Qualitative differences in manic symptoms during mixed versus pure mania

Prefrontal, parietal, and limbic condition-dependent differences in bipolar disorder: a large-scale meta-analysis of functional neuroimaging studies

BACKGROUND

Over the past few decades, neuroimaging research in Bipolar Disorder (BD) has identified neural differences underlying cognitive and emotional processing. However, substantial clinical and methodological heterogeneity present across neuroimaging experiments potentially hinders the identification of consistent neural biomarkers of BD. This meta-analysis aims to comprehensively reassess brain activation and connectivity in BD in order to identify replicable differences that converge across and within resting-state, cognitive, and emotional neuroimaging experiments.

METHODS

Neuroimaging experiments (using fMRI, PET, or arterial spin labeling) reporting whole-brain results in adults with BD and controls published from December 1999-June 18, 2019 were identified via PubMed search. Coordinates showing significant activation and/or connectivity differences between BD participants and controls during resting-state, emotional, or cognitive tasks were extracted. Four parallel, independent meta-analyses were calculated using the revised activation likelihood estimation algorithm: all experiment types, all resting-state experiments, all cognitive experiments, and all emotional experiments. To confirm reliability of identified clusters, two different meta-analytic significance tests were employed.

RESULTS

205 published studies yielding 506 individual neuroimaging experiments (150 resting-state, 134 cognitive, 222 emotional) comprising 5745 BD and 8023 control participants were included. Five regions survived both significance tests. Individuals with BD showed functional differences in the right posterior cingulate cortex during resting-state experiments, the left amygdala during emotional experiments, including those using a mixed (positive/negative) valence manipulation, and the left superior and right inferior parietal lobules during cognitive experiments, while hyperactivating the left medial orbitofrontal cortex during cognitive experiments. Across all experiments, there was convergence in the right caudate extending to the ventral striatum, surviving only one significance test.

CONCLUSIONS

Our findings indicate reproducible localization of prefrontal, parietal, and limbic differences distinguishing BD from control participants that are condition-dependent, despite heterogeneity, and point towards a framework for identifying reproducible differences in BD that may guide diagnosis and treatment.

Cariprazine for the treatment of bipolar mania with mixed features: A post hoc pooled analysis of 3 trials

BACKGROUND

When bipolar I disorder (BP-I) mania is accompanied by subsyndromal depressive symptoms, a more complicated illness presentation results. To qualify for the mixed features specifier during mania, the DSM-5 requires ≥3 "non-overlapping" depressive symptoms (DS); notwithstanding, concerns of this definition's ecological validity and implications for timely diagnosis remain.

METHODS

Herein, patients were pooled from three similarly-designed pivotal trials of cariprazine compared to placebo for BP-I mania (NCT00488618/NCT01058096/NCT01058668) in post hoc analyses of mixed features using three criteria: ≥3 DS (DSM-5), ≥2 DS, and Montgomery-Åsberg Depression Rating Scale (MADRS) total score ≥10. Efficacy of cariprazine compared to placebo was assessed (Week 3) by Young Mania Rating Scale (YMRS) and MADRS scores and rates of mania response and remission.

RESULTS

In pooled patients (N = 1037), cariprazine significantly improved mean YMRS scores compared to placebo for each criterion; LSMDs were ≥3 DS = -3.79 (P = .0248), ≥2 DS = -2.91 (P = .0207), and ≥10 MADRS = -5.49 (P < .0001). More cariprazine- than placebo-treated patients met YMRS response and remission criteria, reaching significance for response in ≥2 DS (34% versus 47%; number-needed-to-treat [NNT] = 8, P = .0483) and ≥10 MADRS (31% versus 57%, NNT = 4, P < .0001) and for remission in ≥2 DS (27% versus 39%, NNT = 9, P = .0462), ≥10 MADRS (23% versus 44%, NNT = 5, P < .0001). Depressive symptoms were improved compared to placebo, reaching statistical significance in the MADRS ≥10 subgroup (LSMD = -1.59, P = .0082).

