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Munkholm K, Jørgensen KJ, Paludan-Müller AS. Electroconvulsive therapy for acute affective episodes in people with bipolar disorder. Hippokratia 2021. [DOI: 10.1002/14651858.cd014996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Klaus Munkholm
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark; Department of Clinical Research, University of Southern Denmark; Odense Denmark
- Open Patient data Exploratory Network (OPEN); Odense University Hospital; Odense Denmark
| | - Karsten Juhl Jørgensen
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark; Department of Clinical Research, University of Southern Denmark; Odense Denmark
- Open Patient data Exploratory Network (OPEN); Odense University Hospital; Odense Denmark
| | - Asger Sand Paludan-Müller
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark; Department of Clinical Research, University of Southern Denmark; Odense Denmark
- Open Patient data Exploratory Network (OPEN); Odense University Hospital; Odense Denmark
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Montes JM, Pascual A, Molins Pascual S, Loeck C, Gutiérrez Bermejo MB, Jenaro C. Assessment Tool of Bipolar Disorder for Primary Health Care: The SAEBD. Int J Environ Res Public Health 2021; 18:8318. [PMID: 34444069 DOI: 10.3390/ijerph18168318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 12/03/2022]
Abstract
Mixed states are highly prevalent in patients with bipolar disorder and require comprehensive scales. Considering this, the current study aims to develop a measure to assess the full spectrum of clinical manifestations of bipolar disorder. A sample of 88 patients was evaluated; the Hamilton Depression Scale (HAM-D), Montgomery-Asberg Depression Scale (MADRS), and the Young Mania Rating Scale (YMRS) were applied, together with the preliminary version of the Scale for the Assessment of Episodes in Bipolar Disorder (SAEBD). After analyzing the appropriateness and statistical properties of the items, discriminant analysis and analysis of diagnostic capacity were performed. The discriminant functions correctly classified 100% of the cases in euthymia, predominant depressive symptoms or mixed symptoms, as well as 92.3% of the cases with predominant manic symptoms. Overall, the functions correctly classified 98.9% of the cases. The area under the curve (0.935) showed high capacity to discriminate between clinical and non-clinical cases (i.e., in euthymia). The SAEBD sensitivity was 0.95, specificity was 0.71, the Positive Predictive Value (PPV) was 0.88, the Negative Predictive Value (NPV) was 0.87, the Positive Likelihood Ratio (+LR) was 3.33, and the Negative Likelihood Ratio (−LR) was 0.07. In conclusion, the SAEBD is a promising scale that shows high reliability and validity, as well as diagnostic utility as a screening tool for use in diverse health care settings.
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Koukopoulos AE, De Chiara L, Simonetti A, Kotzalidis GD, Janiri D, Manfredi G, Angeletti G, Sani G. The Koukopoulos mixed depression rating scale (KMDRS) and the assessment of mixed symptoms during the perinatal period. J Affect Disord 2021; 281:980-988. [PMID: 33039189 DOI: 10.1016/j.jad.2020.08.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/05/2020] [Accepted: 08/24/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Mixed symptoms in depression may underlie bipolar diathesis rather than unipolarity. Uncovering mixed depression (MxD) is crucial for appropriate management, especially in the perinatal period, as it may affect treatment planning and impact future child development. We used a scale specific for identifying MxD and tested its validity in pregnant and postpartum women with depression. METHODS Women developing a major depressive episode (MDE) during their perinatal period extending from pregnancy to one year postpartum from November-2012 through June-2019 were assessed with BPRS-18, EPDS, CGI-S, GAF, HAM-A, HAM-D, Koukopoulos' Mixed Depression Rating Scale (KMDRS), TEMPS, and YMRS. They were classified, based on KMDRS criteria, as with mixed (MxD) or without (nonMxD) mixed symptoms. We conducted ROC analysis and performed factor analysis of the KMDRS. RESULTS Of 45 included, MxD (N = 19) were biased towards diagnosis of bipolar disorder and nonMxD (N = 26) towards major depressive disorder. Other sociodemographic variables did not differ significantly between MxD and nonMxD. MxD scored higher on total YMRS, BPRS, and KMDRS, and on KMDRS-6 Subjective Feelings of Irritability and KMDRS-12 Suicidal Impulsiveness items. The KMDRS correlated in the entire sample, in MxD and nonMxD, with the YMRS and the BPRS, while correlating with the HAM-D in nonMxD only. The KMDRS showed acceptable AUC distribution, with a 68% sensitivity and 58% specificity. Best-fit was three-factor-structure, explaining 54.66% of cumulative variance. LIMITATIONS Small sample and cross-sectional design. CONCLUSIONS The KMDRS is fit for investigating MxD along with the YMRS and the BPRS in perinatal women with a MDE.
