Bipolar II disorder and comorbidity

Self-report screening instruments differentiate bipolar disorder and borderline personality disorder

BACKGROUND

Bipolar disorder (BD) and borderline personality disorder (BPD) share overlapping phenomenology and are frequently misdiagnosed. This study investigated the diagnostic accuracy of the Mood Disorder Questionnaire (MDQ) and McLean Screening Instrument for Borderline Personality Disorder (MSI) in a clinical inpatient setting and whether individual screening items could differentiate BD from BPD.

METHODS

757 sequential inpatients admitted to a Mood Disorder Unit completed both the MDQ and MSI. Screen positive for the MDQ was defined as ≥7/13 symptoms endorsed with concurrence and at least moderate impact. Screen positive for the MSI was defined as a score of ≥7. The clinical discharge summary diagnosis completed by a board-certified psychiatrist was used as the reference standard to identify concordance rates of a positive screen with clinical diagnosis. Individual items predicting one disorder and simultaneously predicting absence of other disorder by odds ratio (OR>and <1) were identified.

RESULTS

Both screening instruments were more specific than sensitive (MDQ 83.7%/ 67.8%, MSI 73.2% / 63.3%). MDQ individual items (elevated mood, grandiosity, increased energy, pressured speech, decreased need for sleep, hyperactivity) were significant predictors of BD diagnosis and non-predictors of BPD diagnosis. Whereas MSI subitem, self-harm behaviors/suicidal attempts predicted BPD in the absence of BD; distrust and irritability were additional predictors of BPD.

CONCLUSION

While this study is limited by the lack of structured diagnostic interview, these data provide differential symptoms to discriminate BD and BPD. Further work with larger datasets and more rigorous bioinformatics machine learning methodology is encouraged to continue to identify distinguishing features of these two disorders to guide diagnostic precision and subsequent treatment recommendations.

Characteristics of bipolar I and II disorder: A study of 8766 individuals

OBJECTIVES

Large-scale studies on phenotypic differences between bipolar disorder type I (BDI) and type II (BDII) are scarce.

METHODS

Individuals with BDI (N = 4806) and BDII (N = 3960) were compared with respect to clinical features, illness course, comorbid conditions, suicidality, and socioeconomic factors using data from the Swedish national quality assurance register for bipolar disorders (BipoläR).

RESULTS

BDII had higher rate of depressive episodes and more frequent suicide attempts than BDI. Furthermore, the BDII group were younger at first sign of mental illness and showed higher prevalence of psychiatric comorbidity but were more likely to have completed higher education and to be self-sustaining than the BDI group. BDII more frequently received psychotherapy, antidepressants, and lamotrigine. BDI patients had higher rate of hospitalizations and elated episodes, higher BMI, and higher rate of endocrine, nutritional, and metabolic diseases. BDI were more likely to receive mood stabilizers, antipsychotic drugs, electroconvulsive therapy, and psychoeducation.

CONCLUSIONS

These results demonstrate clear differences between BDI and II and counter the notion that BDII is a milder form of BDI, but rather a more complex condition with regard to clinical course and comorbidity.

Bipolar disorder and personality disorder

Patients with bipolar disorders experience cyclical changes in mood that present as a range of different syndromes. In classical mania, patients experience episodes of euphoria, whereas in depressive episodes they suffer from depression. In hypomania, patients experience a milder form of mania, and in mixed mania, patients may experience both manic and depressive symptoms simultaneously, or alternate between them rapidly. Because of this wide range of symptoms, bipolar disorders can appear to overlap with other mental disorders, especially personality disorders.

Differential Diagnosis of Bipolar II Disorder and Borderline Personality Disorder

PURPOSE OF REVIEW

Differentiating bipolar (BP) disorders (in particular BP II) from borderline personality disorder (BPD) is a common diagnostic dilemma. We sought to critically examine recent studies that considered clinical differences between BP II and BPD, which might advance their delineation.

RECENT FINDINGS

Recent studies focused on differentiating biological parameters-genetics, epigenetics, diurnal rhythms, structural and functional neuroimaging-with indicative differences not yet sufficient to guide diagnosis. Key differentiating factors include family history, developmental antecedents, illness course, phenomenological differences in mood states, personality style and relationship factors. Less differentiating factors include impulsivity, neuropsychological profiles, gender distribution, comorbidity and treatment response. This review details parameters offering differentiation of BP II from BPD and should assist in resolving a frequent diagnostic dilemma. Future studies should specifically examine the BP II subtype directly with BPD, which would aid in sharpening the distinction between the disorders.

The aldehyde dehydrogenase 2 polymorphisms on neuropsychological performance in bipolar II disorder with or without comorbid anxiety disorder

Anxiety disorders (ADs), the most common comorbid illnesses with bipolar disorder (BP) has been reported to associate with dopamine system. Dopamine, metabolized to 3,4-dihydroxyphenylacetic acid (DOPAC) by aldehyde dehydrogenase 2 (ALDH2), and the distribution of the ALDH2*1/*1, and ALDH2*1/*2+ALDH*2/*2 alleles in the Han Chinese general population is relatively equal. The association between dopamine metabolic enzymes and cognitive performance in patients with bipolar II disorder (BP-II) comorbid with AD is unclear. This study proposed to explore the role of ALDH2 polymorphisms on neuropsychological performance between BP-II comorbid with or without AD. One hundred ninety-seven BP-II patients with and without a comorbid AD were recruited and compared with 130 healthy controls (HCs). A polymerase chain reaction and a restriction fragment length polymorphism analysis were used to determine genotypes for ALDH2, and study participants underwent neuropsychological tests. An interaction between AD comorbidity and the ALDH2 polymorphisms was found in different domain of cognitive dysfunction in the BP-II patients. The ALDH2 polymorphisms might have different effects on the neuropsychological performance of BP-II patients with and without comorbid AD.

The course of bipolar disorder

Bipolar disorder is arguably a pivotal diagnosis in adult psychiatry bounded by schizophrenia on one side and unipolar depression on the other. It represents a wide spectrum of disorders, all sharing common features of elated and depressed mood. The early descriptions of symptom-free euthymia have long been dismissed and the chronic and enduring deficits associated with the disorder are beginning to be better understood. We review the current literature with regard to the course of the disorder, factors that may influence prognosis and common comorbidities.

The relative influence of individual risk factors for attempted suicide in patients with bipolar I versus bipolar II disorder

OBJECTIVES

To compare the relative influence (RI) of individual predictors for lifetime attempted suicide between adults with bipolar I (BDBD-I) and bipolar II disorder (BDBD-II).

METHODS

We conducted an analysis of data from 1465 enrollees in the Mayo Clinic Bipolar Disorder Biobank. Demographic and clinical variables and history of attempted suicide were ascertained using standardized questionnaires. Height and weight were assessed to determine body mass index (BMI); obesity was defined as BMI ≥30kg/m². The frequencies of these variables were compared between persons with and without self-reported lifetime suicide attempts both overall, and within BD-I and BD-II subgroups. Gradient boosting machine (GBM) models were used to quantify the RI of study variables on the risk of lifetime attempted suicide.

RESULTS

Nearly one-third of patients reported having a lifetime suicide attempt. Attempted suicide rates were higher in patients with BD-I than BD-II, but absolute differences were small. Lifetime attempted suicide was associated with female sex, BD-I subtype, psychiatric and substance use comorbidities, binge eating behavior, lifetime history of rapid cycling, other indicators of adverse illness course, and early age of bipolar illness onset in the entire cohort. Differences in the rank-ordering of RI for predictors of attempted suicide between BD-I and BD-II patients were modest. Rapid cycling was a strong risk factor for attempted suicide, particularly in men with BD-I.

LIMITATIONS

Actively psychotic or suicidal patients needing psychiatric hospitalization were initially excluded, but were approached after these acute psychiatric problems resolved.