LIMITATIONS

Post hoc analysis, MADRS  < 18 entry criterion may have prevented assessment of MADRS changes.

CONCLUSIONS

Cariprazine significantly reduced manic and depressive symptoms in patients with mixed features with differential efficacy across the subgroups analyzed herein.

Racing thoughts revisited: A key dimension of activation in bipolar disorder

BACKGROUND

Racing and crowded thoughts are frequently reported respectively in manic and mixed episodes of bipolar disorder (BD). However, questionnaires assessing this symptom are lacking. Here we aimed to investigate racing thoughts across different mood episodes of BD through a self-report questionnaire that we developed, the 34-item Racing and Crowded Thoughts Questionnaire (RCTQ). In addition to assessing its factor structure and validity, we were interested in the RCTQ's ability to discriminate mixed and non-mixed depression.

METHODS

221 BD patients and 120 controls were clinically assessed via the YMRS (mania) and the QIDS-C16 (depression), then fulfilled the RCTQ, rumination, worry, and anxiety measures. Three depression groups were operationalized according to YMRS scores: YMRS scores 2 > 6 and YMRS scores = 1 or 2, for respectively mixed and non-pure depression, and YMRS = 0 for pure-depression.

RESULTS

Confirmatory factor analysis showed that the three-factor model of the RCTQ yielded the best fit indices, which improved after the removal of redundant items, resulting in a 13-item questionnaire. Hypomanic and anxiety symptoms were the main predictors of scores; rumination was not a significant predictor. RCTQ results were similar between mixed groups and non-pure depression, and both were higher than in pure-depression.

LIMITATIONS

Patients' pharmacological treatment might have influenced the results.

CONCLUSIONS

The 13-item RCTQ captures different facets of racing thoughts heightened in hypomanic and mixed states, but also in depression with subclinical hypomanic/activation symptoms (e.g. non-pure depression characterized by enhanced subjective irritability), suggesting that it is particularly sensitive to activation symptoms in BD, and could become a valuable tool in the follow-up of patients.

The significance of mixed states in depression and mania

The DSM-5 definition of mixed features "specifier" of manic, hypomanic and major depressive episodes captures sub-syndromal non-overlapping symptoms of the opposite pole, experienced in bipolar (I, II, and not otherwise specified) and major depressive disorders. This combinatory model seems to be more appropriate for less severe forms of mixed state, in which mood symptoms are prominent and clearly identifiable. Sub-syndromal depressive symptoms have been frequently reported to co-occur during mania. Similarly, manic or hypomanic symptoms during depression resulted common, dimensionally distributed, and recurrent. The presence of mixed features has been associated with a worse clinical course and high rates of comorbidities including anxiety, personality, alcohol and substance use disorders and head trauma or other neurological problems. Finally, mixed states represent a major therapeutic challenge, especially when you consider that these forms tend to have a less favorable response to drug treatments and require a more complex approach than non-mixed forms.

Phenomenology of manic episodes according to the presence or absence of depressive features as defined in DSM-5: Results from the IMPACT self-reported online survey

BACKGROUND

The aim of this study was to describe the phenomenology of mania and depression in bipolar patients experiencing a manic episode with mixed features as defined in the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

METHODS

In this multicenter, international on-line survey (the IMPACT study), 700 participants completed a 54-item questionnaire on demographics, diagnosis, symptomatology, communication of the disease, impact on life, and treatment received. Patients with a manic episode with or without DSM-5 criteria for mixed features were compared using descriptive and inferential statistics.

RESULTS

Patients with more than 3 depressive symptoms were more likely to have had a delay in diagnosis, more likely to have experienced shorter symptom-free periods, and were characterized by a marked lower prevalence of typical manic manifestations. All questionnaire items exploring depressive symptomatology, including the DSM-5 criteria defining a manic episode as "with mixed features", were significantly overrepresented in the group of patients with depressive symptoms. Anxiety associated with irritability/agitation was also more frequent among patients with mixed features.

