Evening chronotype, disordered eating behavior, and poor dietary habits in bipolar disorder

OBJECTIVE

Our aim was to evaluate the relationship between evening chronotype, a proxy marker of circadian system dysfunction, and disordered eating behavior and poor dietary habits in individuals with bipolar disorder (BD).

METHODS

In this cross-sectional study, we evaluated 783 adults with BD. Chronotype was determined using item 5 from the reduced Morningness-Eveningness Questionnaire. The Eating Disorder Diagnostic Scale (EDDS) and the Rapid Eating Assessment for Participants-Shortened Version (REAP-S) were used to assess disordered eating behavior and dietary habits respectively. General linear models and logistic regression models were utilized to evaluate differences between chronotype groups.

RESULTS

Two hundred and eight (27%) BD participants self-identified as having evening chronotypes. Compared to non-evening types, evening types were younger (P < 0.01) and, after controlling for age, had higher mean EDDS composite z-scores (P < 0.01); higher rates of binge-eating (BE) behavior (P = 0.04), bulimia nervosa (P < 0.01), and nocturnal eating binges (P < 0.01); and a higher body mass index (P = 0.04). Compared to non-evening types, evening chronotypes had a lower REAP-S overall score (P < 0.01) and scored lower on the 'healthy foods' and 'avoidance of unhealthy food' factors. Evening types also skipped breakfast more often (P < 0.01), ate less fruit (P = 0.02) and vegetables (P = 0.04), and consumed more fried foods (P < 0.01), unhealthy snacks (P = 0.02), and soft drinks (P = 0.01).

CONCLUSIONS

Our findings suggest that the circadian system plays a role in the disordered eating and unhealthy dietary behaviors observed in BD patients. The circadian system may therefore represent a therapeutic target in BD-associated morbidity that warrants further investigation.

Genome-wide association study of borderline personality disorder reveals genetic overlap with bipolar disorder, major depression and schizophrenia

Borderline personality disorder (BOR) is determined by environmental and genetic factors, and characterized by affective instability and impulsivity, diagnostic symptoms also observed in manic phases of bipolar disorder (BIP). Up to 20% of BIP patients show comorbidity with BOR. This report describes the first case-control genome-wide association study (GWAS) of BOR, performed in one of the largest BOR patient samples worldwide. The focus of our analysis was (i) to detect genes and gene sets involved in BOR and (ii) to investigate the genetic overlap with BIP. As there is considerable genetic overlap between BIP, major depression (MDD) and schizophrenia (SCZ) and a high comorbidity of BOR and MDD, we also analyzed the genetic overlap of BOR with SCZ and MDD. GWAS, gene-based tests and gene-set analyses were performed in 998 BOR patients and 1545 controls. Linkage disequilibrium score regression was used to detect the genetic overlap between BOR and these disorders. Single marker analysis revealed no significant association after correction for multiple testing. Gene-based analysis yielded two significant genes: DPYD (P=4.42 × 10-7) and PKP4 (P=8.67 × 10-7); and gene-set analysis yielded a significant finding for exocytosis (GO:0006887, PFDR=0.019; FDR, false discovery rate). Prior studies have implicated DPYD, PKP4 and exocytosis in BIP and SCZ. The most notable finding of the present study was the genetic overlap of BOR with BIP (rg=0.28 [P=2.99 × 10-3]), SCZ (rg=0.34 [P=4.37 × 10-5]) and MDD (rg=0.57 [P=1.04 × 10-3]). We believe our study is the first to demonstrate that BOR overlaps with BIP, MDD and SCZ on the genetic level. Whether this is confined to transdiagnostic clinical symptoms should be examined in future studies.

Leveraging electronic health records to study pleiotropic effects on bipolar disorder and medical comorbidities

Patients with bipolar disorder (BD) have a high prevalence of comorbid medical illness. However, the mechanisms underlying these comorbidities with BD are not well known. Certain genetic variants may have pleiotropic effects, increasing the risk of BD and other medical illnesses simultaneously. In this study, we evaluated the association of BD-susceptibility genetic variants with various medical conditions that tend to co-exist with BD, using electronic health records (EHR) data linked to genome-wide single-nucleotide polymorphism (SNP) data. Data from 7316 Caucasian subjects were used to test the association of 19 EHR-derived phenotypes with 34 SNPs that were previously reported to be associated with BD. After Bonferroni multiple testing correction, P<7.7 × 10(-5) was considered statistically significant. The top association findings suggested that the BD risk alleles at SNP rs4765913 in CACNA1C gene and rs7042161 in SVEP1 may be associated with increased risk of 'cardiac dysrhythmias' (odds ratio (OR)=1.1, P=3.4 × 10(-3)) and 'essential hypertension' (OR=1.1, P=3.5 × 10(-3)), respectively. Although these associations are not statistically significant after multiple testing correction, both genes have been previously implicated with cardiovascular phenotypes. Moreover, we present additional evidence supporting these associations, particularly the association of the SVEP1 SNP with hypertension. This study shows the potential for EHR-based analyses of large cohorts to discover pleiotropic effects contributing to complex psychiatric traits and commonly co-occurring medical conditions.

Characteristics of responders and non-responders to risperidone monotherapy or placebo in co-occurring bipolar disorder and anxiety disorder

Clinical characteristics predicting response and remission to psychopharmacological treatment of bipolar disorder (BD) and co-occurring anxiety disorders have been understudied. We hypothesized that non-response to risperidone or placebo in individuals with co-occurring BD and anxiety symptoms would be associated with a more severe clinical course of BD, and certain demographic variables. This study was a secondary analysis of a randomized, double-blind, parallel, 8-week study comparing risperidone monotherapy and placebo in individuals with BD plus current panic disorder, current generalized anxiety disorder (GAD), or lifetime panic disorder (n=111) [31]. We compared clinical characteristics of responders (50% improvement on the Hamilton Anxiety Scale [HAM-A]) and non-responders as well as remitters (HAM-A<7) and non-remitters in risperidone treatment (n=54) and placebo (n=57) groups. For non-responders in the risperidone group, co-occurring lifetime panic disorder was significantly more common than for non-responders in the placebo group. Apart from this, no significant differences in course of illness or demographics were found either between or across groups for patients with BD and co-occurring anxiety symptoms receiving risperidone or placebo in this acute phase study.

Comparison of obese men and women with binge eating disorder seeking weight management

OBJECTIVE

This study examined whether obese males with binge eating disorder (BED) seeking weight loss treatment differed significantly from obese females with BED seeking weight loss treatment in developmental variables, weight loss history, current and lifetime prevalence of psychiatric disorders, and metabolic abnormalities.