CONCLUSIONS

The prevalence of lifetime attempted suicide was significantly higher in BD-I than BD-II in this large, cross-sectional cohort. Predictors of attempted suicide were similar in BD-I and BD-II subgroups.

Prevalence and Associated Features of Anxiety Disorder Comorbidity in Bipolar Disorder: A Meta-Analysis and Meta-Regression Study

Objective: Bipolar disorder is highly comorbid with anxiety disorders, however current and lifetime comorbidity patterns of each anxiety disorder and their associated features are not well studied. Here, we aimed to conduct a meta-analysis and meta-regression study of current evidence. Method: We searched PubMed to access relevant articles published until September 2015, using the keywords "Bipolar disorder" or "Affective Psychosis" or "manic depressive" separately with "generalized anxiety," "panic disorder," "social phobia," "obsessive compulsive," and "anxiety." Variables for associated features and prevalence of anxiety disorders were carefully extracted. Results: Lifetime any anxiety disorder comorbidity in BD was 40.5%; panic disorder (PD) 18.1%, generalized anxiety disorder (GAD) 13.3%, social anxiety disorder (SAD) 13.5% and obsessive compulsive disorder (OCD) 9.7%. Current any anxiety disorder comorbidity in BD is 38.2%; GAD is 15.2%, PD 13.3%, SAD 11.7%, and OCD 9.9%. When studies reporting data about comorbidities in BDI or BDII were analyzed separately, lifetime any anxiety disorder comorbidity in BDI and BDII were 38% and 34%, PD was 15% and 15%, GAD was 14% and 16.6%, SAD was 8% and 13%, OCD was 8% and 10%, respectively. Current any DSM anxiety disorder comorbidity in BDI or BDII were 31% and 37%, PD was 9% and 13%, GAD was 8% and 12%, SAD was 7% and 11%, and OCD was 8% and 7%, respectively. The percentage of manic patients and age of onset of BD tended to have a significant impact on anxiety disorders. Percentage of BD I patients significantly decreased the prevalence of panic disorder and social anxiety disorder. A higher rate of substance use disorder was associated with greater BD-SAD comorbidity. History of psychotic features significantly affected current PD and GAD. Conclusions: Anxiety disorder comorbidity is high in BD with somewhat lower rates in BDI vs BDII. Age of onset, substance use disorders, and percentage of patients in a manic episode or with psychotic features influences anxiety disorder comorbidity.

Italian Bipolar II vs I patients have better individual functioning, in spite of overall similar illness severity

Introduction Bipolar disorders (BDs) comprise different variants of chronic, comorbid, and disabling conditions, with relevant suicide and suicide attempt rates. The hypothesis that BD types I (BDI) and II (BDII) represent more and less severe forms of illness, respectively, has been increasingly questioned over recent years, justifying additional investigation to better characterize related sociodemographic and clinical profiles.

METHODS

A sample of 217 outpatients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)-described BD (141 BDI, 76 BDII), without a current syndromal mood episode, was recruited, and sociodemographic and clinical characteristics of BDI and II patients were compared.

RESULTS

BDII patients had significantly more favorable sociodemographics, in relation to occupational stability, cohabitation, and marital status. However, BDII compared with BDI patients had significantly longer duration of untreated illness, more frequent lifetime anxiety disorders comorbidity, longer most recent episode duration, higher rate of depressive first/most recent episode, and more current antidepressant use. In contrast, BDI compared with BDII patients had significantly more severe illness in terms of earlier age at onset; higher rate of elevated first/most recent episode, lifetime hospitalizations, and involuntary commitments; lower Global Assessment of Functioning score; and more current antipsychotic use. BDI and II patients had similar duration of illness, psychiatric family history, lifetime number of suicide attempts, current subthreshold symptoms, history of stressful life events, and overall psychiatric/medical comorbidity.

CONCLUSION

BDII compared with BDI patients had more favorable sociodemographic features, but a mixture of specific unfavorable illness characteristics, confirming that BDII is not just a milder form of BD and requires further investigation in the field.

Who's the Leader, Mania or Depression? Predominant Polarity and Alcohol/Polysubstance Use in Bipolar Disorders

BACKGROUND

Predominant polarity characterises patients who mainly manifest recurrences of depression or mania/hypomania. Alcohol use disorder (AUD) and polysubstance use (PSU), which often complicate bipolar disorder (BD) and affect its clinical course, can influence predominant polarity. Nevertheless, previous studies have not clarified if BD patients differ in predominant polarity from BD patients with substance use disorder (SUD) comorbidity.

OBJECTIVE

The aim of this study was to compare predominant polarity between BD without SUD, BD with AUD and BD with PSU. We also investigated the association between predominant polarity and first episode polarity in each diagnostic group.

METHOD

We evaluated predominant polarity (≥2:1 lifetime depressive vs. manic/hypomanic episodes) in 218 DSM-IV-TR BD patients. Specifically, data were obtained from 86 patients with BD without SUD, 69 patients with BD and AUD, and 63 patients with BD and PSU with alcohol as the primary substance abused.

RESULTS

The three groups significantly differed for predominant polarity. The most common predominant polarity in BD without SUD was manic, while in BD with AUD and in BD with PSU it was depressive. Uncertain predominant polarity was the least common in BD without SUD and BD with PSU, whereas in BD with AUD, manic predominant polarity was least common. Predominant polarity matched onset polarity in all groups.

CONCLUSION

BD without SUD, BD with AUD, and BD with PSU have different predominant polarities. The correspondence between predominant polarity and polarity at the onset may impact diagnosis and treatment of BD.

Threat sensitivity in bipolar disorder

Life stress is a major predictor of the course of bipolar disorder. Few studies have used laboratory paradigms to examine stress reactivity in bipolar disorder, and none have assessed autonomic reactivity to laboratory stressors. In the present investigation we sought to address this gap in the literature. Participants, 27 diagnosed with bipolar I disorder and 24 controls with no history of mood disorder, were asked to complete a complex working memory task presented as "a test of general intelligence." Self-reported emotions were assessed at baseline and after participants were given task instructions; autonomic physiology was assessed at baseline and continuously during the stressor task. Compared to controls, individuals with bipolar disorder reported greater increases in pretask anxiety from baseline and showed greater cardiovascular threat reactivity during the task. Group differences in cardiovascular threat reactivity were significantly correlated with comorbid anxiety in the bipolar group. Our results suggest that a multimethod approach to assessing stress reactivity-including the use of physiological parameters that differentiate between maladaptive and adaptive profiles of stress responding-can yield valuable information regarding stress sensitivity and its associations with negative affectivity in bipolar disorder. (PsycINFO Database Record (c) 2015 APA, all rights reserved).

Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: Systematic review and meta-analysis

BACKGROUND

Comorbidity between substance use disorders (SUDs) and bipolar disorder (BD) is highly prevalent to the extent it may almost be regarded the norm. This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in treatment seeking patients diagnosed with BD in both inpatient and outpatient settings.

METHODS

A comprehensive literature search of Medline, EMBASE, psychINFO and CINAHL databases was conducted from 1990 to 2015. Prevalence of co-morbid SUDs and BD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis.

RESULTS

There were 151 articles identified by electronic searches that yielded 22 large, multi-site studies and 56 individual studies describing comorbid rates of SUDs amongst community dwelling, BD inpatients or outpatients. The SUDs with the highest prevalence in BD were alcohol use (42%) followed by cannabis use (20%) and other illicit drug use (17%). Meta-analysis showed males had higher lifetime risks of SUDs compared to females. BD and comorbid SUDS were associated with earlier age of onset and slightly more hospitalisations than non-users.

