[Risk of affective disorder in multiple sclerosis]

An increased risk for depression has been found in multiple sclerosis (MS). The purpose of the present study has been to give suggestions to guidelines for diagnosis and treatment of depression in MS in Denmark based on the international literature and recommendations. The method was a review of the relevant literature. The study recommends assessment of all MS patients for depression. Treatment of depression with serotonin reuptake inhibitors and/or cognitive behavioural therapy is recommended, depending on the severity of the illness. Caution is recommended in patients receiving beta interferon treatment.

[Diagnosis of bipolar disorder and rationale of early treatment]

The earlier bipolarity is diagnosed and treated, the better the chances of durable recovery The bipolar spectrum consists of a large panel of clinical syndromes with heterogeneous symptoms. Clinical studies show that, on average, a period of nine years elapses between onset of the first mood symptoms and appropriate prescription of mood stabilizers. Tools such as the bipolarity index can help with earlier and more precise diagnosis of bipolarity, and with the choice of the best treatment to prevent complications of bipolar illness.

An approach to the patient with dysregulated mood: major depression and bipolar disorder

Major depressive disorder (MDD) and bipolar disorder are chronic relapsing-remitting illnesses whose effects on mood, behavior, and thinking exact a heavy toll on patients' physical and mental health and on their capacity for satisfying relationships and employment. In the inpatient setting, these affective illnesses and their treatments can complicate the diagnosis, course, therapy, and prognosis of numerous medical conditions. In this article, the authors discuss a general approach for general internists, family practitioners, and other primary care providers to follow in caring for patients with suspected MDD or bipolar disorder.

[Bipolar disorders, challenges and innovations]

The treatment of patients suffering from bipolar disorders is a public healthcare challenge. While the clinical profile of these disorders remains complex, it has clearly evolved over the last few years. The healthcare provision has consequently expanded, particularly with regard to psychoeducational programmes. In this context, the FondaMental Foundation is an example of collaborative work acting for the benefit of the patient.

[Bipolar disorders in children and adolescents]

While difficult, early detection of bipolar disorders in children and adolescents is crucial. Depending on age, diagnosis may be more or less difficult. Family history and the environment must also be taken into account.

Adverse life event reporting and worst illness episodes in unipolar and bipolar affective disorders: measuring environmental risk for genetic research

BACKGROUND

Studies exploring gene-environment interplay in affective disorders now include very large numbers of participants. Methods for evaluating the role of adversity in such studies need to be developed that do not rely on lengthy and labour-intensive interviews. In the present study, a brief questionnaire method for measuring 11 adverse events reported before interview and before their worst illness episodes by bipolar, unipolar and healthy control participants, participating in genetic association studies, was evaluated.

METHOD

Five hundred and twelve bipolar disorder (BD) participants, 1447 participants with recurrent unipolar depression (UPD) and 1346 psychiatrically healthy control participants underwent the researcher-administered version of the List of Threatening Experiences Questionnaire (LTE-Q) for the 6 months before their worst affective episodes for UPD and BD participants, and for the 6 months before interview for the UPD participants and controls.

RESULTS

UPD and BD cases were significantly more likely to report at least one event, as well as more events in the 6 months before interview and before their worst illness episodes, than healthy controls. Both manic and depressive episodes were significantly associated with adverse events in the BD cases. Depressed mood at the time of interview influenced event reporting in UPD and control participants but not the BD cases. Age was negatively correlated with the number of events reported by controls.

CONCLUSIONS

The researcher-administered LTE-Q provides a measure of case-control differences for adversity that is applicable in large genetic association studies. Confounding factors for event reporting include present mood and age.

Postpartum bipolar episodes are not distinct from spontaneous episodes: implications for DSM-V

INTRODUCTION

DSM course modifiers should be based on enough evidence on his impact in the clinical prognosis of patients presenting with a certain clinical feature. The presence of postpartum onset of a mood episode in bipolar disorders has not been sufficiently studied. This is the first prospective clinical study comparing female bipolar patients with and without lifetime history of postpartum mood episode.

METHODS

Systematic prospective follow-up (12 years) of 200 female bipolar I or II patients with or without history of postpartum episodes. Postpartum mood episode was defined according to DSM-IV criteria. Patients with and without postpartum onset of a mood episode were compared regarding clinical and sociodemographic variables.

RESULTS

Lifetime history of postpartum episode was present in 43 patients and absent in 137 patients. Twenty patients were excluded from the study because lack of agreement of the two independent psychiatrist. Both groups showed almost no differences regarding clinical features, functioning or severity.