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Affiliation(s)
- Alexia E Koukopoulos
- Azienda Ospedaliera Universitaria Policlinico Umberto I, Viale dell'Università 30, Rome 00185, Italy; Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy.
| | - Lavinia De Chiara
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy; Center for Prevention and Treatment of Women's Mental Health at Sant'Andrea Hospital of Rome, Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy
| | - Alessio Simonetti
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy; Department of Human Neurosciences, Sapienza University, Viale dell'Università 30, Rome 00185, Italy; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Georgios D Kotzalidis
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy; Center for Prevention and Treatment of Women's Mental Health at Sant'Andrea Hospital of Rome, Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy
| | - Delfina Janiri
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Department of Human Neurosciences, Sapienza University, Viale dell'Università 30, Rome 00185, Italy
| | - Giovanni Manfredi
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Center for Prevention and Treatment of Women's Mental Health at Sant'Andrea Hospital of Rome, Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy; UOC Psichiatria, Day Hospital, Azienda Ospedaliera-Universitaria Sant'Andrea, Via di Grottarossa 1035-1039, Rome 00189, Italy
| | - Gloria Angeletti
- Centro Lucio Bini, Via Crescenzio 42, Rome 00193, Italy; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy; Center for Prevention and Treatment of Women's Mental Health at Sant'Andrea Hospital of Rome, Sapienza University, Via di Grottarossa 1035-1039, Rome 00189, Italy
| | - Gabriele Sani
- Departmentof Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Largo F. Vito 1, Rome 00168, Italy; Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
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Sverdlichenko I, Jansen K, Souza LDDM, da Silva RA, Kapczinski F, Cardoso TDA. Mixed episodes and suicide risk: A community sample of young adults. J Affect Disord 2020; 266:252-257. [PMID: 32056885 DOI: 10.1016/j.jad.2020.01.111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/11/2019] [Accepted: 01/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Suicide is the second leading cause of death among young adults worldwide, and few studies have assessed the factors associated with suicidality in this specific population. Thus, the aim of this study was to assess the association between mixed episodes and suicidality in a community sample of young adults. For this aim, we compared young adults in a mixed episode with individuals in a depressive or (hypo)manic episode, and community controls. METHOD This is a cross-sectional population-based study including young adults aged 18-24 years old. Information about participants' age, sex, self-reported skin color and study status were obtained using a sociodemographic questionnaire. Mixed, (hypo)manic and depressive episodes, as well as suicide risk were assessed using the Mini International Neuropsychiatric Interview. RESULTS The sample included 1560 individuals. Young adults in a mixed episode showed a 13.50 times higher probability to have suicide risk, as compared to community controls (p < 0.001), 5.67 higher probability to have suicide risk as compared to individuals in a (hypo)manic episode (p < 0.001), and 2.18 times higher probability to have suicide risk as compared to young adults in a depressive episode (p < 0.001). LIMITATION The assessment of suicide risk includes both suicide attempts and ideation. CONCLUSION Young adults in a mixed episode showed a higher rate of suicide risk than individuals with depression or mania/hypomania. Considering the already increasing prevalence of suicide among young adults, there is an urgent need for the early diagnosis and treatment of mixed episodes in this specific population.
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Affiliation(s)
- Irina Sverdlichenko
- Mood Disorders Program, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Karen Jansen
- Department of Health and Behavior, Catholic University of Pelotas, Pelotas, RS, Brazil
| | | | | | - Flavio Kapczinski
- Mood Disorders Program, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Taiane de Azevedo Cardoso
- Mood Disorders Program, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada; Department of Health and Behavior, Catholic University of Pelotas, Pelotas, RS, Brazil.
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Shahin I, Bonnin CDM, Saleh E, Helmy K, Youssef UM, Vieta E. Validity of the Shahin Mixed Depression Scale: A Self-Rated Instrument Designed to Measure the Non-DSM Mixed Features in Depression. Neuropsychiatr Dis Treat 2020; 16:2209-2219. [PMID: 33061391 PMCID: PMC7532079 DOI: 10.2147/ndt.s259996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 09/02/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The DSM5-defined mixed features in depression do not include psychomotor agitation, irritability or distractibility because they are considered overlapping symptoms. A growing number of modern psychiatrists have expressed dissatisfaction with this and proposed alternative sets of mixed symptoms that are much more common and clinically relevant. Among such alternative criteria were those proposed by Koukopoulos. He utilized the research diagnostic criteria of agitated depression (RDC-A) as a mixed depression subtype, and validated another form of mixed depression, the Koukopoulos criteria for mixed depression (K-DMX). PURPOSE This study provides psychometric validation for the first self-rated scale designed to measure the most common mixed symptoms in depression as proposed by Koukopoulos. PATIENTS AND METHODS We conducted a multicenter cross-sectional study of 170 patients with unipolar depression. They completed the Shahin Mixed Depression Scale (SMDS) and underwent expert interviews as a gold standard reference. SMDS' psychometric properties were assessed, including Cronbach's alpha, factor analysis, sensitivity, specificity, predictive value and accuracy. RESULTS We found significant association and agreement between mixity according to SMDS and the gold standard (K-DMX and RDC-A according to expert interview) with good internal consistency (Cronbach's alpha=0.87), high sensitivity (=91.4%), specificity (=98.0%), positive predictive value (=96.9%), negative predictive value (= 94.2%) and accuracy (=95.2%). Factor analysis identified one factor for psychomotor agitation and another for mixity without psychomotor agitation. CONCLUSION SMDS was a reliable and valid instrument for assessing the frequently encountered and clinically relevant mixed features in depression.
