Diagnostic conversion from unipolar to bipolar affective disorder-A population-based study

Who transitions to bipolar disorder? A comparison of major depressive disorder, anxiety, and ADHD

BACKGROUND

Diagnostic delays in Bipolar Disorder (BD) are common and may contribute to worse outcomes. While most studies focus on depression as a primary precursor, both anxiety and attention deficit disorders are also frequent initial diagnoses. In the current study, we utilized a large, diverse electronic health record (EHR) dataset to quantify the rates and correlates of conversion to BD from these major precursor diagnoses.

METHODS

Our study analyzed a comprehensive ten-year EHR dataset from Johns Hopkins Medicine, a diverse urban medical center, to assess and compare the rates and correlates of conversion to BD from Major Depressive Disorder (MDD), anxiety disorders, and ADHD. Risk factors for transition were assessed as time-varying variables in proportional hazards models.

RESULTS

Of the 21,341 patients initially included, 1232 later transitioned to a diagnosis of BD. Adjusted-one-year conversion rates for patients with MDD, anxiety disorders, and ADHD were 4.2 %, 3.4 %, and 4.0 %, respectively, with ten-year rates at 11.4 %, 9.4 %, and 10.9 %, respectively. Age (19-29 years), treatment setting (emergency and inpatient), and psychotropic medications were associated with conversion to BD across all precursor diagnoses. Severe and psychotic forms of MDD were among the strongest risk factors for transitioning to BD. Although risk factors for convertion were similar, transition rates were lower in children, particularly in indivudals with ADHD, who showed a higher rate of BD conversion in adults.

CONCLUSIONS

The highest risk of transitioning to BD was observed in patients initially diagnosed with MDD, though significant risk was also noted in those with initial diagnoses of anxiety disorders and adult ADHD.

Predicting Diagnostic Conversion From Major Depressive Disorder to Bipolar Disorder: An EHR Based Study From Colombia

OBJECTIVES

Most bipolar disorder (BD) patients initially present with depressive symptoms, resulting in a delayed diagnosis of BD and poor clinical outcomes. This study aims to identify features predictive of the conversion from Major Depressive Disorder (MDD) to BD by leveraging electronic health record (EHR) data from the Clínica San Juan de Dios Manizales in Colombia.

METHODS

We employed a multivariable Cox regression model to identify important predictors of conversion from MDD to BD.

RESULTS

Analyzing 15 years of EHR data from 13,607 patients diagnosed with MDD, a total of 1610 (11.8%) transitioned to BD. Predictive features of the conversion to BD included severity of the initial MDD episode, presence of psychosis and hospitalization at first episode, family history of BD, and female gender. Additionally, we observed associations with medication classes (positive associations with prescriptions of mood stabilizers, antipsychotics, and negative associations with antidepressants) and a positive association with suicidality, a feature derived from natural language processing (NLP) of clinical notes. Together, these risk factors predicted BD conversion within 5 years of the initial MDD diagnosis, with a recall of 72% and a precision of 38%.

CONCLUSIONS

Our study confirms previously identified risk factors identified through registry-based studies (female gender and psychotic depression at the index MDD episode) and identifies novel ones (suicidality extracted from clinical notes). These results simultaneously demonstrate the validity of using EHR data for predicting BD conversion and underscore its potential for the identification of novel risk factors, thereby improving early diagnosis.

Hypomanic symptoms in major depressive disorder: Prognostic impact and treatment issues

BACKGROUND

Mixed depression (MXD), defined as (hypo)manic symptoms occurring within major depressive episodes, is common in both bipolar and unipolar disorders, but its prognostic and treatment implications remain unclear. This study aimed to examine the relationship between hypomanic symptoms, treatment response and remission of suicidal thoughts.

METHODS

We analyzed 1243 adults with major depressive disorder (MDD), recruited for a naturalistic study on treatment-resistant depression. Data were gathered cross-sectionally and retrospectively through structured interviews and clinical rating scales including the Young Mania Rating Scale (YMRS) and Montgomery-Asberg Depression Rating Scale (MADRS); statistical analyses were performed using univariate and multivariate methods.