LIMITATIONS

The present study does not take account of potential factors that may influence the outcome of a postpartum episode, including obstetric complications and social support before delivery. Similarly, dimensional and qualitative aspects of bipolar disorder were not included in our analysis.

CONCLUSION

The role of postpartum onset as a DSM course modifier should be reconsidered, as it seems to have no impact on prognosis or functioning.

Neuropsychiatric evaluations of postictal behavioral changes

Postictal behavioral changes (PBCs), including psychosis, aggression, and mood change, are commonly observed in patients with epilepsy. Recognition and description of the clinical manifestations of PBCs would help in understanding and treating patients. Additionally, various quantified objective scales that are widely available in clinical psychiatry could be used to assess the clinical symptoms of PBCs. There are few reports in which objective rating scales have been used to assess neuropsychiatric symptoms in patients with epilepsy. However, there have been a small number of studies on interictal psychosis and depression in which either the Brief Psychiatric Rating Scale or the Hamilton Depression Scale was used. These inventories are likely to be useful for the assessment of PBCs. Other rating scales used for schizophrenia, depression, mania, and aggressive behavior are reviewed here. The author suggests that cross-sectional and longitudinal neuropsychiatric measurement combined with other modalities, including functional neuroimaging, could provide clues to the pathophysiology of PBCs.

Early life stressors and genetic influences on the development of bipolar disorder: the roles of childhood abuse and brain-derived neurotrophic factor

OBJECTIVES

Although there is increasing research exploring the psychosocial influences and biological underpinnings of bipolar disorder, relatively few studies have specifically examined the interplay between these factors in the development of this illness. Social-biological models within a developmental psychopathology perspective are necessary to advance our understanding of the processes involved in the onset and course of bipolar disorder. This article presents a review of the empirical literature linking childhood abuse to bipolar disorder, the research to date on the possible role of brain-derived neurotrophic factor (BDNF) in the development of this disorder, followed by a discussion of how childhood abuse may interact with BDNF.

METHODS

A literature search was conducted using Psycinfo to identify relevant articles on childhood abuse, BDNF, and bipolar disorder.

RESULTS

The extant research implicates both childhood abuse and BDNF in the etiology of bipolar disorder. Specifically, there is growing evidence associating early abuse to the development of bipolar disorder. Similarly, the BDNF Val66 allele has been linked with increased susceptibility to bipolar disorder. Based on existing research, a genetic diathesis-transactional stress model is proposed incorporating childhood abuse and the BDNF gene in the pathogenesis of bipolar disorder.

CONCLUSIONS

Although there is some support for this model, the relatively modest amount of relevant literature highlights the need for further research. An integrative theoretical framework including both social and biological processes in bipolar disorder is important for the development of effective prevention and treatment strategies for this disorder.

[Cannabis abuse in patients with psychiatric disorders: an update to old evidence]

OBJECTIVE

To perform an update on cannabis abuse by patients with psychiatric disorders.

METHOD

A search was performed in the electronic databases Medline, The Cochrane Library Database, Lilacs, PubMed, and SciELO, using the keywords 'marijuana abuse', 'cannabis abuse', 'psychiatric disorders', and 'mental disorders'. Articles published until December 2009, dealing with cannabis abuse and dependence in association with other psychiatric disorders were included.

RESULTS

Cannabis abuse was found to be associated with increased risk for the onset of schizophrenia and chronic psychotic symptoms, although these findings require confirmation from additional research. Cannabis seems to be one of the drugs of choice of individuals with bipolar disorder, despite evidence that manic states can be induced by its use. Cannabis abuse also occurs frequently in individuals with anxiety disorders, but the relationship between the chronic nature of these conditions and the use of marijuana remains uncertain. In respect to depression, there is no clear evidence to date that depressive patients use cannabis as a form of self-medication. In individuals with psychiatric disorders, the use of cannabis has been associated with increased positive symptoms, additional negative symptoms in the course of illness, impaired treatment compliance, and more hospitalizations.

CONCLUSION

The abuse of cannabis by patients with psychiatric disorders such as schizophrenia and mood and anxious disorders has a negative impact both in the acute and advanced stages of these conditions, although further investigation on this association is still necessary.