METHODS

Psychiatric (using the Structural Clinical Interview for DSM-IV), medical, and laboratory assessments of 44 obese males with BED were compared with assessments from 44 age- and race-matched obese females with BED seeking weight loss treatment.

RESULTS

High rates of mood disorders, anxiety disorders, and metabolic syndrome were observed in the population as a whole. Obese males with BED had attempted significantly fewer diets, medications and supplements for weight loss before seeking weight loss treatment. The two genders did not differ significantly in any other of the examined variables.

CONCLUSIONS

Our results suggest that while obese men and women with BED who present for weight management are very similar, males had fewer previous attempts at weight loss, possibly related to their less pronounced body dissatisfaction or fewer help-seeking behaviors as compared to females. Our results also support findings of substantial comorbidity among obesity, BED, mood and anxiety disorders, and metabolic syndrome in weight loss seeking populations, in men as well as women.

Use of quetiapine in bipolar disorder: a case series with prospective evaluation

Quetiapine, a new atypical antipsychotic, was added to ongoing treatment of bipolar I outpatients (n=15) for symptoms of illness (mood lability, irritability, psychosis and/or difficulty sleeping). All evaluations were prospectively obtained, with the majority of patients (n=9) showing much or very much improvement on the Clinical Global Impression for Bipolar Disorder (CGI-BP). Somatic complaints were limited. Mean (SD) duration before changes in medication regimens was 134 (100) days. Studies of the use of quetiapine in maintenance treatment of bipolar disorder are warranted.

Evidence that a single nucleotide polymorphism in the promoter of the G protein receptor kinase 3 gene is associated with bipolar disorder

In a genome-wide linkage survey, we have previously shown evidence suggesting that the chromosome 22q12 region contains a susceptibility locus for bipolar disorder (BPD). Two independent family sets yielded lod scores suggestive of linkage at markers in this region near the gene G protein receptor kinase 3 (GRK3). GRK3 is an excellent candidate risk gene for BPD since GRK3 is expressed widely in the brain, and since GRKs play key roles in the homologous desensitization of G protein-coupled receptor signaling. We have also previously shown GRK3 expression to be induced by amphetamine in an animal model of mania using microarray-based expression profiling. To identify possible functional mutations in GRK3, we sequenced the putative promoter region, all 21 exons, and intronic sequence flanking each exon, in 14-22 individuals with BPD. We found six sequence variants in the 5'-UTR/promoter region, but no coding or obvious splice variants. Transmission disequilibrium analyses of one set of 153 families indicated that two of the 5'-UTR/promoter variants are associated with BPD in families of northern European Caucasian ancestry. A supportive trend towards association to one of these two variants (P-5) was then subsequently obtained in an independent sample of 237 families. In the combined sample, the P-5 variant had an estimated allele frequency of 3% in bipolar subjects, and displayed a transmission to non-transmission ratio of 26 : 7.7 (chi(2)=9.6, one-sided P value=0.0019). Altogether, these data support the hypothesis that a dysregulation in GRK3 expression alters signaling desensitization, and thereby predisposes to the development of BPD.

Linkage of a bipolar disorder susceptibility locus to human chromosome 13q32 in a new pedigree series

Bipolar (BP) disorder or manic depressive illness is a major psychiatric disorder for which numerous family, twin and adoption studies support a substantial genetic contribution. Recently, we reported the results of a genome-wide search for BP disorder susceptibility loci in 20 pedigrees. Suggestive evidence for linkage was found in this study at three markers on 13q, representing possibly two peaks separated by 18 cM. We have now collected a second set of 32 pedigrees segregating BP disorder and have tested for evidence of linkage to markers on human chromosome 13q. In this sample, we have replicated the linkage result in 13q32 at D13S154 (lod=2.29), the more proximal of the two original peaks. When all 52 pedigrees were combined, the multipoint maximum lod score peaked approximately 7 cM proximal to D13S154 (lod=3.40), with a second peak occurring between D13S225 and D13S796 (lod=2.58). There have been several other reports of significant linkage to both BP disorder and schizophrenia in this region of chromosome 13. These pedigrees provide additional evidence for at least one locus for BP disorder in 13q32, and are consistent with other reports of a possible genetic overlap between these disorders.

Definition, evaluation, and management of treatment refractory mania

Treatment refractory mania is a common clinical problem. Unfortunately, the treatment of acute mania refractory to standard antimanic and mood-stabilizing medications has not been well studied. This review will discuss the definition, evaluation, and differential diagnosis of treatment refractory mania; the definition of an adequate treatment trial for acute mania; the identification of predictors of treatment response; and clinical trials in treatment refractory mania. Computerized searches of the medical literature regarding treatment refractory mania were undertaken using Paperchase (1966-2001), and bibliographies of all articles identified were reviewed to identify all relevant case reports, case series, clinical trials, and methodologic and phenomenologic reports. Operational definitions of treatment refractory mania were proposed based on sequential nonresponse to adequate trials of antimanic agents. The average time of onset of antimanic agents studied in randomized trials was 1 to 2 weeks. Clinical tools for assessing treatment response retrospectively and prospectively appear to have an important role in managing medication treatment in patients with bipolar disorder. Relatively few reliable predictors of treatment response to established antimanic agents have been identified. However, these predictors represent important factors in treatment selection to minimize the probability of nonresponse. Very few randomized, controlled trials of antimanic agents have been conducted in patients with treatment refractory mania. Field testing of treatment algorithms and systematic collection of data from naturalistic treatment studies should provide much-needed data regarding the efficacy of antimanic agents in treatment refractory mania.

What makes a drug a primary mood stabilizer?

The term 'mood stabilizer' has been applied to a number of medications for the treatment of patients with bipolar disorder. The operational definition of the properties of a mood-stabilizing medication has varied according to the properties of specific medications and the clinical characteristics of the illness. Randomized controlled trials of agents accepted or proposed as mood stabilizers are reviewed to marshall the available evidence in support of this claim. In addition, potential pharmacological mechanisms underlying mood-stabilizing effects of established compounds are reviewed.

