Bipolar Disorder: an impossible diagnosis

Cluster analysis with MOODS-SR illustrates a potential bipolar disorder risk phenotype in young adults with remitted major depressive disorder

OBJECTIVES

Delays in the diagnosis and detection of bipolar disorder can lead to adverse consequences, including improper treatment and increased suicide risk. The Mood Spectrum Self-Report Measure (MOODS-SR) was designed to capture the full spectrum of lifetime mood symptomology with factor scores for depression and mania symptom constellations. The utility of the MOODS-SR as a tool to investigate homogeneous subgroups was examined, with particular focus on a possible bipolar risk subgroup. Moreover, potential patterns of differences in MOODS-SR subtypes were probed using cognitive vulnerabilities, neuropsychological functioning, and ventral striatum connectivity.

METHODS

K-mean cluster analysis based on factor scores of MOODS-SR was used to determine homogeneous subgroupings within a healthy and remitted depressed young adult sample (N = 86). Between-group comparisons (based on cluster subgroupings) were conducted on measures of cognitive vulnerabilities, neuropsychological functioning, and ventral striatum rs-fMRI connectivity.

RESULTS

Three groups of participants were identified: one with minimal symptomology, one with moderate primarily depressive symptomology, and one with more severe manic and depressive symptomology. Differences in impulsivity, neuroticism, conscientiousness, facial perception accuracy, and rs-fMRI connectivity exist between moderate and severe groups.

CONCLUSIONS

Within a sample of people with and without depression histories, a severe subgroup was identified with potentially increased risk of developing bipolar disorder through use of the MOODS-SR. This small subgroup had higher levels of lifetime depression and mania symptoms. Additionally, differences in traits, affective processing, and connectivity exist between those with a more prototypic unipolar subgrouping and those with potential risk for developing bipolar disorder.

DSM-IV diagnosis in depressed primary care patients with previous psychiatric ICD-10 bipolar disorder

BACKGROUND

In the past 20 years, much evidence has accumulated against the overly restrictive diagnostic concepts of hypomania in DSM-IV and DSM-IV-TR. We tested DSM-IV-TR and a broader modified version (DSM-IV-TRm) for their ability to detect bipolarity in patients who had been treated for bipolar disorders (BD) in psychiatric settings, and who now consulted general practitioners (GPs) for new major depressive episodes (MDE).

METHODS

Bipolact II was an observational, single-visit survey involving 390 adult patients attending primary care for MDE (DSM-IV-TR criteria) in 201 GP offices in France. The participating GPs (53.3 ± 6.5 years old, 80.1% male) were trained by the Bipolact Educational Program, and were familiar with the medical care of depressive patients.

RESULTS

Of the 390 patients with MDE, 129 (33.1%) were previously known as bipolar patients (ICD-10 criteria). Most of the latter bipolar patients (89.7%) had previously been treated with antidepressants. Only 9.3% of them met DMS-IV-TR criteria for BD. Conversely, 79.1% of the 129 bipolar patients met DMS-IV-TRm criteria for BD and showed strong associations with impulse control disorders and manic/hypomanic switches during antidepressant treatment.

LIMITATIONS

Limited training of participating GPs, recall bias of patients, and the study not being representative for untreated bipolar patients.

CONCLUSIONS

Very few ICD-10 bipolar patients consulting French GPs for MDE met DSM-IV-TR criteria for bipolar diagnosis, which suggests that DSM-IV-TR criteria are insufficient and too restrictive for the diagnosis of BD. DSM-IV-TRm was more sensitive, but 20% of bipolar patients were undetected.

Could the underestimation of bipolarity obstruct the search for novel antidepressant drugs?

INTRODUCTION

Despite the clinical and social relevance of depression, and the availability of numerous antidepressants and non-pharmacological interventions, response rates remain unsatisfactory and novel therapeutic targets are being explored.

AREAS COVERED

This review starts with a brief overview of the evolution of the current antidepressant drug scenario and ends with a focus on the potential influence of the underestimation of bipolarity on the exploration of novel antidepressant drugs.

EXPERT OPINION

The field of antidepressant drug development has suffered from a relative decline recently and, with the exception of agomelatine, innovative non-monoaminergic antidepressants have yet to be developed. The need for more effective compounds is evident. Clinicians and researchers should pay greater attention to the impact of bipolarity in depression. The ultimate goal of this review is not to discourage the use of antidepressants but rather to encourage judicious prescriptions, and also to solicit a better collaboration between clinicians and preclinical researchers so that more reliable diagnostic criteria can be adopted.

Current nosology of treatment resistant depression: a controversy resistant to revision

Treatment-Resistant Depression (TRD) represents a source of ongoing clinical and nosological controversy and confusion. While no univocal consensus on its definition and specific correlation with major mood disorders has been reached to date, a progressively greater number of evidences tend to suggest a revision of current clinical nosology. Since a better assessment of TRD should be considered mandatory in order to achieve the most appropriate clinical management, this narrative review aims to briefly present current most accepted definitions of the phenomenon, speculating on its putative bipolar diathesis for some of the cases originally assessed as unipolar depression.

A possible case of mixed mania due to neurosarcoidosis treated successfully with methylprednisolone and ziprasidone: another example of frontal-subcortical disinhibition?

Sarcoidosis is an idiopathic systemic granulomatous disease recognized by clinical and radiographic findings, which ultimately require histopathologic confirmation of noncaseating granulomas for a definitive diagnosis. Psychiatric manifestations occur in 20% of patient with neurosarcoidosis [http://dynaweb.ebscohost.com.chekov.evms.edu/Detail.aspx?id=306337&sid=bdce39cc-d2bd-4977-9e4d-786f2e768d57@sessionmgr4]. We present a case of suspected mixed mania due to neurosarcoidosis, with the manic symptoms responding early and robustly to ziprasidone.