Affective disorders in referred children and younger siblings of manic-depressives. Mode of onset and prospective course

Temperament traits mediate the relationship between CACNA1C polymorphisms and bipolar disorder in cisgender women

The influence of temperament traits on bipolar disorder (BD) has been investigated. Both temperament traits and BD are partially genetically determined and seem to be influenced by variations in the CACNA1C gene. These variations presented a significant interactive effect with biological sex, although studies that evaluate this relationship are scarce. Here, we assessed the mediation effect of temperament traits on the relationship between two polymorphisms in the CACNA1C gene (rs1006737 and rs4765913) and BD according to sex. This is a cross-sectional study consisting of 878 Caucasian individuals (508 women and 370 men), aged 18-35, enrolled in a population-based study in the city of Pelotas, Southern Brazil. BD diagnosis was evaluated using the clinical interview MINI 5.0, and temperament traits were assessed via the application of the Affective and Emotional Composite Temperament Scale (AFECTS). Mediation models were tested using the modeling tool PROCESS (version 3.3) for SPSS. Bootstrapping-enhanced mediation analyses in women indicated that traits anger (39%) and caution (27%) mediated the association between the rs4765913 SNP and BD, while traits volition (29%), anger (35%), and caution (29%) mediated the association between the AA haplotype (rs1006737-rs4765913) and the BD. No effect was encountered for cisgender men. Our model revealed that paths from CACNA1C SNPs to BD are mediated by specific temperament traits in women, reinforcing the definition of temperament traits as endophenotypes.

Attention-deficit/hyperactivity disorder and other neurodevelopmental disorders in offspring of parents with depression and bipolar disorder

BACKGROUND

Offspring of parents with major mood disorders (MDDs) are at increased risk for early psychopathology. We aim to compare the rates of neurodevelopmental disorders in offspring of parents with bipolar disorder, major depressive disorder, and controls.

METHOD

We established a lifetime diagnosis of neurodevelopmental disorders [attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, communication disorders, intellectual disabilities, specific learning disorders, and motor disorders] using the Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version in 400 participants (mean age 11.3 + s.d. 3.9 years), including 93 offspring of parents with bipolar disorder, 182 offspring of parents with major depressive disorder, and 125 control offspring of parents with no mood disorder.

RESULTS

Neurodevelopmental disorders were elevated in offspring of parents with bipolar disorder [odds ratio (OR) 2.34, 95% confidence interval (CI) 1.23-4.47, p = 0.010] and major depressive disorder (OR 1.87, 95% CI 1.03-3.39, p = 0.035) compared to controls. This difference was driven by the rates of ADHD, which were highest among offspring of parents with bipolar disorder (30.1%), intermediate in offspring of parents with major depressive disorder (24.2%), and lowest in controls (14.4%). There were no significant differences in frequencies of other neurodevelopmental disorders between the three groups. Chronic course of mood disorder in parents was associated with higher rates of any neurodevelopmental disorder and higher rates of ADHD in offspring.

CONCLUSIONS

Our findings suggest monitoring for ADHD and other neurodevelopmental disorders in offspring of parents with MDDs may be indicated to improve early diagnosis and treatment.

Integrity of cerebellar tracts associated with the risk of bipolar disorder

This study examined the structural brain differences across individuals of different BD stages and the risks of developing bipolar disorder (BD) associated with these brain differences. A total of 221 participants who were recruited from the Guangzhou Brain Hospital and the community were categorized into four groups: NC (healthy control) (N = 77), high risk (HR) (N = 42), ultra-high risk (UHR) (N = 38), and bipolar disorder (BD) (N = 64) based on a list of criteria. Their demographics, clinical characteristics, and diffusion magnetic resonance imaging (dMRI) data were collected. ANCOVA results showed that the HR group had significantly reduced mean diffusivity (MD) (p = 0.043) and radial diffusivity (RD) (p = 0.039) of the left portico-ponto-cerebellar tracts when compared with the BD group. Moreover, logistic regression results showed that the specific diffusivity measures of cerebellar tracts (e.g., cortico-ponto-cerebellar tract), particularly the RD and MD revealed differences between groups at different BD stages after controlling for the covariates. The findings suggested that specific diffusivity (RD and MD) of cerebellar tracts (e.g., cortico-ponto-cerebellar tract) revealed differences between groups at different BD stages which is helpful in detecting the trajectory changes in BD syndromes in the early stages of BD, particularly when the BD syndromes start from HR stage.

Transitioning to bipolar disorder: A systematic review of prospective high-risk studies

PURPOSE OF REVIEW

Bipolar disorder is a highly heritable condition, which can progress from an asymptomatic period in at-risk individuals to a potentially debilitating illness. Identifying individuals who are at a high risk of developing bipolar disorder may provide an opportunity for early intervention to improve outcomes. The main objective of this systematic review is to provide an overview of prospective studies that evaluated the incidence and predictors of transitioning to bipolar disorder among high-risk individuals.

RECENT FINDINGS

Twenty-three publications from 16 cohorts were included in the final review. Most studies focused on familial high-risk groups, while others either used clinical or a combination of clinical and genetic risk factors. The follow-up length was from 1 to 21 years and the rate of conversion to bipolar disorder was between 8 and 25% among different studies. Overall, the results suggest that a combination of genetic and clinical risk factors; namely, subthreshold (hypo)manic symptoms and elevated depressive symptoms, may be required to optimally predict conversion to bipolar disorder.

SUMMARY

The concept of high-risk for bipolar disorder is still in its infancy. Further discussions are needed to work towards an expert consensus on the high-risk criteria for bipolar disorder, taking into account both clinical and genetic risk factors.

Early intervention for people at high risk of developing bipolar disorder: a systematic review of clinical trials

Early intervention approaches are built on the premise of preventing disability, burden, and cognitive sequelae caused by bipolar disorder. The objective of this systematic review was to characterise the effectiveness of all the available psychological and pharmacological treatments for early intervention in people at high risk of developing bipolar disorder. The study was registered with PROSPERO (CRD42019133420). We did a systematic search to identify studies published in ten databases up to March 27, 2020. Randomised controlled trials and cohort studies that assessed the effect of pharmacological or psychological interventions in people at high risk of developing bipolar disorder were included. Studies of first episodes of mania were excluded. Eligible papers were assessed for quality and data were extracted. The primary outcomes were change in manic and depressive symptoms from baseline to endpoint. Of the 2856 citations retrieved by our search, 16 studies were included; five evaluated pharmacotherapeutic strategies (three randomised controlled trials and two open-label studies), ten assessed psychotherapeutic strategies (four randomised controlled trials and six open-label studies), and one randomised controlled trial assessed combination therapy; these 16 trials included a total of 755 participants at high risk of developing bipolar disorder. Quality assessment indicated fair to good quality for open-label studies, and a high risk of bias in four randomised controlled trials. Among the pharmacotherapeutic interventions, there is preliminary support for the efficacy of aripiprazole in reducing mood symptoms in people at high risk of developing bipolar disorder. Psychological interventions were effective for various outcomes. There was substantial methodological heterogeneity across studies. This systematic review underscores the need for multicentre, prospective, methodologically homogeneous studies evaluating conversion to bipolar disorder as an outcome measure.

Reassessing the prevalence of bipolar disorders : clinical significance and artistic creativity

Kraepelin's broad concept of manic-depressive illness was challenged in the 1960s by several European and American investigators. This led to the unipolar-bipolar distinction, with considerable restriction of the boundaries of bipolar disorder in favor of unipolar depressions. This concept has now been implicity adopted by official systems of classification worldwide. This review summarizes recent research data that suggest that a partial return to Kraepelin's broad concept of manic-depressive illness is in order. In reassessing the unipolar-bipolar dichotomy, the authors propose that the classification of depressions should incorporate such nonsymptomatologic considerations as family history, temperament, abruptness of onset, recurrence (periodicity and seasonality), and Pharmacologie response.

Depending on the definitions used, the unipolar-bipolar ratio has ranged from 10:1 to 4:1. Recent American and European investigations, including studies by the authors and their Italian collaborators, suggest that this ratio may be closer to 2:1 and even as low as 1:1. This conclusion is further supported by genetic data, prospective follow-up studies, pharmacologie response, and examination of interepisodic temperaments. Thus, many depressives with premorbid or intermorbid hyperthymie, irritable or cyclothymie temperaments can now be classified as bipolar. Variously referred to as pseudo-unipolar, unipolar II, bipolar III, bipolar II, or the “ soft” bipolar speetrum, these depressive conditions present diagnostic and therapeutic challenges to the clinician. Special subgroups may be at risk for rapid cycling when overexposed to tricyclic antidepressants. Finally, a significant minority of soft bipolars uppear to be prominent in leadership positions and artistic domains.