LIMITATIONS

Retrospective cross-sectional design, sensitive to recall bias. Two of the 6 DSM-5 required criteria for the specifier "with mixed features" were not explored: suicidality and psychomotor retardation.

CONCLUSIONS

Bipolar disorder patients with at least 3 depressive symptoms during a manic episode self-reported typical symptomatology. Anxiety with irritability/agitation differentiated patients with depressive symptoms during mania from those with "pure" manic episodes. The results support the use of DSM-5 mixed features specifier and its value in research and clinical practice.

Prevalence of mixed mania using 3 definitions

OBJECTIVES

Mixed episodes are a combination of depressive and manic symptoms in bipolar disorder (BD). We want to identify the proportion of patients who have depressive symptoms during an acute episode and also the validity of current methods for its diagnosis.

MATERIAL AND METHOD

Cross-sectional multicentre study of patients with type I BD who are admitted to specialized units. 368 patients in 76 centres were included. The patients should have a well established diagnosis of BD and need hospitalisation. The severity of the disorder and clinical status were evaluated upon admission and discharge using CGI-BP-M clinical impression scales, the Hamilton depression scale (HAMD-17) and the Young mania rating scale (YMRS). Upon admission, the necessary criteria for diagnosing a mixed type episode were recorded according to DSM-IV-TR, ICD-10 and McElroy criteria. Clinical judgment of the current type of episode was also recorded.

RESULTS

Prevalence estimations for mixed episodes were: 12.9% according to DSM-IV-TR (n=45), 9% according to ICD-10 (n=31), 16.7% according to McElroy criteria (n=58), and 23.2% according to clinical judgment (n=81). Statistically significant differences were found between the estimated prevalence rates (Cochrane's Q-test, p<0.0001), with the maximum concordance level found between the McElroy and ICD-10 (Kappa=0.66, 95% CI, 0.54-0.77). The DSM-IV-TR criteria only present moderate concordance with ICD-10 (Kappa=0.65, 95% CI, 0.52 to 0.78) and McElroy criteria (Kappa=0.62, 95% CI, 0.50 to 0.74).

CONCLUSIONS

The definition of mixed episodes for BD must be revised to improve consensus and, consequently, therapeutic management. Current diagnostic systems, based on DSM-IV and IDC-10, only capture a limited proportion of patients suffering from mixed episodes, giving rise to important limitations concerning the therapeutic management of BP patients.

Ziprasidone for the treatment of acute manic or mixed episodes associated with bipolar disorder

Ziprasidone, a benzisothiazolyl piperazine-type atypical antipsychotic agent, has a unique receptor-binding profile. A potent antagonist of serotonin 5-HT(2A) and dopamine D(2) receptors, ziprasidone has an affinity for 5-HT(2A) receptors >10-fold higher than its affinity for D(2) receptors. Ziprasidone has been shown to be effective in the treatment of bipolar disorder in patients experiencing manic or mixed episodes. It was significantly more effective than placebo in improving manic symptoms as early as day 2 of treatment in two 3-week placebo-controlled trials as monotherapy. In a 12-week, placebo-controlled trial of patients with acute mania, ziprasidone as monotherapy showed comparable efficacy with, and fewer movement-related adverse events than, haloperidol. It has demonstrated efficacy in two 1-year open-label extension trials, both as monotherapy and in combination with lithium. Ziprasidone has a generally favourable adverse effect profile. In short-term placebo-controlled trials, there were similar discontinuation rates in active treatment and placebo recipients. While twice as many patients treated with ziprasidone compared with placebo discontinued therapy because of adverse events, the number of events was small and adverse effects were generally mild or moderate. The favourable tolerability of ziprasidone has been confirmed in long-term extension studies and its use was not associated with weight gain or dyslipidaemia. Ziprasidone-related movement disorders occurred infrequently.