LIMITATIONS

The results do not take into account the possibility that individuals may have more than one comorbid disorder, such as having more than one SUD, anxiety disorder, or other combination. Some of the meta-analyses were based on relatively few studies with high rates of heterogeneity. Most included studies were cross-sectional and therefore causality cannot be inferred.

CONCLUSIONS

This systematic review shows comorbidity between SUDs and bipolar illness is highly prevalent in hospital and community-based samples. The prevalence of SUDs was similar in patients with bipolar I and bipolar II disorders. This study adds to the literature demonstrating that SUDs are common in BD and reinforces the need to provide better interventions and properly conducted treatment trials to reduce the burden conferred by comorbid SUD and BD.

Comorbidity between bipolar disorder and borderline personality disorder: Prevalence, explanatory theories, and clinical impact

BACKGROUND

The relationship between bipolar disorder (BD) and borderline personality disorder (BPD) has been controversial and widely debated. Specifically, the comorbidity between both disorders has yielded a plethora of research, but there are no comprehensive reviews on this issue.

OBJECTIVE

To determine the empirical evidence regarding the comorbidity between BD and BPD based on prevalence data, explanatory theories for their co-occurrence, and clinical impact of one disorder in the other.

METHOD

A comprehensive search of databases (PubMed and PsycINFO) was performed. Published manuscripts between January 1985 and August 2015 were identified. Overall, 70 studies fulfilled inclusion criteria.

RESULTS

Over a fifth of subjects showed comorbidity between BPD and BD. Empirical evidence from common underlying factors was inconclusive, but BPD appears to be a risk factor for BD. Data also indicated that the negative impact of BPD in BD (e.g., suicidality, worse mood course) was greater than vice verse.

CONCLUSIONS

Given the high prevalence of comorbidity between BD and BPD and the negative effects of BPD in subjects with BD, further studies are needed to clarify the factor associated with the comorbidity between these two disorders. This information is important to develop appropriate treatments for subjects with both disorders, improve their clinical course, and prevent the increased risk of suicidality commonly found in these subjects.

Considering Eligibility for Studies of Deep Brain Stimulation for Treatment-Resistant Depression: Insights From a Clinical Trial in Unipolar and Bipolar Depression

BACKGROUND

While electroconvulsive therapy (ECT) is the most effective treatment for major depression (major depressive disorder [MDD]), deep brain stimulation (DBS) has shown efficacy in patients who have not received benefit from ECT. Studies of DBS are small, and a better understanding of which eligibility criteria lead to exclusion may help achieve a more appropriate balance between scientific rigor and generalizability in future trials. We assessed the rate and reasons for exclusion from a study of DBS for treatment-resistant MDD and bipolar type II (BPII) depression.

METHODS

One thousand ninety-eight adults were screened for a study of DBS for MDD or BPII. Reasons for exclusion were documented. Descriptive statistics were calculated for each reason for exclusion for the entire sample as well as the self-reported MDD and BPII subgroups.

RESULTS

Ninety-eight percent (98%) of patients screened were excluded. Exclusion due to lack of interest or inability to relocate to the study site was high (41%). Following this, primary reasons for exclusion were lack of prior ECT and presence of psychiatric/general medical comorbidity. Patients with MDD were more likely to be excluded because of inadequate ECT, whereas patients with BPII depression were more likely to be excluded for comorbid psychiatric diagnoses and not meeting minimum severity criteria.

CONCLUSIONS

A surprisingly high number of potential participants were excluded because of lack of adequate ECT. This suggests that many patients self-identifying as "treatment resistant" have not truly exhausted available, evidence-based treatments. Overall exclusion rate was high, with key differences in exclusion reasons between the MDD and BPII subgroups. These findings can inform design of future clinical trials for treatment-resistant unipolar and bipolar depression.Clinicaltrials.gov Identifier: NCT00367003.

The prevalence and predictors of bipolar and borderline personality disorders comorbidity: Systematic review and meta-analysis

INTRODUCTION

Data about the prevalence of borderline personality (BPD) and bipolar (BD) disorders comorbidity are scarce and the boundaries remain controversial. We conducted a systematic review and meta-analysis investigating the prevalence of BPD in BD and BD in people with BPD.

METHODS

Two independent authors searched MEDLINE, Embase, PsycINFO and the Cochrane Library from inception till November 4, 2015. Articles reporting the prevalence of BPD and BD were included. A random effects meta-analysis and meta-regression were conducted.

RESULTS

Overall, 42 papers were included: 28 considering BPD in BD and 14 considering BD in BPD. The trim and fill adjusted analysis demonstrated the prevalence of BPD among 5273 people with BD (39.94 ± 11.78 years, 44% males) was 21.6% (95% CI 17.0-27.1). Higher comorbid BPD in BD were noted in BD II participants (37.7%, 95% CI 21.9-56.6, studies=6) and North American studies (26.2%, 95% CI 18.7-35.3, studies=11). Meta regression established that a higher percentage of males and higher mean age significantly (p<0.05) predicted a lower prevalence of comorbid BPD in BD participants. The trim and fill adjusted prevalence of BD among 1814 people with BPD (32.22 ± 7.35 years, 21.5% male) was 18.5% (95% CI 12.7-26.1).

LIMITATIONS

Paucity of longitudinal/control group studies and accurate treatment records.

CONCLUSIONS

BPD-BD comorbidity is common, with approximately one in five people experiencing a comorbid diagnosis. Based on current diagnostic constructs, and a critical interpretation of results, both qualitative and quantitative syntheses of the evidence prompt out the relevance of differences rather similarities between BD and BPD.

Relationships between mixed features and borderline personality disorder in 2811 patients with major depressive episode

OBJECTIVE

The study focused on the relationship between mixed depression and borderline personality disorder (BPD).

METHOD

The sample comprised 2811 patients with a major depressive episode (MDE). Clinical characteristics were compared in patients with (BPD+) and without (BPD-) comorbid BPD and in BPD+ with (MXS+) and without (MXS-) mixed features according to DSM-5 criteria.

RESULTS

A total of 187 patients (6.7%) met the criteria for BPD. A DSM-IV-TR diagnosis of bipolar disorder (BD) was significantly more frequent in patients with BPD+ than in patients with BPD. Patients with BPD+ were significantly younger and reported lower age at onset than BPD-. Patients with BPD+ also showed more hypomania/mania in first-degree relatives in comparison with patients with BPD-, as well as more psychiatric comorbidity, mixed features, atypical features, suicide attempts, prior mood episodes and antidepressant-induced hypo/manic switches. Mixed features according to DSM-5 criteria were observed in 52 (27.8%) BPD+. In comparison with MXS-, MXS+ were significantly younger at age of onset and at prior mood episode and had experienced more mood episodes and hypo/manic switches with antidepressant treatments.

CONCLUSION

Major depressive episode patients with comorbid BPD reported a high prevalence of mixed features and BD. The presence of DSM-5 mixed features in MDE patients with BPD may be associated with complex course and reduced treatment response.

A retrospective study of predictive factors for effective aripiprazole augmentation of antidepressant therapy in treatment-resistant depression

BACKGROUND

Several studies have evaluated the efficacy and tolerability of aripiprazole for augmentation of antidepressant therapy for treatment-resistant depression (TRD). Here, we investigated the efficacy of aripiprazole augmentation for TRD including both major depressive disorder and bipolar disorder and the clinical predictors of treatment efficacy in a Japanese population.

METHODS

Eighty-five depressed Japanese patients who underwent aripiprazole augmentation therapy after failing to respond satisfactorily to antidepressant monotherapy were included in the study. Treatment responses were evaluated based on Clinical Global Impression Improvement scores assessed 8 weeks after initiation of aripiprazole administration. We compared demographic and diagnostic variables, psychiatric medication variables, and clinical variables between remission and nonremission groups.