Dysthymic disorder in an inpatient population. A descriptive study

Patients suffering from various subtypes of dysthymia were compared with regard to demographic, clinical and personality characteristics. Patients with secondary dysthymia, as compared to those with primary dysthymia, had an earlier age of onset and a higher frequency of Axis I co-diagnoses (in particular anxiety disorders). Patients with pure dysthymia, as compared to those with double depression, showed an earlier age of onset of Axis I co-diagnoses, a later age of onset of dysthymic disorder and a shorter duration of the disease.

Dysthymia as a temperamental variant of affective disorder

Dysthymia is estimated to afflict at least 3% of the population worldwide. Because it is a chronic disorder, its prevalence is high in psychiatric and general medical settings. The mystery of this incapacitating depressive subtype — long recognized but only recently sanctioned in the DSM-IV and ICD-10 — is that, in their habitual condition, those suffering from dysthymia lack the classical ‘objective’ or ‘major’ signs of acute clinical depression, such as profound changes in psychomotor and vegetative functions. Instead, patients consult their doctors for more fluctuating complaints consisting of gloominess, lethargy, self-doubt, malaise, and lack of joie de vivre. They typically work hard, but do not enjoy their work. If married, they are deadlocked in bitter and unhappy marriages which lead neither to reconciliation nor separation. For them, their entire existence is a burden: they are satisfied with nothing, complain of everything, and brood about the uselessness of existence. As a result, in the past they were labeled ‘existential depressives’ or ‘depressive characters’ and condemned to the couch, often on a chronic basis. Several lines of research over the past fifteen years have shed new light on the biological origins of this disorder. Sleep neurophysiologic findings have shown that many parameters of paradoxical sleep in dysthymia (such as REM percentage, REM latency, and circadian distribution of REM) are similar to those observed in major affective illness. Furthermore, family studies of dysthymia have demonstrated a significant excess of mood disorders. Indeed, dysthymia has been identified in childhood, and prospective follow-up has demonstrated major affective breakdowns including bipolar switches in up to 20%. Coupled with sleep findings, these family and follow-up data suggest that dysthymia is best considered as ‘trait depression’, a constitutional variant of major affective illness. As expected from the early onset chronic nature of the disturbance, in both clinical and epidemiological studies, the social and health burden of dysthymia has been found to be considerable and comparable to that of major medical disorders. The foregoing clinical and biological data have provided the impetus for well-designed pharmacological trials in dysthymia, and a new therapeutic optimism.

An International Society of Bipolar Disorders task force report: Precursors and prodromes of bipolar disorder

OBJECTIVES

To clarify the clinical features preceding the onset of bipolar disorder (BD) has become a public health priority for the prevention of high morbidity and mortality. BD remains frequently under- or misdiagnosed, and under- or mistreated, often for years.

METHODS

We assessed the predictive value of precursors and prodromes of BD. We assessed precursors of first-lifetime manic or hypomanic episodes with/without mixed features in retrospective and prospective studies. The task force evaluated and summarized separately assessments of familial risk, premorbid personality traits, retrospective, and prospective studies.

RESULTS

Cyclothymic features, a family history of BD, retrospectively reported attenuated manic symptoms, prospectively identified subthreshold symptoms of hypomania, recurrence of depression, panic anxiety and psychotic features, have been identified as clinical precursors of BD. The prodromal symptoms like [hypo]mania often appears to be long enough to encourage early identification and timely intervention.

CONCLUSIONS

The predictive value of any risk factor identified remains largely unknown. Prospective controlled studies are urgently needed for prevention and effective treatment.

At-risk studies and clinical antecedents of psychosis, bipolar disorder and depression: a scoping review in the context of clinical staging

Identifying young people at risk of developing serious mental illness and identifying predictors of onset of illness has been a focus of psychiatric prediction research, particularly in the field of psychosis. Work in this area has facilitated the adoption of the clinical staging model of early clinical phenotypes, ranging from at-risk mental states to chronic and severe mental illness. It has been a topic of debate if these staging models should be conceptualised as disorder-specific or transdiagnostic. In order to inform this debate and facilitate cross-diagnostic discourse, the present scoping review provides a broad overview of the body of literature of (a) longitudinal at-risk approaches and (b) identified antecedents of (homotypic) illness progression across three major mental disorders [psychosis, bipolar disorder (BD) and depression], and places these in the context of clinical staging. Stage 0 at-risk conceptualisations (i.e. familial high-risk approaches) were identified in all three disorders. However, formalised stage 1b conceptualisations (i.e. ultra-high-risk approaches) were only present in psychosis and marginally in BD. The presence of non-specific and overlapping antecedents in the three disorders may support a general staging model, at least in the early stages of severe psychotic or mood disorders.

A NATURALISTIC EXPLORATORY STUDY OF OBSESSIVE-COMPULSIVE BIPOLAR COMORBIDITY IN YOUTH

BACKGROUND

Growing evidence supports the comorbidity between bipolar disorder (BD) and obsessive-compulsive disorder (OCD) in children and adolescents. Our aim is to further explore clinical and treatment implications of this comorbidity, as it appears in clinical practice.

METHOD

The sample included 429 consecutive patients with BD and/or OCD as primary diagnoses, followed for a mean period of 6 months (range 4-9 months), 172 with BD (102 males, mean age 13.7±2.9 years), 169 with OCD (118 males, mean age of 13.2±2.7 years) and 88 with comorbid BD+OCD (56 males, mean age 14.2±2.6 years, 52 with BD as the primary diagnosis), followed for a mean period of 6 months (range 4-9 months). The comorbid group was compared to pure BD and OCD groups, to explore differential clinical and treatment features.

RESULTS

The BD-OCD comorbidity was found in 33.8% of the BD patients and in 34.2% of the OCD patients. Age at onset of BD and OCD were not different in pure and "comorbid" groups. The comorbid group presented a higher occurrence of BD type II and hoarding symptoms, and more frequently received a psychotherapy and second generation antipsychotics, but it presented the poorest outcome in terms of response to treatments. Severity at baseline (clinical severity and functional impairment), hoarding obsessions and compulsions, and conduct disorder comorbidity were associated with a treatment non-response.

LIMITATIONS

A selection bias may have increased the rate of comorbidity, as most of the patients were referred to our tertiary hospital for severe BD and/or OCD and pharmacological treatment. We have used CGI-I as an outcome measure, not a specific measure of BD or OCD symptoms' severity and improvement. The short duration of the follow-up may limit our conclusions.

CONCLUSIONS

The timely identification of BD-OCD comorbidity may have relevant clinical implications in terms of symptomatology, course, treatment and outcome.

Risk of recurrence after a single manic or mixed episode - a systematic review and meta-analysis

OBJECTIVES

For the first time to estimate the risk of recurrence among patients with a single manic/mixed episode by systematically reviewing prior studies on cohorts of adults, and cohorts of children and adolescents, respectively.

METHODS

A systematic literature search up to August 2017 was carried out including studies in which < 25% of the participants were estimated to have had a mood episode that required pharmacological treatment prior to the index manic or mixed episode at inclusion.

RESULTS

Three studies including a total of 293 adult patients with a single manic or mixed episode and three studies of children and adolescents including 126 patients were identified. In the adult studies, 31%, 40% and 42% experienced recurrence after recovery within 1 year, 59% after 2 years, and 58% after 4 years, respectively. In the studies on children and adolescents, 40% and 52% experienced recurrence after recovery within 1 year, 30% and 60% after 2 years and 64% and 67% after 4 to 5 years, respectively. Results from meta-analyses showed a 1-year rate of recurrence of 35% (95% confidence interval [CI]: 30-41%) in adults, and in adolescents/children, a 1-year rate of recurrence of 48% (95% CI: 38-58%), a 2-year rate of 46% (95% CI: 33-60%) and a 4-5-year rate of recurrence of 65% (95% CI: 52-77%; as data from different studies were included at 1, 2 and 5 years, rates of recurrence did not increase steadily with time).

CONCLUSIONS

The rate of recurrence is high among adults as well as children and adolescents. It is important that clinicians and patients as well as relatives are well informed about these high risks when deciding to start maintenance treatment or not following onset of a single manic or mixed episode.

What can we learn from offspring studies in bipolar disorder?

We offer a contemporary review of studies of the offspring of parents with bipolar disorder and explore the clinical characteristics of these populations. We discuss how different methodological approaches may influence study findings and may explain some of the heterogeneity in the results reported. We also highlight some of the environmental risk factors that may increase the likelihood of transition from an ‘at-risk’ or high-risk state to bipolar disorder. Last, we briefly discuss the implications of study findings for early intervention strategies and comment on such issues as genetic counselling and primary and early secondary prevention programmes.