RESULTS

Hypomanic symptoms were present in 651 patients (45 %), while 307 patients (25 %) responded to treatment. Both treatment responders (p < 0.0001) and those who achieved remission from suicide ideation (p = 0.0085) showed lower hypomanic (YMRS) scores. Multivariate analysis showed that hypomanic symptoms were negatively linked to treatment response (O.R. 0.71-0.87), while bipolar spectrum markers such as age at illness onset (O.R. 1.00-1.03) and MDD recurrence (O.R. 0.47-0.89) predicted remission from suicidal thoughts. Medications commonly used to treat bipolar disorder showed some benefits, with dopamine/serotonin antagonists improving suicide ideation (p < 0.0001) and mood stabilizers being associated with reduced hypomanic symptoms (p = 0.0003).

LIMITATIONS

The study lacked prospective clinical assessments and treatment randomization.

CONCLUSION

Hypomanic symptoms are common in unipolar depression; their assessment is essential to identify challenging-to-treat cases and select the best pharmacological options.

Mapping review of register-based cohort studies of bipolar disorder

OBJECTIVES

Register-based cohorts allow us to better understand bipolar disorder over a life course. They are inclusive and their long-term data collection provides a longer scope than most clinical trials. This mapping review provides an overview of register-based cohort studies of bipolar disorder to inform researchers of the strengths and limitations to this body of research and identify gaps for future research.

METHODS

A systematic search was performed of Medline, EMBASE, and PsycINFO databases. Cohort studies were included if they focused on bipolar disorder and had a minimum of 1 year of longitudinal data. Studies needed to be from databases that monitor the whole state or national population. A descriptive analysis of the studies' populations and methodology provides an overview of this field of study and identifies evidence gaps.

RESULTS

A hundred and forty-six studies were included. The majority were from databases in Taiwan (n = 63), Denmark (n = 38), Sweden (n = 23), and Finland (n = 11). Forty-eight studies focused on aetiological questions. Sixty prognostic studies identified cohorts with bipolar disorder and described the impact of the illness by considering comorbidity, prescribing patterns, social functioning, and mortality. Thirty-six treatment studies focused on the efficacy and adverse effects of pharmaceuticals and ECT. No studies focused on psychological treatments.

CONCLUSION

Bipolar disorder research should include register-based cohorts with greater geopolitical and cultural diversity. Custodians of health registers should consider how non-pharmaceutical interventions such as psychotherapy are captured. Register-based cohorts investigating treatments of bipolar disorder should consider long-term social outcomes alongside the usual clinical outcomes.

Real-world case series of maintenance theta burst stimulation therapy following response to acute theta burst stimulation therapy for difficult-to-treat depression

OBJECTIVE

Treatment and management for difficult-to-treat depression are challenging, especially in a subset of patients who are at high risk for relapse and recurrence. The conditions that represent this subset are recurrent depressive disorder (RDD) and bipolar disorder (BD). In this context, we aimed to examine the effectiveness of maintenance transcranial magnetic stimulation (TMS) on a real-world clinical basis by retrospectively extracting data from the TMS registry data in Tokyo, Japan.

METHODS

Data on patients diagnosed with treatment-resistant RDD and BD who received maintenance intermittent theta burst stimulation (iTBS) weekly after successful treatment with acute iTBS between March 2020 and October 2023 were extracted from the registry.

RESULTS

All patients (21 cases: 10 cases with RDD and 11 cases with BD) could sustain response, and 19 of them further maintained remission. In this study, maintenance iTBS did not exacerbate depressive symptoms in any of the cases, but may rather have the effect of stabilizing the mental condition and preventing recurrence.

CONCLUSIONS

This case series is of great clinical significance because it is the first study to report on the effectiveness of maintenance iTBS for RDD and BD, with a follow-up of more than 2 years. Further validation with a randomized controlled trial design with a larger sample size is warranted.

Abnormal stability of spontaneous neuronal activity as a predictor of diagnosis conversion from major depressive disorder to bipolar disorder

OBJECTIVE

Bipolar disorder (BD) is often misdiagnosed as major depressive disorder (MDD) in the early stage, which may lead to inappropriate treatment. This study aimed to characterize the alterations of spontaneous neuronal activity in patients with depressive episodes whose diagnosis transferred from MDD to BD.

METHODS

532 patients with MDD and 132 healthy controls (HCs) were recruited over 10 years. During the follow-up period, 75 participants with MDD transferred to BD (tBD), and 157 participants remained with the diagnosis of unipolar depression (UD). After excluding participants with poor image quality and excessive head movement, 68 participants with the diagnosis of tBD, 150 participants with the diagnosis of UD, and 130 HCs were finally included in the analysis. The dynamic amplitude of low-frequency fluctuations (dALFF) of spontaneous neuronal activity was evaluated in tBD, UD and HC using functional magnetic resonance imaging at study inclusion. Receiver operating characteristic (ROC) analysis was performed to evaluate sensitivity and specificity of the conversion prediction from MDD to BD based on dALFF.