White matter hyperintensities, suicide risk and late-onset affective disorders: an overview of the current literature

White matter hyperintensities (WMHs) refer to areas of hyperintense signal on T2- or proton density-weighted brain magnetic resonance imaging. Although WMHs are a common finding in patients with bipolar disorder (BD), particularly with a later disease onset, some studies report a higher frequency of WMHs only in unipolar affective disorders. We reviewed the literature examining examining both the severity and presence of WMHs in late life and particularly in individuals with late-onset BD (LOBD). Studies investigating white matter lesions in LOBD were systematically retrieved and the reference lists of these studies were scanned for additional relevant studies of neuroimaging in LOBD. The majority of neuroimaging studies reported an association between older age and LOBD and the presence of WMHs in LOBD. Also, we found in a small sample of patients preliminary evidence of a significant relationship between older age with late-onset BD and WMHs having a higher prevalence of cardiovascular and cerebrovascular risk factors. In conclusion over 60 years older individuals with LOBD and WMHs might have a type of illness characterized by more neuropathological changes and biologically different compared to non LOBD. This is consistent with the hypothesis of vascular mania. WMHs could be a reliable biological risk marker for late onset mood disorders.

[First manic episode in the elderly--consider a subdural haematoma due to head trauma as cause]

A manic episode in old age presents a diagnostic challenge to the clinician due to the different symptomatology often difficult to distinguish from delirium, dementia, agitated depression and psychosis. To complicate matters further, a first episode of mania in later life is very often based on underlying physical and cerebral pathology ('secondary mania'). Many causes of 'secondary mania', including neurological, systemic or endocrine diseases, infections, intoxications, apnoea, post-thoracic surgery and vitamin B12 deficiency have been described to date, but there have been no reports on subdural haematomas in this context. However, the elderly are more prone to subdural haematomas following head trauma than younger patients. We present two case reports of older patients with a first manic episode in later life probably caused by subdural haematomas. A first episode of mania in later life always requires thorough assessment of the patient to determine physical and cerebral pathology.

Oxidative imbalance in bipolar disorder subtypes: a comparative study

OBJECTIVE

The oxidants are related with the membrane-associated pathologies in the central nervous system and may have an important role in neuropsychiatric disorders. Several studies were performed on the effects of free radicals in bipolar disorder. However, there are no studies investigating the effects of free radicals both in the subtypes of BD (Bipolar disorders I and II) and in antidepressant induced mania (AIM). In this study, we aimed to investigate the status of oxidative metabolism in BD and its subtypes.

METHODS

94 bipolar patients (BD I-II and AIM) diagnosed according to DSM IV and as control group 41 healthy subjects were included to the study. The total antioxidant status (TAS), total oxidant status (TOS) and oxidative stress index (OSI) were examined in the properly obtained plasma samples of subjects and healthy controls included in the study.

RESULTS

The patients' TAS, TOS and OSI were significantly higher than the controls. TAS is negatively correlated with the number of previous total episodes in BD I. The BD I group appeared to have higher TOS compared to BD II group.

CONCLUSIONS

Oxidative balance is impaired in bipolar disorder. Antioxidant levels may be increased compensatorily in response to increased oxidant levels. Another important result of our study was that in the comparison of the three disease subtypes BD I group was found to have higher TOS compared to the BD II group. This finding is compatible with the literature on BD I and may be associated with the more severe course of BD I.

Mitochondrial dysfunction and psychiatric disorders

Mitochondria are intracellular organelles crucial in the production of cellular energy. Mitochondrial diseases may result from malfunctions in this biochemical cascade. Several investigators have proposed that mitochondrial dysfunction is related to the pathophysiology of bipolar disorder (BD), major depressive disorder (MDD) and schizophrenia (SZ). The authors reviewed recent study findings and tried to delineate the current understanding of the correlation between mitochondrial dysfunction and psychiatric disorders. A growing body of evidence suggests that mitochondrial dysfunction is important in patients with psychiatric disorders. The evidence include impaired energy metabolism in the brain detected using results of magnetic resonance spectroscopy, electron microscopy, co-morbidity with mitochondrial diseases, the effects of psychotropics on mitochondria, increased mitochondrial DNA (mtDNA) deletion in the brain, and association with mtDNA mutations/polymorphisms or nuclear-encoded mitochondrial genes. It is possible that the new information will lead to a focus on psychiatric disorder as a metabolic disease. Treatment with psychotropics might ultimately enhance energy metabolism and reduce the damage of oxidative stress. The next step in the study of mitochondrial dysfunction in patients with psychiatric disorders should be clarification of how mitochondrial dysfunction, a nonspecific risk factor, causes specific symptoms. Further study of mitochondrial dysfunction in patients with psychiatric disorder is expected to be useful for the development of cellular disease markers and new psychotropics.