A Double-Blind and Placebo-Controlled Trial of Aripiprazole in Symptomatic Youths at Genetic High Risk for Bipolar Disorder

OBJECTIVE

To determine if acute treatment with aripiprazole (APZ) would be superior to treatment with placebo in reducing dysfunctional symptoms of elevated mood and/or irritability in symptomatic children and adolescents at familial high risk for bipolar disorder (BPD) whose mood episodes occur spontaneously. These are patients we have previously referred to as suffering from "cyclotaxia."

METHODS

This was single-site, randomized, double-blind, placebo-controlled outpatient clinical trial in which youths aged 5-17 years who met diagnostic criteria for either cyclothymic disorder (CYC) or BPD not otherwise specified (BP-NOS) were randomly assigned to receive either APZ or placebo. Eligible participants had at least one parent with BPD, another first- or second-degree relative afflicted with a mood disorder, and also had not responded to psychotherapy. Treatment with APZ was initiated at a dose of approximately 0.1 mg/kg/day and could be increased by approximately 0.05 mg/kg/day at each study visit. Patients were seen weekly for 4 weeks and then every other week thereafter for 12 weeks. The primary outcome measure was mean change from baseline on Young Mania Rating Scale (YMRS) total score.

RESULTS

A total of 59 patients (30 APZ, 29 placebo) aged 11.8 (SD = 2.7) years were randomized and returned for at least one postbaseline assessment. The mean total daily doses of active APZ and placebo were 7.1 mg (SD = 3.7) and 7.4 mg (SD = 4.2), respectively. At the 12-week time point, APZ was superior to placebo on the primary outcome measure (p < 0.005). Most adverse events were mild and transient in nature. There was a significant difference in weight gain from baseline between patients who received APZ (2.3 kg [SD = 3.3]) and those who received placebo (0.7 kg [SD = 1.8]).

CONCLUSION

This double-blind trial found that APZ was significantly more efficacious than placebo in reducing symptoms of mania in children and adolescents with cyclotaxia.

Characteristics of depression among offspring at high and low familial risk of bipolar disorder

OBJECTIVES

Having a parent with bipolar disorder (BP) is a very strong risk factor for developing BP. Similarly, depression among youth is a clinical risk factor for subsequent BP. We evaluated whether mood symptomatology in depressed youth is different between those at high and low familial risk to develop BP.

METHODS

The most severe major depressive episode in BP offspring (N=61) and community control offspring (N=20) was evaluated using expanded depression and mania rating scales derived from the Schedule for Affective Disorders and Schizophrenia for Children Present Version. The results were adjusted for any between-group significant demographic differences and for multiple comparisons.

RESULTS

The severity of depressive symptoms and the percentage of offspring with severe depressive symptoms, especially atypical depressive features, were significantly higher in the depressed offspring of BP parents compared to the depressed controls (P_s <.05). The depressive symptoms were helpful to identify a high-risk group (e.g., odds ratio [OR] for hypersomnia: 22.4, 95% confidence interval [CI]: 1.3-404, P=.04). In addition, there were significantly more depressed offspring of BP parents with subsyndromal manic symptoms than controls (52.5% vs 20%, OR: 4.2, 95% CI: 1.2-14.7, P<.01).

CONCLUSIONS

Depressed BP offspring had more severe depression including atypical depressive symptoms, and were more likely to have subsyndromal mixed manic symptoms than depressed control offspring. Prospective studies to evaluate whether these youth are at high risk to develop BP are warranted. If replicated, the results of this study have important clinical (e.g., treatment of depression in depressed offspring of BP parents) and research implications.

Differences in cognitive deficits in individuals with subthreshold syndromes with and without family history of bipolar disorder

Little is known about the development of cognitive deficits prior to the official onset of bipolar disorder (BP). The aim of this study was to investigate neurocognitive performance in two early stages of BP. This high-risk design study recruited a group of offspring of parents with BP (n = 58), aged 8-28 years. Based on the subthreshold syndromes, the "unaffected" offspring were further divided into high-risk (HR) and ultra-high-risk (UHR) stages. For comparison, a group of individuals with subthreshold symptoms but without family history of psychiatric disorder (n = 17) and 48 healthy controls (HCs) were included. The MATRICS Consensus Cognitive Battery (MCCB) and Tower of London task were applied to assess neuropsychological performance. The HR offspring performed significantly poorer on verbal learning and memory when compared with HCs, indicating that the deficits may serve as neurocognitive endophenotypes for BP. Deficits in working memory, visual-spatial memory, and cognitive planning were observed in the UHR offspring when compared with HCs, suggestive of risk of developing BP. The deficits observed in the UHR offspring were absent in the individuals with subthreshold symptoms without psychiatric family history. Our data suggest that cognitive deficits become apparent prior to the official onset of BP, with specific deficits observable in different early stages. These results nonetheless are based on small sample size and a cross-sectional design. Given this and the heterogeneity of bipolar disorders, these findings should be interpreted cautiously and require replication.

Onset polarity in bipolar disorder: A strong association between first depressive episode and suicide attempts

BACKGROUND

The role of onset polarity (OP) in patients with bipolar disorder (BD) has been increasingly investigated over the last few years, for its clinical, prognostic, and therapeutic implications. The present study sought to assess whether OP was associated with specific correlates, in particular with a differential suicidal risk in BD patients.

METHODS

A sample of 362 recovered BD patients was dichotomized by OP: depressed (DO) or elevated onset (EO: hypomanic/manic/mixed). Socio-demographic and clinical variables were compared between the subgroups. Additionally, binary logistic regression was performed to assess features associated with OP.

RESULTS

DO compared with EO patients had older current age and were more often female, but less often single and unemployed. Clinically, DO versus EO had a more than doubled rate of suicide attempts, as well as significantly higher rates of BD II diagnosis, lifetime stressful events, current psychotropics and antidepressants use, longer duration of the most recent episode (more often depressive), but lower rates of psychosis and involuntary commitments.

LIMITATIONS

Retrospective design limiting the accurate assessment of total number of prior episodes of each polarity.

CONCLUSIONS

Our results support the influence of OP on BD course and outcome. Moreover, in light of the relationship between DO and a higher rate of suicide attempts, further investigation may help clinicians in identifying patients at higher risk of suicide attempts.

Early interventions for youths at high risk for bipolar disorder: a developmental approach

In recent decades, ongoing research programmes on primary prevention and early identification of bipolar disorder (BD) have been developed. The aim of this article is to review the principal forms of evidence that support preventive interventions for BD in children and adolescents and the main challenges associated with these programmes. We performed a literature review of the main computerised databases (MEDLINE, PUBMED) and a manual search of the literature relevant to prospective and retrospective studies of prodromal symptoms, premorbid stages, risk factors, and early intervention programmes for BD. Genetic and environmental risk factors of BD were identified. Most of the algorithms used to measure the risk of developing BD and the early interventions programmes focused on the familial risk. The prodromal signs varied greatly and were age dependent. During adolescence, depressive episodes associated with genetic or environmental risk factors predicted the onset of hypomanic/manic episodes over subsequent years. In prepubertal children, the lack of specificity of clinical markers and difficulties in mood assessment were seen as impeding preventive interventions at these ages. Despite encouraging results, biomarkers have not thus far been sufficiently validated in youth samples to serve as screening tools for prevention. Additional longitudinal studies in youths at high risk of developing BD should include repeated measures of putative biomarkers. Staging models have been developed as an integrative approach to specify the individual level of risk based on clinical (e.g. prodromal symptoms and familial history of BD) and non-clinical (e.g. biomarkers and neuroimaging) data. However, there is still a lack of empirically validated studies that measure the benefits of using these models to design preventive intervention programmes.

Early-onset and very-early-onset bipolar disorder: distinct or similar clinical conditions?

OBJECTIVE

This study aimed to examine differences in the clinical presentation of very-early-onset (VEO) and early-onset (EO) bipolar disorder (BD) not fully explored previously.

METHODS

We selected two groups of subjects with BD from the Maritime Bipolar Registry based on age at onset of first major mood episode (VEO with onset prior to age 15 years; EO ranging from 15 to 18 years) and compared them with a reference group (onset after 18 years of age). There were 363 subjects (240 with bipolar I disorder and 123 with bipolar II disorder; mean age 44.2 ± 12.8 (SD) years), with 41 subjects in the VEO and 95 in the EO groups.

RESULTS

In comparison with the EO and reference groups, more subjects in the VEO group developed major depression as an index episode (88% for the VEO group versus 61% for the EO group and 54% for the reference group), and had an unremitting clinical course (65% versus 42% and 42%, respectively), rapid cycling (54% versus 34% and 28%, respectively), and comorbid attention-deficit hyperactivity disorder (17% versus 1% and 3%, respectively); a higher proportion of the VEO group had first-degree relatives with affective disorders compared with the EO and reference groups (0.41 versus 0.32 and 0.29, respectively), and they had lower scores on the Global Assessment of Functioning scale (mean scores of 64 versus 70 and 70). Overall, the EO group was similar to the reference group on most measures, except for increased suicidal behavior VEO 53%, EO 44% and reference group 25%). The results of polychotomous logistic regression also support the view that VEO BD represents a rather specific subtype of BD.

