature review

This review sought to summarize the literature on current practices and forms of psychoeducation in the management of patients with bipolar disorder (BD), including only randomized controlled trials to ensure the best level of evidence. An extensive review of the available literature was conducted using PubMed/MEDLINE, Embase, and PsychInfo databases from inception to April 28th, 2022. The search yielded 381 studies. Seventy articles were included after removing duplicates and applying the inclusion/exclusion criteria. A best-evidence synthesis was used to identify the key results of each study and summarize the outcomes. Eleven descriptive categories were made. They encompass different forms of psychoeducation compared or combined with other psychosocial interventions, varying in setting (individual or group), with or without family members, structured or unstructured, mediated or not by digital tools (smartphone, internet). Globally, these studies show that psychoeducation is important in the treatment of BD, as it leads to a decrease in relapses, mood episodes, hospitalizations, and improved functioning or quality of life. Some studies also showed the benefits of psychoeducation on the patient's level of knowledge of pharmacological treatment and the disorder or compliance with medication, as well as reduced self-stigma. The limitations of this review are linked to the selection of only RCTs and the reliance on their post-hoc analyses. This review confirms the benefit of psychoeducation and psychosocial interventions on the evolution of BD (in different outcomes, including quality of life, relapse, and rehospitalization rates, for example). More recent interventions, such as mindfulness or online psychoeducation, represent an interesting option but more evidence is needed.

Self-stigma and bipolar disorder: A systematic review and best-evidence synthesis

BACKGROUND

Bipolar disorder is a severe and chronic mental illness characterized by recurrent major depressive episodes and mania or hypomania. In addition to the burden of the disease and its consequences, self-stigma can impact people with bipolar disorder. This review investigates the current state of research in self-stigma in bipolar disorder.

METHODS

An electronic search was carried out until February 2022. Three academic databases were systematically searched, and best-evidence synthesis was made.

RESULTS

Sixty-six articles were related to self-stigma in bipolar disorder. Seven key themes were extracted from these studies: 1/ Comparison of self-stigma in bipolar disorder and other mental illnesses, 2/ Sociocultural context and self-stigma, 3/ Correlates and predictors of self-stigma, 4/ Consequences of self-stigma, 5/ Treatments and self-stigma, 6/ Management of self-stigma, and 7/ Self-stigma and recovery in bipolar disorder.

LIMITATIONS

Firstly, a meta-analysis could not be performed due to the heterogeneity of the studies. Secondly, limiting the search to self-stigma has excluded other forms of stigma that also have an impact. Thirdly, the under-reporting of negative or nonsignificant results due to publication bias and unpublished studies might have limited the accuracy of this reviews' synthesis.

CONCLUSION

Research on self-stigma in persons with bipolar disorder has been the focused on different aspects, and interventions to reduce self-stigmatization have been developed, but evidence of their effectiveness is still sparse. Clinicians need to be attentive to self-stigma, its assessment, and its empowerment in their daily clinical practice. Future work is required to establish valid strategies to fight self-stigma.

Perceived public stigma and perceived public exposure by persons living with bipolar disorder: A qualitative study

BACKGROUND

Stigma impact the lives of persons living with bipolar disorder.

AIM

The aim of this study was to explore how perceived public stigma is described by people living with bipolar disorder and examine the links between perceived public stigma and perceived public exposure.

METHOD

Face-to-face in-depth interviews were conducted in a purposive sample of euthymic people living with bipolar disorder recruited in a mood disorder ambulatory unit.

RESULTS

Thematic analysis of the transcript yielded five independent themes that were related to perceived public stigma. Perceived public stigma of bipolar disorder was modeled as comprising the three elements of public stigmas (stereotype, prejudice, and discrimination), with the addition of public exposure as a core component.

CONCLUSION

The representation of bipolar disorder in society via newspapers, films/TV series, conferences, and celebrity self-disclosures is considered to have multiple impacts. People living with bipolar disorder have also reported a perceived public stigma of bipolar disorder that has both specific features and characteristics of general mental illness.

Association between burnout and stigma in physicians

BACKGROUND

Physicians suffering from burnout are more likely to develop depression, substance dependence, and cardiovascular diseases, which can affect their practices. Stigmatization is a barrier to seeking treatment. This study aimed to understand the complex links between burnout among medical doctors and the perceived stigma.

METHODS AND FINDINGS

Online questionnaires were sent to medical doctors working in five different departments of the Geneva University Hospital. The Maslach Burnout Inventory (MBI) was used to assess burnout. The Stigma of Occupational Stress Scale in Doctors (SOSS-D) was used to measure the three stigma dimensions. Three hundred and eight physicians participated in the survey (response rate: 34%). Physicians with burnout (47%) were more likely to hold stigmatized views. Emotional exhaustion was moderately correlated with perceived structural stigma (r = 0.37, P < .001) and weakly correlated with perceived stigma (r = 0.25, P = 0.011). Depersonalization was weakly correlated with personal stigma (r = 0.23, P = 0.04) and perceived other stigma (r = 0.25, P = 0.018).

CONCLUSION

These results suggest the need to adjust for existing burnout and stigma management. Further research needs to be conducted on how high burnout and stigmatization impact collective burnout, stigmatization, and treatment delay.

[Stigma and self-stigma in psychiatric diseases: current issues and practices]

Stigmatization and self-stigmatization of people suffering from mental disorders have been denounced for several years, however they still impact treatment and identity construction. Education, social sharing, and institutional engagement are interventions that challenge public stigma. Interventions based on individual or group therapies that oppose self-stigma proved effective. Questions regarding the effects of media coverage or the intersectionality of stigmatized identities remain open. In this article, we made a summary of the current situation based on recent literature.

Is Coping with Stigma by Association Role-Specific for Different Family Members? A Qualitative Study with Bipolar Disorder Patients' Relatives

Trying to cope with stigma by association (SBA) often results in behaviors leading to social isolation and withdrawal. This study aimed at exploring the stigma-related experiences of family members of persons living with bipolar disorder (PW-BD). A semi-structured interview was conducted with relatives of PW-BD. Open-ended questions addressed three issues: awareness of public stigma of bipolar disorder, experiences of associative stigma, and ways of coping with experiences of SBA. Data were collected from a purposive sample of 21 family members. Experiences of SBA were specifically related to the different family roles. Parents had to deal with responsibility, partners with the choice of staying or not, and siblings with "a sort of duty." These specific prejudices enhanced specific coping strategies. This is the first study to highlight specific issues and coping from the perspective of family members. Based on these findings, specific targeted interventions could be developed.