[Late-onset bipolar disorder following right thalamic injury]

Bipolar disorder occurs in the elderly ages and is frequently associated to a brain injury -cerebrovascular disease. Its diagnosis is based on the finding of an ischemic injury in specific regions of the brain. The case of a 63-year-old male with cardiovascular risk factors, who was admitted due to maniform picture during a two-year long bipolar affective syndrome is presented. The neuroimaging tests showed lacunar infarction in the right thalamus and diffuse foci of ischemia in subcortical white matter having right predominance. Due to the refractoriness to psychodrugs of an endogenomorphic depressive episode, electroconvulsive therapy was prescribed, with normalization of motor component, although without mood stabilization. The therapeutic strategies and the evolution of this form of bipolarity are discussed.

Stimulating brains, altering minds

Deep-brain stimulation has been used to treat advanced Parkinson disease and other neurological and psychiatric disorders that have not responded to other treatments. While deep-brain stimulation can modulate overactive or underactive regions of the brain and thereby improve motor function, it can also cause changes in a patient's thought and personality. This paper discusses the trade-offs between the physiological benefit of this technique and the potential psychological harm.

Delirious mania and malignant catatonia: a report of 3 cases and review

Delirious mania is often difficult to distinguish from excited catatonia. While some authors consider delirious mania a subtype of catatonia, the distinction between the two entities is important as treatment differs and effects outcome. It appears that as catatonia is described as having non-malignant and malignant states, the same division of severity may also apply to delirious mania. Non-malignant delirious mania meets the criteria for mania and delirium without an underlying medical disorder. The patients are amnestic, may lose control of bowel and bladder, but still respond to atypical antipsychotics and mood stabilizers. However, with increasing progression of the disease course and perhaps with an increasing load of catatonic features, delirious mania may convert to a malignant catatonic state (malignant delirious mania) which is worsened by antipsychotics and requires a trial of benzodiazepines and/or ECT. Three case reports are presented to illustrate the diagnostic conundrum of delirious mania and several different presentations of malignant catatonia.

[Feeling for affective psychosis]

The paper presents new research results on the pathogenesis of depression and mania and future perspectives on diagnosis and treatment. On the one hand, we know that depression most often develops in the interplay between genes and the environment; and, on the other hand, that depression and mania may be induced suddenly by deep brain stimulation of the subthalamic areas. Ongoing studies aim to identify biomarkers for depression and mania, and results from recent research suggest that neuroticism, abnormal response to the DEX-CRH test, increased frontotemporal serotonine 2A binding, abnormal emotional processing and deceased executive function may be candidates for such biomarkers. These biomarkers may help to improve diagnosis and treatment in the future.

[ER stress and psychiatric disorders]

Various stresses cause the accumulation of unfolded proteins in the endoplasmic reticulum (ER). For this serious "ER stress", cells have unfolded protein responses (UPR) consisting of the translation block, the induction of chaperones, and ER-associated degradation (ERAD). If cells do not overcome the ER stress by UPR, ER-mediated apoptosis occurs. Recent reports showed that several diseases, such as ischemic diseases, viral infections, diabetes, and neurodegenerative diseases, are caused by ER stress. In psychiatric disorders, it was recently reported that ER stress is involved in bipolar disorders. There were reports that drugs for bipolar disorders induce chaperones, that polymorphism of the molecule of ER stress is significantly related to the bipolar disorder, and that the causal gene of the autosomal recessive disease having mood disorder as a phenotype is induced by ER stress. Another report showed that ER stress is involved in sleep disturbances.

Some new food for thought: the role of vitamin D in the mental health of older adults

Vitamin D, a multipurpose steroid hormone vital to health, has been increasingly implicated in the pathology of cognition and mental illness. Hypovitaminosis D is prevalent among older adults, and several studies suggest an association between hypovitaminosis D and basic and executive cognitive functions, depression, bipolar disorder, and schizophrenia. Vitamin D activates receptors on neurons in regions implicated in the regulation of behavior, stimulates neurotrophin release, and protects the brain by buffering antioxidant and anti-inflammatory defenses against vascular injury and improving metabolic and cardiovascular function. Although additional studies are needed to examine the impact of supplementation on cognition and mood disorders, given the known health benefits of vitamin D, we recommend greater supplementation in older adults.

Does lower response to alcohol explain the high co-morbidity between bipolar disorder and alcohol dependence?