Epidemiology, diagnosis and management of mixed mania

The presence of depressive symptomatology during acute mania has been termed mixed mania, dysphoric mania, depressive mania or mixed bipolar disorder. Highly prevalent, mixed mania occurs in at least 30% of bipolar patients. Correct diagnosis is a major challenge. The DSM diagnostic criteria, the most widely adopted clinical convention, require a complete manic and complete depressive syndrome co-occurring for at least 1 week. However, recent alternative categorical and dimensional studies of manic phenomenology have shown that there are certain depressive symptoms or constellations that have special clinical importance when describing mixed states, such as depressed mood and anxiety symptomatology that do not overlap with manic symptoms. Patients with mixed mania are over-represented in the subgroup with severe and treatment-resistant symptoms. The course and prognosis of mixed mania are worse than that of pure manic forms in the medium and long term, with higher recurrence rates, higher frequency of co-morbid substance abuse and greater risk of suicidal ideation and attempts. Moreover, mixed manic episodes are usually associated with increased depression during follow-up, greater risk of rapid cycling course and higher prevalence of physical co-morbidities, principally related to thyroid function. All these factors are very relevant to selection of treatment. There are three crucial steps in the treatment of mixed mania--making the correct diagnosis, starting treatment early, and considering not only the acute state but also maintenance treatment and the patient's long-term outcome. Although challenging, acute mixed episodes are treatable. To date there have been no controlled studies devoted exclusively to treatment of mixed mania, and the only controlled data available therefore derive from sub-analyses of randomised clinical trials. Both short-term and maintenance treatments of patients with mixed mania require experience and usually involve the combination of different treatments. As a general rule, there is some consensus about discontinuing antidepressants during mixed mania. Olanzapine, aripiprazole or valproate semisodium (divalproex sodium) are first-line drugs for mild episodes; severe episodes of mixed mania usually require treatment with a combination of valproate semisodium or lithium plus an antipsychotic, preferably an atypical agent. Carbamazepine is also useful for the treatment of mixed mania. High-dose medications are sometimes needed to control the episode, and time to remission is usually longer than in pure mania. Importantly, patients with mixed manic episodes have more adverse events of psychopharmacological treatment. In some cases, electroconvulsive therapy is required.

Quetiapine dosage in bipolar disorder episodes and mixed states

OBJECTIVE

Although the maximal quetiapine doses in the published studies were restricted to 800 mg/day, higher quetiapine doses are not unusual in clinical practice. The aim of the present study was to evaluate the effectiveness, tolerability and clinical reasons associated to the use of high dosage of quetiapine (>800 mg), when used under routine clinical conditions, in a sample of bipolar disorder and schizoaffective bipolar inpatients.

METHODS

Charts of all bipolar and schizoaffective adult inpatients, who had received quetiapine for a mood episode between 1999 and 2005 were retrospectively reviewed. These charts also included the assessment of manic and depressive symptoms on admission and at discharge using the Beck-Rafaelsen Mania Scale (MAS) and the Montgomery Asberg depression rating scale (MADRS), respectively.

RESULTS

Data of 50 patients were analyzed. The overall F in repeated measures ANOVA revealed a significant MAS scores reduction between admission and discharge. MAS scores reduction did not differ between the high and low quetiapine groups. Similarly, a significant MADRS reduction was found. Again, no differences between the high and the low dose group were found. Logistic regression analysis of the 50 patients revealed only mixed episodes predicted high quetiapine dosage.

CONCLUSIONS

The present study confirms quetiapine efficiency and tolerability in the treatment of bipolar episodes, even in doses > to 800 mg and found a link between quetiapine doses and mixed episodes.

'Bipolar missed states': the diagnosis and clinical salience of bipolar mixed states

OBJECTIVE

To explore diagnostic and treatment issues concerning bipolar mixed states.

METHOD

Bipolar mixed states are described and concerns about diagnostic and treatment difficulties are summarized and discussed.

RESULT

Mixed states can present with equal admixtures of depressive or manic symptoms, or more commonly one component predominates. There is fair consensus, although little data, regarding the management of manic mixed states. However depressive mixed states are far more complex both in terms of recognition and management. People suffering from mixed states characteristically present with complaints of depression.