CONCLUSIONS

Our results suggest the recognized correlates of early-onset BD may be driven by subjects at the lowest end of the age at onset spectrum.

The genetics of early-onset bipolar disorder: A systematic review

BACKGROUND

Early-onset bipolar disorder has been associated with a significantly worse prognosis than late-onset BD and has been hypothesized to be a genetically homogenous subset of BD. A sizeable number of studies have investigated early-onset BD through linkage-analyses, candidate-gene association studies, genome-wide association studies (GWAS), and analyses of copy number variants (CNVs), but this literature has not yet been reviewed.

METHODS

A systematic review was conducted using the PubMed database on articles published online before January 15, 2015 and after 1990. Separate searches were made for linkage studies, candidate gene-association studies, GWAS, and studies on CNVs.

RESULTS

Seventy-three studies were included in our review. There is a lack of robust positive findings on the genetics of early-onset BD in any major molecular genetics method.

LIMITATIONS

Early-onset populations were quite small in some studies. Variance in study methods hindered efforts to interpret results or conduct meta-analysis.

CONCLUSIONS

The field is still at an early phase for research on early-onset BD. The largely null findings mirror the results of most genetics research on BD. Although most studies were underpowered, the null findings could mean that early-onset BD may not be as genetically homogenous as has been hypothesized or even that early-onset BD does not differ genetically from adult-onset BD. Nevertheless, clinically the probabilistic developmental risk trajectories associated with early-onset that may not be primarily genetically determined continued to warrant scrutiny. Future research should dramatically expand sample sizes, use atheoretical research methods like GWAS, and standardize methods.

Cyclothymia reloaded: A reappraisal of the most misconceived affective disorder

Data emerging from both academic centers and from public and private outpatient facilities indicate that from 20% to 50% of all subjects that seek help for mood, anxiety, impulsive and addictive disorders turn out, after careful screening, to be affected by cyclothymia. The proportion of patients who can be classified as cyclothymic rises significantly if the diagnostic rules proposed by the DSM-5 are reconsidered and a broader approach is adopted. Unlike the DSM-5 definition based on the recurrence of low-grade hypomanic and depressive symptoms, cyclothymia is best identified as an exaggeration of cyclothymic temperament (basic mood and emotional instability) with early onset and extreme mood reactivity linked with interpersonal and separation sensitivity, frequent mixed features during depressive states, the dark side of hypomanic symptoms, multiple comorbidities, and a high risk of impulsive and suicidal behavior. Epidemiological and clinical research have shown the high prevalence of cyclothymia and the validity of the concept that it should be seen as a distinct form of bipolarity, not simply as a softer form. Misdiagnosis and consequent mistreatment are associated with a high risk of transforming cyclothymia into severe complex borderline-like bipolarity, especially with chronic and repetitive exposure to antidepressants and sedatives. The early detection and treatment of cyclothymia can guarantee a significant change in the long-term prognosis, when appropriate mood-stabilizing pharmacotherapy and specific psychological approaches and psychoeducation are adopted. The authors present and discuss clinical research in the field and their own expertise in the understanding and medical management of cyclothymia and its complex comorbidities.

A Multi-Dimensional and Integrative Approach to Examining the High-Risk and Ultra-High-Risk Stages of Bipolar Disorder

BACKGROUND

Validating the high-risk (HR) and ultra-high-risk (UHR) stages of bipolar disorder (BP) may help enable early intervention strategies.

METHODS

We followed up with 44 offspring of parents with BP, subdividing into the HR and UHR categories. The offspring were aged 8-28 years and were free of any current DSM-IV diagnoses. Our multilevel, integrative approach encompassed gray matter (GM) volumes, brain network connectivity, neuropsychological performance, and clinical outcomes.

FINDINGS

Compared with the healthy controls (HCs) (n = 33), the HR offspring (n = 26) showed GM volume reductions in the right orbitofrontal cortex. Compared with the HR offspring, the UHR offspring (n = 18) exhibited increased GM volumes in four regions. Both the HR and UHR offspring displayed abnormalities in the inferior occipital cortex regarding the measures of degree and centrality, reflecting the connections and roles of the region, respectively. In the UHR versus the HR offspring, the UHR offspring exhibited upwards-shifted small world topologies that reflect high clustering and efficiency in the brain networks. Compared with the HCs, the UHR offspring had significantly lower assortativity, which was suggestive of vulnerability. Finally, processing speed, visual-spatial, and general function were impaired in the UHR offspring but not in the HR offspring.

INTERPRETATION

The abnormalities observed in the HR offspring appear to be inherited, whereas those associated with the UHR offspring represent stage-specific changes predisposing them to developing the disorder.

Childhood-compared to adolescent-onset bipolar disorder has more statistically significant clinical correlates

BACKGROUND

The strengths and limitations of considering childhood-and adolescent-onset bipolar disorder (BD) separately versus together remain to be established. We assessed this issue.

METHODS

BD patients referred to the Stanford Bipolar Disorder Clinic during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD Affective Disorders Evaluation. Patients with childhood- and adolescent-onset were compared to those with adult-onset for 7 unfavorable bipolar illness characteristics with replicated associations with early-onset patients.

RESULTS

Among 502 BD outpatients, those with childhood- (<13 years, N=110) and adolescent- (13-18 years, N=218) onset had significantly higher rates for 4/7 unfavorable illness characteristics, including lifetime comorbid anxiety disorder, at least ten lifetime mood episodes, lifetime alcohol use disorder, and prior suicide attempt, than those with adult-onset (>18 years, N=174). Childhood- but not adolescent-onset BD patients also had significantly higher rates of first-degree relative with mood disorder, lifetime substance use disorder, and rapid cycling in the prior year. Patients with pooled childhood/adolescent - compared to adult-onset had significantly higher rates for 5/7 of these unfavorable illness characteristics, while patients with childhood- compared to adolescent-onset had significantly higher rates for 4/7 of these unfavorable illness characteristics.

LIMITATIONS

Caucasian, insured, suburban, low substance abuse, American specialty clinic-referred sample limits generalizability. Onset age is based on retrospective recall.

CONCLUSIONS

Childhood- compared to adolescent-onset BD was more robustly related to unfavorable bipolar illness characteristics, so pooling these groups attenuated such relationships. Further study is warranted to determine the extent to which adolescent-onset BD represents an intermediate phenotype between childhood- and adult-onset BD.

Lithium in the treatment of bipolar disorder: pharmacology and pharmacogenetics

After decades of research, the mechanism of action of lithium in preventing recurrences of bipolar disorder remains only partially understood. Lithium research is complicated by the absence of suitable animal models of bipolar disorder and by having to rely on in vitro studies of peripheral tissues. A number of distinct hypotheses emerged over the years, but none has been conclusively supported or rejected. The common theme emerging from pharmacological and genetic studies is that lithium affects multiple steps in cellular signaling, usually enhancing basal and inhibiting stimulated activities. Some of the key nodes of these regulatory networks include GSK3 (glycogen synthase kinase 3), CREB (cAMP response element-binding protein) and Na(+)-K(+) ATPase. Genetic and pharmacogenetic studies are starting to generate promising findings, but remain limited by small sample sizes. As full responders to lithium seem to represent a unique clinical population, there is inherent value and need for studies of lithium responders. Such studies will be an opportunity to uncover specific effects of lithium in those individuals who clearly benefit from the treatment.

Correlation between Peripheral Levels of Brain-Derived Neurotrophic Factor and Hippocampal Volume in Children and Adolescents with Bipolar Disorder

Pediatric bipolar disorder (PBD) is a serious mental disorder that affects the development and emotional growth of affected patients. The brain derived neurotrophic factor (BDNF) is recognized as one of the possible markers of the framework and its evolution. Abnormalities in BDNF signaling in the hippocampus could explain the cognitive decline seen in patients with TB. Our aim with this study was to evaluate possible changes in hippocampal volume in children and adolescents with BD and associate them to serum BDNF. Subjects included 30 patients aged seven to seventeen years from the ProCAB (Program for Children and Adolescents with Bipolar Disorder). We observed mean right and left hippocampal volumes of 41910.55 and 41747.96 mm(3), respectively. No statistically significant correlations between peripheral BDNF levels and hippocampal volumes were found. We believe that the lack of correlation observed in this study is due to the short time of evolution of BD in children and adolescents. Besides studies with larger sample sizes to confirm the present findings and longitudinal assessments, addressing brain development versus a control group and including drug-naive patients in different mood states may help clarify the role of BDNF in the brain changes consequent upon BD.