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Affiliation(s)
| | - Caterina Del Mar Bonnin
- Barcelona Bipolar Disorders and Depressive Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Elsayed Saleh
- Department of Psychiatry, Mansoura University, Mansoura, Egypt
| | - Khaled Helmy
- Training and Research Unit, New Nozha Hospital, Alexandria, Egypt.,Ciconia Recovery London (CRL), London, UK
| | - Usama M Youssef
- Department of Psychiatry, Zagazig University, Zagazig, Egypt
| | - Eduard Vieta
- Barcelona Bipolar Disorders and Depressive Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
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Abstract
BACKGROUND Tamoxifen is an oral medication that has been proposed as a potential treatment for bipolar disorder. Tamoxifen acts to inhibit the intracellular action of protein kinase C, which is also an action of well-established treatments such as lithium and valproate. Here we aimed to identify randomised controlled trials (RCTs) of tamoxifen in the treatment of bipolar disorder and synthesise their results using meta-analysis. METHODS RCTs were identified by searching of electronic databases and from discussion with experts in the field. Data were extracted, and meta-analyses performed in R. RESULTS Five placebo-controlled RCTs of tamoxifen in the treatment of acute mania were identified. There were no trials in the treatment of episodes of bipolar depression, or for relapse prevention. The studies of mania treatment were of between three and six weeks duration. Tamoxifen was studied either as monotherapy (two trials) or as augmentation of lithium or valproate (three trials). Change in mania scale scores favoured tamoxifen over placebo: SMD -2.14 (95% CI -3.39 to -0.89; 4 trials), as did endpoint mania scale scores SMD 1.23 (95% CI 0.60-1.87; 5 trials). Response rates were also higher: RR 4.35 (1.99-9.50; 4 trials). Acceptability was similar to placebo: RR 1.03 (0.94-1.13; 5 trials). CONCLUSIONS Tamoxifen appears to be a promising potential treatment for episodes of mania. Future studies could investigate its effects as an adjunct to dopamine antagonists for improved anti-manic efficacy, and establish its longer term effects on mood, particularly depression and relapse.
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Affiliation(s)
- Jorge Palacios
- 1 Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Ayşegül Yildiz
- 2 Department of Psychiatry, Dokuz Eylül University, Izmir, Turkey
| | - Allan H Young
- 1 Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Matthew J Taylor
- 1 Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,3 Department of Psychiatry, University of Oxford, Oxford, UK
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Sani G, Vöhringer PA, Barroilhet SA, Koukopoulos AE, Ghaemi SN. The Koukopoulos Mixed Depression Rating Scale (KMDRS): An International Mood Network (IMN) validation study of a new mixed mood rating scale. J Affect Disord 2018; 232:9-16. [PMID: 29459190 DOI: 10.1016/j.jad.2018.01.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/14/2018] [Accepted: 01/29/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND It has been proposed that the broad major depressive disorder (MDD) construct is heterogenous. Koukopoulos has provided diagnostic criteria for an important subtype within that construct, "mixed depression" (MxD), which encompasses clinical pictures characterized by marked psychomotor or inner excitation and rage/anger, along with severe depression. This study provides psychometric validation for the first rating scale specifically designed to assess MxD symptoms cross-sectionally, the Koukopoulos Mixed Depression Rating Scale (KMDRS). METHODS 350 patients from the international mood network (IMN) completed three rating scales: the KMDRS, Montgomery-Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS). KMDRS' psychometric properties assessed included Cronbach's alpha, inter-rater reliability, factor analysis, predictive validity, and Receiver Operator Curve analysis. RESULTS Internal consistency (Cronbach's alpha = 0.76; 95% CI 0.57, 0.94) and interrater reliability (kappa = 0.73) were adequate. Confirmatory factor analysis identified 2 components: anger and psychomotor excitation (80% of total variance). Good predictive validity was seen (C-statistic = 0.82 95% CI 0.68, 0.93). Severity cut-off scores identified were as follows: none (0-4), possible (5-9), mild (10-15), moderate (16-20) and severe (> 21) MxD. LIMITATIONS Non DSM-based diagnosis of MxD may pose some difficulties in the initial use and interpretation of the scoring of the scale. Moreover, the cross-sectional nature of the evaluation does not verify the long-term stability of the scale. CONCLUSIONS KMDRS was a reliable and valid instrument to assess MxD symptoms.