The frequency of the co-occurrence between alcohol use disorders and bipolar disorder is well documented. However, the etiology of this association is discussed. Among the most quoted hypothesis, high alcohol consumption has been considered as a form of self-medication. At variance with this assumption, we hypothesized that mania is associated with a low level of response to alcohol. Indeed, a low level of response to alcohol was previously associated with an increased risk of alcohol dependence in a high risk population. We discuss the neurobiological findings supporting our assumption, including the decreased reward-related brain activation in mania and further propose a brief study design to test this hypothesis.

A genome-wide association study implicates diacylglycerol kinase eta (DGKH) and several other genes in the etiology of bipolar disorder

The genetic basis of bipolar disorder has long been thought to be complex, with the potential involvement of multiple genes, but methods to analyze populations with respect to this complexity have only recently become available. We have carried out a genome-wide association study of bipolar disorder by genotyping over 550,000 single-nucleotide polymorphisms (SNPs) in two independent case-control samples of European origin. The initial association screen was performed using pooled DNA, and selected SNPs were confirmed by individual genotyping. While DNA pooling reduces power to detect genetic associations, there is a substantial cost saving and gain in efficiency. A total of 88 SNPs, representing 80 different genes, met the prior criteria for replication in both samples. Effect sizes were modest: no single SNP of large effect was detected. Of 37 SNPs selected for individual genotyping, the strongest association signal was detected at a marker within the first intron of diacylglycerol kinase eta (DGKH; P=1.5 x 10(-8), experiment-wide P<0.01, OR=1.59). This gene encodes DGKH, a key protein in the lithium-sensitive phosphatidyl inositol pathway. This first genome-wide association study of bipolar disorder shows that several genes, each of modest effect, reproducibly influence disease risk. Bipolar disorder may be a polygenic disease.

Treatment-emergent mania in unipolar and bipolar depression: focus on repetitive transcranial magnetic stimulation

This review focused on the treatment-emergent mania/hypomania (TEM) associated with repetitive transcranial magnetic stimulation (rTMS) treatment of depression. English-language literature published from 1966-2006 and indexed in Medline was searched. Ten of 53 randomized controlled trials on rTMS treatment of depression specifically addressed TEM. The pooled TEM rate is 0.84% for the active treatment group and 0.73% for the sham group. The difference is not statistically significant. Along with case reports, a total of 13 cases of TEM associated with rTMS treatment of depression have been published. Most of these patients were diagnosed with bipolar disorder and the majority of patients experiencing TEM took medication concurrent with rTMS. The parameters of rTMS used in these cases were scattered over the spectrum of major parameters explored in previous studies. Most train durations and intervals were within the published safety guidelines of the field. Reducing the frequency of sessions from two per day to one per day might be associated with a lower likelihood of TEM recurrence. The severity of manic symptoms varied significantly, but all cases responded to treatment that included a decrease or discontinuation of antidepressant and/or rTMS treatment and/or use of anti-manic medication. Current data suggests that rTMS treatment carries a slight risk of TEM that is not statistically higher than that associated with sham treatment. More systematic studies are needed to better understand TEM associated with rTMS. Special precautions and measures should be adopted to prevent, monitor, and manage TEM in research and practice.

[Neurosarcoidosis as a cause of manic psychosis]

A case report and a systematic review of the literature show that neurosarcoidosis can present initially as a manic episode with psychotic features. The diagnosis of neurosarcoidosis is based on a combination of clinical features, and radiological and histopathological findings. Contrast-enhanced MRI and lumbar puncture are the most sensitive investigations for detecting neurosarcoidosis. Corticosteroids are the treatment of choice. Very few data are available concerning the efficacy of psychotropic drugs for the treatment of psychiatric symptoms caused by neurosarcoidosis.

[Psychopathology in the children of parents with bipolar mood disorder]

OBJECTIVE

The aims of this study were to determine the rate of psychopathology in the children of parents with bipolar disorder and to examine the relationship between the psychopathology in these children and the characteristics of bipolar disorder in their parents.

METHOD

The study included 36 children of 28 bipolar I parents and 33 children of 28 control parents, all between the ages of 6 and 17 years. The bipolar parents and all of the children were screened using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L) and the Schedule for Affective Disorders and Schizophrenia for School Aged Children, Present and Lifetime Version (K-SADS-PL), respectively. The spouses of bipolar parents completed the Symptom Checklist-90-Revised (SCL-90-R) and the children completed the Parenting Style Scale (PSS).