RESULTS

The aripiprazole augmentation remission rate was 36.5%. Multiple logistic regression analysis indicated that aripiprazole augmentation was significantly more effective for bipolar depression than for major depressive disorder, and both absence of comorbid anxiety disorders and current episode duration >3 months were significantly associated with the efficacy of aripiprazole augmentation.

CONCLUSION

Polarity of depression, comorbidity of anxiety disorders, and current episode duration may predict the efficacy of aripiprazole augmentation for TRD including both major depressive disorder and bipolar disorder. Among them, comorbidity of anxiety disorders was significantly related to the efficacy for TRD including only major depressive disorder. Additional studies are needed to examine the association between the efficacy of aripiprazole augmentation and bipolarity, and these findings should be validated further in a prospective study.

Lifetime prevalence of anxiety disorders in people with bipolar disorder: a systematic review and meta-analysis

BACKGROUND

Anxiety disorders are increasingly recognised as an important determinant of outcomes in patients with bipolar disorder. However, a reliable estimate of their prevalence is still missing, because the published prevalence of anxiety disorders in individuals with bipolar disorder varies widely. In this study, we aimed to quantify the lifetime prevalence of anxiety disorders in individuals with bipolar disorder and compare it with rates in people without the disorder.

METHODS

We searched the Web of Knowledge and Medline (through the PubMed interface) for articles published in any language from the database inception dates up until June 1, 2014, using a combination of the word "bipolar" and search terms for anxiety disorders. We included studies that reported original data about the lifetime prevalence of DSM-III and DSM-IV anxiety disorders in adults with bipolar disorder that recruited participants irrespective of comorbidities and that used a validated diagnostic interview to establish the diagnoses of bipolar disorder and at least one anxiety disorder. We excluded studies that reported only the current prevalence or if we were unable to establish whether they described current or lifetime prevalence, and those with discrepancies in the data that could not be resolved by contacting the authors. We did a random-effects meta-analysis of lifetime prevalence of DSM-III and DSM-IV anxiety disorders in adults with bipolar disorder, in which we quantified the lifetime prevalence of any anxiety disorder in people with bipolar disorder. We compared this prevalence in people with bipolar I disorder versus those with bipolar II disorder, and in people with bipolar disorder versus population controls.

FINDINGS

Data from 40 studies, including 14 914 individuals from North America, Europe, Australia, South America, and Asia, indicate that the lifetime prevalence of anxiety disorders in individuals with bipolar disorder is 45% (95% CI 40-51). Direct comparison in five samples with a total of 1378 individuals with bipolar disorder and 56 812 population controls without bipolar disorder indicates a three-fold increase (risk ratio [RR] 3·22 [95% CI 2·41-4·29]; p<0·0001) in the prevalence of anxiety disorders in those with bipolar disorder. 13 studies that included both individuals with bipolar I disorder (n=4270) and those with bipolar II disorder (n=1939) showed no difference in the lifetime prevalence of anxiety disorders between these subtypes (RR 1·07 [95% CI 0·96-1·20]; p=0·223). We noted significant heterogeneity among included studies that was not accounted for by reported differences in study characteristics.

INTERPRETATION

People with bipolar disorder are at increased risk of anxiety disorders compared with those without bipolar disorder; nearly one in two has an anxiety disorder in their lifetime. Anxiety disorders should therefore be assessed alongside the mood symptoms in patients with bipolar disorder.

FUNDING

Capital Health Research Fund.

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.

Prevalence and clinical correlates of alcohol use disorders among bipolar disorder patients: results from the Brazilian Bipolar Research Network

OBJECTIVES

To investigate prevalence rates and clinical correlates of alcohol use disorders (AUD) among bipolar disorder (BD) patients in a large sample from the Brazilian Bipolar Research Network.

METHODS

Four hundred and eighty-three DSM-IV BD patients, divided according to the presence or absence of a lifetime AUD diagnosis (BD-AUD vs. BD-nonAUD), were included. Demographic and clinical characteristics of these two groups were compared. Logistic regression was performed to identify which characteristics were most strongly associated with a lifetime AUD diagnosis.

RESULTS

Nearly 23% presented a lifetime AUD diagnosis. BD-AUD patients were more likely to be male, to present rapid cycling, post-traumatic stress disorder (PTSD), anorexia, other substance use disorders (SUD), family history of SUD, any substance misuse during the first mood episode, history of psychosis, suicide attempts, and younger age at onset of illness than BD-nonAUD patients. Logistic regression showed that the variables most strongly associated with a lifetime AUD diagnosis were SUD (non-alcohol), any substance misuse during the first mood episode, PTSD, male gender, suicide attempt, family history of SUD, and younger age at onset of BD.

CONCLUSIONS

BD-AUD patients begin their mood disorder earlier and present more suicidal behaviors than BD-nonAUD patients. Personal and family history of SUD may be good predictors of comorbid AUD among BD patients. These variables are easily assessed in the clinical setting and may help to identify a particularly severe subgroup of BD patients.

The relationship between borderline personality disorder and bipolar disorder

It is clinically important to recognize both bipolar disorder and borderline personality disorder (BPD) in patients seeking treatment for depression, and it is important to distinguish between the two. Research considering whether BPD should be considered part of a bipolar spectrum reaches differing conclusions. We reviewed the most studied question on the relationship between BPD and bipolar disorder: their diagnostic concordance. Across studies, approximately 10% of patients with BPD had bipolar I disorder and another 10% had bipolar II disorder. Likewise, approximately 20% of bipolar II patients were diagnosed with BPD, though only 10% of bipolar I patients were diagnosed with BPD. While the comorbidity rates are substantial, each disorder is nontheless diagnosed in the absence of the other in the vast majority of cases (80% to 90%). In studies examining personality disorders broadly, other personality disorders were more commonly diagnosed in bipolar patients than was BPD. Likewise, the converse is also true: other axis I disorders such as major depression, substance abuse, and post-traumatic stress disorder are also more commonly diagnosed in patients with BPD than is bipolar disorder. These findings challenge the notion that BPD is part of the bipolar spectrum.

Stressful life events in bipolar I and II disorder: cause or consequence of mood symptoms?

BACKGROUND

Life events are assumed to be triggers for new mood episodes in bipolar disorder (BD). However whether life events may also be a result of previous mood episodes is rather unclear.

METHOD

173 bipolar outpatients (BD I and II) were assessed every three months for two years. Life events were assessed by Paykel׳s self-report questionnaire. Both monthly functional impairment due to manic or depressive symptomatology and mood symptoms were assessed.

RESULTS

Negative life events were significantly associated with both subsequent severity of mania and depressive symptoms and functional impairment, whereas positive life events only preceded functional impairment due to manic symptoms and mania severity. These associations were significantly stronger in BD I patients compared to BD II patients. For the opposite temporal direction (life events as a result of mood/functional impairment), we found that mania symptoms preceded the occurrence of positive life events and depressive symptoms preceded negative life events.

LIMITATIONS

The use of a self-report questionnaire for the assessment of life events makes it difficult to determine whether life events are cause or consequence of mood symptoms. Second, the results can only be generalized to relatively stable bipolar outpatients, as the number of severely depressed as well as severely manic patients was low.

CONCLUSIONS

Life events appear to precede the occurrence of mood symptoms and functional impairment, and this association is stronger in BD I patients. Mood symptoms also precede the occurrence of life event, but no differences were found between BD I and II patients.