Psychogenic excoriation. Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment

Psychogenic excoriation (also called neurotic excoriation, acne excoriée, pathological or compulsive skin picking, and dermatotillomania) is characterised by excessive scratching or picking of normal skin or skin with minor surface irregularities. It is estimated to occur in 2% of dermatology clinic patients and is associated with functional impairment, medical complications (e.g. infection) or substantial distress. Psychogenic excoriation is not yet recognised in the DSM. We propose preliminary operational criteria for its diagnosis that take into account the heterogeneity of behaviour associated with psychogenic excoriation and allow for subtyping along a compulsivity-impulsivity spectrum. Psychiatric comorbidity in patients with psychogenic excoriation, particularly mood and anxiety disorders, is common. Patients with psychogenic excoriation frequently have comorbid disorders in the compulsivity-impulsivity spectrum, including obsessive-compulsive disorder, body dysmorphic disorder, substance use disorders, eating disorders, trichotillomania, kleptomania, compulsive buying, obsessive-compulsive personality disorder, and borderline personality disorder. There are few studies of the pharmacological treatment of patients with psychogenic excoriation. Case studies, open trials and small double-blind studies have demonstrated the efficacy of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in psychogenic excoriation. Other pharmacological treatments that have been successful in case reports include doxepin, clomipramine, naltrexone, pimozide and olanzapine. There are no controlled trials of behavioural or psychotherapeutic treatment for psychogenic excoriation. Treatments found to be effective in case reports include a behavioural technique called 'habit reversal'; a multicomponent programme consisting of self-monitoring, recording of episodes of scratching, and procedures that produce alternative responses to scratching; and an 'eclectic' psychotherapy programme with insight-oriented and behavioural components.

The Stanley Foundation Bipolar Treatment Outcome Network. II. Demographics and illness characteristics of the first 261 patients

BACKGROUND

Since recent NIMH Bipolar Disorder Workshops highlighted the dearth of longitudinal and controlled studies of bipolar illness, the Stanley Foundation Bipolar Network (SFBN) has recruited a large cohort of patients with bipolar disorder to begin to address these issues. This report describes the demographics and course of illness characteristics of this study population.

METHODS

The first 261 outpatients to be diagnosed by the Structured Clinical Interview for DSM-IV (SCID) and complete a detailed patient and a brief clinician questionnaire are described. All patients met DSM-IV criteria for bipolar I (n=211), bipolar II (n=42), or NOS (n=5) or schizoaffective (n=3), bipolar type. Chi-square and t-tests were used to examine statistically significant associations among important demographic and descriptive items.

RESULTS

The general demographic and illness characteristics were similar to those in many bipolar clinical samples and not dissimilar from those reported in epidemiological surveys. The majority of patients had been hospitalized, with almost half reporting a worsening of illness over time, and two-thirds were not asymptomatic between episodes. First treatment for patients had been delayed by an average of 10 years from illness onset (by SCID). Almost a third of patients had attempted suicide at least once, and 30% reported current suicidal ideation at study entry. A total of 62% reported moderate to severe impact of the illness on occupational functioning. Early onset bipolar illness (< or =17 years old) was associated with increased frequency of mood switches, worsening course of illness, and history of early abuse (physical, verbal, or sexual).

CONCLUSION

The SFBN represents a sample of predominantly BP I patients largely recruited from the community who will be followed in detail longitudinally, participate in clinical trials, and thus help advance our understanding and treatment of this life-threatening medical disorder. While there is a broad range of illness characteristics and severity, the majority of patients have been severely impacted by their illness despite the availability of multiple conventional treatment approaches in the community. These data further underscore the need for development of new and earlier treatment interventions.

LIMITATION

The SFBN population is limited by the lack of random selection and represents a cohort willing to be treated and followed intensively in academic tertiary referral centers. While its characteristics are similar to many clinical study populations, the generalizability to non-clinic populations remains uncertain.

The Stanley Foundation Bipolar Treatment Outcome Network. I. Longitudinal methodology

The NIMH-Stanley Foundation Bipolar Treatment Outcome Network, a multisite clinical trials network, has been established to address many of the neglected areas of research in bipolar illness. The Network was designed so that it would be able to conduct randomized clinical trials at several different levels of methodologic rigor (blinded and open-label) both in academic and community practice settings in order to better assess long-term efficacy of existing treatments and develop new ones. In this fashion, large numbers of representative patients with bipolar disorder have been enrolled with an additional focus of elucidating possible clinical and biological predictors of treatment response. The unique focus of the Network is its systematic longitudinal approach to illness so that patients can be assessed comprehensively over the long-term in sequential randomized clinical trials at critical clinical decision points where data on relative efficacy are inadequate. Bipolar I and bipolar II patients with a range of illness variants and comorbidities are included. Daily prospective ratings of severity of mania and depression and associated degree of functional impairment are completed on the NIMH-Life Chart Method and a modified Clinical Global Impressions Scale for Bipolar Illness (CGI-BP) is utilized. More detailed cross-sectional ratings for depression (Inventory of Depressive Symptomatology), mania (Young Mania Rating Scale), and psychosis (Positive and Negative Syndrome Scale) are additionally used at academic centers. This article describes the rationale for the Network, its guiding principles, methods, and study design to systematically assess the highly variable course of bipolar illness and its response to current and future treatments.

Rate of switch in bipolar patients prospectively treated with second-generation antidepressants as augmentation to mood stabilizers

INTRODUCTION

Bipolar patients with breakthrough major depressive episodes despite ongoing adequately-dosed mood stabilizer medication were randomized in a double-blind manner to one of three antidepressants with different mechanisms of action: bupropion, sertraline, or venlafaxine. Preliminary data are presented on the switch rates into hypomania or mania for the antidepressants as a group prior to unblinding the specific individual drug efficacy and tolerability data in this ongoing clinical trial.

METHODS

Subjects included 64 bipolar patients who participated at five sites in a 10-week double-blind trial for depression and a 1-year blinded continuation maintenance phase for responders. Nonresponders were re-randomized such that there were 95 acute treatment phases. In the acute phase, doses were titrated to clinical response, side effects, or maximum dose of bupropion (450 mg/day), sertraline (200 mg/day), or venlafaxine (375 mg/day). Daily ratings on the National Institute of Mental Health-Life Chart Methodology (NIMH-LCM) were inspected for the degree of improvement on the Clinical Global Impressions scale as revised for bipolar illness (CGI-BP) and the occurrence of hypomania or mania.

RESULTS

Thirty-five (37%) of the 95 acute treatment phases were associated with a much or very much improved rating in depression on the CGI-BP. Thirteen (14%) of these 95 acute trials of antidepressants as adjuncts to mood stabilizers were associated with switches, seven into hypomania and six into mania. Forty-two patients elected to go into the continuation phase in 48 instances. Sixteen (33%) of the continuation phase trials were associated with mood switches, 10 into hypomania and six into mania.

CONCLUSIONS

In this randomized double-blind prospective study of three second-generation antidepressants (bupropion, sertraline, and venlafaxine) in bipolar patients whose depression broke through ongoing treatment with mood stabilizers, switches into hypomania or mania occurred in 14% of the acute phases and 33% of the continuation phases. Individual data on each drug will be assessed in the next phase of the study after more subjects are recruited and the blind is broken.