Narrative enhancement and cognitive therapy (NECT) to improve social functioning in people with serious mental illness: study protocol for a stepped-wedge cluster randomized controlled trial

Background

Self-stigma is highly prevalent in serious mental illness (SMI) and is associated with poorer clinical and functional outcomes. Narrative enhancement and cognitive therapy (NECT) is a group-based intervention combining psychoeducation, cognitive restructuring and story-telling exercises to reduce self-stigma and its impact on recovery-related outcomes. Despite evidence of its effectiveness on self-stigma in schizophrenia-related disorders, it is unclear whether NECT can impact social functioning.

Methods

This is a 12-centre stepped-wedge cluster randomized controlled trial of NECT effectiveness on social functioning in SMI, compared to treatment as usual. One hundred and twenty participants diagnosed with schizophrenia, bipolar disorder or borderline personality disorder will be recruited across the 12 sites. The 12 centres participating to the study will be randomized into two groups: one group (group 1) receiving the intervention at the beginning of the study (T0) and one group (group 2) being a control group for the first 6 months and receiving the intervention after (T1). Outcomes will be compared in both groups at T0 and T1, and 6-month and 12-month outcomes for groups 1 and 2 will be measured without a control group at T2 (to evaluate the stability of the effects over time). Evaluations will be conducted by assessors blind to treatment allocation. The primary outcome is personal and social performance compared across randomization groups. Secondary outcomes include self-stigma, self-esteem, wellbeing, quality of life, illness severity, depressive symptoms and personal recovery.

Discussion

NECT is a promising intervention for reducing self-stigma and improving recovery-related outcomes in SMI. If shown to be effective in this trial, it is likely that NECT will be implemented in psychiatric rehabilitation services with subsequent implications for routine clinical practice.

Trial registration

ClinicalTrials.gov NCT03972735. Trial registration date 31 May 2019.

Self-Destigmatization Process? Experiences of Persons Living with Bipolar Disorder: A Qualitative Study

This qualitative study investigated subjective experiences of self-stigmatization and self-destigmatization among people living with bipolar disorder (BD). We conducted in-depth interviews focusing on self-stigmatization and self-destigmatization with 22 individuals living with BD. The interview transcripts were thematically analyzed using a mixed inductive and deductive approach. Thirty-six codes were extracted and organized into six themes: language, behaviors, relationships, personal experience, identity, and healthcare. Each theme was characterized by an evolution process, and the codes were distributed in a step-by-step order as landmarks. The process begins with the experience of self-stigmatization, and develops toward self-destigmatization. This study presents a new six-dimension process called the "self-destigmatization process" (SDP), a personal and interrelational process that deconstructs self-stigmatization. Clinicians can use the landmarks of the process for clinical assessment and therapeutic interventions to increase recovery orientation.

Follow-up study of 67 first episode schizophrenic patients and their involvement in religious activities

We studied the characteristics of religious practice in a cohort of 67 first admission schizophrenic patients over 5 years. Thirty percent of these patients were involved in religious activities, either with an established religion or in a marginal group. They were mostly women, who had a good premorbid psychosocial adaptation and tended not to be substance abusers. Their social adaptation was improved at year 5. They were as compliant with their ambulatory treatment as the other patients. However, when controlling for the inclusion characteristics, a similar outcome was shown between the group of practicing patients and the nonpracticing group. Religious activity may not be by itself the cause of this favorable outcome, as it is probable that only the patients who are less symptomatic and relatively well adapted could actually join a religious movement. The fact that many schizophrenic patients find an occupation and relationships in religious activities that they would not find elsewhere should encourage the psychiatric community target its occupational goals.

Resting-state functional connectivity of emotion regulation networks in euthymic and non-euthymic bipolar disorder patients

Background

Previous functional magnetic resonance imaging studies in bipolar disorder (BD) have evidenced changes in functional connectivity (FC) in brain areas associated with emotion processing, but how these changes vary with mood state and specific clinical symptoms is not fully understood.

Methods

We investigated resting-state FC between a priori regions of interest (ROIs) from the default-mode network and key structures for emotion processing and regulation in 27 BD patients and 27 matched healthy controls. We further compared connectivity patterns in subgroups of 15 euthymic and 12 non-euthymic patients and tested for correlations of the connectivity strength with measures of mood, anxiety, and rumination tendency. No correction for multiple comparisons was applied given the small population sample and pre-defined target ROIs.

Results

Overall, regardless of mood state, BD patients exhibited increased FC of the left amygdala with left sgACC and PCC, relative to controls. In addition, non-euthymic BD patients showed distinctive decrease in FC between right amygdala and sgACC, whereas euthymic patients showed lower FC between PCC and sgACC. Euthymic patients also displayed increased FC between sgACC and right VLPFC. The sgACC–PCC and sgACC–left amygdala connections were modulated by rumination tendency in non-euthymic patients, whereas the sgACC-VLPFC connection was modulated by both the current mood and tendency to ruminate.

Conclusions

Our results suggest that sgACC-amygdala coupling is critically affected during mood episodes, and that FC of sgACC play a pivotal role in mood normalization through its interactions with the VLPFC and PCC. However, these preliminary findings require replication with larger samples of patients.

Internalized stigmatization in borderline personality disorder and attention deficit hyperactivity disorder in comparison to bipolar disorder

INTRODUCTION

Internalized stigma constitutes a major concern in mental health illness. It has numerous repercussions on patients, including poor self-esteem, higher illness severity, poor adherence to care and reduced global functioning. The goal of this study was to compare internalized stigma between three diagnoses frequently seen in psychiatric practice: Borderline personality disorder (BPD), Attention deficit-hyperactivity disorder (ADHD) and Bipolar disorder (BD).

METHODS

A total of 244 French-speaking patients were recruited in a specialized psychiatric center at University Hospitals of Geneva, Switzerland. 39 patients had a diagnosis of BPD, 136 had ADHD and 69 had BD. Every subjects completed the Internalized Stigma of Mental Illness (ISMI) scale, which is the most widely used scale employed to measure of internalized stigma. One way ANOVA analysis with adjustment on age and gender was done to compare the three groups (BPD, ADHD, BD).