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Affiliation(s)
- Gabriele Sani
- NeSMOS Department, Sapienza University of Rome, Italy; Department of Psychiatry, Tufts Medical Center, Boston, MA, USA; Centro Lucio Bini, Rome, Italy; Tufts University School of Medicine, USA.
| | - Paul A Vöhringer
- Department of Psychiatry, Tufts Medical Center, Boston, MA, USA; Psychiatry Department, Hospital Clinico University of Chile, Chile; Millenium Institute for Depression and Personality Research, Ministry of Economy, Macul, Santiago, Chile; Tufts University School of Medicine, USA
| | - Sergio A Barroilhet
- Department of Psychiatry, Tufts Medical Center, Boston, MA, USA; University of Chile, Chile; Tufts University School of Medicine, USA
| | - Alexia E Koukopoulos
- Centro Lucio Bini, Rome, Italy; Umberto I Hospital, Psychiatry Department, Rome, Italy
| | - S Nassir Ghaemi
- Tufts University School of Medicine, USA; Department of Psychiatry, Harvard Medical School, USA; Translational Medicine-Neuroscience, Novartis Institutes of Biomedical Research, Cambridge, MA, USA
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Abstract
BACKGROUND Bipolar disorder is a common recurrent illness with high levels of chronicity. Previous trials have suggested that the anticonvulsant topiramate may be efficacious in bipolar disorder. This is an update of a previous Cochrane review (last published 2006) on the role of topiramate in bipolar disorder. OBJECTIVES To assess the effects of topiramate for acute mood episodes in bipolar disorder in adults compared to placebo, alternative pharmacological treatment, and combination pharmacological treatment as measured by treatment of symptoms on specific rating scales for individual episodes. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Controlled Trials Register to 13 October 2015, which includes records from the Cochrane Central Register of Controlled Trials (CENTRAL) all years; MEDLINE 1950-; EMBASE 1974-; and PsycINFO 1967-.We performed handsearching, reviewing of grey literature and reference lists, and correspondence with authors and pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials comparing topiramate with placebo or with active agents in the treatment of acute mood episodes in adult male and female patients with bipolar disorder. DATA COLLECTION AND ANALYSIS Two review authors independently performed data extraction and methodological quality assessment. For analysis, we used odds ratio (OR) for binary efficacy outcomes and mean difference (MD) for continuously distributed outcomes. MAIN RESULTS This review included six studies with a total of 1638 male and female participants, of all ethnic backgrounds in both inpatient and outpatient settings. In five studies, participants were experiencing a manic or mixed episode, and in the other study the participants met the criteria for a depressive phase. Topiramate was compared with placebo and alternative pharmacological treatment as both monotherapy and as adjunctive treatment.Moderate-quality evidence showed topiramate to be no more or less efficacious than placebo as monotherapy, in terms of mean change on Young Mania Rating Scale (YMRS) (range 0 to 60), at endpoint 3 weeks (MD 1.17, 95% confidence interval (CI) -0.52 to 2.86; participants = 664; studies = 3; P = 0.17) and at endpoint 12 weeks (MD -0.58, 95% CI -3.45 to 2.29; participants = 212; studies = 1; P = 0.69; low-quality evidence). For the same outcome, low-quality evidence also showed topiramate to be no more or less efficacious than placebo as add-on therapy (endpoint 12 weeks) (MD -0.14, 95% CI -2.10 to 1.82; participants = 287; studies = 1; P = 0.89) in the treatment of manic and mixed episodes. We found high-quality evidence that lithium was more efficacious than topiramate as monotherapy in the treatment of manic and mixed episodes in terms of mean change on YMRS (range 0 to 60) (endpoint 12 weeks) (MD 8.46, 95% CI 5.86 to 11.06; participants = 449; studies = 2; P < 0.00001).For troublesome side effects experienced of any nature, we found no difference between topiramate and placebo as monotherapy (endpoint 12 weeks) (OR 0.68, 95% CI 0.33 to 1.40; participants = 212; studies = 1; P = 0.30; low-quality evidence) or as add-on therapy (endpoint 12 weeks) (OR 1.10, 95% CI 0.58 to 2.10; participants = 287; studies = 1; P = 0.76; low-quality evidence). In terms of participants experiencing side effects of any nature, we found no difference between topiramate and an alternative drug as monotherapy (endpoint 12 weeks) (OR 0.87, 95% CI 0.50 to 1.52; participants = 230; studies = 1; P = 0.63; low-quality evidence) or as add-on therapy (endpoint 8 weeks) (OR 1.57, 95% CI 0.42 to 5.90; participants = 36; studies = 1; P = 0.50; very low-quality evidence).We considered five of the studies to be at low risk of selection bias for random sequence generation, performance, detection, attrition, and reporting biases, and at unclear risk for allocation concealment and other potential sources of bias. We considered the McIntyre 2000 study to be at high risk of performance bias; unclear risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, and other potential sources of bias; and at low risk for attrition bias and reporting bias. AUTHORS' CONCLUSIONS It is not possible to draw any firm conclusions about the use of topiramate in clinical practice from this evidence. The only high-quality evidence found was that lithium is more efficacious than topiramate when used as monotherapy in the treatment of acute affective episodes in bipolar disorder, and we note that this evidence came from only two studies. Moderate-quality evidence showed that topiramate was no more or less efficacious than placebo as monotherapy when a 3-week endpoint was used, but the quality of the evidence for this outcome at a 12-week endpoint dropped to low. As we graded the quality of the evidence for the other findings as low and very low, it was not possible to draw any conclusions from the results.To best address this research question, if investigators see the indication in so doing, more double-blind randomised controlled trials could be conducted that are more explicit with regard to methodological issues. In particular, investigators could compare placebo, alternative, and combination treatments (including a wide range of mood stabilisers), atypical antipsychotics for manic and mixed episodes, and antidepressants in combination with mood stabilisers or atypical antipsychotics for depressive episodes.