RESULTS

The rate of psychopathology was higher in the children of bipolar parents than in those of the control parents. Affective disorders and disruptive behavior disorders were observed with significantly greater frequency in the children of the bipolar parents. Attitudes in study group parents were related to the presence of psychopathology in their children.

CONCLUSION

The results of this study suggest that children of bipolar parents have an increased risk of developing psychiatric disorders, especially affective disorders and disruptive behavior disorders. The children of bipolar patients need to be screened for psychiatric symptoms and referred for psychiatric assistance when necessary.

Association analysis of the chromosome 4p15-p16 candidate region for bipolar disorder and schizophrenia

Several independent linkage studies have identified chromosome 4p15-p16 as a putative region of susceptibility for bipolar disorder (BP), schizophrenia (SCZ) and related phenotypes. Previously, we identified two subregions (B and D) of the 4p15-p16 region that are shared by three of four 4p-linked families examined. Here, we describe a large-scale association analysis of regions B and D (3.8 and 4.5 Mb, respectively). We selected 408 haplotype-tagging single nucleotide polymorphisms (SNPs) on a block-by-block basis from the International HapMap project and tested them in 368 BP, 386 SCZ and 458 control individuals. Nominal significance thresholds were determined using principal component analysis as implemented in the program SNPSpD. In region B, overlapping SNPs and haplotypes met the region-wide threshold (P<or=0.0005) at the global and individual haplotype test level and clustered in two regions. In region D, no individual SNPs were nominally significant, but multiple global and individual haplotypes were associated with BP and/or SCZ (region-wide threshold, P<or=0.0003). These overlapping haplotypes fell into two regions. Within each of these four clusters, at least one globally significant haplotype withstood permutation testing (P(gp)<or=0.05). Five predicted genes were found within these associated regions, while Known/RefSeq genes, including KIAA0746 and PPARGC1A, mapped nearby. There were also nine other clusters within regions B and D with nominally significant haplotypes, but only at the individual haplotype level. KIAA0746, PPARGC1A, GPR125, CCKAR and DKFZp761B107 overlapped with these regions. This study has identified significant associations between BP and SCZ within the chromosome 4p linkage region, resulting in candidate regions worthy of further investigation.

Neuropsychiatric syndromes associated with multiple sclerosis

Multiple sclerosis is associated with diverse behavioral changes. Rates of major depression approach 50% over the course of patients' lives, rates of bipolar disorder and psychosis are twice as common when compared to rates in the general population and pseudobulbar affect will afflict one in ten patients. However, these disorders often respond well to pharmacologic treatment and in the case of major depression, some forms of psychotherapy too. This article summarizes these mental state changes, their pathogenesis and treatment. Correct diagnosis and treatment can substantially improve the quality of life for MS patients.

Age comparison of treatment adherence with antipsychotic medications among individuals with bipolar disorder

BACKGROUND

Few studies have evaluated medication adherence among older vs younger individuals with bipolar disorder (BPD). We compared adherence with antipsychotic medication among older (age 60 and older) and younger individuals using a large case registry (n = 73,964).

METHODS

Adherence was evaluated using the medication possession ratio (MPR) for patients receiving antipsychotic medication.

RESULTS

Twenty six thousand five hundred and thirty younger individuals (mean age 46.9) and 6,461 older individuals (mean age 69.2) were prescribed antipsychotic medication. Among older individuals, 61.0% (n = 3,350) were fully adherent, while 19.0% (n = 1,043) were partially adherent and 20.0% (n = 1,098) were non-adherent. Among younger individuals, 49.5% (n = 10,644) were fully adherent, while 21.8% (n = 4,680) were partially adherent, and 28.7% (n = 6,170) were non-adherent. As with younger patients, comorbid substance abuse and homelessness predicted non-adherence among older patients with BPD.

CONCLUSION

Older individuals with BPD were more adherent with antipsychotic medications compared to younger individuals. However, a substantial proportion (approximately 39%) of older patients with BPD still have difficulties with adherence.

Vascular mania: an old concept in danger of sclerosing? A clinical overview

OBJECTIVE

To review the evidence for an association between vascular disease and mania, and in this context, to assess the suitability of previously proposed diagnostic criteria.

METHOD

Relevant articles were retrieved and reviewed with the aid of search engines [MEDLINE, PsychInfo and EMBASE from 1996 to 2006] using pertinent search terms. Because of the paucity of data, systematic criteria for levels of evidence could not be applied.