RESULTS

Participants with BPD reported higher ISMI score than subjects with ADHD and BD. BD experienced more internalized-stigma than ADHD. Higher ISMI score was also associated with higher severity of the respective disorder, poorer quality of life and unemployment.

LIMITATIONS

Limitations of this research include the small sample, especially in BPD group. A disequilibrium between male and female subjects can also impact our results. Observational nature of our study mean that we can only make correlation between variables and not infer causality. Finally, other confounding factors not taken into account in this study may have had influence on stigma.

CONCLUSIONS

Our findings are coherent with recent literature on BPD reporting high level of distress and of stigmatization. This has serious consequences on provided care and need to be address by mental health professionals to assure the optimal service to this population.

Bipolar spectrum disorder: What evidence for pharmacological treatment? A systematic review

BACKGROUND AND OBJECTIVES

Bipolar spectrum disorder (BSD) is an extended concept of bipolar disorder (BD) that includes conditions that do not fulfill the criteria. There is no recommendation today about its treatment. We reviewed relevant literature focusing on pharmacological treatments, looking for high-strength evidence leading to guidelines.

METHODOLOGY

A literature search was conducted using MedLine / PubMed database and Google Scholar up to September 2018. Search words were related to BSD and pharmacological treatment.

RESULTS

The literature search yielded 621 articles. Out of these, 35 articles met our selection criteria. There was limited high quality data. Only one randomized control trial (RCT) and one randomized open label trial were found. Most studies used different definition of BSD.

CONCLUSIONS

There is a considerable lack of data and no evidence supporting efficacy of pharmacological treatment for BSD. There is a need for a consensus on the definition of BSD and more evidence studies to evaluate drug's effectiveness in this condition.

Modulation of brain response to emotional conflict as a function of current mood in bipolar disorder: preliminary findings from a follow-up state-based fMRI study

We used functional magnetic resonance imaging (fMRI) to examine affective control longitudinally in a group of patients with bipolar disorder (BD). Participants comprised 12 BD patients who underwent repeated fMRI scans in euthymic (n=11), depressed (n=9), or hypomanic (n=9) states, and were compared with 12 age-matched healthy controls. During fMRI, participants performed an emotional face-word interference task with either low or high attentional demands. Relative to healthy controls, patients showed decreased activation of the cognitive control network normally associated with conflict processing, more severely during hypomania than during depression, but regardless of level of task demand in both cases. During euthymia, a decreased response to conflict was observed only during the high load condition. Additionally, unlike healthy participants, patients exhibited deactivation in several key areas in response to emotion-conflict trials - including the rostral anterior cingulate cortex during euthymia, the hippocampus during depression, and the posterior cingulate cortex during hypomania. Our results indicate that the ability of BD patients to recruit control networks when processing affective conflict, and the abnormal suppression of activity in distinct components of the default mode network, may depend on their current clinical state and attentional demand.

Subjective experience of thought overactivation in mood disorders: beyond racing and crowded thoughts

BACKGROUND

Racing thoughts, crowded thoughts and flight of ideas are frequent symptoms in mood disorders, but the underlying subjective experience of overactivation of thought processes remains poorly documented.

METHODS

Qualitative analysis of audiotaped interviews explored subjective experience of thought overactivation in patients with mood disorders (sample 1, n = 45). Quantitative analysis considered the properties of a newly developed rating scale in sample 1, in an additional sample of patients with mood disorders (sample 2, n = 37) and in healthy subjects (sample 3, n = 38).

RESULTS

Qualitative analysis of individual interviews revealed that 5 conceptual categories characterized thought overactivation: sequential thought flow, overstimulation, competition for resource allocation, unexpected/unexplained onset, and association with mood and emotions. A principal component analysis of the initial 16-item rating scale indicated that a single component explained 55.9% of the variance, with major and exclusive contributions from 9 items, which were retained in the final 9-item Subjective Thought Overactivation Questionnaire (STOQ; Cronbach's α = 0.95). Total score correlated significantly with activation, depression and perceived conflict subscales of the Internal State Scale (ISS; rs = 0.57-0.66, p < 0.001). It was associated with decreased well-being (ISS; rs = -0.48, p = 0.001) and increased state anxiety (State-Trait Anxiety Inventory; rs = 0.60, p < 0.001). The STOQ score was significantly higher in patients than in healthy subjects. It allowed distinguishing between ISS mood states, with the highest median score in mixed states.

LIMITATIONS

Sample size, representativeness, possible bias in qualitative analysis, and quality of expert consensus.

CONCLUSIONS

Qualitative analysis of clinical interviews, together with a new short rating scale, contributed to a documentation of subjective thought overactivation, an important but often undetected feature in mood disorders.

Childhood maltreatment and methylation of the glucocorticoid receptor gene NR3C1 in bipolar disorder

BACKGROUND

Early-life adversities represent risk factors for the development of bipolar affective disorder and are associated with higher severity of the disorder. This may be the consequence of a sustained alteration of the hypothalamic-pituitary-adrenal (HPA) axis resulting from epigenetic modifications of the gene coding for the glucocorticoid receptor (NR3C1).

AIMS

To investigate whether severity of childhood maltreatment is associated with increased methylation of the exon 1F NR3C1 promoter in bipolar disorder.

METHOD

A sample of people with bipolar disorder (n = 99) were assessed for childhood traumatic experiences. The percentage of NR3C1 methylation was measured for each participant.

RESULTS

The higher the number of trauma events, the higher was the percentage of NR3C1 methylation (β = 0.52, 95% CI 0.46-0.59, P<<0.0001). The severity of each type of maltreatment (sexual, physical and emotional) was also associated with NR3C1 methylation status.

CONCLUSIONS

Early-life adversities have a sustained effect on the HPA axis through epigenetic processes and this effect may be measured in peripheral blood. This enduring biological impact of early trauma may alter the development of the brain and lead to adult psychopathological disorder.