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Affiliation(s)
- Katie Pigott
- Institute of Pyschiatry, King's Collegec/o Ms Caroline Loveland, Centre for Affective DisordersPO72, De Crespigny ParkDenmark HillLondonUKSE5 8AF
| | - Ilaria Galizia
- King's College London, Institute of PsychiatryCentre for Affective DisordersDe Crespigny ParkLondonUKSE5 8AF
- Department of Basic Medical Science, Neuroscience and Sense Organs, Aldo Moro UniversityBariItaly
| | - Kamini Vasudev
- Western UniversityDepartments of Psychiatry and medicineVictoria HospitalLondonONCanada
| | - Stuart Watson
- Wolfson Research CentreAcademic Psychiatry and Regional Affective Disorders ServiceCampus for Ageing and VitalityNewcastle‐upon‐TyneTyne and WearUKNE4 5PL
| | - John Geddes
- University of Oxford/Warneford HospitalDepartment of PsychiatryOxfordUKOX3 7JX
| | - Allan H Young
- Institute of Psychiatry, King's College LondonCentre for Affective DisordersPO72, De Crespigny ParkDenmark HillLondonUKSE5 8AF
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Shansis FM, Reche M, Capp E. Evaluating response to mood stabilizers in patients with mixed depression: A study of agreement between three different mania rating scales and a depression rating scale. J Affect Disord 2016; 197:1-7. [PMID: 26950019 DOI: 10.1016/j.jad.2016.02.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 02/18/2016] [Accepted: 02/26/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of the present study was to evaluate agreement between three pairs formed by one of three mania scales (Young Mania Rating Scale [YMRS], Bech-Rafaelsen Mania Scale [BRMS], or the Clinician-Administered Rating Scale for Mania [CARS-M]) and a single depression scale (21-item Hamilton Depression Rating Scale [21-HAM-D]) for evaluation of response to mood stabilizers in patients with mixed bipolar disorder. METHODS Between 2010 and 2014, 68 consecutive bipolar type I and II outpatients with mixed depression as per DSM-IV-TR and Cincinnati criteria were included in this 8-week open-label trial to randomly receive carbamazepine, lithium carbonate, or valproic acid as monotherapy. RESULTS Patterns of response (defined as a reduction of at least 50% in one of the mania scales and on the 21-HAM-D) were strikingly similar: 21-HAM-D+YMRS=22.1%, 21-HAM-D+BRMS=20.6%, and 21-HAM-D+CARS-M=23.5% (p<0.368). Assessment of agreement revealed very high kappa coefficients: 21-HAM-D+YMRS vs. 21-HAM-D+CARS-M, kappa=0.87; 21-HAM-D+YMRS vs. 21-HAM-D+BRMS, kappa=0.78; 21-HAM-D+CARS-M vs. 21-HAM-D+BRMS, kappa=0.91 (p<0.001). LIMITATIONS The decision to combine a depression rating scale with any one mania rating scale to assess treatment response in patients with mixed depression is questionable. CONCLUSIONS The present study suggests that any one of the three tested mania rating scales (YMRS, BRMS, and CARS-M) can be combined with the 21-HAM-D to assess treatment response in patients with mixed bipolar disorder. This should give clinicians an added measure of confidence in using this strategy until valid, and specific instruments are developed for assessment of mixed states.