Bipolar disorder incidence between children and adolescents: A brief communication

BACKGROUND

Bipolar affective disorder is one of most injurious psychiatric diseases, not, rarely leading patient for suicide, and its prevalence keeps increasing worldwide, notably on low and, middle-income countries. For children living in northeast Brazil, extreme social conditions constitute, an environment of special vulnerability.

OBJECTIVE

Here we show that bipolar disorder incidence, between children and adolescents in this Brazilian region increased 34.2% from 2005 to 2014 and, in, the same area and age group, deaths provoked by self-caused injuries also became progressively, greater.

RESULTS

According to DATASUS, the Brazilian national databank for public health, information, in the last five years, we observed an increase of Bipolar Disorder incidence rates under, 19 year-old of about 34.2% in the northeast region of Brazil, while the increase for Brazilian general, population was 12.4%. If considered only patients under 10, this number is even greater, of 47.2%. Content of Table 2 shows this disproportion, while comparing the advance of bipolar disorder, morbidity indices nationwide and worldwide.

CONCLUSION

Children living in Brazil's northeast, region are in a condition of extreme social disadvantage, what can be determinant for the recent and, sequential increase of bipolar disorder prevalence and the mortality in this age-group due to suicide, one of possible reflections of untreated mood disorders. For protecting these children is important to, identify the factors which prevent these illnesses and promote resilience for these young people.

Early risk factors for adult bipolar disorder in adolescents with mood disorders: a 15-year follow-up of a community sample

BACKGROUND

We aimed to outline the early risk factors for adult bipolar disorder (BPD) in adolescents with mood disorders.

METHODS

Adolescents (16-17 years old) with mood disorders (n = 287; 90 participants with hypomania spectrum episodes and 197 with major depressive disorder [MDD]) were identified from a community sample. Fifteen years later (at 30-33 years of age), mood episodes were assessed (n = 194). The risk of developing BPD (n = 22), compared with MDD (n = 104) or no mood episodes in adulthood (n = 68), was estimated via logistic regression. Adolescent mood symptoms, non-mood disorders, and family characteristics were assessed as potential risk factors.

RESULTS

Among the adolescents with mood disorders, a family history of BPD was the strongest predictor of developing BPD compared with having no mood episodes in adulthood (OR = 5.94; 95% CI = 1.11-31.73), whereas disruptive disorders significantly increased the risk of developing BPD compared with developing MDD (OR = 2.94; CI = 1.06-8.12). The risk that adolescents with MDD would develop adult BPD, versus having no mood episodes in adulthood, was elevated among those with an early disruptive disorder (OR = 3.62; CI = 1.09-12.07) or multiple somatic symptoms (OR = 6.60; CI = 1.70-25.67). Only disruptive disorders significantly predicted adult BPD among adolescents with MDD versus continued MDD in adulthood (OR = 3.59; CI = 1.17-10.97). Only a few adolescents with hypomania spectrum episodes continued to have BPD as adults, and anxiety disorders appeared to increase this risk.

CONCLUSIONS

Although most of the identified potential risk factors are likely general predictors of continued mood disorders, disruptive disorders emerged as specific predictors of developing adult BPD among adolescents with MDD.

Personality disorders in offspring of mothers with mood disorders: results from a longitudinal family study

Offspring of mothers with mood disorders are known to be at risk for a range of adverse outcomes, but the prevalence of personality disorders (PDs) in this group is unknown. The goal of this study was to assess risk of PD diagnoses and symptoms in offspring of mothers with and without mood disorders, and to explore contributing factors to this risk. This longitudinal study assessed PDs and symptoms of PDs in offspring of mothers with bipolar disorder (O-BD), major depression (O-MDD), and no psychiatric diagnosis (O-WELL) in mid-adolescence and in early adulthood. O-BD were more likely to develop a Cluster B PD than O-MDD or O-WELL in adolescence, and more likely to develop a Cluster B PD then O-WELL in early adulthood. Dimensional analyses revealed that O-BD had elevated symptoms in PDs across all PD clusters at mid-adolescence and young adulthood. O-MDD showed elevated symptoms of antisocial PD at both time points, and of obsessive-compulsive PD at young adulthood. Offspring of mothers with mood disorders, especially O-BD, are at increased risk for PD diagnoses and symptoms in mid-adolescence and early adulthood. Contributing factors to risk of PD symptoms in at-risk offspring are discussed.

Antecedents of manic versus other first psychotic episodes in 263 bipolar I disorder patients

OBJECTIVE

As initial episode type can predict later morbidity in bipolar disorder, we tested the hypothesis that clinical antecedents might predict initial episode types.

METHOD

We studied 263 first-episode, adult, DSM-IV-TR type I bipolar disorder (BD-I) subjects within the McLean-Harvard-International First-Episode Project. Based on blinded assessments of antecedents from SCID examinations and clinical records, we compared first lifetime manic vs. other (mixed, depressive, or non-affective) major psychotic episodes.

RESULTS

We identified 32 antecedents arising at early, intermediate or later times, starting 12.3±10.7 years prior to first lifetime major psychotic episodes. Based on multivariate modeling, antecedents associated significantly and independently with other (n=113) more than manic (n=150) first lifetime major psychotic episodes ranked by odds ratio: more early attentional disturbances, more late depression, more early perplexity, more detoxification, more early unstable mixed affects, more antidepressants, more early dysphoria, more intermediate depression, more early impulsivity, more late anhedonia, longer early-to-intermediate intervals, more intermediate substance abuse, more family history of major depression, and younger at earliest antecedents. Antecedents selectively preceding manic more than other first psychotic episodes included more late behavioral problems and more risk of familial BD-I.

CONCLUSION

Clinical antecedents in adult, BD-I patients, beginning a decade before first major episodes and progressing through sequential stages were dissimilar in manic vs. other first psychotic episodes.

Hypomania spectrum disorder in adolescence: a 15-year follow-up of non-mood morbidity in adulthood

BACKGROUND

We investigated whether adolescents with hypomania spectrum episodes have an excess risk of mental and physical morbidity in adulthood, as compared with adolescents exclusively reporting major depressive disorder (MDD) and controls without a history of adolescent mood disorders.

METHODS

A community sample of adolescents (N = 2 300) in the town of Uppsala, Sweden, was screened for depressive symptoms. Both participants with positive screening and matched controls (in total 631) were diagnostically interviewed. Ninety participants reported hypomania spectrum episodes (40 full-syndromal, 18 with brief episode, and 32 subsyndromal), while another 197 fulfilled the criteria for MDD without a history of a hypomania spectrum episode. A follow up after 15 years included a blinded diagnostic interview, a self-assessment of personality disorders, and national register data on prescription drugs and health services use. The participation rate at the follow-up interview was 71% (64/90) for the hypomania spectrum group, and 65.9% (130/197) for the MDD group. Multiple imputation was used to handle missing data.

RESULTS

The outcomes of the hypomania spectrum group and the MDD group were similar regarding subsequent non-mood Axis I disorders in adulthood (present in 53 vs. 57%). A personality disorder was reported by 29% of the hypomania spectrum group and by 20% of the MDD group, but a statistically significant difference was reached only for obsessive-compulsive personality disorder (24 vs. 14%). In both groups, the risk of Axis I disorders and personality disorders in adulthood correlated with continuation of mood disorder. Prescription drugs and health service use in adulthood was similar in the two groups. Compared with adolescents without mood disorders, both groups had a higher subsequent risk of psychiatric morbidity, used more mental health care, and received more psychotropic drugs.

CONCLUSIONS

Although adolescents with hypomania spectrum episodes and adolescents with MDD do not differ substantially in health outcomes, both groups are at increased risk for subsequent mental health problems. Thus, it is important to identify and treat children and adolescents with mood disorders, and carefully follow the continuing course.

Re-examining the risk for switch from unipolar to bipolar major depressive disorder in youth with ADHD: a long term prospective longitudinal controlled study

BACKGROUND

Recent studies have identified subthreshold forms of bipolar (BP)-I disorder and deficits in emotional regulation as risk factors for bipolar disorder in youth. The primary aim of this study was to investigate whether emotional dysregulation and subthreshold forms of BP-I disorder increase the risk for BP switches in ADHD youth with non-bipolar MDD.

METHODS

We used data from two large controlled longitudinal family studies of boys and girls with and without ADHD. Subjects (N=522) were followed prospectively and blindly over an average follow up period of 11.4 years. Comparisons were made between ADHD youth with unipolar major depression (MDD) who did (N=24) and did not (N=79) switch to BP-I disorder at follow-up.