RESULTS

Compared to HC, tBD exhibited elevated dALFF at left premotor cortex (PMC_L), right lateral temporal cortex (LTC_R) and right early auditory cortex (EAC_R), and UD showed reduced dALFF at PMC_L, left paracentral lobule (PCL_L), bilateral medial prefrontal cortex (mPFC), right orbital frontal cortex (OFC_R), right dorsolateral prefrontal cortex (DLPFC_R), right posterior cingulate cortex (PCC_R) and elevated dALFF at LTC_R. Furthermore, tBD exhibited elevated dALFF at PMC_L, PCL_L, bilateral mPFC, bilateral OFC, DLPFC_R, PCC_R and LTC_R than UD. In addition, ROC analysis based on dALFF in differential areas obtained an area under the curve (AUC) of 72.7%.

CONCLUSIONS

The study demonstrated the temporal dynamic abnormalities of tBD and UD in the critical regions of the somatomotor network (SMN), default mode network (DMN), and central executive network (CEN). The differential abnormal patterns of temporal dynamics between the two diseases have the potential to predict the diagnosis transition from MDD to BD.

Predictors of diagnostic conversion from major depression to bipolar disorder: a Swedish national longitudinal study

BACKGROUND

It is clinically important to predict the conversion of major depression (MD) to bipolar disorder (BD). Therefore, we sought to identify related conversion rates and risk factors.

METHODS

This cohort study included the Swedish population born from 1941 onward. Data were collected from Swedish population-based registers. Potential risk factors, including family genetic risk scores (FGRS), which were calculated based on the phenotypes of relatives in the extended family and not molecular data, and demographic/clinical characteristics from these registers were retrieved. Those with first MD registrations from 2006 were followed up until 2018. The conversion rate to BD and related risk factors were analyzed using Cox proportional hazards models. Additional analyses were performed for late converters and with stratification by sex.

RESULTS

The cumulative incidence of conversion was 5.84% [95% confidence interval (95% CI) 5.72-5.96] for 13 years. In the multivariable analysis, the strongest risk factors for conversion were high FGRS of BD [hazard ratio (HR) = 2.73, 95% CI 2.43-3.08], inpatient treatment settings (HR = 2.64, 95% CI 2.44-2.84), and psychotic depression (HR = 2.58, 95% CI 2.14-3.11). For late converters, the first registration of MD during the teenage years was a stronger risk factor when compared with the baseline model. When the interactions between risk factors and sex were significant, stratification by sex revealed that they were more predictive in females.

CONCLUSIONS

Family history of BD, inpatient treatment, and psychotic symptoms were the strongest predictors of conversion from MD to BD.

Predicting diagnostic conversion from major depressive disorder to bipolar disorder: an EHR based study from Colombia

Bipolar Disorder (BD) is a severe and chronic disorder characterized by recurrent episodes of depression, mania, and/or hypomania. Most BD patients initially present with depressive symptoms, resulting in a delayed diagnosis of BD and poor clinical outcomes. This study leverages electronic health record (EHR) data from the Clínica San Juan de Dios Manizales in Colombia to identify features predictive of the transition from Major Depressive Disorder (MDD) to BD. Analyzing EHR data from 13,607 patients diagnosed with MDD over 15 years, we identified 1,610 cases of conversion to BD. Using a multivariate Cox regression model, we identified severity of the initial MDD episode, the presence of psychosis and hospitalization at first episode, family history of mood or psychotic disorders, female gender to be predictive of the conversion to BD. Additionally, we observed associations with medication classes (prescriptions of mood stabilizers, antipsychotics, and antidepressants) and clinical features (delusions, suicide attempt, suicidal ideation, use of marijuana and alcohol use/abuse) derived from natural language processing (NLP) of clinical notes. Together, these risk factors predicted BD conversion within five years of the initial MDD diagnosis, with a recall of 72% and a precision of 38%. Our study confirms many previously identified risk factors identified through registry-based studies (such as female gender and psychotic depression at the index MDD episode), and identifies novel ones (specifically, suicidal ideation and suicide attempt extracted from clinical notes). These results simultaneously demonstrate the validity of using EHR data for predicting BD conversion as well as underscore its potential for the identification of novel risk factors and improving early diagnosis.