A pilot study of topiramate as monotherapy in the treatment of acute mania

This small-scale pilot study was performed to grossly document safety and any evidence of efficacy of topiramate in bipolar disorder. Ten patients hospitalized for acute mania were given open-label topiramate monotherapy for up to 28 days. The mean Young Mania Rating Scale (YMRS) score decreased from 32 (range, 26-40) at baseline to 22 (range, 2-40) at the end of the study. Five patients exhibited evidence of moderate to marked improvement, three subjects had at least a 50% reduction in YMRS scores, and the other two patients experienced an improvement of 25% to 49% on the YMRS. The preliminary findings of this small series suggest that topiramate may be effective in acute mania. Double-blind controlled trials are now needed to further investigate the efficacy and safety of topiramate in bipolar disorder.

The Stanley Foundation Bipolar Network. 2. Preliminary summary of demographics, course of illness and response to novel treatments

BACKGROUND

The Stanley Foundation Bipolar Network (SFBN) evaluates treatments, course and clinical and neurobiological markers of response in bipolar illness.

AIMS

To give a preliminary summary of emerging findings in these areas.

METHOD

Studies with established and potentially antimanic, antidepressant and mood-stabilising agents range from open case series to double-blind randomised clinical trials, and use the same core assessment methodology, thereby optimising the comparability of the outcomes. The National Institute of Mental Health Life Chart Method is the core instrument for retrospective and prospective longitudinal illness description.

RESULTS

The first groups of patients enrolled show a considerable degree of past and present symptomatology, psychiatric comorbidity and functional impairment. There are associations of both genetic and early environmental factors with more severe courses of illness. Open case series with add-on olanzapine, lamotrigine, gabapentin or topiramate show a differential spectrum of effectiveness in refractory patients.

CONCLUSIONS

The SFBN provides important new data for the understanding and treatment of bipolar disorder.

The Stanley Foundation Bipolar Network. I. Rationale and methods

BACKGROUND

The Stanley Foundation Bipolar Network (SFBN) was created to address the paucity of help studies in bipolar illness.

AIMS

To describe the rationale and methods of the SFBN.

METHOD

The SFBN includes five core sites and a number of affiliated sites that have adopted consistent methodology for continuous longitudinal monitoring of patients. Open and controlled studies are performed as patients' symptomatology dictates.

RESULTS

The reliability of SFBN raters and the validity of the rating instruments have been established. More than 500 patients are in continuous daily longitudinal follow-up. More than 125 have been randomised to one of three of the newer antidepressants (bupropion, sertraline and venlafaxine) as adjuncts in a study of mood stabilizers and 93 to omega-3 fatty acids. A number of open clinical case series have been published.

CONCLUSIONS

Well-characterised patients are followed in a detailed continuous longitudinal fashion in both opportunistic case series and double-blind, randomised controlled trials with reliable and validated measures.

Ziprasidone: a new atypical antipsychotic

This paper reviews the clinical pharmacology, efficacy and safety of the new atypical antipsychotic, ziprasidone. All published citations regarding ziprasidone were retrieved and reviewed using a MEDLINE search (completed for citations to early 2001). In addition, abstracts from recent scientific meetings presenting data not yet published were reviewed. Like other new antipsychotic medications, ziprasidone fits the profile of an atypical agent, exerting efficacy in positive and negative symptoms of psychosis, as well as affective symptoms, with a low risk of neurological and neuroendocrinological side effects. Unlike newer agents, it does not appear to be associated with weight gain in most patients.

Bipolar disorder

Bipolar disorder (manic-depressive illness) is a common, recurrent, and severe psychiatric disorder that affects 1% to 3% of the US population. The illness is characterized by episodes of mania, depression, or mixed states (simultaneously occurring manic and depressive symptoms). Bipolar disorder frequently goes unrecognized and untreated for many years without clinical vigilance. New screening tools have been developed to assist physicians in making the diagnosis. Fortunately, several medications are now available to treat the acute mood episodes of bipolar disorder and to prevent further episodes with maintenance treatment.

Divalproex sodium in sex offenders with bipolar disorders and comorbid paraphilias: an open retrospective study

BACKGROUND

This study evaluated divalproex response in sex offenders with a bipolar disorder.

METHODS

We reviewed the records of all sex offenders who participated in a residential rehabilitative program who received divalproex for treatment of a bipolar disorder. Patients' mood symptoms and, when present, comorbid paraphilic symptoms, were retrospectively assessed using the CGI severity scale.

RESULTS

Sex offenders displayed significant improvement in manic symptoms with divalproex treatment. However, there was no significant improvement in paraphilic symptoms in the subset of patients admitting to these symptoms.

CONCLUSION

Divalproex may be effective for manic symptoms in sex offenders with a bipolar disorder. However, for bipolar sex offenders with comorbid paraphilias, the drug may not be effective for paraphilic symptoms.

LIMITATIONS

This study was limited by its retrospective, open-label design, lack of systematic means of assessing manic and paraphilic symptoms, and small sample size.

CLINICAL RELEVANCE

Divalproex may be a helpful adjunct in the treatment of the subset of sex offenders who have a bipolar disorder.

Prior stimulant treatment in adolescents with bipolar disorder: association with age at onset

OBJECTIVES

To compare demographic and clinical characteristics between bipolar adolescents with and without a history of stimulant treatment, we hypothesized that adolescents treated with stimulants would have an earlier age at onset of bipolar disorder, independent of co-occurring attention-deficit-hyperactivity disorder (ADHD).

METHOD

Thirty-four adolescents hospitalized with mania were assessed using the Washington University at St Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS). We systematically evaluated age at onset of bipolar disorder and pharmacological treatment history.

RESULTS

Bipolar adolescents with a history of stimulant exposure prior to the onset of bipolar disorder had an earlier age at onset of bipolar disorder than those without prior stimulant exposure. Additionally, bipolar adolescents treated with at least two stimulant medications had a younger age at onset compared with those who were treated with one stimulant. There was no difference in age at onset of bipolar disorder between bipolar adolescents with and without ADHD.

CONCLUSIONS

Our results suggest that stimulant treatment, independent of ADHD, is associated with younger age at onset of bipolar disorder. A behavioral sensitization model is proposed to explain our findings. There are several limitations to our study including the small sample size, the retrospective assessment of stimulant exposure and age at onset of bipolar disorder, and the inclusion of only hospitalized patients, who may be more likely to present with a severe illness. Nonetheless, future prospective longitudinal investigations that systematically assess the effects of stimulant medications in children with or at genetic risk for bipolar disorder are warranted.