CONCLUSIONS

The boundaries between depressive mixed states and agitated depression are vague, yet carry substantial therapeutic implications. Bipolar mixed states are often difficult to treat, and tend to take much longer to settle than either pure mania or depression. Furthermore there is data that treatment with antidepressants can worsen the course of mixed states. Hence missed diagnoses can potentially have negative clinical implications. Therefore in this paper the clinical presentation, diagnosis and therapy of mixed states is reviewed with a view to improving management.

Dimensions of mania: differences between mixed and pure episodes

OBJECTIVE

The presence of at least five dimensions in mania has recently been established. This study extends previous findings by comparing the dimensions of pure vs. mixed mania.

MATERIALS AND METHOD

One hundred and three inpatients with bipolar I disorder, manic or mixed (DSM IV), were assessed with SCID-I, YMRS and HDRS-21. The five-factor solution found after applying factorial analysis with Varimax rotation was compared between manic and mixed patients.

RESULTS

There were differences between pure mania and mixed states on factor 1 (depression) and factor 3 (hedonism). There was a tendency to present higher values on factor 5 (activation) in the pure manic group. No differences were found in factor 2 (dysphoria) and factor 4 (psychosis).

DISCUSSION

Hedonism and activation dimensions are present to a lesser degree in mixed states. Although the principal difference between mixed and pure bipolar disorder is the existence of depressive symptoms, the depressive dimension is strongly present in patients with pure mania.

CONCLUSIONS

There is need to search for core depressive symptoms in all patients suffering from mania and to evaluate their outcome in clinical trials.

[Diagnosis and treatment of mixed states]

Mixed States are described in the literature using based on different definitions resulting in different descriptions of the clinical and demographic characteristics, of these episodes, but although they are always asdeemed a severe form of Bipolar disorder with worse prognosis and more prevalent than previously described. The aim of this article is to present a review of these different definitions and their impact on the study of mixed states. Pharmacological treatment is also discussed.

Depression with versus without manic features in rapid-cycling bipolar disorder

Depression has been identified as a hallmark feature of rapid-cycling bipolar disorder, although less attention has been paid to the presence of manic features accompanying depression in rapid cyclers. To provide greater information about the extent to which depression arises with or without salient manic features in rapid cycling, we conducted a preliminary study of rapid cycling in outpatients seeking treatment at an academic specialty center for bipolar disorder. Forty DSM-IV affectively symptomatic bipolar outpatients with past year DSM-IV rapid cycling underwent systematic evaluation of symptoms and illness characteristics. Manic and depressive symptoms, treatments, and clinical features were rated by standardized scales. Major depression was present in most rapid cyclers (85%), but salient manic features were also evident in half of all depressed rapid cyclers. A lifetime history of suicide attempts was significantly more common in rapid cyclers who presented with major depression plus salient manic features than in those who presented with pure depression or pure mania (p = .033). Antidepressants were being prescribed for approximately one third of depressed rapid cycling patients regardless of the presence of concomitant manic features, whereas mood stabilizers tended to be used less often when manic features accompanied depression. Depression in conjunction with manic symptoms, rather than pure depression alone, may be more common among rapid-cycling bipolar patients who seek treatment. Lifetime suicide risk may be greater among rapid cycling patients whose depression occurs in tandem with manic symptoms. Prescribing habits in the community that favor antidepressants over mood stabilizers may promote further mood destabilization in this population. Further studies with larger sample sizes are needed to affirm these provisional findings.

