Manic Symptoms During Depressive Episodes in 1,380 Patients With Bipolar Disorder: Findings From the STEP-BD

BackgroundReported rates of bipolar syndromes are highly variable between studies because of age differences, differences in diagnostic criteria, or restriction of sampling to clinical contacts.MethodIn 1395 adolescents aged 14–17 years, DSM-IV (hypo)manic episodes (manic and hypomanic episodes combined), use of mental health care, and five ordinal subcategories representing the underlying continuous score of (hypo)manic symptoms (‘mania symptom scale’) were measured at baseline and approximately 1.5, 4 and 10 years later using the Munich-Composite International Diagnostic Interview (DIA-X/M-CIDI).ResultsIncidence rates (IRs) of both (hypo)manic episodes and (hypo)manic symptoms (at least one DSM-IV core symptom) were far higher (714/105 person-years and 1720/105 person-years respectively) than traditional estimates. In addition, the risk of developing (hypo)manic episodes was very low after the age of 21 years [hazard ratio (HR) 0.031, 95% confidence interval (CI) 0.0050–0.19], independent of childhood disorders such as attention deficit hyperactivity disorder (ADHD). Most individuals with hypomanic and manic episodes were never in care (87% and 62% respectively) and not presenting co-morbid depressive episodes (69% and 60% respectively). The probability of mental health care increased linearly with the number of symptoms on the mania symptom scale. The incidence of the bipolar categories, in particular at the level of clinical morbidity, was strongly associated with previous childhood disorders and male sex.ConclusionsThis study showed, for the first time, that experiencing (hypo)manic symptoms is a common adolescent phenomenon that infrequently predicts mental health care use. The findings suggest that the onset of bipolar disorder can be elucidated by studying the pathway from non-pathological behavioural expression to dysfunction and need for care.

Download Full-text

Bipolar Disorder (BD) and Obsessive Compulsive Disorder (OCD) Comorbidty or Varied Episodes in the Same Disorder

European Psychiatry ◽

10.1016/s0924-9338(09)70830-2 ◽

2009 ◽

Vol 24 (S1) ◽

pp. 1-1

Author(s):

E. Oral ◽

E. Ozan ◽

E. Deveci ◽

N. Aydın ◽

I. Kirpinar

Keyword(s):

Bipolar Disorder ◽

Depressive Symptoms ◽

Lithium Carbonate ◽

Treatment Resistant ◽

Obsessive Compulsive ◽

Obsessive Compulsive Symptoms ◽

Compulsive Disorder ◽

Manic Symptoms ◽

Episodic Course ◽

Depressive Episodes

Previous studies have suggested that OCD has comorbidity with bipolar disorder (BD) (1,2). We evaluated the three bipolar OCD cases.C1: Because of the OCD symptoms Chlomipramine was started. Her OCD symptoms improved in several days but manic symptoms was apeeared, switched to Lithium Carbonate. In her out patient exams, manic and obsessive compulsive symptoms were almost never observed simultaneously at the course.C2: In 2003, her complaints started as combined OCD and Manic symptoms, Risperidon and Lithium carbonate were started, manic and OCD symptoms improved. In 2005, OCD and Depressive symptoms appeared together. She got improved with Lithium Carbonate and Chlomipramine. She had one episode with obsessive and manic symptoms or obsessive and depressive symptoms every year till now. Her uncle had Depression and her aunt had Bipolar disorder.C3: Because of his OCD symptoms we prescribed SSRI and lower dose antipsychotic. At that time he hospitalized for his manic symptoms, his OCD was partially remitted. His manic symptoms improved with Lithium carbonate1200p/d. He had resistant obsessive compulsive symptoms and episodic manic symptoms. His father had M. Depressive episodes.Conclusion:Our cases suggest that bipolar OCD has episodic course, treatment resistant symtomatology, high family loading and high frequency of recurrence.