A pilot study of rapid lithium administration in the treatment of acute mania

OBJECTIVES

The use of rapid lithium dosage administration, a strategy that could lead to rapid improvement in mania, has been largely unexamined. In this open-label, pilot, acute-treatment study, we sought to determine the safety and tolerability of lithium administered at 20 mg/ kg/day. A secondary aim was to provide preliminary data regarding the efficacy of this strategy in ameliorating manic, depressive, and psychotic symptoms.

METHODS

Fifteen patients hospitalized with DSM-IV bipolar disorder, manic or mixed, and who provided written informed consent, received lithium 20 mg/kg/day for up to 10 days. Patients were evaluated for adverse effects daily. Lithium levels were obtained on days 2, 3, 4, 5, 7, and 10 or at study termination. Electrocardiograms (EKGs) were performed at baseline and on days 1-5, 7, and 10 or at study termination. Symptomatic improvement was assessed daily using the Young Mania Rating Scale, 24-item Hamilton Depression Rating Scale, and the Scale for Assessment of Positive Symptoms (SAPS).

RESULTS

Five of the 15 patients completed the 10-day study period. Two patients dropped out due to adverse events. Seven patients did not complete the inpatient trial because of improvement sufficient to allow hospital discharge. All patients achieved serum lithium concentrations > or =0.6 mEq/L after 1 day of treatment; the mean + SD concentration on day 5 was 1.1 (+/- 0.1) mEq/L on day 5. There were significant reductions from baseline to endpoint on all rating scales, except the SAPS bizarre behavior subscale.

CONCLUSIONS

These pilot data suggest that lithium 20 mg/kg/day was well tolerated and that this strategy may produce rapid improvement in affective and psychotic symptoms. These impressions require confirmation in double-blind, randomized trials.

An overview of the treatment of schizoaffective disorder

Schizoaffective disorder is a common, chronic, and frequently disabling psychiatric disorder. However, its pharmacologic treatment has not been well studied. The authors review studies of traditional and novel pharmacologic agents in treatment of schizoaffective disorder, and based on the findings, present preliminary pharmacologic treatment guidelines for the disorder.

Valproate as a loading treatment in acute mania

Evidence from earlier studies indicates that the antimanic action of valproate becomes most apparent within 1-4 days of achieving serum concentrations 50 micrograms/ml, that valproate can be orally loaded with achievement of therapeutic serum concentrations within the first several days of treatment, there is a rapid onset of response, and minimal side effects. To provide further data on the safety and efficacy of valproate oral loading in the treatment of acute mania, we evaluated 13 consecutive patients with acute manic syndromes who received valproate initiated at a dosage of 20 mg/kg/day. In most cases, valproate was added to other psychotropics. All 13 patients received at least 5 full days of valproate maintained at or above 20 mg/kg/day, and valproate serum concentrations were 50 micrograms/ml (mean +/- SD = 88 + 25) by the second or third day of treatment. Ten (77%) patients displayed a moderate or marked response. Side effects were infrequent and minor. Consistent with our earlier study, these findings suggest that valproate can be safely administered via a loading dose of 20 mg/kg/day to patients with acute mania, including those on other psychotropics, and that it may produce a rapid response with minimal side effects.

New developments in the pharmacologic treatment of schizoaffective disorder

BACKGROUND

Schizoaffective disorder is a common, chronic, and frequently disabling psychiatric disorder. However, the pharmacologic treatment of this disorder has not been well studied.

METHOD

The authors reviewed the available literature regarding the acute and prophylactic pharmacologic treatment of schizoaffective disorder

RESULTS

Fourteen controlled studies, and only 10 using modern criteria to define the disorder, reported on the efficacy of typical antipsychotics, thymoleptics, or the combination in the acute treatment of schizoaffective disorder. In acute treatment studies of schizoaffective disorder, bipolar type (manic), typical antipsychotics and lithium were comparable in efficacy except in agitated patients for whom antipsychotics were superior. The combination of lithium and antipsychotics appeared to be superior to antipsychotics alone in this patient subtype. In the only controlled study of the acute treatment of schizoaffective disorder, depressive type, combined treatment with antipsychotics and antidepressants was not superior to treatment with antipsychotics alone.

CONCLUSION

Although combination treatment with antipsychotics and thymoleptics is common practice in the prophylactic management of schizoaffective disorder, the efficacy of this strategy has not been studied in controlled trials. Recent preliminary data from open trials suggest that the mood stabilizers valproate and carbamazepine and the novel antipsychotics clozapine and risperidone may be promising new treatments for schizoaffective disorder. Evidence implicating 5-HT2 receptor blockade as an important mechanism underlying possible thymoleptic activity for clozapine and risperidone is also reviewed.

Minimizing and managing antidepressant side effects

Side effects often complicate the use of antidepressants for treatment of patients with major depression. Aggressive minimization and management of antidepressant side effects may relieve discomfort and distress, improve quality of life, enable clinicians to use appropriate medications at therapeutic doses, improve compliance, and thus enhance overall outcome. In this article we present recommendations for the management of side effects associated with antidepressant medications. Specifically, strategies are provided for the management of anticholinergic, cardiovascular, sedative, and activating side effects. Strategies for the management of antidepressant-associated insomnia, hypomania and mania, sexual dysfunction, appetite stimulation and weight gain, cognitive impairment, and parathesias are also discussed.

Neuroleptic malignant syndrome and malignant hyperthermia: end of a controversy?

Two primary hypotheses have been proposed to explain the pathophysiology of the neuroleptic malignant syndrome (NMS): 1) that NMS is produced by abrupt and extensive central dopamine receptor blockade by neuroleptics, particularly in nigrostriatal and hypothalamic pathways; and 2) that NMS, like malignant hyperthermia (MH), results from a preexisting defect in skeletal muscle metabolism that is unmasked or provoked by neuroleptic exposure. To evaluate these models, the authors review studies published since 1980 of the clinical features, epidemiology, risk factors, laboratory assessment, and relevant animal models of NMS and MH. Data from these studies suggest that although NMS and MH are clinically similar, they are pharmacologically distinct, implying that cross-reactivity between triggering agents is unlikely to occur.

Anticonvulsants and antipsychotics in the treatment of bipolar disorder

A number of recent advances in clinical psychopharmacology regarding anticonvulsant and new antipsychotic medications have important implications with respect to the treatment of patients who have bipolar disorder. The authors reviewed the available literature on the efficacy of the anticonvulsants valproate, carbamazepine, gabapentin, and lamotrigine for the treatment of bipolar disorder. They also reviewed the use of standard and new antipsychotic medications for the treatment of various aspects of the illness. Valproate and carbamazepine have been shown to be effective in the treatment of acute mania in controlled trials. Preliminary data suggest that these agents may differ in their time course of antimanic activity and predictors of response. Neither agent has been extensively studied in controlled trials in bipolar depression or as maintenance therapy, although carbamazepine has received the most systematic study in these areas. Gabapentin and lamotrigine are only now being evaluated in controlled trials in patients who have bipolar disorder. Antipsychotics are commonly used in the treatment of patients with acute mania and as maintenance treatment. However, the use of standard antipsychotics in acute mania is associated with a number of limitations. New antipsychotic agents may possess thymoleptic as well as antipsychotic activity, but they have not been studied in controlled trials in bipolar disorder.