Retrospective assessment of premorbid psychopathology and cognitive impairments in bipolar disorder

The present study investigated whether premorbid psychopathological and cognitive impairment symptoms could be retrospectively identified during the childhood and adolescence of those later diagnosed with bipolar disorder (BPD). The present sample consisted of 30 adults diagnosed with BPD, 30 of their significant-others, a group-matched control group of 30 adults (without any reported psychological or cognitive disorders), and 30 of their significant-others. The adults diagnosed with BPD and the control group completed a self-report form of the retrospective version of the Coolidge Personality and Neuropsychological Inventory (CPNI-R) as they were before the age of 16 years. The significant-others reported on the adults diagnosed with BPD or upon their controls. Initial two-factor analyses of variance revealed that on a comprehensive measure of psychopathology and of cognitive impairment, those diagnosed with BPD scored significantly higher than the control group on the self-report and the significant-other forms, with large effects sizes. Overall, the overarching research hypothesis was confirmed: adults diagnosed with BPD and their significant-others could report salient prodromes during their childhood or adolescence.

The clinical impact of mood disorder comorbidity on social anxiety disorder

BACKGROUND

High comorbidity rates of mood disorders have been reported in patients with social anxiety disorder (SAD). Our study aims to identify the frequency of comorbid Axis I disorders in patients with SAD and to investigate the impact of psychiatric comorbidity on SAD.

METHODS

The study included 247 patients with SAD. Thirty eight patients with bipolar depression (SAD-BD), 150 patients with major depressive disorder (SAD-MDD) and 25 patients who do not have any mood disorder comorbidity (SAD-NOMD) were compared.

RESULTS

Around 90% of SAD patients had at least one comorbid disorder. Comorbidity rates of lifetime MDD and BD were 74.5% and 15.4%, respectively. There was no comorbidity in the SAD-NOMD group. Atypical depression, total number of depressive episodes and rate of PTSD comorbidity were higher in SAD-BD than in SAD-MDD. Additionally, OCD comorbidity was higher in SAD-BD than in SAD-NOMD. SAD-MDD group had higher social anxiety severity than SAD-NOMD.

CONCLUSIONS

Mood disorder comorbidity might be associated with increased severity and decreased functionality in patients with SAD.

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.

Problematic boundaries in the diagnosis of bipolar disorder: the interface with borderline personality disorder

It is clinically important to recognize both bipolar disorder and borderline personality disorder (BPD) in patients seeking treatment for depression, and it is important to distinguish between the two. The most studied question on the relationship between BPD and bipolar disorder is their diagnostic concordance. Across studies approximately 10 % of patients with BPD had bipolar I disorder and another 10 % had bipolar II disorder. Likewise, approximately 20 % of bipolar II patients were diagnosed with BPD, though only 10 % of bipolar I patients were diagnosed with BPD. While the comorbidity rates are substantial, each disorder is, nonetheless, diagnosed in the absence of the other in the vast majority of cases (80-90 %). In studies examining personality disorders broadly, other personality disorders were more commonly diagnosed in bipolar patients than was BPD. Likewise, the converse is also true: other axis I disorders such as major depression, substance abuse, and post-traumatic stress disorder are more commonly diagnosed in patients with BPD than is bipolar disorder. Studies comparing patients with BPD and bipolar disorder find significant differences on a range of variables. These findings challenge the notion that BPD is part of the bipolar spectrum. While a substantial literature has documented problems with the under-recognition and under-diagnosis of bipolar disorder, more recent studies have found evidence of bipolar disorder over-diagnosis and that BPD is a significant contributor to over-diagnosis. Re-conceptualizing the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, diagnostic criteria for bipolar disorder as a type of test, rather than the final word on diagnosis, shifts the diagnostician from thinking solely whether a patient does or does not have a disorder to considering the risks of false-positive and false-negative diagnoses, and the ease by which each type of diagnostic error can be corrected by longitudinal observation.

Genetic variants of the BDNF and DRD3 genes in bipolar disorder comorbid with anxiety disorder

BACKGROUND

The high comorbidity rate between bipolar disorder (BP) and anxiety disorder (AD) has been studied in depth. This comorbidity is not as high in Han Chinese in Taiwan. Therefore, we explored the genetic effects BP comorbid with AD.

METHODS

We recruited 1316 participants: 286 with BP-I, 681 with BP-II, and 349 healthy Controls. Genotypes of the BDNF Val66Met and DRD3 Ser9Gly polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis.

RESULTS

The DRD3 Ser9Gly polymorphism was associated with BP-II comorbid with AD (BPII(+AD)), and the BDNF Val66Met polymorphism was associated with BP-I comorbid with AD (BPI(+AD)). An interaction between the Val/Val genotype of the BDNF Val66Met and Gly/Gly polymorphism of the DRD3 Ser9Gly was found in BPII(+AD), but not in BP-II not comorbid with AD (BPI(-AD)) compared with healthy Controls.

LIMITATION

The low comorbidity rate of AD in both BP subtypes, especially BP-I, limit generalizing our findings.

CONCLUSION

The involvement of the dopaminergic pathway in AD was confirmed, particularly with BP-II rather than BP-I. Because the Val/Val genotype of the BDNF Val66Met polymorphism, rather than the other two polymorphisms, has been associated with anxiety, it seems to affect BP-I comorbid with AD without the involvement of the DRD3 Seg9Gly polymorphism, but may modify the involvement of DRD3 Gly/Gly in BP-II comorbid with AD.

Genetic variability at IMPA2, INPP1 and GSK3β increases the risk of suicidal behavior in bipolar patients

Bipolar patients (BP) are at high risk of suicide. Causal factors underlying suicidal behavior are still unclear. However, it has been shown that lithium has antisuicidal properties. Genes involved in its putative mechanism of action such as the phosphoinositol and the Wnt/β-catenine pathways could be considered candidates for suicidal behavior (SB). Our aim was to investigate the association of the IMPA1 and 2, INPP1, GSK3α and β genes with suicidal behavior in BP. 199 BP were recruited. Polymorphisms at the IMPA1 (rs915, rs1058401 and rs2268432) and IMPA2 (rs66938, rs1020294, rs1250171 and rs630110), INPP1 (rs3791809, rs4853694 and 909270), GSK3α (rs3745233) and GSK3β (rs334558, rs1732170 and rs11921360) genes were genotyped. All patients were grouped and compared according to the presence or not of history of SB (defined as the presence of at least one previous suicidal attempt). Single SNP analyses showed that suicide attempters had higher frequencies of AA genotype of the rs669838-IMPA2 and GG genotype of the rs4853694-INPP1gene compared to non-attempters. Results also revealed that T-allele carriers of the rs1732170-GSK3β gene and A-allele carriers of the rs11921360-GSK3β gene had a higher risk for attempting suicide. Haplotype analysis showed that attempters had lower frequencies of A:A haplotype (rs4853694:rs909270) at the INPP1 gene. Higher frequencies of the C:A haplotype and lower frequencies of the A:C haplotype at the GSK-3β gene (rs1732170:rs11921360) were also found to be associated to SB in BP. Therefore, our results suggest that genetic variability at IMPA2, INPP1 and GSK3β genes is associated with the emergence of SB in BP.

Differential diagnosis of bipolar affective disorder type II and borderline personality disorder: analysis of the affective dimension

BACKGROUND

Differential diagnosis between bipolar affective disorder type II and borderline personality disorder can be problematic yet a priority for effective treatment planning. Diagnosis is problematic when symptoms do not present enough intensity or duration to clear the issue but also when there is a relative overlap of criteria between both disorders. If for many patients, the diagnosis is more easily differentiated, confounding conditions are found in 20% of cases for which it becomes a significant issue.

METHOD

A research with the key words affective instability, borderline personality disorder, and bipolar disorder on Medline and Psych-Info was done. Other references were found through this review in related articles. Comparison of data about the affective dimensions concerning bipolar disorder and borderline personality disorder was noted.

RESULTS

Affective instability is a confounding factor: quality and intensity of affects, speed of fluctuations, affective response to social stress, and its modulation are core elements of affective instability that need to be analyzed to clarify a proper diagnosis.