RESULTS

The rate of conversion to BP-I disorder at follow up was higher in MDD subjects with subthreshold BP-I disorder at baseline compared to those without (57% vs. 21%; OR=9.57, 95% CI=1.62-56.56, p=0.013) and in MDD subjects with deficient emotional self-regulation (OR=3.54, 95% CI=1.08-11.60, p=0.037).

LIMITATIONS

The sample was largely Caucasian, so these results may not generalize to minority groups. The sample of youth with SED was small, which limited the statistical power for some analyses.

CONCLUSIONS

Switches from unipolar MDD to BP-I disorder in children with ADHD and MDD were predicted by baseline subthreshold BP-I disorder symptoms and baseline deficits in emotional regulation. More work is needed to assess whether these risk factors are operant outside the context of ADHD.

Disturbances in reality testing as markers of risk in offspring of parents with bipolar disorder: a systematic review from a developmental psychopathology perspective

OBJECTIVES

This comprehensive review examined the prevalence and progression of disturbances in reality testing (DRT), defined as psychotic symptoms, cognitive disruptions, and thought problems, in offspring of parents with bipolar disorder (O-BD). Our approach was grounded in a developmental psychopathology perspective and considered a broader phenotype of risk within the bipolar-schizophrenia spectrum as measured by categorical and dimensional assessments of DRT in high-risk youth.

METHODS

Relevant studies were identified from numerous sources (e.g., PubMed, reference sections, and colleagues). Inclusion criteria were: (i) family risk studies published between 1975 and 2012 in which O-BD were contrasted with a comparison group (e.g., offspring of parents who had other psychiatric disorders or were healthy) on DRT outcomes and (ii) results reported for categorical or dimensional assessments of DRT (e.g., schizophrenia, psychotic symptoms, cluster A personality traits, or thought problems), yielding a total of 23 studies.

RESULTS

Three key findings emerged: (i) categorical approaches of DRT in O-BD produced low incidence base rates and almost no evidence of significant differences in DRT between O-BD and comparison groups, whereas (ii) many studies using dimensional assessments of DRT yielded significant group differences in DRT. Furthermore, (iii) preliminary evidence from dimensional measures suggested that the developmental progression of DRT in O-BD might represent a prodrome of severe psychological impairment.

CONCLUSIONS

Preliminary but promising evidence suggests that DRT is a probable marker of risk for future impairment in O-BD. Methodological strengths and weaknesses, the psychometric properties of primary DRT constructs, and future directions for developmental and longitudinal research with O-BD are discussed.

Dimensional endophenotypes in bipolar disorder: affective dysregulation and psychosis proneness

BACKGROUND

The clinical phenotype of bipolar disorder (BPD) is heterogeneous and the genetic architecture of the disorder is complex and not well understood. Given these complications, it is possible that the identification of intermediate phenotypes ("endophenotypes") will be useful in elucidating the complex genetic mechanisms that result in the disorder. The examination of unaffected relatives is critical in determining whether a particular trait is genetically-relevant to BPD. However, few dimensional traits related to BPD have been assessed in unaffected relatives of patients.

METHODS

We assessed affective temperament and schizotypy in 55 discordant sibling pairs and 113 healthy controls (HCs) using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego, Auto-questionnaire version (TEMPS-A) to assess affective temperament and the Schizotypal Personality Questionnaire (SPQ) to assess schizotypy.

RESULTS

BPD patients scored significantly higher than HCs on all subscales of the SPQ and on all but one subscale (hyperthymic) of the TEMPS-A (all p<0.01). Siblings demonstrated scores that were significantly intermediate to patients and HCs on the anxious subscale of the TEMPS-A and on the interpersonal deficits and disorganized subscales of the SPQ.

LIMITATIONS

We did not investigate the BPD spectrum as most patients were diagnosed with BPD I (n=47). Most of the patients had experienced psychosis (n=42) and so we were unable to examine whether psychosis status impacted upon affective temperament or schizotypy in patients or their siblings.

CONCLUSION

These data suggest that schizotypy and affective temperament represent dimensional traits that are likely to underlie the genetic risk for BPD.

[Predicting bipolar disorder: what can we learn from prospective cohort studies?]

INTRODUCTION

Bipolar disorder (BD) is a life course illness; and there is increasing awareness of the many personal, social and economic consequences of the illness in older adults. However, it is important to emphasize that BD usually begins in late adolescence or early adulthood and 75 % cases have a first episode in this age period. This early onset and the associated level of disability mean that BD is the 4th leading cause of global disease burden in adolescents and young adults. Internationally, mental health services are increasingly striving to diagnose and treat BD as early as possible to try to prevent poor outcomes. In addition, researchers are using methods employed previously in psychosis studies as these may help us to recognise the earliest manifestations of BD. If it is possible to identify sub-threshold and 'ultra high risk' syndromes for BD, this might lead to new interventions that could target the prevention of first episodes of mania. One approach to understanding these risk syndromes is to examine prospective community cohort studies and BD offspring studies.

METHODS

This paper reviews prospective cohort studies that identify robust risk factors in early illness onset, which was defined as age at onset of BD between 15-25 years.

RESULTS

We found that although > 50 % of individuals who developed BD had developed a putative BD prodrome prior to 14 years of age, this usually began with non-specific symptoms that overlap with similar presentations for those who later develop psychosis or severe depression. However, there are some features that seem to better identify groups with a BD "at-risk" syndrome. This syndrome is frequently composed of several factors such as mood lability, depressive episodes, prior anxiety, sleep and/or conduct disorders, attention and concentration impairment, altered energy patterns, and a family history of mania and/or depression. The course of these early predictors suggests the precursor syndromes are composed of mini-clusters of symptoms many of which are episodic and change over time. During the early phases of BD, most of the affective disturbances reported were depressive in polarity and started during adolescence, there were few manic or mixed or psychotic episodes with an onset before puberty. The pathogenesis of BD demonstrates a gradual progression from non-specific to more specific symptoms and then to frank BD features.

CONCLUSION

Prospective community and offspring BD cohort studies are approaches that together can help us understand the evolution of BD and allow us to define the developmental pathways. Further, identifying subjects with BD "at-risk" syndrome using a clinical staging model may allow benign interventions to be used as first-line treatment - such as neuroprotective agents like essential fatty acids; second line treatments, with a less benign risk to benefit ratio should be reserved for severe or resistant cases.

Heritability and genome-wide SNP linkage analysis of temperament in bipolar disorder

BACKGROUND

The many attempts to identify genes for bipolar disorder (BD) have met with limited success, which has generally been attributed to genetic heterogeneity and small gene effects. However, it is also possible that the categorical phenotypes used in genetic studies of BD are not the most informative or biologically relevant. We have explored aspects of temperament as quantitative phenotypes for BD through the use of the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Auto-questionnaire (TEMPS-A), which is designed to assess lifelong, milder aspects of bipolar symptomatology and defines five temperaments: hyperthymic, dysthymic, cyclothymic, irritable, and anxious.

METHODS

We compared temperament scores between diagnostic groups and assessed heritability in a sample of 101 families collected for genetic studies of BD. A genome-wide SNP linkage study was then performed in the subset of 51 families for which genetic data was available.

RESULTS

Significant group differences were observed between BD subjects, their first-degree relatives, and independent controls, and all five temperaments were found to be significantly heritable, with heritabilities ranging from 21% for the hyperthymic to 52% for the irritable temperaments. Suggestive evidence for linkage was observed for the hyperthymic (chromosomes 1q44, 2p16, 6q16, and 14q23), dysthymic (chromosomes 3p21 and 13q34), and irritable (chromosome 6q24) temperaments.

LIMITATIONS

The relatively small size of our linkage sample likely limited our ability to reach genome-wide significance in this study.

CONCLUSIONS

While not genome-wide significant, these results suggest that aspects of temperament may prove useful in the identification of genes underlying BD susceptibility.

Screening for bipolar disorder in adolescents with the mood disorder questionnaire-adolescent version (MDQ-A) and the child bipolar questionnaire (CBQ)

AIM

Screening instruments for bipolar disorders (BDs) in children and adolescents have been developed recently. The present study examined performances of the French versions of the mood disorder questionnaire-adolescent version (MDQ-A) and child bipolar questionnaire (CBQ) in a sample of in- and outpatients.

METHODS

Seventy-six adolescents (age 13-18) and parents first completed the MDQ-A (adolescent and parent versions) and CBQ screening instruments. About 3 weeks later, they had a diagnostic interview with the Kiddie-schedule for affective disorders and schizophrenia-present and lifetime (K-SADS-PL), and the adolescent MDQ-A self-report was completed a second time.