Affective temperaments in alcohol and opiate addictions

Temperament is considered as a biological disposition reflected by relatively stable features related to mood and reactivity to external and internal stimuli, including variability in emotional reactions. The aim of the present study is to test the hypothesis that affective temperaments might differ according to co-occurring mood disorders among patients with alcohol and/or opiate dependence; to explore the relationship between temperaments and dual substance use disorders (SUDs, alcohol and other drugs). Ninety-two patients attending an alcohol addiction treatment facility and 47 patients in an opiate addiction treatment facility were assessed for SUDs, mood disorders and affective temperaments using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego 39-item auto-questionnaire. Comparison of patients with bipolar disorder, depressive unipolar disorder and no (or substance-induced) mood disorder revealed significant differences for the cyclothymic subscale, with highest scores among patients with bipolar disorder. No difference was observed for the depressive, irritable, hyperthymic and anxious subscales. After adjustment for age, gender and bipolar disorder, irritable temperament was a significant risk factor for past or present history of drug use disorders in patients treated for alcohol addiction (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.05-1.93). Anxious temperament was a significant risk factor for history of alcohol use disorders in patients treated for opiate addiction (OR 3.30, 95% CI 1.36-7.99), whereas the hyperthymic subscale appeared as a significant protective factor (OR 0.65, 95% CI 0.42-0.99). The results highlight the need to consider temperamental aspects in further research to improve the long-term outcome of patient with addictive disorders, who often present complex comorbidity patterns.

Mental disorders in offspring of parents with bipolar and major depressive disorders

OBJECTIVES

There is limited information on the specificity of associations between parental bipolar disorder (BPD) and major depressive disorder (MDD) and the risk of psychopathology in offspring. The chief aim of the present study was to investigate the association between mood disorder subtypes in the two parents and mental disorders in the offspring.

METHODS

A total of 376 offspring (aged 6.0-17.9 years; mean=11.5years) of 72 patients with BPD (139 offspring), 56 patients with MDD (110 offspring), and 66 controls (127 offspring) participated in a family study conducted in two university hospital centers in Switzerland. Probands, offspring, and biological co-parents were interviewed by psychologists blind to proband diagnoses, using a semi-structured diagnostic interview.

RESULTS

Rates of mood and anxiety disorders were elevated among offspring of BPD probands (34.5% any mood; 42.5% any anxiety) and MDD probands (25.5% any mood; 44.6% any anxiety) as compared to those of controls (12.6% any mood; 22.8% any anxiety). Moreover, recurrent MDD was more frequent among offspring of BPD probands (7.9%) than those of controls (1.6%). Parental concordance for bipolar spectrum disorders was associated with a further elevation in the rates of mood disorders in offspring (64.3% both parents versus 27.2% one parent).

CONCLUSIONS

  These findings provide unique information on the broad manifestations of parental mood disorders in their offspring. The earlier onset and increased risk of recurrent MDD in the offspring of parents with BPD compared to those of controls suggests that the episodicity characterizing BPD may emerge in childhood and adolescence.

Frequency of dysphoria and mixed states

BACKGROUND

Mixed states are a complex entity in the field of mood disorders. Dysphoria has been advocated as an important clinical dimension of mixed states. The objective of this work is to study the frequency of dysphoria within a population of patients with DSM-IV major depressive and/or manic episodes and to determine if it may help establish diagnostic criteria for subthreshold cases of depressive or manic mixed states.

SAMPLING AND METHODS

A total of 165 patients were assessed using the Mini International Neuropsychiatric Interview complemented by a section defining dysphoria as a constellation of 3 among 4 symptoms (inner tension, irritability, aggressive behavior and hostility).

RESULTS

When classifying patients according to the number of symptoms of the opposite polarity, changes in the frequency of dysphoria revealed a clear contrast between the 2 opposite manic and depressive poles and the full mixed state (DSM-IV definition). The frequency of dysphoria was 17.5% in pure depression, 22.7% in pure mania and 73.3% in full mixed state. Two threshold effects were identified: (1) the frequency of dysphoria increased from 17.5 to 61.1% (p = 0.002) when the number of manic symptoms in DSM-IV depressed patients increased from 0 to 1, and (2) dysphoria increased from 14.3 to 69.2% (p = 0.057) when the number of depressive symptoms increased from 2 to 3 in DSM-IV manic patients.

CONCLUSION

Dysphoria is strongly but not necessarily associated with mixed states. When used as a clinical marker for mixed states, dysphoria confirms the modern delimitations of sub-threshold mixed states by specifying the required number of symptoms of the opposite polarity (which could be lower for depressive mixed states than for manic mixed states). The study has limitations related to the inclusion of patients who are not drug-free, to the definition of dysphoria and to the sample size.

Phenomenology of mixed states: a principal component analysis study

OBJECTIVES

To contribute to the definition of external and internal limits of mixed states and study the place of dysphoric symptoms in the psychopathology of mixed states.

METHODS

One hundred and sixty-five inpatients with major mood episodes were diagnosed as presenting with either pure depression, mixed depression (depression plus at least three manic symptoms), full mixed state (full depression and full mania), mixed mania (mania plus at least three depressive symptoms) or pure mania, using an adapted version of the Mini International Neuropsychiatric Interview (DSM-IV version). They were evaluated using a 33-item inventory of depressive, manic and mixed affective signs and symptoms.

RESULTS

Principal component analysis without rotation yielded three components that together explained 43.6% of the variance. The first component (24.3% of the variance) contrasted typical depressive symptoms with typical euphoric, manic symptoms. The second component, labeled 'dysphoria', (13.8%) had strong positive loadings for irritability, distressing sensitivity to light and noise, impulsivity and inner tension. The third component (5.5%) included symptoms of insomnia. Median scores for the first component significantly decreased from the pure depression group to the pure mania group. For the dysphoria component, scores were highest among patients with full mixed states and decreased towards both patients with pure depression and those with pure mania.

CONCLUSIONS

Principal component analysis revealed that dysphoria represents an important dimension of mixed states.

Social phobia is associated with suicide attempt history in bipolar inpatients

OBJECTIVES

In an attempt to reduce the phenotypical heterogeneity in an ongoing genetic study of suicidal behavior, we investigated the impact of comorbid anxiety disorders on suicidal behavior in bipolar disorder (BD) patients.

METHODS

Anxiety disorders were compared in 406 BD I and BD II patients with or without lifetime history of suicide attempt.

RESULTS

Among anxiety disorders, only social phobia (SP) was significantly associated with history of suicide attempt in BD [p<0.001, odds ratio 4.26 (2.284-7.946)]. Moreover, onset of SP was found to precede onset of BD.