LIMITATIONS

There is further necessity for research about affective instability in the 2 diagnoses.

CONCLUSIONS

Making a valid differential diagnosis has an important clinical value in order for the clinician to plan proper treatment. Analysis of the affective experience and its qualitative and quantitative facets can help establish it.

COMT and BDNF interacted in bipolar II disorder not comorbid with anxiety disorder

Bipolar disorder (BP), especially bipolar II disorder (BP-II), is highly comorbid with anxiety disorder (AD). Monoaminergic dysfunction has been implicated in the pathogenesis of BP, it may be important to investigate genes such as the catechol-O-methyltransferase (COMT), involved in monoamine metabolism and brain-derived neurotrophic factor (BDNF) genes, modulating the monoamine system. We therefore examined the association of the COMT Val158Met and BDNF Val66Met polymorphisms with BP-II with and without comorbidity of AD, and possible interactions between these genes. Seven hundred and seventy-one participants were recruited: 314 with bipolar-II without AD, 117 with bipolar-II with AD, and 340 healthy controls. The genotypes of the COMT and BDNF polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis. Logistic regression analysis showed a significant effect of the COMT and the BDNF polymorphisms, and a significant interaction effect for the Val/Val genotypes of the BDNF Val66Met polymorphism and the COMsT Val158Met Val/Met and Met/Met genotypes (P=0.007, 0.048) discriminated between BP-II without AD patients and controls. Our findings provide initial evidence that the COMT and BDNF genes interact in bipolar-II without AD. Our findings suggest the involvement of dopaminergic pathway in the pathogenesis of bipolar-II.

Quetiapine monotherapy as treatment for anxiety symptoms in patients with bipolar depression: a pooled analysis of results from 2 double-blind, randomized, placebo-controlled studies

OBJECTIVE

To evaluate the efficacy and tolerability of quetiapine monotherapy for anxiety symptoms in patients with bipolar disorder experiencing depression in the BipOLar DEpRession (BOLDER I and II) studies.

METHOD

A post hoc analysis of anxiety symptoms in 1,051 acutely depressed patients with bipolar I or II disorder (DSM-IV) from 2 double-blind, randomized, placebo-controlled 8-week studies of quetiapine (300 or 600 mg once daily) was conducted. Anxiety symptoms were assessed using Hamilton Anxiety Rating Scale (HARS) total and psychic (items 1-6, 14) and somatic (items 7-13) anxiety subscale scores (mixed-model repeated measure and last-observation-carried-forward analysis of change from baseline at each assessment). The BOLDER I study was conducted between September 2002 and October 2003, and the BOLDER II study was conducted between June 2004 and August 2005.

RESULTS

Mean baseline HARS total scores were similar across the treatment groups (300 mg/d: 18.9, 600 mg/d and placebo: both 18.6). There was a significantly greater improvement from baseline in mean HARS total scores at the first evaluation (week 1) in both quetiapine groups compared with placebo (300 mg/d: -4.6, P < .001 and 600 mg/d: -4.1, P = .003 vs placebo: -2.8). These improvements were sustained through week 8 with both quetiapine doses (300 mg/d: -10.1, P < .001 and 600 mg/d: -10.5, P < .001 vs placebo: -6.9). At week 8, there was also significant improvement from baseline in HARS psychic and somatic anxiety subscale scores compared with placebo (P < .001). The baseline severity of anxiety did not impact the improvement in depressive symptoms. Common adverse events included dry mouth, sedation, somnolence, and dizziness.

CONCLUSIONS

In this pooled analysis, quetiapine monotherapy was more effective than placebo and generally well tolerated for the treatment of both depressive and anxiety symptoms in patients with bipolar disorder.

TRIAL REGISTRATION

clinicaltrials.gov Identifiers: NCT00060489 (BOLDER I) and NCT00083954 (BOLDER II).

A randomized pilot study of psychotherapy and quetiapine for the acute treatment of bipolar II depression

OBJECTIVES

The differential roles of psychotherapy and pharmacotherapy in the management of bipolar (BP) II depression are unknown. As a first step toward exploring this issue, we conducted a pilot study to evaluate the feasibility and acceptability of comparing a BP-specific psychotherapy [Interpersonal and Social Rhythm Therapy (IPSRT)] to quetiapine as treatments for BP-II depression.

METHODS

Unmedicated individuals (n = 25) meeting DSM-IV criteria for BP-II disorder, currently depressed, were randomly assigned to weekly sessions of IPSRT (n = 14) or quetiapine (n = 11), flexibly dosed from 25-300 mg. Participants were assessed with weekly measures of mood and followed for 12 weeks. Treatment preference was queried prior to randomization.

RESULTS

Using mixed effects models, both groups showed significant declines in the 25-item Hamilton Rating Scale for Depression [F(1,21) = 44, p < 0.0001] and Young Mania Rating Scale [F(1,21) = 20, p = 0.0002] scores over time but no group-by-time interactions. Dropout rates were 21% (n = 3) and 27% (n = 3) in the IPSRT and quetiapine groups, respectively. Overall response rates (defined as ≥ 50% reduction in depression scores without an increase in mania scores) were 29% (n = 4) in the IPSRT group and 27% (n = 3) in the quetiapine group. Measures of treatment satisfaction were high in both groups. Treatment preference was not associated with outcomes.

CONCLUSIONS

Outcomes in participants with BP-II depression assigned to IPSRT monotherapy or quetiapine did not differ over 12 weeks in this small study. Follow-up trials should examine characteristics that predict differential response to psychotherapy and pharmacotherapy.

Low anxiety disorder comorbidity rate in bipolar disorders in Han Chinese in Taiwan

OBJECTIVES

Studies report high comorbidity of lifetime anxiety disorders with bipolar disorders in Western patients, but it is unclear in Taiwan. The authors explored the comorbidity of anxiety disorders in different bipolar disorder subtypes in Han Chinese in Taiwan.

METHODS

Three hundred twenty-five patients with bipolar disorder (bipolar I: 120; bipolar II: 205) disorder were recruited from two general medical outpatient services. They were evaluated and their diagnoses confirmed by a psychiatrist using the Chinese version of the Modified Schedule of Affective Disorder and Schizophrenia-Lifetime. The exclusion criteria were: any DSM-IV-TR Axis I diagnosis, other than bipolar disorder, being outside the 18-65-year-old age range, any other major and minor mental illnesses except anxiety disorder, any neurological disorders or organic mental disorders.

RESULTS

Thirty-two (26.7%) of patients were comorbid with lifetime anxiety disorder and bipolar I, 80 (39.0%) with lifetime anxiety disorder and bipolar II, 7 (5.8%) were comorbid with two or more anxiety disorders and bipolar I, and 27 (13.2%) with two or more anxiety disorders and bipolar II.

CONCLUSION

That more than twice as many bipolar II than bipolar I patients reported two or more anxiety disorders implies that the complication is more prevalent in bipolar II patients.

Differences between bipolar I and bipolar II disorders in clinical features, comorbidity, and family history

BACKGROUND

The present study was designed to investigate whether bipolar II disorder (BP-II) has different characteristics from bipolar I disorder (BP-I), not only in manic severity but also in clinical features, prior course, comorbidity, and family history, sufficiently enough to provide its nosological separation from BP-I.

METHODS

Comprehensive clinical evaluation was performed based on information available from ordinary clinical settings. Seventy-one BP-I and 34 BP-II patients were assessed using the Diagnostic Interview for Genetic Studies, Korean version. Psychiatric assessment for first-degree relatives (n=374) of the probands was performed using the modified version of the Family History-Research Diagnostic Criteria.