Speech rate as a sticky switch: a multiple lesion case analysis of mutism and hyperlalia

Though it has long been known on the basis of clinical associations and serendipitous observation that speech rate is related to mood and psychomotor baseline, it is less known that speech rate is also related to libido and to immune function. We make the case for a bipolar phenomenon of "psychic tonus," encompassing all these dimensions. The elated, agitated, libidinal, immunofacilitated, and talkative pole is an "approach" disposition primarily activated by the normal left hemisphere-especially, though not exclusively, its frontal lobe. The dejected, lethargic, delibidinized, immunosuppressed, and mute pole is an "avoidance" disposition primarily activated by the normal right hemisphere-especially, though not exclusively, its frontal lobe. In support of this proposed model, we present new evidence, via meta-analysis of previously published single lesion case reports, of a highly significant association between right hemisphere lesions and non-aphasic hyperlalia, and between left hemisphere lesions and non-aphasic mutism.

Anxiety and depression: One, two or three disorders?

The study deals with theoretical psychiatric proposals about relations between anxiety and depressive disorders. Three theoretical positions developed on the basis of numerous evidence on relationship of anxiety and depressive disorders: unitaristic (anxious and depressive disorders represent one disorder with different clinical pictures or phases of the disorder), pluralistic (there are two classes of disorders with clearly recognizable boundaries) and anxious-depressive position (mixed anxious-depressive disorder represents also a single disorder). Possible reasons for antagonisms, connections (i.e. lack of connections) to some proposals of psychologists are commented upon, as well as the significance of this problem for classification of mental disorders in general.

Genetic animal models of anxiety

The focus of this review is on progress achieved in identifying specific genes conferring risk for anxiety disorders through the use of genetic animal models. We discuss gene-finding studies as well as those manipulating a candidate gene. Both human and animal studies thus far support the genetic complexity of anxiety. Clinical manifestations of these diseases are likely related to multiple genes. While different anxiety disorders and anxiety-related traits all appear to be genetically influenced, it has been difficult to ascertain genetic influences in common. Mouse studies have provisionally mapped several loci harboring genes that affect anxiety-related behavior. The growing array of mutant mice is providing valuable information about how genes and environment interact to affect anxious behavior via multiple neuropharmacological pathways. Classical genetic methods such as artificial selection of rodents for high or low anxiety are being employed. Expression array technologies have as yet not been employed, but can be expected to implicate novel candidates and neurobiological pathways.

The boundary between mixed and manic episodes in the ICD-10 classification

OBJECTIVE

To investigate the boundary between ICD-10 mixed and manic episodes, which has apparently remained understudied.

METHOD

In-patients with ICD-10 mixed (n=36) and manic episodes (n=145) were compared in terms of demographic, clinical, therapeutical and outcome variables.

RESULTS

Of in-patients with manic episode, 26 (18%) had several depressive symptoms at admission. These patients (dysphoric manic patients) were very similar to patients with ICD-10 mixed episode in terms of current symptomatic presentations and several clinical and therapeutic variables, which were significantly different from those in patients with pure mania.

CONCLUSION

The ICD-10 boundary between mixed and manic episodes is unlikely to be effective although experienced clinicians made the diagnoses. The system may have a high probability of diagnosing dysphoric manic patients as having manic episode, despite their great similarities to patients with mixed episode in terms of current psychopathological presentations as well as clinically important variables.

Bipolar disorder with comorbid substance abuse: diagnosis, prognosis, and treatment

Alcohol and drug abuse occur frequently in individuals with bipolar disorder, but clinicians may often feel ill-prepared to identify such multi-diagnosis syndromes, to contextualize drug abuse alongside affective symptoms, and to formulate appropriate treatment strategies. Plausible explanations for high comorbidity rates between bipolar illness and substance use disorders are complex and likely embrace numerous factors that extend beyond simple, older theories about drug use as sheer "self-medication." Evidence from epidemiologic, family-genetic, pharmacologic, psychosocial, and clinical psychopathology studies suggest that a majority of bipolar patients are at risk for developing lifetime drug or alcohol-related problems, which may in turn contribute to more varied and complex clinical presentations, accelerated relapses, worsening of depressive features, poorer lithium response, functional disability, and elevated suicide risk. In this article, the author reviews essential concepts about the phenomenology and treatment outcome of bipolar illness with substance use comorbidities and offers a systematic approach to the diagnosis and management of patients with such dual diagnoses.