CONCLUSIONS

This result suggests that SP is an important risk factor for suicidal behavior in BD. Further studies are required to determine whether comorbid SP may help to identify a more homogeneous BD sub-group, especially when studies of suicidal behavior are conducted. A second question is whether SP identifies a sub-group of subjects with BD who have a more severe illness course and whether treatment of SP with selective serotonin reuptake inhibitor (SSRI) antidepressants is associated with improvement or worsening of the course of BD.

Olanzapine plasma level in relation to antimanic effect in the acute therapy of manic states

The aim of this study was to evaluate internal as well as external validity of the two most frequently used mania scales, the Young Mania Rating Scale (YMRS) and the Bech-Rafaelsen Mania Scale (MAS), in patients with DSM-IV mania. Mokken analysis was used to evaluate internal validity in which a coefficient of homogeneity of 0.40 or higher indicates that the total score is a sufficient statistic. The external validity was evaluated by plasma-level relationship of olanzapine. In total, 20 patients with DSM-IV mania were analysed, and the coefficient of homogeneity was acceptable for the MAS, but not for the YMRS. In a subgroup of females who over 2 weeks had received a fixed dose of 20 mg olanzapine daily, a significant association was found between MAS scores and plasma levels, but this association was not obtained with the YMRS. In conclusion, the MAS was found superior to the YMRS in regard to both internal and external validity.

[Body contouring surgery after massive weight loss]

After massive weight loss, former obese patients have adipose and cutaneous excess, the skin has lost all its elasticity. Functional and psychological consequences can be significant. Between January 2000 and January 2005, 122 patients underwent some kind of plastic surgery following massive weight loss. In more than 90% of thecases, patients underwent abdominoplasty, associated with liposuction, breast surgery, thighs or arms dermolipectomy or facelift. Multiple simultaneous body contouring surgeries on a single patient is often performed because it's convenient and does not increase morbidity, as long as operative time and blood loss is limited. Overall patient's satisfaction is good, and a favorable impact on quality of life is demonstrated.

Lithium augmentation in venlafaxine non-responders: an open study

Thirteen major depressive patients not responding to a 4-week venlafaxine 300 mg treatment were eligible for a 4-week open trial of lithium addition. Two patients had to stop lithium for a possible moderate serotonin syndrome and five patients became responders, including one dramatic response and two semi-rapid responses.

[Translation and validation of a French version of the Young Mania Rating Scale (YMRS)]

Both the Young Mania Rating Scale (YMRS) and the Mania Assessment Scale (MAS) have been widely used during the last decade for the evaluation of severity of mania in clinical trials. For both scales good inter-rater reliability, validity and sensitivity to change have been reported. The French version of the MAS has been validated. To our know-ledge, the YMRS has not yet been translated into French and validated. The main objective of the present study was to validate a French version of the YMRS and to test its use in manic patients entering a study on the effectiveness of valproic acid and olanzapine combination. After translating the items in French, we tested this version of the YMRS on two samples of psychiatric patients recruited in a ward of adult inpatients (18 to 65 Years old) at the Department of Psychiatry, Geneva University Hospital. The first sample included 18 (hypo) manic inpatients (10 males, 8 females). Mean age was 37.0 (standard deviation 10.1). Interviews were video taped and assessed by three different judges on both scales (YMRS and MAS). The second sample included 20 inpatients (5 males, 15 females) who provided written informed consent to enter a study on the association of valproic acid and olanzapine in the treatment of mania. Mean age was 40.0 (standard deviation 11.3). Patients were followed over four weeks and assessed on both scales (YMRS and MAS) every seven days (day 0, 7, 14, 21 and 28). On day 7, patients were assessed during a joint interview by two of three judges who independently administered both scales in permuted order. On days 0, 14, 21 and 28, patients were evaluated by one of the same three raters. Inter-rater reliability was assessed by comparing item scores and total scores assigned by different judges with intra-class correlation coefficient ICC (2,1). Three judges were considered for patients in sample 1. Two judges were considered for patients in sample 2 (day 7 assessment). Concurrent validity with the MAS was analysed in sample 2 on days 0, 7, 14, 21 and 28 using Spearman rank-order correlation coefficient. Sensitivity to change was assessed in sample 2 by comparing total score at inclusion and at last observation using Wilcoxon signed ranks test. For both the MAS and YMRS, intraindividual change was calculated as the difference between total scores at inclusion and discharge (last observation carried forward approach). The relationship between changes on the two scales was analysed through Spearman correlation coefficient. Significance level was set to 0.05 for each test. Ranges of YMRS total scores were 2 to 32 in sample 1 and 1 to 28 in sample 2, indicating symptom severity from euthymic to moderately manic. Inter-rater reliability was very good for the total scores in both samples, both for the MAS and the YMRS (ICC>0.89). When considering YMRS individual items, correlation coefficient varied from 0.61 to 0.96 in the first sample. In the second sample, 9 of 11 items displayed values above 0.63. The remaining two items, increased motor activity and energy and Language-thought disorder, presented modest inter-rater reliability (ICC=0.54 and 0.50 respectively). This was largely attributable to a single patient, who was perceived very differently by the two judges (scores 0-2 for increased motor activity and energy; 1-4 for Language-thought disorder). When this patient was excluded, intra-class correlation coefficients were above 0.69 for both items. Overall, inter-rater reliability of the YMRS items was in the same range as for the MAS items (0.61-0.96 vs 0.61-0.93 in sample 1; 0.50-0.93 vs 0.54-0.83 in sample 2). Correlation between the two instruments was very high and statistically significant at each weekly assessment (rs>0.91, p<0.001) except for day 21 which displayed a somewhat lower correlation (rs=0.75, p<0.01). This latter result was attributed to a reduced spread of values and number of patients on day 21. YMRS and MAS total scores as a function of time in patients receiving combined treatment with olanzapine and valproic acid (sample 2) show that for both at for both scales, total scores significantly decreased from day 0 to last observation (Wilcoxon signed ranks test, p<0.001), with median decrease of 18 points both on the YMRS (range 9-32) and MAS (range 10-33). Median relative decrease was 67% for the YMRS and 69% for the MAS. When analysing the relationship between intraindividual changes on the YMRS and MAS, highly significant correlation was observed (Spearman rs=0.93, p<0.001), showing that the two scales were virtually interchangeable in assessing treatment efficacy. In conclusion, the YMRS is a simple and easy-to-use instrument for measuring severity of manic symptoms The newly translated French version was satisfactory in terms of inter-rater reliability, concurrent validity with the MAS, and sensitivity to change in patients receiving treatment for manic symptoms. This should allow its future use for international comparison studies.

