The modified SCID Hypomania Module (SCID-Hba): a detailed systematic phenomenologic probing

Differential characteristics of bipolar I and II disorders: a retrospective, cross-sectional evaluation of clinical features, illness course, and response to treatment

BACKGROUND

The distinction between bipolar I and bipolar II disorder and its treatment implications have been a matter of ongoing debate. The aim of this study was to examine differences between patients with bipolar I and II disorders with particular emphasis on the early phases of the disorders.

METHODS

808 subjects diagnosed with bipolar I (N = 587) or bipolar II disorder (N = 221) according to DSM-IV criteria were recruited between April 1994 and March 2022 from tertiary-level mood disorder clinics. Sociodemographic and clinical variables concerning psychiatric and medical comorbidities, family history, illness course, suicidal behavior, and response to treatment were compared between the bipolar disorder types.

RESULTS

Bipolar II disorder patients were more frequently women, older, married or widowed. Bipolar II disorder was associated with later "bipolar" presentation, higher age at first (hypo)mania and treatment, less frequent referral after a single episode, and more episodes before lithium treatment. A higher proportion of first-degree relatives of bipolar II patients were affected by major depression and anxiety disorders. The course of bipolar II disorder was typically characterized by depressive onset, early depressive episodes, multiple depressive recurrences, and depressive predominant polarity; less often by (hypo)mania or (hypo)mania-depression cycles at onset or during the early course. The lifetime clinical course was more frequently rated as chronic fluctuating than episodic. More patients with bipolar II disorder had a history of rapid cycling and/or high number of episodes. Mood stabilizers and antipsychotics were prescribed less frequently during the early course of bipolar II disorder, while antidepressants were more common. We found no differences in global functioning, lifetime suicide attempts, family history of suicide, age at onset of mood disorders and depressive episodes, and lithium response.

CONCLUSIONS

Differences between bipolar I and II disorders are not limited to the severity of (hypo)manic syndromes but include patterns of clinical course and family history. Caution in the use of potentially mood-destabilizing agents is warranted during the early course of bipolar II disorder.

[Mental disorders in patients with acromegaly]

AIM

To study mental disorders in acromegaly due to somatotropinoma.

MATERIAL AND METHODS

The study included 115 consecutively recruited patients with acromegaly (95 female and 20 male, aged from 21 to 78 years). Acromegaly was diagnosed by endocrinologists according to current guidelines based on clinical, laboratory data and brain MRI. All patients underwent a clinical psychiatric interview based on ICD-10 criteria. The Mini-Mental State Examination scale and Hypomania-Checklist (HCL-32) were used.

RESULTS

Mental disorders were diagnosed in 79.1% of patients. Organic spectrum disorders were found in 46.1%, bipolar spectrum disorders in 35.7%, schizophrenia spectrum disorders in 4.3%. The patients with bipolar spectrum disorders had significantly lower serum insulin-like growth factor 1 (IGF-1) levels compared to patients with organic spectrum disorders (p=0.01). The presence of organic spectrum disorders was associated with older age and number of somatic comorbidities (р=0.0001 and 0.001).

CONCLUSION

The prevalence of bipolar, organic and schizophrenia spectrum disorders in patients with acromegaly exceeds that in the general population. Significantly lower IGF-1 levels in acromegalic patients with bipolar disorders, compared to those with organic disorders, can have some implications to their pathogenesis.

Psychomotor agitation in major depressive disorder is a predictive factor of mood-switching

BACKGROUND

The relationship between psychomotor agitation in unipolar depression and mood-switching from depression to manic, hypomanic and mixed states has been controversial. We investigated the future risk of initial mood-switching as a function of psychomotor agitation in unipolar depression.

METHODS

We identified 189 participants diagnosed with major depressive disorder (MDD). We divided all patients with MDD into two categories (1) agitated patients (n=74), and (2) non-agitated patients (n=115). These groups were prospectively followed and compared by time to mood-switching. Kaplan-Meier survival curves, log-rank test for trend for survivor functions, and Cox proportional hazard ratio estimates for a multivariate model were conducted to examine the risk of mood-switching by psychomotor agitation.

RESULTS

During follow-up, mood-switching occurred in 20.3% of the agitated patients and 7.0% of the non-agitated patients. In the Kaplan-Meier survival estimates for time to incidence of mood-switching with agitated or non-agitated patients, the cumulative probability of developing mood-switching for agitated patients was higher than those for non-agitated patients (log-rank test: χ(2)=7.148, df=1, p=0.008). Survival analysis was also performed using Cox proportional hazards regression within a multivariate model. The agitation remained significantly associated with incidence of mood-switching (HR=2.98, 95% CI: 1.18-7.51).

LIMITATIONS

We did not make a clear distinction between antidepressant-induced mood-switching and spontaneous switching.

CONCLUSIONS

The main finding demonstrated that MDD patients with agitation were nearly threefold as likely to experience mood-switching, suggesting that psychomotor agitation in MDD may be related to an indicator of bipolarity.