Download Full-text

The effect of smartphone-based monitoring on illness activity in bipolar disorder: the MONARCA II randomized controlled single-blinded trial

Psychological Medicine ◽

10.1017/s0033291719000710 ◽

2019 ◽

Vol 50 (5) ◽

pp. 838-848 ◽

Cited By ~ 18

Author(s):

Maria Faurholt-Jepsen ◽

Mads Frost ◽

Ellen Margrethe Christensen ◽

Jakob E. Bardram ◽

Maj Vinberg ◽

...

Keyword(s):

Quality Of Life ◽

Bipolar Disorder ◽

Perceived Stress ◽

Intervention Group ◽

Control Group ◽

Manic Symptoms ◽

Randomized Controlled ◽

Depressive Episodes ◽

Depressive And Manic Symptoms

AbstractBackgroundRecently, the MONARCA I randomized controlled trial (RCT) was the first to investigate the effect of smartphone-based monitoring in bipolar disorder (BD). Findings suggested that smartphone-based monitoring sustained depressive but reduced manic symptoms. The present RCT investigated the effect of a new smartphone-based system on the severity of depressive and manic symptoms in BD.MethodsRandomized controlled single-blind parallel-group trial. Patients with BD, previously treated at The Copenhagen Clinic for Affective Disorder, Denmark and currently treated at community psychiatric centres, private psychiatrists or GPs were randomized to the use of a smartphone-based system or to standard treatment for 9 months. Primary outcomes: differences in depressive and manic symptoms between the groups.ResultsA total of 129 patients with BD (ICD-10) were included. Intention-to-treat analyses showed no statistically significant effect of smartphone-based monitoring on depressive (B = 0.61, 95% CI −0.77 to 2.00, p = 0.38) and manic (B = −0.25, 95% CI −1.1 to 0.59, p = 0.56) symptoms. The intervention group reported higher quality of life and lower perceived stress compared with the control group. In sub-analyses, the intervention group had higher risk of depressive episodes, but lower risk of manic episodes compared with the control group.ConclusionsThere was no effect of smartphone-based monitoring. In patient-reported outcomes, patients in the intervention group reported improved quality of life and reduced perceived stress. Patients in the intervention group had higher risk of depressive episodes and reduced risk of manic episodes. Despite the widespread use and excitement of electronic monitoring, few studies have investigated possible effects. Further studies are needed.

Download Full-text

Bipolar Disorder (BD) and Obsessive Compulsive Disorder (OCD) Comorbidty or Varied Episodes in the Same Disorder

European Psychiatry ◽

10.1016/s0924-9338(09)70594-2 ◽

2009 ◽

Vol 24 (S1) ◽

pp. 1-1

Author(s):

E. Oral ◽

E. Ozan ◽

E. Deveci ◽

N. Aydın ◽

I. Kirpinar

Keyword(s):

Bipolar Disorder ◽

Depressive Symptoms ◽

Lithium Carbonate ◽

Treatment Resistant ◽

Obsessive Compulsive ◽

Obsessive Compulsive Symptoms ◽

Compulsive Disorder ◽

Manic Symptoms ◽

Episodic Course ◽

Depressive Episodes

Previous studies have suggested that OCD has comorbidity with bipolar disorder (BD) (1,2). We evaluated the three bipolar OCD cases.C1: Because of the OCD symptoms Chlomipramine was started. Her OCD symptoms improved in several days but manic symptoms was apeeared, switched to Lithium Carbonate. In her out patient exams, manic and obsessive compulsive symptoms were almost never observed simultaneously at the course.C2: In 2003, her complaints started as combined OCD and Manic symptoms, Risperidon and Lithium carbonate were started, manic and OCD symptoms improved. In 2005, OCD and Depressive symptoms appeared together. She got improved with Lithium Carbonate and Chlomipramine. She had one episode with obsessive and manic symptoms or obsessive and depressive symptoms every year till now. Her uncle had Depression and her aunt had Bipolar disorder.C3: Because of his OCD symptoms we prescribed SSRI and lower dose antipsychotic. At that time he hospitalized for his manic symptoms, his OCD was partially remitted. His manic symptoms improved with Lithium carbonate1200p/d. He had resistant obsessive compulsive symptoms and episodic manic symptoms. His father had M. Depressive episodes.Conclusion:Our cases suggest that bipolar OCD has episodic course, treatment resistant symtomatology, high family loading and high frequency of recurrence.