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Affiliation(s)
- Flávio Milman Shansis
- Postgraduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), School of Medicine, Porto Alegre, RS, Brazil; Teaching and Research Program in Mood Disorders (PROPESTH), Hospital Psiquiátrico São Pedro, Porto Alegre, RS, Brazil.
| | - Mateus Reche
- Teaching and Research Program in Mood Disorders (PROPESTH), Hospital Psiquiátrico São Pedro, Porto Alegre, RS, Brazil; Postgraduate Program in Obstetrics and Gynecology, UFRGS, School of Medicine, Porto Alegre, RS, Brazil
| | - Edison Capp
- Postgraduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), School of Medicine, Porto Alegre, RS, Brazil; Postgraduate Program in Obstetrics and Gynecology, UFRGS, School of Medicine, Porto Alegre, RS, Brazil; Service of Obstetrics and Gynecology, Hospital de Clinicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil; Department of Obstetrics and Gynecology, UFRGS, School of Medicine, Porto Alegre, RS, Brazil; Department of Gynecological Endocrinology and Reproductive Medicine, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
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Fagiolini A, Coluccia A, Maina G, Forgione RN, Goracci A, Cuomo A, Young AH. Diagnosis, Epidemiology and Management of Mixed States in Bipolar Disorder. CNS Drugs 2015; 29:725-40. [PMID: 26369921 DOI: 10.1007/s40263-015-0275-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Approximately 40% of patients with bipolar disorder experience mixed episodes, defined as a manic state with depressive features, or manic symptoms in a patient with bipolar depression. Compared with bipolar patients without mixed features, patients with bipolar mixed states generally have more severe symptomatology, more lifetime episodes of illness, worse clinical outcomes and higher rates of comorbidities, and thus present a significant clinical challenge. Most clinical trials have investigated second-generation neuroleptic monotherapy, monotherapy with anticonvulsants or lithium, combination therapy, and electroconvulsive therapy (ECT). Neuroleptic drugs are often used alone or in combination with anticonvulsants or lithium for preventive treatment, and ECT is an effective treatment for mixed manic episodes in situations where medication fails or cannot be used. Common antidepressants have been shown to worsen mania symptoms during mixed episodes without necessarily improving depressive symptoms; thus, they are not recommended during mixed episodes. A greater understanding of pathophysiological processes in bipolar disorder is now required to provide a more accurate diagnosis and new personalised treatment approaches. Targeted, specific treatments developed through a greater understanding of bipolar disorder pathophysiology, capable of affecting the underlying disease processes, could well prove to be more effective, faster acting, and better tolerated than existing therapies, therefore providing better outcomes for individuals affected by bipolar disorder. Until such time as targeted agents are available, second-generation neuroleptics are emerging as the treatment of choice in the management of mixed states in bipolar disorder.
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Verdolini N, Agius M, Ferranti L, Moretti P, Piselli M, Quartesan R. The State of the Art of the DSM-5 "with Mixed Features" Specifier. ScientificWorldJournal 2015; 2015:757258. [PMID: 26380368 DOI: 10.1155/2015/757258] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/10/2015] [Indexed: 11/30/2022] Open
Abstract
The new DSM-5 “with mixed features” specifier (MFS) has renewed the interest of the scientific community in mixed states, leading not only to new clinical studies but also to new criticisms of the current nosology. Consequently, in our paper we have reviewed the latest literature, trying to understand the reactions of psychiatrists to the new nosology and its epidemiological, prognostic, and clinical consequences. It seems that the most widespread major criticism is the exclusion from the DSM-5 MFS of overlapping symptoms (such as psychomotor agitation, irritability, and distractibility), with a consequent reduction in diagnostic power. On the other hand, undoubtedly the new DSM-5 classification has helped to identify more patients suffering from a mixed state by broadening the narrow DSM-IV-TR criteria. As for the clinical presentation, the epidemiological data, and the therapeutic outcomes, the latest literature does not point out a univocal point of view and further research is needed to fully assess the implications of the new DSM-5 MFS. It is our view that a diagnostic category should be preferred to a specifier and mixed states should be better considered as a spectrum of states, according to what was stated many years ago by Kraepelin.
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Monahan PO, Stump T, Coryell WH, Harezlak J, Marcoulides GA, Liu H, Steeger CM, Mitchell PB, Wilcox HC, Hulvershorn LA, Glowinski AL, Iyer-Eimerbrink PA, McInnis M, Nurnberger JI. Confirmatory test of two factors and four subtypes of bipolar disorder based on lifetime psychiatric co-morbidity. Psychol Med 2015; 45:2181-2196. [PMID: 25823794 DOI: 10.1017/s0033291715000185] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The first aim was to use confirmatory factor analysis (CFA) to test a hypothesis that two factors (internalizing and externalizing) account for lifetime co-morbid DSM-IV diagnoses among adults with bipolar I (BPI) disorder. The second aim was to use confirmatory latent class analysis (CLCA) to test the hypothesis that four clinical subtypes are detectible: pure BPI; BPI plus internalizing disorders only; BPI plus externalizing disorders only; and BPI plus internalizing and externalizing disorders. METHOD A cohort of 699 multiplex BPI families was studied, ascertained and assessed (1998-2003) by the National Institute of Mental Health Genetics Initiative Bipolar Consortium: 1156 with BPI disorder (504 adult probands; 594 first-degree relatives; and 58 more distant relatives) and 563 first-degree relatives without BPI. Best-estimate consensus DSM-IV diagnoses were based on structured interviews, family history and medical records. MPLUS software was used for CFA and CLCA. RESULTS The two-factor CFA model fit the data very well, and could not be improved by adding or removing paths. The four-class CLCA model fit better than exploratory LCA models or post-hoc-modified CLCA models. The two factors and four classes were associated with distinctive clinical course and severity variables, adjusted for proband gender. Co-morbidity, especially more than one internalizing and/or externalizing disorder, was associated with a more severe and complicated course of illness. The four classes demonstrated significant familial aggregation, adjusted for gender and age of relatives. CONCLUSIONS The BPI two-factor and four-cluster hypotheses demonstrated substantial confirmatory support. These models may be useful for subtyping BPI disorders, predicting course of illness and refining the phenotype in genetic studies.