RESULTS

The literature is limited by the preponderance of case reports or case series, the use of overlapping terms, such as secondary mania, disinhibition syndrome and poststroke mania, and variable definitions of mania per se. There is general support for a tentative association between mania and vascular risk factors, and also between mania and cerebrovascular disease. Such associations seem best described by the term vascular mania for the sake of clinical utility, although it erroneously conveys causality. Proposed diagnostic criteria have defined a late-age at onset (50 years +) sub-type of mania, with associated neuroimaging and neuropsychological changes which are not specific to this age group.

CONCLUSION

Further studies are needed to determine whether mania associated with vascular disease is a specific and separate sub-type with a late-age at onset. An alternative framework for considering vascular mania is proposed.

Brain-specific tryptophan hydroxylase 2 (TPH2): a functional Pro206Ser substitution and variation in the 5'-region are associated with bipolar affective disorder

The neurotransmitter serotonin [5-hydroxytryptamine (5-HT)] controls a broad range of biological functions that are disturbed in affective disorder. In the brain, 5-HT production is controlled by tryptophan hydroxylase 2 (TPH2). In order to assess the possible contribution of TPH2 genetic variability to the aetiology of bipolar affective disorder (BPAD), we systematically investigated common and rare genetic variation in the TPH2 gene through a sequential sequencing and SNP-based genotyping approach. Our study sample comprised two cohorts of BPAD from Germany and Russia, totalling 883 patients and 1300 controls. SNPs located in a haplotype block covering the 5' region of the gene as well as a rare, non-synonymous SNP, resulting in a Pro206Ser substitution, showed significant association with bipolar disorder. The odds ratio for the minor allele in the pooled sample was 1.5 (95% CI 1.2-1.9) for rs11178997 (in the 5'-associated haplotype block) and 4.8 (95% CI 1.6-14.8) for rs17110563 encoding the Pro206Ser substitution. Examination of the functional effects of TPH2 Pro206Ser provided evidence for a reduced thermal stability and solubility of the mutated enzyme, suggesting reduced 5-HT production in the brain as a pathophysiological mechanism in BPAD.

Manic behavior resulting from left frontal closed head injury in an adult with fetal alcohol syndrome

Closed head trauma has been associated with various neuropsychiatric sequelae, including mood disturbances such as depression and mania. Although mood disturbances can occur with injury to either hemisphere, mania has been primarily associated with right-side frontal lobe injury. We present a case of manic behavior after a closed head injury to the left hemisphere in an adult with preexisting fetal alcohol syndrome.

Cotard's syndrome in adolescents and young adults is associated with an increased risk of bipolar disorder

OBJECTIVES

To assess the effect of age at onset on the phenomenology of Cotard's syndrome (CS) as a recent study reported a high rate of occurrence of bipolar disorder (BD) in adolescents and young adults with CS followed up for > or =2 years.

METHODS

We reviewed all cases of CS reported since it was first described. A statistical analysis was carried out to determine the effect of age at onset on CS phenomenology.

RESULTS

We found 138 cases including 21 cases aged 25 years or younger. In these younger CS patients, BD was more frequent, and the risk of associated BD was increased nine times (p < 0.0001). Within the BD sub-group (n = 27), admixture analysis identified two sub-groups with mean ages at onset of 18.7 years [standard deviation (SD) = 3.2] and 50.5 years (SD = 11.7).

CONCLUSIONS

Young people with CS should be monitored carefully for the onset of BD, and families should be educated about this risk. Treatment with mood stabilizers can be helpful for those who develop BD. Within BD associated with CS, early versus late onset should be distinguished.

Genotype and childhood sexual trauma moderate neurocognitive performance: a possible role for brain-derived neurotrophic factor and apolipoprotein E variants

BACKGROUND

Limited success in the identification of genetic variants underpinning psychiatric illness has prompted attempts to elucidate gene-environment interactions and illness-associated endophenotypes. Here we measured childhood sexual abuse, a potential environmental risk factor, and verbal and visual recall and recognition memory, a possible illness-associated endophenotype in a cohort of bipolar disorder (BPD) subjects and their relatives. We predicted that memory would be affected by sexual trauma and that a number of functional polymorphisms previously implicated in BPD and cognition would moderate the effect of psychological trauma on memory.

METHODS

A cohort of 350 individuals from 47 BPD families was recruited, tested with a neuropsychological battery, and given the Childhood Trauma Questionnaire (CTQ). Eleven different genetic variants previously found to be relevant to BPD or memory dysfunction were typed.