Efficacy of etodolac on gait in hip osteoarthritis as assessed by Bessou's locometer: a randomized, crossover, double-blind study versus placebo. Groupe de Recherche sur le Handicap de L'appareil Locomoteur

OBJECTIVES

To assess the efficacy of a single, oral dose of etodolac (300 mg), a nonsteroidal antiinflammatory drug, on gait and pain in patients with unilateral hip osteoarthritis (hOA).

DESIGN

Sixteen patients (8 F, 8 M; mean age: 61+/-11.2 years) with painful hOA were included in a randomized, crossover, double-blind study versus placebo. Space and time parameters were assessed using Bessou's locometer and pain was evaluated using the visual analog scale (VAS) at t0 (before taking the drug), t60 (min), t120, and t180 after taking a 300-mg tablet of etodolac.

RESULTS

Walking speed was significantly faster only between t0 and t180 under etodolac versus placebo (P< 0.02). Walking speed increased between t0, t60, t120 and t180 with etodolac (P< 0.003), but not with placebo. Stride length increased (P< 0.0001) only on the hOA side, while the time parameters of gait for etodolac- and placebo-treated patients did not differ. VAS values differed significantly at t0 (P< 0.01) between etodolac and placebo groups, but no significant difference was observed at t60, t120 and t180.

CONCLUSIONS

Bessou's locometer was able to demonstrate the efficacy of 300 mg of etodolac on gait in hOA. Walking speed was faster 3 h after taking the drug, essentially due to a greater stride length. Pain reduction in the etodolac group contributed to gait improvement. It was concluded that gait performances improved because of less hip pain and thus a greater range of motion after etodolac intake.

The analysis of peculiar urinary (and other) calculi: an endless source of challenge

The exact composition of calculi is clinically important, but many specimens are not examined, with resultant loss of important information. We describe the incidence and nature of false stones, peculiar calculi and crystals growing on surprising materials. We studied 3100 calculi (97% urinary, 2% digestive and 1% others). Fourier transform infrared spectroscopy was used to identify calculi by detailed comparison with libraries of reference spectra. We also used UV-visible spectroscopy, nuclear magnetic resonance and gas chromatography-mass spectrometry for specific situations. Among 3100 calculi, 154 (5%) had an unusual composition; 101 specimens (3.3%) were false calculi or artifacts, 31 (1%) contained drugs or metabolites and 22 (0.7%) corresponded to crystallizations around other materials. The findings contribute to immediate patient management and to advances in scientific and medical knowledge. We conclude that the analysis of all calculi must be carried out, to determine their composition, and an efficient strategy must be used.

[Monolobar Caroli's disease. Apropos of 12 cases]

BACKGROUND

Caroli's disease is the dilatation of the segmental intrahepatic bile ducts. It usually affects the entire liver but can occasionally involve only one lobe, commonly the left. This study included 12 cases of unilobular disease, nine localised in the left lobe and three in the right lobe, which were all treated by liver resection.

PATIENTS AND METHODS

These 12 patients underwent surgery between 1974 and 1997. There were six men and six women (mean age: 51 years). The initial presentation and diagnosis were reported. The mean interval between the first symptoms and diagnosis was 12.5 years. Eight of the 12 patients had undergone 22 surgical or endoscopic procedures prior to liver resection. In the present series a preoperative ultrasonogram or CT scan established the diagnosis in all cases. Six patients did not have stones in the gallbladder.

RESULTS

Surgical treatment consisted in seven left lobectomies, two left hepatectomies and three right hepatectomies (Couinaud's classification). A intrahilar cholangiojejunostomy was performed in five cases. Pathological examination showed cystic dilatation of the intrahepatic segmental and subsegmental bile ducts, measuring from a few millimetres to 4 cm, which contained calculi. Two cases were associated with congenital hepatic fibrosis. An intrahepatic focus of ectopic pancreatic tissue was seen in one case. There were no cases with cholangiocarcinoma. One patient developed a biliary fistula which required reoperation. All patients had an uneventful long term postoperative course except for one patient who died of colon carcinoma 3 years postoperatively.

CONCLUSION

When associated with other malformations, most notably congenital hepatic fibrosis, this commonly diffuse disease is called Caroli's syndrome. The unilobar form, most usually involving the left lobe of the liver, is called Caroli's disease. Both monolobar and diffuse types are often characterised by recurrent bouts of cholangitis and, in over half of the cases, by common bile duct stones without gallbladder stones.

Molecular diagnosis of Ureaplasma urealyticum in an immunocompetent patient with destructive reactive polyarthritis

Polymerase chain reaction (PCR) amplification, which is a useful method for detecting infectious agents in joints, has potential utility in the molecular diagnosis of venereal-associated arthritis. Among pathogens detected by this technique, Ureaplasma urealyticum, which is primarily associated with reactive arthritis (ReA), is also implicated in septic arthritis in immunocompromised patients. We report here a case of destructive polyarthritis, initially suggestive of septic arthritis, in an immunocompetent patient whose PCR positivity for U. urealyticum DNA in one joint, in conjunction with the disease outcome and histologic findings, led to the diagnosis of destructive ReA.

The use of the Expressed Emotion Index as a predictor of outcome in first admitted schizophrenic patients in a French speaking area of Switzerland

A 5 year prospective study of 44 first admission schizophrenic patients was conducted in Geneva, in order to evaluate the prognostic value of Expressed Emotion (EE). The predictive power of the EE index was tested on 3 variables of outcome: relapse rates, social adaptation and hospital stays. The EE index and the outcome measures tended to be associated. After the third year, patients living with high EE relatives were significantly more maladjusted and relapsed more than those living with low EE relatives. At intake, the patients presenting more premorbid features lived in high EE households. Our results show that initial measure of EE in a first episode cohort is predictive of outcome over a five-year period. This may not be causal, as it cannot be excluded that poorer premorbid functioning alone may result in poorer outcome, and may also elicit high EE in the relative.