New uses for antidepressants: social phobia

Data from recent epidemiologic surveys of community populations indicate that social phobia is a common psychiatric disorder and is associated with substantial functional impairment in a number of patients. Social phobia is also often comorbid with major depression, substance use disorders, and other anxiety disorders. Fortunately, a variety of antidepressant medications have been reported to alleviate the symptoms of social phobia. Controlled studies have shown substantial efficacy for the monoamine oxidase inhibitors phenelzine, moclobemide, and brofaromine and the serotonin selective reuptake inhibitors fluvoxamine and sertraline. Other serotonin reuptake inhibitors and venlafaxine have shown promise in case reports and open trials.

Mania, psychosis, and antipsychotics

Although psychotic symptoms often occur in the manic phase of bipolar disorder, psychotic mania has been and continues to be frequently misdiagnosed as schizophrenia or other psychotic illnesses. In addition, the role of antipsychotic agents in the acute and maintenance treatment of psychotic mania remains unclear. In this paper, we present an overview of studies of psychosis in mania. We also review studies of conventional and newer antipsychotic agents in the acute and maintenance treatment of psychotic mania to help clarify the role of these agents in treating this illness.

Health-economic implications of the onset of action of antimanic agents

BACKGROUND

Three medications, lithium, valproate, and carbamazepine, have been shown to be effective in the treatment of acute mania in randomized, controlled clinical trials. Additional research over the past decade has provided data regarding potential differences between these medications according to their time course of onset and clinical predictors of response in acute mania. These differences have potential impact on both the choice of medication and the health-economics of the treatment of acute mania.

METHOD

Published reports regarding the time course of onset, clinical factors associated with response, and health-economic impact of the treatment of acute mania with lithium, valproate, and carbamazepine were reviewed (PAPERCHASE data base, 1966 to present, terms: bipolar disorder, drug treatment, lithium, valproate, and carbamazepine).

RESULTS

Valproate, when administered via an oral loading dosage, may have a more rapid onset of action than lithium and carbamazepine. Preliminary data suggest that specific clinical factors associated with response differ between the three medications. Health-economic studies suggest that treatment of acute mania with valproate may be associated with greater cost savings due to shorter lengths of hospital stay, particularly in patients with mixed mania and rapid cycling. Patients treated with the combination of carbamazepine and lithium also had reduced hospital lengths-of-stay in one study. Lithium may have greater cost savings in patients with classic mania.

CONCLUSION

Preliminary data from studies reviewed suggest that important differences exist between lithium, valproate, and carbamazepine in their time course of onset and factors associated with response in the treatment of patients with acute mania. These differences may also impact the cost savings associated with treatment with these agents.

Kleptomania, compulsive buying, and binge-eating disorder

Although recognized since at least the early 19th century, kleptomania, compulsive buying, and binge-eating disorder are poorly understood conditions that have received little systematic study. In this article, we review the available studies of these three conditions, which suggest that they are more common than realized, occur more frequently in women than in men, cause significant morbidity, are related to other psychiatric disorders (especially to one another, impulse control disorders, obsessive-compulsive disorder, and mood disorders), and often respond to available psychopharmacologic and psychological treatments. We hypothesize that these three conditions might best be viewed as impulse control disorders that belong to an extended family of compulsive-impulsive spectrum disorders. The compulsive-impulsive spectrum disorders may, in turn, belong to the larger family of affective spectrum disorder.

Compliance with maintenance treatment in bipolar disorder

Studies of compliance with pharmacologic treatment in patients with bipolar disorder have primarily involved outpatients receiving lithium. To date, very little data addresses the rates of noncompliance in patients with bipolar disorder treated with other available mood stabilizers (e.g. divalproex, carbamazepine). One hundred and forty patients initially hospitalized for a bipolar disorder, manic or mixed episode, were evaluated prospectively over 1 year to assess their compliance with pharmacotherapy. Compliance was assessed by a clinician-administered questionnaire, using information from the patient, treaters, and significant others. Seventy-one patients (51%) were partially or totally noncompliant with pharmacologic treatment during the 1-year followup period. Noncompliance was significantly associated with the presence of a comorbid substance use disorder. Denial of need was the most common reason cited for noncompliance. Compliance was associated with being male and Caucasian and with treatment with combined lithium and divalproex or with this combination and an antipsychotic. Noncompliance with pharmacotherapy remains a substantial problem in the treatment of patients with bipolar disorder.

Antipsychotics in the treatment of mood disorders and risk of tardive dyskinesia

Psychosis occurs commonly in patients with mood disorders and has traditionally been treated with typical antipsychotics. Exposure to typical antipsychotics poses a risk for the emergence of tardive dyskinesia. Atypical antipsychotics may have advantages over typical agents in the treatment of patients with mood disorders complicated by psychotic features. The studies of typical and atypical antipsychotics in the treatment of mood disorders were reviewed. Similarly, studies regarding the risk of tardive dyskinesia from typical and atypical agents in patients with mood disorders were surveyed. Typical and atypical antipsychotics appear to be comparably effective in the treatment of acute mania. Limited data regarding these medications in psychotic depression are available. Advantages of atypical antipsychotics include, for most agents, minimal extrapyramidal and prolactin effects, inherent thymoleptic activity, and lower rates of tardive dyskinesia. Atypical antipsychotics appear to have a number of advantages over typical agents in the treatment of patients with psychotic mood disorders.

Body dysmorphic disorder: an obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both?

Over the past century, body dysmorphic disorder (BDD), a preoccupation with an imagined or slight defect in appearance, has been hypothesized to be related to obsessive-compulsive disorder (OCD). More recently, BDD has also been hypothesized to be a form of affective spectrum disorder. Affective spectrum disorder refers to a family of disorders postulated to have a common pathophysiologic abnormality. This grouping of disorders has been identified on the basis of their response to pharmacologic treatments and is supported by comorbidity and family studies. Available data suggest that BDD should be considered a candidate form of affective spectrum disorder--a disorder that may eventually be demonstrated to belong to this family of disorders. Available data also strongly support the hypothesis that BDD is an obsessive-compulsive spectrum disorder. Because OCD itself has been hypothesized to be an affective spectrum disorder, BDD may be more narrowly conceptualized as an obsessive-compulsive spectrum disorder and more broadly as a candidate form of affective spectrum disorder.