Under-reporting bipolar disorder in large-scale epidemiologic studies

BACKGROUND

To investigate if the prevalence of bipolar disorder in epidemiologic studies is an underestimate, as suggested by clinical studies.

METHODS

We analyzed data from 8 countries that participated in the World Mental Health Survey Initiative (n=47,552). We identified 6.8% and 18.9% of the sample who we think were screened out inappropriately (SCI) from the euphoric and irritable bipolar sections respectively. We compared them to those who were allowed to continue the section (CONT, 2.6% of the sample for euphoric; 1.0% for irritable) and to the reference group (REF, 69.5% of the sample).

RESULTS

The SCI group had consistently higher rates of major depression (29.1% vs. 6.4%), earlier age of onset (24.3y vs. 32.4y), more suicide attempts (13.3% vs. 5.9%), and more episodes (4.2 vs. 2.7) than the REF for the euphoric group. Similar findings exist for the irritable group. Also, comorbidity with anxiety, disruptive behavior disorders and substance use were much higher than the REF.

LIMITATIONS

As with all epidemiologic studies, recall bias cannot be ruled out.

CONCLUSIONS

The findings above suggest that a number of the SCI subjects belong to the bipolar group. A revision of instruments used in epidemiologic research will probably prove what clinical studies have been showing that bipolar disorder is more common than has been reported.

Validation of the Russian version of the Hypomania Checklist (HCL-32) for the detection of Bipolar II disorder in patients with a current diagnosis of recurrent depression

BACKGROUND

There are no validated screening tools for Bipolar Disorder (BD) in Russia.

OBJECTIVE

To validate the Russian version of the HCL-32 for the detection of Bipolar II disorder (BD II) in patients with Recurrent Depressive Disorder (RDD).

METHODS

409 patients with a current diagnosis of RDD were recruited. The diagnosis was confirmed by the validated Russian version of the Mini International Neuropsychiatric Interview (MINI). Another investigator interviewed the patients using the НСL-32 questions.

RESULTS

The total HCL-32 score in patients with BD II was significantly higher than in patients with RDD: 18.2 (4.22) versus 10.85 (5.81) (p<0.001, d=1447). At the cut-off 14 points the sensitivity was 83.7%, specificity 71.9% (p<0.001). The Cronbach's alpha was 0.887 that means good internal consistency. The best discrimination was achieved with 8 items: decreased need for sleep, less shyness or inhibition, talkativeness, more jokes and puns, jumping thoughts distractibility, exhausting or irritating others and high and more optimistic mood. We proposed the reduced variant of the scale, that includes only these 8 variables, with sensitivity 90.5%, specificity 69.8% (AUC=0.88).

CONCLUSIONS

The Russian version of the HCL-32 displayed a good ratio of sensitivity to specificity and can be recommended as a validated screening instrument. An 8-item version of HCL needs further research.

LIMITATIONS

Limitations include the specific nature of the sample, the HCL-32 assessment carried out by a psychiatrist, no comparison with other BD screening scales. The results of the 8-item version may be sample and culture dependent.

Usefulness of the combined application of the Mood Disorder Questionnaire and Bipolar Spectrum Diagnostic Scale in screening for bipolar disorder

OBJECTIVE

This study aimed to examine whether combined application of the Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) is more effective than exclusive application of either tool in screening for bipolar disorder (BD).

METHOD

The MDQ and BSDS were completed by a total of 113 patients diagnosed with BD and major depressive disorder who were experiencing a current major depressive episode. The initial diagnosis of the subject was confirmed during a 1-year follow-up period. When each MDQ and BSDS optimal cutoff score was calculated, a modified scoring method for the MDQ that considered only one item was used to increase its performance in this population. The following three combinations of the cutoff scores for the two tools were used to screen for BD: (A) The score on either the MDQ or BSDS was greater than or equal to the cutoff score; (B) the scores on both the MDQ and BSDS were greater than or equal to the cutoff score; and (C) Reducing either cutoff score by 1 point resulted in the MDQ and BSDS scores being greater than or equal to the cutoff score. The sensitivity, specificity, positive predictive value, and negative predictive value of the three methods, the MDQ, and the BSDS were compared for screening BD.

RESULTS

The sensitivity and specificity of the MDQ were 0.741 and 0.844, respectively, and those for the BSDS were 0.731 and 0.742, respectively. These indicators for the combined application of the MDQ and BSDS were as follows, respectively: method A 0.901 and 0.688, method B 0.580 and 0.875, and method C 0.691 and 0.844. Method A was superior to using one measure alone as well as to methods B and C with regard to sensitivity and negative predictive values. Method A also showed a higher sensitivity for BD subtypes than did the individual tools. Compared with the use of individual instruments, method A showed a similar positive predictive value.

CONCLUSION

This study suggests that combined use of the MDQ and BSDS is more effective than the individual use of either of these measures in screening for BD. The data also showed that when both tools were used, the most effective interpretation of the results in terms of screening for BD was achieved when positive scores were defined as those that were equal to or greater than the cutoff for the MDQ or BSDS.