[Stability and predictive role of emotions, expressed by families in the development of a cohort of schizophrenic patients in the course of 5 years]

A prospective study of 44 first admission schizophrenic patients was conducted in Geneva, in order to evaluate the prognostic value of Expressed Emotion (EE), as well as its stability. The predictive power of the EE index was tested on three variables of outcome: relapse rate, social adaptation and hospital stay. At intake, the patients presenting more premorbid features lived in high EE households. The EE index and the outcome measures tended to be associated. After the third year, patients living with high EE relatives were significantly more maladjusted and relapsed more than those living with low EE relatives. The EE index was stable during the five years. Our results show that initial measure of EE in a first episode cohort is predictive of outcome over a five year period. This may not be causal as it cannot be excluded that poorer premorbid functioning alone may result in poorer outcome, and may also elicit high EE in relative.

[Four year follow-up of social adjustment of a cohort of schizophrenic patients]

Sixty-seven first episode schizophrenic patients (PSE-Catego criteria) have been included in this study in order to evaluate their prognosis and the factors predictive of their evolution. Potential predictive factors consisted of anamnestic and demographic data, scores on the Disability Assessment Schedule (DAS-WHO) and relatives' Expressed Emotion index (EE), measured by the Camberwell Family Interview (CFI). The outcome was assessed monthly by the Global Assessment Scale (GAS/DSM III-R). At four years, 39 patients (58%) were still being followed. 33% of the patients presented a good evolution (EGF > or = 51) and 67% of the patients a bad evolution (EGF < 51). Four factors predictive of the psychosocial adaptation were extracted using regression analysis: premorbid psychosocial evolution, EE, sex and psychiatric family history. These 4 factors predicted correctly 85% of cases. Moreover, the monthly follow-up of these patients pointed to three types of evolution: the patients presenting a good and stable evolution (22%), those presenting a bad and stable evolution (33%) and those presenting an oscillating evolution which fluctuated between good and bad periods (44%). However, no predictive factors of the psychosocial adaptation of these oscillating patients could be identified through the statistical analysis. These results take all their importance regarding the treatment of schizophrenic patients, for whom the therapeutic plans which have to be settled should take into account their prognosis in the most precise manner. Moreover, the predictive value of EE on psychosocial adaptation for a 4 years period is confirmed.

Altered growth and phenotype in clonal mycN transfectants of the SK-N-SH neuroblastoma cell line

We have attempted to distinguish in human neuroblastoma between the effects of mycN on differentiation and its potential to promote malignant progression. Others have observed out-growth of autocrine cells with evidence of an advanced malignant phenotype in a mycN-transfected clonal cell line derived from the single-copy mycN neuroblastoma, SK-N-SH. We have now transfected the parental cell line with the same mycN expression vector and selected 5 clones characterized by unique and stable chromosomal integration sites and variable exogenous copy numbers. mycN gene expression was variable in the different clones and correlated roughly with the copy number of transfected mycN genes. Clones with minimal levels of mycN gene expression had a neuroblastic phenotype and low numbers of surface HLA class-I molecules. Clones with high levels of mycN expression had a Schwann/glial-like phenotype with higher surface HLA class-I display without imbalance of expression of specific loci and accelerated growth. Two such clones were capable of anchorage-independent growth in the absence of serum, and acquired tumorigenic properties. Our results show that exogenous mycN expression can be associated with a differentiation of neuroblastoma cells along the Schwann/glial pathway and can induce accelerated and autonomous growth.

Feasibility of quality of life assessment in a randomized phase III trial of small cell lung cancer--a lesson from the real world--the Swiss Group for Clinical Cancer Research SAKK

Between 1985 and 1990 the Swiss Group for Clinical Cancer Research (SAKK) for the first time assessed quality of life (QL) variables in 188 patients in a multicenter small-cell lung cancer trial that compared two different regimens of combination chemotherapy. QL-assessment was scheduled at the beginning of each of the six treatment cycles. The self-rating QL questionnaire included an early version of the EORTC QL questionnaire, a mood adjective checklist (Bf-S) and a single linear analogue scale (LASA) measuring general well-being. Compliance with completion of the scheduled questionnaires varied between 37% and 58% over the six cycles, and between 21% and 68% among the 7 participating institutions. Mean compliance was 49%. The institution was found the only significant factor predicting compliance (p < 0.001). Patient age, sex, education and biological prognostic factors at randomization were not predictors of compliance. Although compliance was poor, the data received was of high quality. We suggest practical guidelines for improving compliance with QL data collection in multicenter clinical trials.

Differentiation-related expression of adhesion molecules and receptors on human neuroblastoma tissues, cell lines and variants

The expression of cellular adhesion molecules (CAM) involved in cell adhesion and immune recognition was measured on neuroblastoma tissue samples, on a neuroblastoma (NB) cell line, SK-N-SH, and on 3 phenotypically different variants, SH-SY5Y, SH-EP, SH-IN, representing neuronal, Schwannian/glial or intermediate NB-cell types. Immunohistochemical analysis of CAM expression by NB and related tumors at different stages of differentiation revealed a co-expression of several CAM (ICAM-1/CD54, LFA-3, VLA-2 and HLA-ABC) associated with low stages and more highly differentiated NB tumors and peripheral neuroepitheliomas (PN). In contrast, N-CAM was uniformly expressed on all NB tumors. Flow cytometric analysis of CAM surface expression by SK-N-SH and variant cells revealed highly variable phenotypes. Expression of ICAM-1, LFA-3, VLA-2 and HLA-ABC molecules was associated with the epithelial cell type represented by the SH-EP variant. In contrast, low expression of these molecules and high expression of N-CAM was associated with the neuronal SH-SY5Y cells. Exposure of the NB cells to differentiation inducers (retinoic acid, 5'-bromodeoxyuridine and phorbol esters) and cytokines (tau-interferon, alpha-tumor necrosis factor) resulted in a variable up-regulation of the expression of all CAMs, except N-CAM, regardless of the type of differentiation induced. In an attempt to establish a link between the pattern of expression of CAM on NB cells and their susceptibility to natural killer (NK) or lymphokine-activated killer (LAK) cell lysis, the analysis revealed that NB cells expressing CAM and a differentiated phenotype were less susceptible to NK lysis, but no difference in the sensitivity of the NB cell types to LAK effectors was observed. Treatment of NB target cells with cytokines or PMA decreased their susceptibility to NK and LAK lysis, while induction of differentiation with RA or BUdR resulted in no changes in the sensitivity to NK and LAK lysis. In conclusion, expression of HLA-ABC and several co-regulated CAMs was shown to be associated with a differentiated phenotype in NB, with an overall decreased sensitivity to NK/LAK effector cells.