Anticonvulsants in the treatment of bipolar disorder

In the last decade, a proliferation of research has emerged concerning the use of somatic treatments with anticonvulsant properties, e.g., carbamazepine, valproate, clonazepam, oxcarbazepine, and electroconvulsive therapy (ECT), for patients with bipolar disorder. A sufficient number of controlled studies have been conducted to allow critical review of the evidence supporting the efficacy of these treatments for acute bipolar manic and depressive episodes, as well as for the prevention of subsequent episodes. Further research is needed to establish the prophylactic efficacy of anticonvulsants as maintenance therapies and, perhaps most importantly, to provide clinical and biological predictors of response.

Antiepileptic drugs for the treatment of panic disorder

Evidence from preclinical studies, preliminary clinical reports, pharmacologic challenge studies and a small number of controlled trials suggests that several antiepileptic agents--valproate, carbamazepine, and clonazepam--may have therapeutic effects in the treatment of patients with panic disorder. We review the theoretical basis and available clinical data supporting the use of these agents in panic disorder.

Axis I psychiatric comorbidity and its relationship to historical illness variables in 288 patients with bipolar disorder

OBJECTIVE

Bipolar disorder often co-occurs with other axis I disorders, but little is known about the relationships between the clinical features of bipolar illness and these comorbid conditions. Therefore, the authors assessed comorbid lifetime and current axis I disorders in 288 patients with bipolar disorder and the relationships of these comorbid disorders to selected demographic and historical illness variables.

METHOD

They evaluated 288 outpatients with bipolar I or II disorder, using structured diagnostic interviews and clinician-administered and self-rated questionnaires to determine the diagnosis of bipolar disorder, comorbid axis I disorder diagnoses, and demographic and historical illness characteristics.

RESULTS

One hundred eighty-seven (65%) of the patients with bipolar disorder also met DSM-IV criteria for at least one comorbid lifetime axis I disorder. More patients had comorbid anxiety disorders (N=78, 42%) and substance use disorders (N=78, 42%) than had eating disorders (N=9, 5%). There were no differences in comorbidity between patients with bipolar I and bipolar II disorder. Both lifetime axis I comorbidity and current axis I comorbidity were associated with earlier age at onset of affective symptoms and syndromal bipolar disorder. Current axis I comorbidity was associated with a history of development of both cycle acceleration and more severe episodes over time.

CONCLUSIONS

Patients with bipolar disorder often have comorbid anxiety, substance use, and, to a lesser extent, eating disorders. Moreover, axis I comorbidity, especially current comorbidity, may be associated with an earlier age at onset and worsening course of bipolar illness. Further research into the prognostic and treatment response implications of axis I comorbidity in bipolar disorder is important and is in progress.

Health values of patients with bipolar disorder

BACKGROUND

Despite a growing number of studies of patients' health values (utilities), little is known about health values of patients with mental illness, particularly bipolar (manic-depressive) disorder.

METHODS

We administered a computerized rating scale, time tradeoff, and standard gamble to 53 patients. Patients were asked to rate or value their current state of health overall and then their current mental health. In addition, we administered the SF-36; Inventory of Depressive Symptoms (IDS-C); Positive and Negative Syndrome Scale (PANSS); Young Mania Rating Scale (YMRS); and Global Assessment of Functioning Scale.

RESULTS

The patients' median (25th, 75th percentile) age was 43 (37, 50); 62% were female. Mean (+/- SD) health ratings for current overall health were 68.0 (+/- 20.3) vs. 61.0 (+/- 25.7) for current mental health (p-value for difference = 0.02). On the time tradeoff, scores for current overall health averaged 0.71 (+/- 0.37) vs. 0.61 (+/- 0.39) for current mental health (p = 0.02); on the standard gamble, mean scores were 0.77 (+/- 0.32) for current overall health vs. 0.70 (+/- 0.35) for current mental health (p = 0.11). In univariate analyses, rating scale, time-tradeoff, and standard gamble scores for both current overall health and for current mental health were correlated with the SF-36 and all psychiatric scale (magnitude of r = 0.22-0.76) except the YMRS (magnitude of r < or = 0.13). In multivariable analyses, health values for current overall health were related to factors different from those that were related to health values for current mental health (R2 = 0.38-0.65), and none of the health value measures was related to the YMRS.

CONCLUSION

Health values of patients with bipolar disorder are higher for their current health overall than for their current state of mental health. Health values are related to certain health status attributes and to level of depression but perhaps not to level of mania.

Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire

OBJECTIVE

Bipolar spectrum disorders, which include bipolar I, bipolar II, and bipolar disorder not otherwise specified, frequently go unrecognized, undiagnosed, and untreated. This report describes the validation of a new brief self-report screening instrument for bipolar spectrum disorders called the Mood Disorder Questionnaire.

METHOD

A total of 198 patients attending five outpatient clinics that primarily treat patients with mood disorders completed the Mood Disorder Questionnaire. A research professional, blind to the Mood Disorder Questionnaire results, conducted a telephone research diagnostic interview by means of the bipolar module of the Structured Clinical Interview for DSM-IV.

RESULTS

A Mood Disorder Questionnaire screening score of 7 or more items yielded good sensitivity (0.73) and very good specificity (0.90).

CONCLUSIONS

The Mood Disorder Questionnaire is a useful screening instrument for bipolar spectrum disorder in a psychiatric outpatient population.

A double-blind, placebo-controlled, prophylaxis study of lamotrigine in rapid-cycling bipolar disorder. Lamictal 614 Study Group

BACKGROUND

Patients with rapid-cycling bipolar disorder are often treatment refractory. This study examined lamotrigine as maintenance monotherapy for rapid-cycling bipolar disorder.

METHOD

Lamotrigine was added to patients' current psychotropic regimens and titrated to clinical effect during an open-label treatment phase. Stabilized patients were tapered off other psychotropics and randomly assigned to lamotrigine or placebo monotherapy for 6 months. Time to additional pharmacotherapy for emerging symptoms was the primary outcome measure. Secondary efficacy measures included survival in study (time to any premature discontinuation), percentage of patients stable without relapse for 6 months, and changes in the Global Assessment Scale and Clinical Global Impressions-Severity scale. Safety was assessed from adverse event, physical examination, and laboratory data.