Diagnosing bipolar disorder in the community setting

BACKGROUND

Bipolar disorder (BD) is a common psychiatric illness. Diagnosing this condition is challenging, due to the frequent need to make the diagnosis based on historical symptoms, the lack of specificity of many of the symptoms, and the absence of accurate objective measures to confirm the diagnosis. A lack of consensus among psychiatrists as to the breadth of the diagnosis, increasing pressures to make a diagnosis quickly in clinical settings, and the availability of broader spectrum treatments have also served to foster uncertainty in diagnosis. This article examines the process of diagnosing BD, reviews factors that can confound the diagnostic process, and discusses how the sensitivity and specificity of the diagnosis can be improved.

METHODS

A MEDLINE search and a manual search of textbooks and abstracts from scientific meetings were conducted. Results were limited to publications in English, but no timeframe limitations were used.

RESULTS

The standard for diagnosing BD remains the psychiatric interview, with laboratory, genetic, radiographic, and neuroimaging tests still investigational, and psychological tests and questionnaires serving an ancillary role. The sensitivity and specificity of the BD diagnosis is less than optimal, with the condition being both overlooked and diagnosed when it is not present.

CONCLUSIONS

Factors leading to diagnostic uncertainty and approaches to improve the sensitivity and specificity of the BD diagnosis are discussed. A paradigm for differentiating between BD and borderline personality disorder is offered.

The 'true' prevalence of bipolar II disorder

PURPOSE OF REVIEW

Many studies - including meta-analyses - do not distinguish between bipolar I and II disorder. The aim of this study is to review the recent literature on the prevalence, correlates, consequences, and treatment patterns of bipolar II disorder.

RECENT FINDINGS

In the past 2 years, several important studies have been conducted in the bipolar II field. The World Mental Health Survey initiative provides us with prevalence rate across 11 countries, while several meta-analyses on suicide and neurocognition directly compared bipolar I with bipolar II, informing us on the severe consequences of bipolar II disorder. Results from studies showed that the lifetime prevalence rate of bipolar II disorder in adults across 11 countries was 0.4%. Rates of bipolar II disorder in prospective studies of adolescents are substantially greater, with lifetime rates approaching 3-4%.

SUMMARY

Evidence from these studies regarding comparable clinical consequences, patterns of comorbidity, suicide attempts, family history, and treatment patterns to bipolar I disorder document the validity of the bipolar II subtype.

Latent class analysis of manic and depressive symptoms in a population-based sample in São Paulo, Brazil

BACKGROUND

Current diagnostic criteria cannot capture the full range of bipolar spectrum. This study aims to clarify the natural co-segregation of manic-depressive symptoms occurring in the general population.

METHODS

Using data from the Sao Paulo Catchment Area Study, latent class analysis (LCA) was applied to eleven manic and fourteen depressive symptoms assessed through CIDI 1.1 in 1464 subjects from a community-based study in Sao Paulo, Brazil. All manic symptoms were assessed, regardless of presence of euphoria or irritability, and demographics, services used, suicidality and CIDI/DSM-IIIR mood disorders used to external validate the classes.

RESULTS

The four obtained classes were labeled Euthymics (EU; 49.1%), Mild Affectives (MA; 31.1%), Bipolars (BIP; 10.7%), and Depressives (DEP; 9%). BIP and DEP classes represented bipolar and depressive spectra, respectively. Compared to DEP class, BIP exhibited more atypical depressive characteristics (hypersomnia and increase in appetite and/or weight gain), risk of suicide, and use of services. Depressives had rates of atypical symptoms and suicidality comparable to oligosymptomatic MA class subjects.

LIMITATIONS

The use of lay interviewers and DSM-IIIR diagnostic criteria, which are more restrictive than the currently used DSM-IV TR.

CONCLUSIONS

Findings of high prevalence of bipolar spectrum and of atypical symptoms and suicidality as indicators of bipolarity are of great clinical importance, due to different treatment needs, and higher severity. Lifetime sub-affective and syndromic manic symptoms are clinically significant, arguing for the need of revising DSM bipolar spectrum categories.

Bipolar depression: overview and commentary

Depressive phases are the most prevalent component of bipolar disorders, even with modern treatment. Bipolar depressive morbidity is often misdiagnosed and is limited in response to available treatments. These conditions are especially debilitating and are associated with psychiatric comorbidity, substance abuse, functional disability, and increased mortality owing to early suicide and accidents, and later medical illnesses. There is growing awareness that bipolar depression is one of the greatest challenges in modern psychiatry. It is essential to differentiate various forms of depression, dysthymia, and dysphoric mixed states of bipolar disorders from the clinical features of more common, unipolar major depressive disorders. In bipolar depression, antidepressant responses often are unsatisfactory, and these agents probably are overused. Emerging treatments, including several anticonvulsant and modern antipsychotic drugs, as well as lithium-alone or in selected combinations-are partially effective for bipolar depression. Interest in recognizing bipolar depression and seeking more effective, specific, and safer treatments for it are growing.