RESULTS

The frequency of depressive episodes was higher in BP-II (p=0.009) compared to BP-I. Further, seasonality (p=0.035) and rapid-cycling course (p=0.062) were more common in BP-II. Regarding manic expression, 'elated mood' was predominant in BP-II whereas 'elated mood' and 'irritable mood' were equally prevalent in BP-I. With regard to depressive symptoms, psychomotor agitation, guilty feeling, and suicidal ideation were more frequently observed in BP-II. BP-II patients exhibited a higher trend of lifetime co-occurrence of an axis I diagnosis (p=0.09), and a significantly higher incidence of phobia and eating disorder. The overall occurrence rate of psychiatric illness in first-degree relatives was 15.4% in BP-I and 26.5% in BP-II (p=0.01). Major depression (p=0.005) and substance-related disorder (p=0.051) were more prevalent in relatives of BP-II probands.

CONCLUSION

Distinctive characteristics of BP-II were identified in the current study and could be adopted to facilitate the differential diagnosis of BP-I and BP-II in ordinary clinical settings.

Psychotic versus non-psychotic bipolar II disorder

INTRODUCTION

Psychotic symptoms in bipolar II disorder, allowed by definition only during a depressive episode, are present in a range between 3% and 45%. Little is known regarding the impact of psychotic symptoms on the clinical course of bipolar II patients. Findings from previous reports are controversial and focused specifically on bipolar I disorder. The aim of this study was to ascertain the clinical characteristics of individuals with bipolar II disorder with and without lifetime history of psychotic symptoms.

METHODS

The sample consisted of 164 DSM-IV Bipolar II patients consecutively recruited from the Barcelona Bipolar Disorder Program. Patients were divided in Bipolar II patients with (N=32) and without (N=132) lifetime history of psychotic symptoms. Clinical and sociodemographic features were compared.

RESULTS

Thirty-two out of 164 patients with bipolar II disorder had a history of psychosis during depression (19.5%). Bipolar II patients with a history of psychotic symptoms showed a higher number of hospitalizations than patients without such a history (p<0.001). They were also older but were less likely to have a family history of bipolar illness and any mental disorder than non-psychotic bipolar II patients. Melancholic and catatonic features were significantly more frequent in psychotic bipolar II patients (p<0.001).

CONCLUSIONS

Our findings confirm that the presence of psychotic symptoms in bipolar II disorder is not rare. Psychotic bipolar II disorder may be a different phenotype from non-psychotic bipolar disorder.

DSM-IV depressive symptom expression among individuals with a history of hypomania: a comparison to those with or without a history of mania

In an effort to advance an understanding of the phenomenology of bipolar II depression, the current study used methods based in item response theory to evaluate differences in DSM-IV depression symptom endorsement in an epidemiological sample of individuals with a history of hypomania (i.e., bipolar II depression) in comparison to: a) individuals with a history of mania (i.e., bipolar I depression), and b) individuals without a history of hypomania or mania (i.e., unipolar depression). Clinical interview data were drawn from a subsample (n = 13,753) of individuals with bipolar II, bipolar I, or unipolar depression who had participated in the National Epidemiologic Survey on Alcohol and Related Conditions. A two-parameter item response model was used to estimate differential item functioning (DIF) between these groups. Differences in severity parameter estimates revealed that suicidal ideation/attempt was less likely to be endorsed across most levels of depression severity in bipolar II versus bipolar I disorder. There were no significant differences between groups on the remaining DSM-IV symptoms. Although preliminary, current study data are consistent with recent assertions that depression may be understood as a clinical phenomenon that is consistent across the major affective disorders. An exception to this conclusion may be in the area of suicidal ideation, which requires additional attention.

Comorbidity of generalized anxiety disorder and substance use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

Prior research has consistently documented a strong association between generalized anxiety disorder (GAD) and substance use disorder (SUD). Comorbidity of GAD and SUD (GAD-SUD) represents clinical challenges, as the patients' symptoms are often more severe and are frequently prolonged, making their management more complex when compared with individuals with GAD only. The purpose of this study was to examine whether individuals with GAD-SUD differ meaningfully from individuals with GAD and no SUD comorbidity (GAD-NSUD) in terms of demographic characteristics, risk factors, psychiatric comorbidity, and clinical correlates.

METHOD

Data were derived from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (N = 43,093). Diagnoses were made using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version.

RESULTS

We found that the lifetime prevalence rate of GAD-SUD is about 2.04%, while that of GAD-NSUD is 2.10%. Individuals with GAD-SUD showed higher psychiatric comorbidity rates than those with GAD-NSUD. Treatment-seeking rates for GAD are equally low in individuals with GAD-SUD and GAD-NSUD. Both groups were as likely to receive pharmacologic treatment for anxiety.

CONCLUSIONS

The findings of our study indicate that individuals with GAD-SUD constitute half of the lifetime prevalence of GAD and that GAD-SUD is associated with high overall vulnerability for additional psychopathology, particularly in the externalizing spectrum; higher disability; and higher use of alcohol and drugs to relieve anxiety symptoms.

A prospective latent analyses study of psychiatric comorbidity of DSM-IV bipolar I and II disorders

OBJECTIVE

To test two hypotheses of psychiatric comorbidity in bipolar disorder (BD): (i) comorbid disorders are independent of BD course, or (ii) comorbid disorders associate with mood.

METHODS

In the Jorvi Bipolar Study (JoBS), 191 secondary-care outpatients and inpatients with DSM-IV bipolar I disorder (BD-I) or bipolar II disorder (BD-II) were evaluated with the Structured Clinical Interview for DSM-IV Disorders, with psychotic screen, plus symptom scales, at intake and at 6 and 18 months. Three evaluations of comorbidity were available for 144 subjects (65 BD-I, 79 BD-II; 76.6% of 188 living patients). Structural equation modeling (SEM) was used to examine correlations between mood symptoms and comorbidity. A latent change model (LCM) was used to examine intraindividual changes across time in depressive and anxiety symptoms. Current mood was modeled in terms of current illness phase, Beck Depression Inventory (BDI), Young Mania Rating Scale, and Hamilton Depression Rating Scale; comorbidity in terms of categorical DSM-IV anxiety disorder diagnosis, Beck Anxiety Inventory (BAI) score, and DSM-IV-based scales of substance use and eating disorders.

RESULTS

In the SEM, depression and anxiety exhibited strong cross-sectional and autoregressive correlation; high levels of depression were associated with high concurrent anxiety, both persisting over time. Substance use disorders covaried with manic symptoms (r = 0.16-0.20, p < 0.05), and eating disorders with depressive symptoms (r = 0.15-0.32, p < 0.05). In the LCM, longitudinal intraindividual improvements in BDI were associated with similar BAI improvement (r = 0.42, p < 0.001).

CONCLUSIONS

Depression and anxiety covary strongly cross-sectionally and longitudinally in BD. Substance use disorders are moderately associated with manic symptoms, and eating disorders with depressive mood.

Preliminary results of a fine-grain analysis of mood swings and treatment modalities of bipolar I and II patients using the daily prospective life-chart-methodology

OBJECTIVE

The study aimed to increase the knowledge about the detailed course differences between different forms of bipolar disorder.

METHOD

Using the prospective life-chart-clinician version, we compared the fine-grain analysis of mood swings and treatment modalities of 18 bipolar II with 31 bipolar I patients.

RESULTS

During an observational period of a mean of 26 months we observed an increase of euthymic days, and a decrease of (sub)depressive and (hypo)manic days. Days in a (sub)depressed state were more frequent than days of (hypo)mania as well as days of subdepression or hypomania in comparison to days of full-blown depression or mania. Bipolar II patients showed an increase in hypomanic days receiving more frequently antidepressants. Bipolar I patients, with a decrease of manic days, were significantly taking more often mood stabilizers.

CONCLUSION

Treatment in a specialized bipolar clinic improves the overall outcome, but bipolar II disorder seems to be still treated sub-optimally with a possible iatrogenic increase of hypomanic days.