RESULTS

Eight of 76 patients (10.5%) met K-SADS-PL diagnostic criteria for BD. Test-retest reliability of the adolescent MDQ-A self-report was moderate (kappa = 0.66), whereas agreement between adolescent and parent reports was poor (kappa = 0.07). Sensitivity and specificity of the MDQ-A with respect to K-SADS-PL were 75.0% and 57.4% for the adolescent version, and 87.5% and 63.2% for the parent version. Corresponding figures were 50.0% and 73.5% for the CBQ. All three screening instruments had low positive predictive values (17.1% for the MDQ-A adolescent version; 21.9% for the MDQ-A parent version; 18.2% for the CBQ), whereas negative predictive values were higher than 90%.

CONCLUSIONS

The present study points to modest performances of the MDQ-A and CBQ to detect BDs in adolescents, with diagnostic criteria for BD being unmet for a majority of patients who screened positive.

Psychometric properties of the Chinese (Mandarin) TEMPS-A: a population study of 985 non-clinical subjects in China

BACKGROUND

The TEMPS-A (Temperament Evaluation of Memphis, Pisa, Paris and San Diego) is a 110-item auto-questionnaire (self-rated) which consists of five temperament scales: depressive, cyclothymic, hyperthymic, irritable and anxious temperaments. It has been translated into over 25 languages and validated in at least 12, with broad cross-cultural cogency. This is a first attempt to validate the TEMPS-A in a very large Chinese population speaking Mandarin.

METHODS

The Chinese TEMPS-A was adapted from the original English version following a rigorous process of forward translation and backward translation (after the approval of the English back translation by H.S.A. and K.K.A.), it was administered to 985 non-clinical Chinese subjects aged between 18-60 years (53.8% female) in four communities in Guangzhou City, China. A subset of 105 subjects was retested approximately six weeks later. Standard psychometric tests of reliability and validation were performed.

RESULTS

The test-retest reliability for depressive (0.74), cyclothymic (0.71), hyperthymic (0.67), irritable (0.66) and anxious (0.83) were respectively as shown in the parentheses. For internal consistency, Chronbach alphas coefficients were 0.68, 0.85, 0.82, 0.83 and 0.87, respectively. Exploratory factor analysis revealed 2 super factors, Factor I loading on anxious, cyclothymic, irritable, and depressive temperaments; and Factor II loading on hyperthymic. Depressive, cyclothymic, irritable and anxious temperaments were correlated with each other. Males had significantly higher scores than females for the hyperthymic and irritable temperaments. The prevalence of the dominant depressive (2.9%), cyclothymic (5.6%), hyperthymic (1.3%), irritable (7.0%) and anxious (5.3%) temperaments were respectively as shown in the parentheses.

LIMITATIONS

Although it is likely that generalizability of our scale is good for the entire Mandarin-speaking ethnic composition of China today, future research is needed to establish this conclusively.

CONCLUSION

The Chinese TEMPS-A standardized on one of the largest non-clinical samples in any of the other national studies to date, has good internal consistency, coheres well with validated versions in other languages. The findings suggest that it is a psychometrically sound instrument to assess affective temperaments in clinical and biological studies in China.

Discriminant and convergent validity of TEMPS-A[P]. Correlation with Occupational Personality Questionnaire (OPQ32) during a stressful situation

BACKGROUND

The Temperament Evaluation of the Memphis, Pisa, Paris and San Diego Questionnaire (TEMPS) has, in its self and rater-wise evaluation form, been designed to evaluate temperamental characteristics in clinical and non-clinical populations.

METHODS

In this study we aim to extend the field of correlations of TEMPS to include the Occupational Personality Questionnaire, ipsative version (OPQ32i). These correlations, if present, could provide a partial contribute to the validation process of TEMPS, currently in progress in various countries. OPQ32 is a self-report personality questionnaire designed to give information on an individual's preferred behavior, as assessed in terms of a number of work-related characteristics. In 921 applicants, who were competing to become cadets in the Italian Navy, we assessed, during the entrance examination, the correlations between TEMPS-A[P] and OPQ32i.

RESULTS

Depressive temperament implies a low level of ability to relate to others; hyperthymic temperament implies high levels of feelings and emotions, and the capability to relate to people; cyclothymic temperament appears to be distinguished by creativity and a low level of relationships with others; irritable temperament partly overlaps with cyclothymic temperament, the main difference being the higher level of energy and the lower level of empathy of irritable subjects.

CONCLUSIONS

The four affective temperaments, in our sample, proved to significantly differ in the work capacity features measured by OPQ32 factors. These observed correlations between the two tests partially contributes to the ongoing validation process of TEMPS-A[P]. From a personality standpoint this study further supports the hypothesis that temperaments belong to the realm of normality rather than that of pathology, in line with their putative adaptive role.

Hypomania spectrum disorders from adolescence to adulthood: a 15-year follow-up of a community sample

BACKGROUND

There is a lack of scientific knowledge about the broader spectrum of hypomania in adolescence and the course over time. To investigate this, we used longitudinal data spanning from adolescence to age 31 years.

METHOD

A community sample of adolescents (N=2300) was screened for depressive symptoms. Adolescents (16-17 years) with a positive screening and matched controls were interviewed with a structured diagnostic interview. A blinded follow-up assessment was conducted 15 years later, with a structured diagnostic interview covering the age span 19-31 years. Questions about treatment and family history were included.

RESULTS

Ninety adolescents (16-17 years) with a lifetime hypomania spectrum episode (3.9% of the total sample) were identified: 40 with fullsyndromal, 18 with brief-episode (<4 day), and 32 with subsyndromal (1-2 main symptoms and 1-2 additional symptoms) hypomania. The hypomania symptoms reported by the fullsyndromal and the brief-episode groups were similar, whereas the subsyndromal group per definition reported fewer symptoms. Of the 90 adolescents with a hypomania spectrum episode, 64 (71%) participated in the follow-up interview. Mania in adulthood was reported by 2 (3%), hypomania by an additional 4 (6%), and major depression by 38 (59%). Incidence of mood episodes in adulthood did not differ between the subgroups of hypomania spectrum.

LIMITATIONS

29% of the participants with hypomania spectrum were lost to follow-up.

CONCLUSION

The results indicate that only a small proportion of adolescents with hypomania spectrum episodes continue to have (hypo)mania in adulthood. Thus, maintenance or prophylactic treatment does not seem warranted for this group.

TEMPS-A[P] temperament profile related to professional choice. Differences between applicants to become a cadet officer in the Italian Air Force or Navy

BACKGROUND

Temperament appears to be a factor involved in professional attitudes. The most impressive findings are those on the importance of cyclothymia in art and of hyperthymia in leadership.

AIM

In this study we raise the issue of whether the relationship between hyperthymic temperament and the choice of a military career, previously reported among Italian Air Force applicants, can be extended to another military service such as the Italian Navy.

METHODS

We compared temperaments between those who had applied to become a cadet officer in the Italian Air Force or in the Italian Navy, with special reference to gender differences and the ability of the two types of applicants to pass the psychiatric examination for admission that we had recently assessed in the Italian Air Force.

RESULTS

Hyperthymic traits were well represented in both these armed services. Navy applicants differed from air-force applicants in obtaining higher depressive, cyclothymic and irritable scores. Navy applicants who passed the psychiatric entrance examination (PEE) showed the same incidence of hyperthymic temperament as their Air Force counterparts, but higher depressive, cyclothymic and irritable scores. Considering gender, among Air Force applicants depressive traits were better represented in males; conversely, among Navy applicants they were better represented in females. If we consider gender together with PEE results, the highest hyperthymic scores were more frequently found among males who passed and females who failed to pass the PEE. On the other hand, a greater number of cyclothymic traits were found in females who passed and males who failed to pass the PEE.

CONCLUSIONS

It was confirmed that hyperthymic temperament represents the temperamental profile of those who aim to become a cadet officer in the Italian armed forces. This study further supports the idea that hyperthymic traits bring distinct advantages in a professional field, such as a military career, which is closely related to leadership.

Translation and adaptation of the Bipolar Prodrome Symptom Scale-Retrospective: Patient Version to Brazilian portuguese

BACKGROUND: Bipolar disorder (BD) is a chronic and often severe mental disease, associated with a significant burden in affected individuals. The characterization of a premorbid (prodromal) period and possible development of preventive interventions are recent advances in this field. Attempts to characterize high-risk stages in BD, identifying symptoms prior to the emergence of a first manic/hypomanic episode, have been limited by a lack of standardized criteria and instruments for assessment. The Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R), developed by Correll and collaborators, retrospectively evaluates symptoms that occur prior to a first full mood episode in individuals with BD. OBJECTIVE: To describe the translation and adaptation process of the BPSS-R to Brazilian Portuguese. METHOD: Translation was conducted as follows: 1) translation of the scale from English to Brazilian Portuguese by authors who have Portuguese as their first language; 2) merging of the two versions by a committee of specialists; 3) back-translation to English by a translator who is an English native speaker; 4) correction of the new version in English by the author of the original scale; 5) finalization of the new version in Brazilian Portuguese. RESULTS: All the steps of the translation process were successfully accomplished, resulting in a final version of the instrument. CONCLUSIONS: The Brazilian Portuguese version of the BPSS-R is a potentially useful instrument to investigate prodromal period of BD in Brazil.