Antidepressant emergent mood switch in major depressive disorder: onset, clinical correlates and impact on suicidality

Antidepressant (AD)- emergent mood switch (AEMS) is a common complication of bipolar depression. This study aimed to investigate the prevalence and clinical correlates of subthreshold AEMS (i.e. not fulfilling DSM criteria for hypomanic episodes) in major depressive disorder (MDD) and, prognostically, its impact on AD treatment outcome and suicidality. The study involved 425 outpatients with MDD followed during the acute phase (12 weeks) and continuation (weeks 13-28) AD treatment. AEMS was assessed through the Altman Self-Rating Mania scale (ASRM ≥ 6). Several clinical features differentiated individuals with or without subthreshold AEMS (n = 204 vs. 221): negative self-perception [odds ratio (OR) 1.017-1.565]; panic disorder (OR 1.000-1.091); subthreshold hypomanic episodes (OR 1.466-13.352); childhood emotional abuse (OR 1.053-2.447); lifetime suicidal behaviour (OR 1.027-1.236); AD-related remission (χ 2  = 22.903 P  < 0.0001) and suicide ideation (χ 2  = 16.701 P  < 0.0001). In AEMS earlier onset showed a strong correlation with bipolar spectrum disorder (overall score: P  = 0.0053; mixed depression: P  = 0.0154; subthreshold hypomania: P  = 0.0150) whereas late-onset was associated with more severe suicidal behaviour ( P  < 0.001). In conclusion, our results demonstrate that subthreshold mood switches occur frequently in unipolar depression during acute AD treatment as well as in continuation phase. Time of switch onset seems to have the greatest diagnostic and prognostic value.

Disease progression to bipolar disorder among adolescents and young adults with antidepressant-resistant and antidepressant-responsive depression: Does antidepressant class matter?

Studies have demonstrated a positive relationship between antidepressant resistance and the progression of bipolar disorder. However, the influence of antidepressant classes such as selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) in this context has yet to be investigated. A total of 5,285 adolescents and young adults with antidepressant-resistant depression and 21,140 with antidepressant-responsive depression were recruited in the present study. The antidepressant-resistant depression group was divided into two subgroups: only resistant to SSRIs (n = 2,242, 42.4%) and additionally resistant to non-SSRIs (n = 3,043, 57.6%) groups. The status of bipolar disorder progression was monitored from the date of depression diagnosis to the end of 2011. Patients with antidepressant-resistant depression were more likely to develop bipolar disorder during the follow-up (hazard ratio [HR]: 2.88, 95% confidence interval [CI]: 2.67-3.09) than those with antidepressant-responsive depression. Furthermore, the group that was additionally resistant to non-SSRIs were at the highest risk of bipolar disorder (HR: 3.02, 95% CI: 2.76-3.29), followed by the group that was only resistant to SSRIs (2.70, 2.44-2.98). Adolescents and young adults with antidepressant-resistant depression, especially those who responded poorly to both SSRIs and SNRIs, were at increased risk of subsequent bipolar disorder compared with those with antidepressant-responsive depression. Further studies are warranted to elucidate the molecular pathomechanisms underlying the resistance to SSRIs and SNRIs and subsequent bipolar disorder.

Interleukin-8 and tumor necrosis factor-alpha in youth with mood disorders-A longitudinal study

Bipolar disorder (BD) is one of the most disabling psychiatric illnesses. Over half of BD patients experienced early onset of the disease, and in most cases, it begins with a depressed mood episode. Up to 50% of adolescents initially diagnosed with major depressive disorder (MDD) convert to bipolar spectrum disorder. Diagnostic tools or biomarkers to facilitate the prediction of diagnosis conversion from MDD to BD are still lacking. Our study aimed to find biomarkers of diagnosis conversion in young patients with mood disorders. We performed a 2-year follow-up study on 69 adolescent patients diagnosed with MDD or BD. The control group consisted of 31 healthy youths. We monitored diagnosis change from MDD to BD. Impulsiveness was assessed using Barratt Impulsiveness Scale (BIS-11) and defense mechanisms using Defense Style Questionnaire (DSQ-40). According to the immunological hypothesis of mood disorders, we investigated baseline cytokines levels either in depressive or hypomanic/manic episodes. We correlated interleukin 8 (IL-8) and Tumor Necrosis Factor-alpha (TNF-alpha) levels with clinical factors. We detected higher IL-8 and TNF-alpha in patients in hypomanic/manic compared to depressed episodes. We found correlations of cytokine levels with immature defense style. We did not discover predictors of diagnosis conversion from MDD to BD.