RESULTS

324 patients with rapid-cycling bipolar disorder (DSM-IV criteria) received open-label lamotrigine, and 182 patients were randomly assigned to the double-blind maintenance phase. The difference between the treatment groups in time to additional pharmacotherapy did not achieve statistical significance in the overall efficacy population. However, survival in study was statistically different between the treatment groups (p = .036). Analyses also indicated a 6-week difference in median survival time favoring lamotrigine. Forty-one percent of lamotrigine patients versus 26% of placebo patients (p = .03) were stable without relapse for 6 months of monotherapy. Lamotrigine was well tolerated; there were no treatment-related changes in laboratory parameters, vital signs, or body weight. No serious rashes occurred.

CONCLUSION

This was the largest and only prospective placebo-controlled study of rapid-cycling bipolar disorder patients to date; results indicate lamotrigine monotherapy is a useful treatment for some patients with rapid-cycling bipolar disorder.

Validation of the prospective NIMH-Life-Chart Method (NIMH-LCM-p) for longitudinal assessment of bipolar illness

BACKGROUND

Systematic and accurate depiction of a patient's course of illness is crucial for assessing the efficacy of maintenance treatments for bipolar disorder. This need to rate the long-term prospective course of illness led to the development of the National Institute of Mental Health prospective Life Chart Methodology (NIMH-LCM-p or LCM). The NIMH-LCM-p allows for the daily assessment of mood and episode severity based on the degree of mood associated functional impairment. We have previously presented preliminary evidence of the reliability and validity of the LCM, and its utility in clinical trials. This study is a further and more extensive validation of the clinician rated NIMH-LCM-p.

METHODS

Subjects included 270 bipolar patients from the five sites participating in the Stanley Foundation Bipolar Network. Daily prospective LCM ratings on the clinician form were initiated upon entry, in addition to at least monthly ratings with the Inventory of Depressive Symptomatology-clinician rated (IDS-C), the Young Mania Rating Scale (YMRS) and the Global Assessment of Functioning (GAF). We correlated appropriate measures and time domains of the LCM with the IDS-C, YMRS and GAF.

RESULTS

Severity of depression on the LCM and on the IDS-C were highly correlated in 270 patients (r = -0.785, P < 0.001). Similarly, a strong correlation was found between LCM mania and the YMRS (r = 0.656, P < 0.001) and between the LCM average severity of illness and the GAF (r = -0.732, P < 0.001).

CONCLUSIONS

These data further demonstrate the validity and potential utility of the NIMH-LCM-p for the detailed daily longitudinal assessment of manic and depressive severity and course, and response to treatment.

Methodological issues in developing new acute treatments for patients with bipolar illness

One important aim of the recent reorganization of the National Institute of Mental Health (NIMH) is to streamline the development of new treatments for patients with severe mental illnesses, such as bipolar disorder. Researching new treatments for patients with bipolar disorder presents specific problems not readily addressed by traditional efficacy trial methodologies that aim to maximize internal validity. This article reexamines several assumptions that have guided the design of these efficacy trials but that also create obstacles for studies of bipolar disorder and suggests potential solutions. This article draws on literature from neurology and psychiatry and discussions at a MacArthur Foundation-sponsored Conference on Longitudinal Methodology in 1992 (David J. Kupfer, M.D., Chair), which brought together investigators to consider alternative designs for patients with severe and persistent mental illness. In addition, we benefited from discussions at two NIMH-sponsored conferences, one held in 1989 (Prien and Potter 1990) and the other in 1994 (Prien and Rush 1996), at which investigators and methodologists discussed issues surrounding the development and conduct of informative efficacy trials for patients with bipolar disorder. Based on these discussions and recent literature reviews, we 1) outline common problems in the development and evaluation of effective acute treatments for bipolar disorder and 2) suggest possible solutions to these impediments. We also discuss alternative designs by which to build a sequence of acute treatment studies from which efficacy, safety, and the comparative value of different treatments can be established.

Pharmacologic agents for the treatment of acute bipolar mania

The knowledge base regarding the medical treatment of acute bipolar mania is rapidly expanding. Information about agents with established antimanic properties is increasing, and more agents with putative antimanic properties are being identified. We first review the controlled studies supporting the efficacy of the established antimanic agents lithium, valproate, and carbamazepine and standard antipsychotics. We then review available research on two important classes of drugs that are emerging as potential treatments for acute mania: the novel antipsychotics, which include clozapine, olanzapine, quetiapine, risperidone, and ziprasidone, and the new antiepileptics, which include gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate, and zonisamide. We conclude that although controlled data are accumulating to support the efficacy of several atypical antipsychotics in the treatment of acute bipolar mania, particularly olanzapine, ziprasidone, and risperidone, the novel antiepileptics need more extensive study before it can be concluded that any of them possess specific antimanic properties. We also conclude that as the medical options for acute bipolar mania expand, treatment guidelines must remain both evidence based and flexible, so that they represent cutting edge medical science yet can be tailored to the specific needs of individual patients.

Evaluating the parent-of-origin effect in bipolar affective disorder. Is a more penetrant subtype transmitted paternally?

BACKGROUND

Numerous genetic mechanisms and modes of transmission underlying bipolar affective disorder (BPAD) have been postulated. Recently, the discovery of genomic imprinting and mitochondrial transmission of illness in humans has stimulated study of parent-of-origin effects in the transmission of BPAD.

METHODS

We examined a large sample of families from an associated linkage study to search for a possible parent-of-origin effect. Selecting for unilineal families with at least one offspring and/or parent diagnosed with BPAD after structured interview, we conducted three analyses: (1) the rates of illness among mothers and fathers of offspring affected with BPAD; (2) the observed frequency of transmission and rates of illness among maternal and paternal lineages; and (3) the rates of affective illness among offspring of parents affected with BPAD.

RESULTS

Our results indicate no significant differences in the rates of illness among mothers and fathers of offspring affected with BPAD. Also, the frequency of transmission and rates of illness among maternal and paternal lineages did not differ significantly. However, the rate of BPAD among the offspring of fathers affected with BPAD was significantly higher than for mothers with the illness.

LIMITATIONS

Substantially more women than men, and maternal than paternal relatives were studied - introducing possible gender biases.

CONCLUSIONS

These results suggest a possible paternal parent-of-origin effect.

Current issues in the identification and management of bipolar spectrum disorders in 'special populations'

Bipolar disorder is a common, lifelong condition that can present during childhood, adolescence, adulthood or later in life. It may occur alone but, more frequently, is complicated by comorbid psychiatric and medical disorders. As such, bipolar disorder presents in many different special populations, each of which warrants specific considerations of diagnosis, treatment and management. This review summarizes common issues concerning recognition of bipolar disorder, particularly in younger patients, discusses the prevalence and treatment of anxious disorder and addictive comorbidity, and considers bipolar disorder in the institutionalized and forensic populations. Treatment options and the supporting evidence are discussed.