The significance of at-risk or prodromal symptoms for bipolar I disorder in children and adolescents

While in the early identification and intervention of psychosis-specific instruments and risk criteria have been generated and validated, research into indicated preventive strategies for bipolar I disorder (BD I) has only recently gained momentum. As the first signs of BD I often start before adulthood, such efforts are especially important in the vulnerable pediatric population. Data are summarized regarding the presence and nature of potentially prodromal, that is, subsyndromal, symptoms prior to BD I, defined by first-episode mania, focusing on pediatric patients. Research indicates the possibility of early identification of youth at clinical high risk for BD. Support for this proposition comes from retrospective studies of BD I patients, as well as prospective studies of community samples, offspring of BD I subjects, youth with depressive disorders, and patients at high risk for psychosis or with bipolar spectrum disorders without lifetime history of mania. These data provide essential insight into potential signs and symptoms that may enable presyndromal identification of BD I in youth. However, except for offspring studies, broader prospective approaches that focus on youth at clinical high risk for BD I and on developing specific interviews and (or) rating scales and risk criteria are mostly missing, or in their early stage. More work is needed to determine valid and sufficiently specific clinical high-risk criteria, to distinguish risk factors, endophenotypes, and comorbidities from prodromal symptomatology, and to develop phase-specific interventions that titrate the risk of intervention to the risk of transition to mania and to functional impairment or distress. Moreover, studies are needed that determine potential differences in prodromal symptoms and trajectories between children, adolescents, and adults, and the best phase-specific interventions.

A 16-year prospective study of prodromal features prior to BPI onset in well Amish children

BACKGROUND

Longitudinal research of well Amish children over 16 years to identify the pattern and frequency of prodromal symptoms/behaviors associated with onset of BPI disorder during childhood or adolescence.

METHODS

Parental informants were interviewed annually using structured and semi-structured interviews to record medical, developmental and behavioral/symptomatic data for their children in two samples. The bipolar sample had 115 children with a BPI parent. The control sample had 106 children of well parents, with and without a positive family history for mood disorders. A panel of clinicians assigned risk ratings independently and blind to family relations.

RESULTS

Eight children, age 13 or older, onset with BPI in the bipolar sample compared with one in the control sub-sample (well parent of a BPI sibling). The specific "pre-school" behaviors/symptoms that most identified children with BPI from well children in control samples were: sensitivity, crying, hyper-alertness, anxiety/worry and somatic complaints. During school years, parents reported mood (sad) and energy changes (low not high) decreased sleep and fearfulness as key symptoms.

LIMITATIONS

The sample of 9 BPI onsets is small. However, a variable age of onset means many children remain at risk. Although not statistically significant, 34.6% of the bipolar sample youngsters carry risk ratings compared to 15.2% among controls.

CONCLUSIONS

The miniclusters of prodromal features that emerged pre-school (ages 1-6), were "episodic" through childhood (7-12) and appeared to mimic adult recurrent illness. Prepubertal onset with mania did not occur. The pattern of prodromal symptoms has clinical relevance for its potential predictive value for onset with BPI disorder and early intervention.

Cyclothymic disorder in youth: why is it overlooked, what do we know and where is the field headed?

Cyclothymic disorder is a chronic and impairing subtype of bipolar disorder, largely neglected in pediatric research. Consequently, it is rarely diagnosed clinically despite potentially being the most prevalent form of bipolar disorder. Lack of attention has added to confusion about the diagnosis and clinical presentation of cyclothymic disorder. In pediatric studies, cyclothymic disorder is commonly grouped with 'subthreshold' presentations of bipolar disorder under the undifferentiated label 'bipolar disorder not otherwise specified'. However, research indicates that cyclothymic disorder can be reliably distinguished from the other forms of bipolar disorder and from other childhood disorders. Importantly, cyclothymic disorder may be a diathesis for more acute presentations of bipolar disorder, warranting a prominent role in dimensional models of mood and psychopathology. Current evidence suggests that cyclothymic disorder has the potential to make unique contributions to our understanding of the risk factors and outcomes associated with bipolar disorder. This potential has yet to be fully realized, limiting our knowledge and ability to intervene in a meaningful way with youth who are exhibiting symptoms of a major mood disorder. Including cyclothymic disorder in future research studies of children - particularly longitudinal outcome studies - is essential for understanding the developmental trajectory of bipolar spectrum disorders and learning how to accurately diagnosis and treat the full spectrum of bipolar disorders.

Aripiprazole in pediatric psychosis and bipolar disorder: a clinical review

BACKGROUND

Aripiprazole is an atypical antipsychotic with unique pharmacological properties, used for a variety of indications, including psychotic and mood disorders in youth. Existing literature was reviewed to summarize experience with this agent in that population.

METHODS

A review of relevant literature using the key words aripiprazole, children, pediatric, all child, schizophrenia, bipolar disorder, and atypical antipsychotics was conducted.

RESULTS

A total of 140 articles and book chapters were identified, of which 7 reported double-blind controlled trials with aripiprazole, 5 were meta-analyses of pooled data, 11 were open label trials, 10 were chart reviews, and 17 were case reports or case series.

LIMITATIONS

Although every effort was made to locate all available data, some information from posters or researchers was not available. Publication bias tends to report positive outcomes with a treatment, while negative studies are less likely to be reported. Most trials are of short duration.

CONCLUSIONS

Treatment with aripiprazole is associated with significant reduction of the Positive and Negative Symptom Scale (PANSS) scores in youth with schizophrenia, and reductions in items in the negative symptom scores at higher doses (30 mg/day). Significant reductions in the Young Mania Rating Scale (YMRS) have been demonstrated in youth with bipolar disorder. In mixed populations, reductions in the Clinical Global Impressions Scale (CGI-S) have also been demonstrated when compared with treatment with placebo. Head-to-head comparisons are fewer in number, and overall aripiprazole compares favorably with other atypical antipsychotics (ATAs) in the populations studied. Treatment with aripiprazole is reported to have a lower incidence of weight gain, and less elevation of prolactin. At higher doses, it appears more likely to result in extrapyramidal symptoms (EPS) and tremor.

Genome-wide association study of temperament in bipolar disorder reveals significant associations with three novel Loci

BACKGROUND

The many attempts to identify genes for bipolar disorder (BD) have met with limited success, which has generally been attributed to genetic heterogeneity and small gene effects. However, it is also possible that the categorical phenotypes used in genetic studies of BD are not the most informative or biologically relevant. Although quantitative phenotypes provide an alternative to categorical phenotypes based on diagnosis, they have not been fully exploited in BD genetics due to the lack of accessible biological measures. We have explored aspects of temperament as quantitative phenotypes that might define subtypes of BD with different clinical features and courses of illness. Temperament is a heritable personality factor that establishes the baseline level of reactivity, mood, and energy of a person.

METHODS

We have performed a genome-wide association study with genotype data from the Bipolar Genome Study and 1263 bipolar subjects that had completed the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A). The TEMPS-A is designed to assess lifelong, milder aspects of bipolar symptomatology and defines five temperaments: hyperthymic, dysthymic, cyclothymic, irritable, and anxious.

RESULTS

The irritable temperament produced the most significant result with a genome-wide significant p value of 1.7 × 10(-8) on chromosome 1. The hyperthymic temperament produced additional genome-wide significant p values of 4.1 × 10(-8) and 2.1 × 10(-8) on chromosomes 12 and 22, respectively.

CONCLUSIONS

These results suggest that aspects of temperament might define subtypes of BD that are more clinically and genetically homogenous, which might aid in the identification of predisposing genetic variants.

Beyond the guidelines for bipolar disorder: practical issues in long-term treatment with lithium

OBJECTIVE

Several treatment guidelines are available for clinicians working with patients with bipolar disorder (BD), but some of the more nuanced aspects of lithium therapy go beyond the scope of such guidelines. Therefore, in this perspective, our objective was to focus on specific practical issues of lithium treatment, including the selection and initiation of long-term treatment, and management and discontinuation (if indicated) of lithium prophylaxis.

METHOD

We conducted a focused review of the relevant literature on the treatment of BD.

RESULTS

Consultation requests to a BD specialty service often relate to issues for which there is limited evidence, including when to initiate long-term treatment, whether choice of mood stabilizer is specific, how long to treat acute episodes, whether to switch or add on medication when treatment fails, how long to continue effective treatment, and what medication to use when a lithium-responsive patient must discontinue lithium.

CONCLUSION

Optimal long-term treatment of BD will require more research as well as better alignment of clinical and training programs.