[Expressed emotion: past, present, future]

Expressed Emotion (EE) proved to be the best single predictor of relapse in schizophrenia in 1972. Since then, studies on EE were oriented in three directions: Replication of the original study in different countries, improvement of the methodology and clinical applications. The analysis of different key studies shows that EE is a powerful predictor factor, although it is influenced by other variables such as culture.

In vitro modulation and relationship between N-myc and HLA class I RNA steady-state levels in human neuroblastoma cells

Neuroblastoma cell lines and tumors are characterized by low HLA class I expression. The majority of neuroblastoma cell lines and a high percentage of disseminated tumors display amplification of the nuclear protooncogene N-myc. An inverse correlation between HLA class I expression and N-myc amplification and overexpression has been recently described in neuroblastomas (NBs). In this study we have shown that cytokines (recombinant gamma-interferon, recombinant alpha-tumor necrosis factor), differentiation agents (dibutyryl cyclic AMP, phorbol myristate acetate) and growth factors (nerve growth factor, epithelial growth factor) were able to influence the growth rate and surface expression of HLA class I molecules as well as of a tumor-associated antigen on 2 representative NB cell lines. Induced decreased growth rate in NB cells was not always related to decreased N-myc expression. Analysis at the mRNA level revealed that both N-myc and HLA class I RNA steady-state levels could be modulated by several substances, including recombinant gamma-interferon, phorbol myristate acetate, dibutyryl cyclic AMP, and epithelial growth factor and were not necessarily linked. An inverse correlation between N-myc and HLA mRNA levels was observed only after exposure of NB cells to recombinant alpha-tumor necrosis factor. We conclude that N-myc and HLA class I RNA steady-state levels can be modulated independently and suggest that they are not necessarily inversely regulated.

Monoclonal antibodies to gamma-interferon treated LAN-1 cells detect modulation of ganglioside GD2 exposure on human neuroblastoma cells

A panel of 8 new Mabs have been produced against neuroblastoma cells (LAN-1) previously treated with IFN-gamma. All selected Mabs from 2 different fusions have been shown to detect epitopes on the GD2 ganglioside molecules highly expressed on all cells of neural crest origin including neuroblastoma, glioblastoma and melanoma. Our results imply that modulation of GD2 exposure on NB cells is dependent on culture conditions and moreover that IFN-gamma increases the surface expression of GD2 and thereby enhances their immunogenicity.

New anti-GD2 monoclonal antibodies produced from gamma-interferon-treated neuroblastoma cells

Three monoclonal antibodies (IgG2) have been produced from hybridomas obtained by fusion of murine myeloma cells and spleen cells of mice hyperimmunized with gamma-interferon-treated neuroblastoma cells. The 3 MAbs, 7A4, 2A6 and IG8, detected an antigen present on neuroblastoma tumors and cell lines, but also on some neuro-ectoderm-derived tissues and cells. All 3 clones were shown to react with an epitope of the di-sialo-ganglioside GD2 molecules highly expressed by some neuro-ectoderm-derived tumors, mainly neuroblastoma. Whereas MAb IG8 specificity was restricted to GD2 and its o-acylated form, MAb 2A6 and 7A4 were also able to detect GD3 at high concentration of antibody as shown by TLC analysis and immunodetection. The 3 MAbs were able to lyse 100% neuroblastoma cells in the presence of rabbit or human complement. Direct binding assays with 125I-labelled MAbs showed that MAb 7A4 might be a good candidate for in vivo immunolocalization experiments. The high proportion of anti-GD2 MAbs obtained by our fusion and the increased binding of anti-GD2 MAbs on gamma-IFN-treated neuroblastoma cells suggests a modulation of the exposure and an increase in the immunogenicity of GD2 induced by gamma-IFN.

In vitro antigenic modulation of human neuroblastoma cells induced by IFN-gamma, retinoic acid and dibutyryl cyclic AMP

Testing with a panel of 26 monoclonal antibodies (MAbs) showed the antigenic profile of 13 human neuroblastoma cell lines to be characterized by a generally poor antigenic expression; therefore, Interferon-gamma (IFN-gamma), dibutyryl cyclic-AMP and retinoic acid were used to analyse the modulation of surface antigenic expression during differentiation. Treatment of neuroblastoma cell lines with IFN-gamma resulted mainly in induction or increase of class-I MHC antigenic expression. Induction of class-II MHC antigens was obtained on only one neuroblastoma cell line out of 13, thus representing an exceptional event. An increase in some other antigens expressed by neuroblastoma cell lines was also observed. In contrast, and in addition to morphological maturation, treatment of these cell lines with the differentiation inducer dibutyryl-cyclic-AMP (dbc-AMP), resulted in general down-modulation of antigenic expression, particularly of neuroblastoma-associated 5A7 or Leu7 antigens. Retinoic acid treatment had no significant effect on MHC antigens, but it decreased expression of 5A7 and Leu7 antigens, and markedly increased the expression of the melanoma-associated antigen Me14-D12. The similarity between the antigenic profile of in vitro differentiated neuroblastoma cells and that of mature ganglioneuroma cells suggests that compounds like cyclic-AMP or retinoic acid are excellent tools for further investigations of the mechanisms of neuroblastoma differentiation and might have important clinical applications.

[Glycosylation and isoelectric properties of complete and defective rabies viruses (author's transl)]

From a structural point of view an essential distinction between complete and defective rabies viruses is difference in size. In addition, isoelectric properties differ. The complete virus has an isoelectric point approaching neutrality, whereas the defective virus focuses between pH 3-4.7. The isoelectric points of the glycoprotein from complete and defective viruses differ in a corresponding fashion. The Pasteur virus cultivated on BHK21C13 cells, contains glycoproteins, the glycopeptides of which have a structure containing the following five monosaccharides: sialic acid, D-galactose, (N-acetyl)D-glucosamine, D-mannose and L-fucose. The glycosylation of the glycoproteins is different, at least in so far as the relative sialic acid/glucosamine ratio is concerned.

[Rabies glycoprotein purification by isoelectric focusing (author's transl)]

A glycoprotein was extracted with Triton X100 from rabies virus grown in primary foetal bovine kidney cells. This glycoprotein was further purified by iso electro focusing and showed a major peak at pH 7,0 and a smaller peak at pH 4,6. Purified fractions were migrated on polyacrylamide gels and assayed for immunogenicity.