RESULTS

As predicted, scores on the sexual abuse scale of the CTQ were negatively associated with memory performance. Furthermore, the low-activity Met allele of the brain-derived neurotrophic factor (BDNF) gene and the epsilon4 allele of the apolipoprotein E gene interacted with sexual abuse scores to result in reduced memory test performance.

CONCLUSIONS

Apolipoprotein E and BDNF exert a neurotrophic effect in response to cellular injury. Their possible moderation of the association between sexual abuse and memory performance might indicate that there is some degree of overlap in the pathophysiological mechanisms by which psychological and physical trauma impact brain function. The finding of an environmental effect on memory performance and a gene-environment interaction on this hypothetical endophenotype of BPD illustrates the difficulty of identifying genetically and phenotypically simple intermediate traits for molecular genetic studies.

[Revisiting bipolar disorder]

According to the theory of evolution of Charles Darwin which is an author of The Origin of Species, human being evolves after long time to be profitable to "prosperity of a kind", and it is thought that there is the adaptive meaning. In other words, man stand on various creatures in number, and it may be said that human being building a high civilized society is the creature which was able to have an element of chosen mind and body in natural selection. However, a disease does not disappear from our daily life and tends to consider us to be "the misfortune" even if we human being is easy to suffer from a disease. "Evolution medicine" (Darwinian medicine) drop hint of meaning/the significance in aging and the process of the pathology. This paper refers to such a conception of bipolar disorder.

Association of distinct allelic haplotypes of DISC1 with psychotic and bipolar spectrum disorders and with underlying cognitive impairments

Bipolar disorder (BPD) and schizophrenia (SCZ) have at least a partially convergent aetiology and thus may share genetic susceptibility loci. Multiple lines of evidence emphasize the role of disrupted-in-schizophrenia-1 (DISC1) gene in psychotic disorders such as SCZ. We monitored the association of allelic variants of translin-associated factor X (TSNAX)/DISC1 gene cluster using 13 single-nucleotide polymorphisms (SNPs) in 723 members of 179 Finnish BPD families. Consistent with an earlier finding in Finnish SCZ families, the haplotype T-A of rs751229 and rs3738401 at the 5' end of DISC1 was over-transmitted to males with psychotic disorder (P = 0.008; for an extended haplotype P = 0.0007 with both genders). Haplotypes at the 3' end of DISC1 associated with bipolar spectrum disorder (P = 0.0002 for an under-transmitted haplotype T-T of rs821616 and rs1411771, for an extended haplotype P = 0.0001), as did a two-SNP risk haplotype at the 5' end of TSNAX (P = 0.007). The risk haplotype for psychotic disorder also associated to perseverations (P = 0.035; for rs751229 alone P = 0.0012), and a protective haplotype G-T-G with rs1655285 in addition to auditory attention (P = 0.0059). The 3' end variants associated with several cognitive traits, with the most robust signal for rs821616 and verbal fluency and rs980989 and psychomotor processing speed (P = 0.011 for both). These results support involvement of DISC1 in the genetic aetiology of BPD and suggest that its distinct variants contribute to variation in the dimensional features of psychotic and bipolar spectrum disorders. Finding of alternative associating haplotypes in the same set of BPD families gives evidence for allelic heterogeneity within DISC1, eventually leading to heterogeneity in the clinical outcome as well.

Comorbid substance use disorder in women with bipolar disorder associated with criminal arrest

OBJECTIVES

Previous research has indicated that comorbid substance abuse in patients with bipolar disorder (BPD) is strongly linked to criminal arrest. This study was conducted to further evaluate possible gender differences in substance use and risk of criminality in BPD.

METHODS

Subjects were selected from all inmates with a DSM-IV diagnosis of BPD type I at Los Angeles County correctional facility. As a comparison, a sample of Los Angeles County patients with BPD type I who had not been arrested during the course of their psychiatric treatment within LA County was identified. The county's Management Information System (MIS) was utilized to obtain primary and secondary diagnoses as well as demographic information.

RESULTS

The odds of having a comorbid substance use diagnosis for arrested female patients was more than 38 times that for community female patients (odds ratio = 38.75). Women were more likely to have been arrested for violent and substance use charges; men were more likely to have been arrested for theft and miscellaneous charges.

CONCLUSIONS

Substance abuse appears to be a significant risk factor for arrest in patients with BPD and is especially significant for women with BPD. Our study suggests that comorbid BPD and substance use in women may significantly increase the risk of criminal arrest.