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Affiliation(s)
- P O Monahan
- Department of Biostatistics,Indiana University School of Medicine,Indianapolis,IN,USA
| | - T Stump
- Department of Biostatistics,Indiana University School of Medicine,Indianapolis,IN,USA
| | - W H Coryell
- Department of Psychiatry,Roy J. and Lucille A. Carver College of Medicine,University of Iowa,Iowa City,IA,USA
| | - J Harezlak
- Department of Biostatistics,Indiana University School of Medicine,Indianapolis,IN,USA
| | - G A Marcoulides
- Research Methods & Statistics Program,Graduate School of Education,University of California-Riverside,Riverside,CA,USA
| | - H Liu
- Department of Biostatistics,Indiana University School of Medicine,Indianapolis,IN,USA
| | - C M Steeger
- Department of Psychology,College of Arts and Letters,University of Notre Dame,Notre Dame,IN,USA
| | - P B Mitchell
- School of Psychiatry,University of New South Wales,Sydney,NSW,Australia
| | - H C Wilcox
- Department of Psychiatry and Behavioral Sciences,Johns Hopkins School of Medicine,Baltimore,MD,USA
| | - L A Hulvershorn
- Department of Psychiatry,Indiana University School of Medicine,Indianapolis,IN,USA
| | - A L Glowinski
- Department of Psychiatry,Washington University School of Medicine,St Louis,MO,USA
| | - P A Iyer-Eimerbrink
- Department of Psychiatry,Indiana University School of Medicine,Indianapolis,IN,USA
| | - M McInnis
- Department of Psychiatry,School of Medicine,University of Michigan,Ann Arbor,MI,USA
| | - J I Nurnberger
- Department of Psychiatry,Indiana University School of Medicine,Indianapolis,IN,USA
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Abstract
PURPOSE OF REVIEW To provide an update regarding the nosological status of, and treatments for, bipolar mixed states. RECENT FINDINGS Mixed states are increasingly recognized as relatively common. The nosological approach in DSM-5 reflects a more liberal application of a mixed states specifier to either the depressed or manic pole of bipolar disorder. The presence of mixed features is associated with a worse clinical course and higher rates of comorbidities including substance abuse. There is ongoing debate about the role of antidepressants in the evolution of such states, but there is increasing consensus that the presence of mixed features should preclude the use of antidepressants. SUMMARY Clinical vigilance and careful evaluation are required to ensure mixed states are not missed in the clinical context. Atypical antipsychotics are emerging as the medications of choice in the pharmacological management of mixed states. Furthermore, research is required into the aetiogenesis and effective treatment of mixed states.
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Thermenos HW, Makris N, Whitfield-Gabrieli S, Brown AB, Giuliano AJ, Lee EH, Faraone SV, Tsuang MT, Seidman LJ. A functional MRI study of working memory in adolescents and young adults at genetic risk for bipolar disorder: preliminary findings. Bipolar Disord 2011; 13:272-86. [PMID: 21676130 PMCID: PMC3822581 DOI: 10.1111/j.1399-5618.2011.00920.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES In this report, we seek to (i) identify a potential neuroimaging endophenotype for bipolar disorder (BD) in emotion regulatory and autonomic circuitry in young first-degree relatives of persons with BD; and (ii) replicate our previous work identifying the functional neuroanatomy of working memory (WM) in an older sample of relatives of persons with BD. METHODS Ten adolescent and young adult (age 13-24) unmedicated, non-ill, first-degree relatives of persons with BD (RELS) and 10 demographically comparable healthy controls performed a 2-back WM task and a 0-back control task during functional magnetic resonance imaging (fMRI). fMRI data were collected on a 1.5 Tesla scanner and analyzed using SPM-2. Mood was assessed on the day of scanning. RESULTS The groups did not differ on any demographic, neuropsychological, or in-scanner task performance variables. In contrast to controls, RELS showed (i) weak task-dependent modulation activity in the cerebellar vermis (CV), insula, and amygdala/parahippocampal region, and (ii) exaggerated modulation of activity in the frontopolar cortex and brainstem, even after controlling for potential confounders. Many of the group differences were driven by differences in activity in the low-level (0-back) baseline task. CONCLUSIONS Young, unmedicated RELS exhibited altered task-dependent modulation of frontopolar, CV, and insula activity during WM, especially during the low-level (0-back) baseline task. Results are largely consistent with our initial study of older adult RELS, suggesting these alterations may represent biomarkers of genetic risk for BD.