How suicidal bipolar patients are depends on how suicidal ideation is defined

BACKGROUND

Suicidal ideation indicates risk for suicidal acts. How different definitions and measures for suicidal ideation influence its prevalence, correlates and predictive validity among bipolar disorder (BD) patients is unknown.

METHODS

Among the 191 BD patients in the Jorvi Bipolar Study (JoBS), suicidal ideation at baseline was measured using the Scale for Suicidal Ideation (SSI), Hamilton Depression Scale (HAM-D) item 3 and Beck Depression Inventory (BDI) item 9 and by asking whether patients had seriously considered suicide. The predictive value of different definitions of ideation on suicide attempts during a six-month follow-up was investigated.

RESULTS

Altogether 74% of patients had suicidal ideation as defined in at least one of the above-mentioned ways, but only 29% met the criteria for all ways; agreement between definitions ranged from low to moderate (kappa coefficient 0.15 to 0.70). The correlates of suicidal ideation overlapped, but were not identical. Of the measures investigated, a baseline SSI score >or=8 had the best combination of sensitivity (0.81) and specificity (0.69) and a positive predictive value (PPV) of 32% for an attempted suicide during follow-up.

LIMITATIONS

All plausible measures for suicidal ideation could not be investigated.

CONCLUSIONS

Who is classified as having suicidal ideation depends strongly on the definition and means of measurement among BD patients. Different measures for ideation have the potential to cause inconsistency when correlates of suicidal ideation are investigated. For clinically predicting suicide attempts during the next few months, an SSI score >or=8 may best combine sensitivity and specificity.

Coffee and cigarette use: association with suicidal acts in 352 Sardinian bipolar disorder patients

OBJECTIVE

Abuse of illicit drugs and alcohol is prevalent in bipolar disorder (BPD) patients, and is an adverse prognostic factor. Much less is known about correlates of nicotine and caffeine consumption, but tobacco smoking is tentatively associated with suicidal behavior.

METHODS

Retrospective analysis of demographic and clinical factors among 352 longitudinally assessed DSM-IV types I and II BPD patients contrasted patients with versus without consumption of nicotine or caffeine, based on univariate comparisons and multiple regression modeling.

RESULTS

Current smoking (46%) and coffee drinking (74% of cases) were common, and significantly and independently associated with suicidal acts [coffee: odds ratio (OR) = 2.42, 95% confidence interval (CI): 1.15-5.09; smoking: OR = 1.79, CI: 1.02-3.15; both p < 0.001]. Risk increased with more smoking (cigarettes/day; r(s) = 0.383; p < 0.0001) and greater coffee consumption (cups/day; r(s) = 0.312; p = 0.008). Neither intake was related to yearly rates of all episodes, depressions, or manias.

CONCLUSIONS

This is the first report to associate suicidal acts with coffee consumption in BPD patients, and it confirmed an association with smoking. Pending further evidence, the findings underscore the importance of monitoring use of even legal and mildly psychotropic substances by BPD patients.

Atypical depression is associated with suicide attempt in bipolar disorder

OBJECTIVE

There is a dearth of research focusing on factors associated with suicide attempts. High rates of atypical depression have been reported in studies including unipolar and bipolar II patients. In this study, the association between suicide attempt and atypical depression, in addition to other major risk factors, was evaluated in 390 bipolar I and II out-patients.

METHOD

Variables were defined according to DSM-IV criteria, and assessed with a Structured Interview for DSM-IV (axis I and II). History of suicide attempt was obtained through interviews with patients and relatives. Attempters and non-attempters were compared using univariate and multivariate analysis.

RESULTS

Attempters showed significantly higher rates of atypical depression, family history of completed suicide, depression at index episode and cluster B personality disorder.

CONCLUSION

Our results highlight the relevance of atypical depression in bipolar disorder. A more accurate identification of potential attempters may contribute to the development of effective preventive treatment strategies.

Axis II comorbidity in euthymic bipolar disorder patients: no differences between bipolar I and II subtypes

BACKGROUND

Bipolar disorder type II (BDII) has been considered since its distinction from bipolar disorder type I (BDI) as a milder form, on the basis of cross-sectional symptoms intensity. Longitudinal data, on the contrary, do suggest that it is at least as severe as BDI, if not even more chronic and impairing. Few studies investigated differences in Axis II comorbidity in bipolar disorder patients according to bipolar subtypes, and none examined patients during prolonged euthymia. The aim of the study was to determine comorbidity rates for personality disorders in euthymic bipolar subjects, comparing bipolar type I and II disorders (BDI and BDII).

METHODS

186 DSM-IV (SCID-I) bipolar disorder subjects were enrolled; all patients were euthymic for at least two months, as confirmed by a HAM-D<8 and a YMRS<6. Axis II comorbidity was evaluated through SCID-II. Differences in Axis II comorbidity rates were examined with the Pearson's Chi-square test.

RESULTS

Of the subjects included, 71 had BDI and 115 BDII. At least a personality disorder was present in 42.5% of all bipolars, 43.7% of BDI and 41.7% of BDII. No differences were detected between the two subgroups for any single personality disorder.

LIMITATIONS

We relied only on the patients' reports in assessing personality disorders; the sample was made of subjects referred to a tertiary centre who were able to maintain euthymia.

CONCLUSIONS

Our study confirms the high comorbidity rates for personality disorders in bipolar subjects and provides evidence that BDII, with regard to Axis II comorbidity, is as severe as BDI.

Commonalities and differences in characteristics of persons at risk for narcissism and mania

Clinicians have long noted overlap in some of the key features of narcissism and bipolar disorder, including excessively high goals and impulsivity. In addition, empirical findings consistently document high levels of comorbidity between the two conditions. To better understand the similarities and differences in psychological qualities associated with mania- and narcissism-related vulnerabilities, we administered to 233 undergraduates a broad range of measures pertaining to goals and affects (both their experience and their dysregulation) and impulsivity. As hypothesized, tendencies toward both narcissism and hypomania related to elevations on measures of affective and goal dysregulation. In addition, hypomania tendencies were related to higher impulsivity, but that association did not appear for narcissistic tendencies. Results highlight key commonalities and differences between those at risk for mania versus narcissism. Future research should examine these relationships in clinically diagnosed samples.

Functional impairment and previous suicide attempts in bipolar disorder

OBJECTIVE

The aim of the present study was to assess the association between previous suicide attempts and functional impairment among euthymic patients with bipolar disorder (BD).

METHODS

Seventy-one Diagnostic Statistical Manual IV (DSM-IV) patients with BD and 61 healthy volunteers were recruited from the Bipolar Disorder Program at the Clinic Hospital of Barcelona. Patients with (n = 36, 50.7%) and without (n = 35, 49.3%) previous suicide attempts were assessed using the Structured Clinical Interview for DSM-IV-TR (SCID-P). Previous suicide attempts were carefully investigated by means of patient and caregiver interview and by a standard structured interview from the protocol of our BD Program. The Functioning Assessment Short Test (FAST) was employed to assess functional impairment.

RESULTS

Euthymic patients with previous suicide attempts showed functional impairment, particularly in occupational (F = 30.39; p = 0.001) and cognitive functioning (F = 18.43; p = 0.001). In addition, family history of psychiatric illness (χ2: 6.49; degrees of freedom (df) = 2;132; p = 0.010), family history of affective disorders (χ2 = 5.57; p = 0.017), psychotic symptoms (χ2 = 5.88; p = 0.014) and axis II comorbidity were associated with previous suicide attempts (χ2 = 5.16; p = 0.021).

CONCLUSION

Bipolar patients with previous suicide attempts had lower overall functioning than patients who did not attempt suicide. Previous suicide attempts were particularly associated with the occupational and cognitive domains of functioning.