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Affiliation(s)
- Heidi W Thermenos
- Division of Public Psychiatry, Department of Psychiatry, Massachusetts Mental Health Center, Beth Israel Deaconess Medical Center, Boston, USA.
| | - Nikos Makris
- Massachusetts General Hospital/Martinos Center for Biomedical Imaging, Charlestown
,Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston
,Departments of Neurology and Radiology, Center for Morphometric Analysis, Massachusetts General Hospital, Boston
| | - Susan Whitfield-Gabrieli
- McGovern Institute for Brain Research and Poitras Center for Affective Disorders Research, Massachusetts Institute of Technology, Cambridge, MA
| | - Ariel B Brown
- Massachusetts General Hospital/Martinos Center for Biomedical Imaging, Charlestown
,Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston
,McGovern Institute for Brain Research and Poitras Center for Affective Disorders Research, Massachusetts Institute of Technology, Cambridge, MA
| | - Anthony J Giuliano
- Division of Public Psychiatry, Department of Psychiatry, Massachusetts Mental Health Center, Beth Israel Deaconess Medical Center, Boston
| | - Erica H Lee
- Division of Public Psychiatry, Department of Psychiatry, Massachusetts Mental Health Center, Beth Israel Deaconess Medical Center, Boston
| | - Stephen V Faraone
- Departments of Psychiatry, Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY
| | - Ming T Tsuang
- Department of Psychiatry, Center for Behavioral Genomics, University of California at San Diego, La Jolla, CA, USA
| | - Larry J Seidman
- Division of Public Psychiatry, Department of Psychiatry, Massachusetts Mental Health Center, Beth Israel Deaconess Medical Center, Boston
,Massachusetts General Hospital/Martinos Center for Biomedical Imaging, Charlestown
,Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston
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Houston JP, Gatz JL, Degenhardt EK, Jamal HH. Symptoms predicting remission after divalproex augmentation with olanzapine in partially nonresponsive patients experiencing mixed bipolar I episode: a post-hoc analysis of a randomized controlled study. BMC Res Notes 2010; 3:276. [PMID: 21044339 PMCID: PMC2987872 DOI: 10.1186/1756-0500-3-276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 11/02/2010] [Indexed: 11/17/2022] Open
Abstract
Background Rating scale items in a 6-week clinical trial of olanzapine versus placebo augmentation in patients with mixed bipolar disorder partially nonresponsive to ≥14 days of divalproex monotherapy were analyzed to characterize symptom patterns that could predict remission. At baseline, the two treatment groups were similar. Findings Factor analysis with Varimax rotation was performed post hoc on baseline items of the 21-Item Hamilton Depression Rating Scale (HDRS-21) and Young Mania Rating Scale (YMRS). Backwards-elimination logistic regression ascertained factors predictive of protocol-defined endpoint remission (HDRS-21 score ≤ 8 and YMRS score ≤ 12) with subsequent determination of optimally predictive factor score cutoffs. Factors for Psychomotor activity (YMRS items for elevated mood, increased motor activity, and increased speech and HDRS-21 agitation item) and Guilt/Suicidality (HDRS-21 items for guilt and suicidality) significantly predicted endpoint remission in the divalproex+olanzapine group. No factor predicted remission in the divalproex+placebo group. Patients in the divalproex+olanzapine group with high pre-augmentation psychomotor activity (scores ≥10) were more likely to remit compared to those with lower psychomotor activity (odds ratio [OR] = 3.09, 95% confidence interval [CI] = 1.22-7.79), and patients with marginally high Guilt/Suicidality (scores ≥2) were less likely to remit than those with lower scores (OR = 0.37, 95% CI = 0.13-1.03). Remission rates for divalproex+placebo vs. divalproex+olanzapine patients with high psychomotor activity scores were 22% vs. 45% (p = 0.08) and 33% vs. 48% (p = 0.29) for patients with low Guilt/Suicidality scores. Conclusions Patients who were partially nonresponsive to divalproex treatment with remaining high vs. low psychomotor activity levels or minimal vs. greater guilt/suicidality symptoms were more likely to remit with olanzapine augmentation. Trial Registration ClinicalTrials.gov; http://clinicaltrials.gov/ct2/show/NCT00402324?term=NCT00402324&rank=1, Identifier: NCT00402324
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Affiliation(s)
- John P Houston
- US Medical Neuroscience, Lilly USA, LLC; Drop Code 4133, Indianapolis, IN 46285 USA.
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