Download Full-text

Comorbid Premenstrual Dysphoric Disorder and Bipolar Disorder: A Review

Frontiers in Psychiatry ◽

10.3389/fpsyt.2021.719241 ◽

2021 ◽

Vol 12 ◽

Author(s):

Anastasiya Slyepchenko ◽

Luciano Minuzzi ◽

Benicio N. Frey

Keyword(s):

Bipolar Disorder ◽

Selective Serotonin Reuptake Inhibitors ◽

Clinical Presentation ◽

Premenstrual Dysphoric Disorder ◽

Severe Form ◽

Course Of Illness ◽

Manic Symptoms ◽

Mixed Features ◽

Depressive Episodes ◽

Degrees Of Severity

Bipolar disorder (BD) differs in its clinical presentation in females compared to males. A number of clinical characteristics have been associated with BD in females: more rapid cycling and mixed features; higher number of depressive episodes; and a higher prevalence of BD type II. There is a strong link between BD and risk for postpartum mood episodes, and a substantial percentage of females with BD experience premenstrual mood worsening of varying degrees of severity. Females with premenstrual dysphoric disorder (PMDD)—the most severe form of premenstrual disturbances—comorbid with BD appear to have a more complex course of illness, including increased psychiatric comorbidities, earlier onset of BD, and greater number of mood episodes. Importantly, there may be a link between puberty and the onset of BD in females with comorbid PMDD and BD, marked by a shortened gap between the onset of BD and menarche. In terms of neurobiology, comorbid BD and PMDD may have unique structural and functional neural correlates. Treatment of BD comorbid with PMDD poses challenges, as the first line treatment of PMDD in the general population is selective serotonin reuptake inhibitors, which produce risk of treatment-emergent manic symptoms. Here, we review current literature concerning the clinical presentation, illness burden, and unique neurobiology of BD comorbid with PMDD. We additionally discuss obstacles faced in symptom tracking, and management of these comorbid disorders.

Download Full-text

Mixed features in bipolar disorder

CNS Spectrums ◽

10.1017/s1092852916000869 ◽

2016 ◽

Vol 22 (2) ◽

pp. 134-140 ◽

Cited By ~ 26

Author(s):

Eva Solé ◽

Marina Garriga ◽

Marc Valentí ◽

Eduard Vieta

Keyword(s):

Bipolar Disorder ◽

Diagnostic Category ◽

Specific Treatment ◽

Unipolar Depression ◽

Manic Symptoms ◽

Dsm 5 ◽

Increased Risk ◽

Mixed Features ◽

Major Depressive Episodes ◽

Depressive Episodes

Mixed affective states, defined as the coexistence of depressive and manic symptoms, are complex presentations of manic-depressive illness that represent a challenge for clinicians at the levels of diagnosis, classification, and pharmacological treatment. The evidence shows that patients with bipolar disorder who have manic/hypomanic or depressive episodes with mixed features tend to have a more severe form of bipolar disorder along with a worse course of illness and higher rates of comorbid conditions than those with non-mixed presentations. In the updated Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5), the definition of “mixed episode” has been removed, and subthreshold nonoverlapping symptoms of the opposite pole are captured using a “with mixed features” specifier applied to manic, hypomanic, and major depressive episodes. However, the list of symptoms proposed in the DSM–5 specifier has been widely criticized, because it includes typical manic symptoms (such as elevated mood and grandiosity) that are rare among patients with mixed depression, while excluding symptoms (such as irritability, psychomotor agitation, and distractibility) that are frequently reported in these patients. With the new classification, mixed depressive episodes are three times more common in bipolar II compared with unipolar depression, which partly contributes to the increased risk of suicide observed in bipolar depression compared to unipolar depression. Therefore, a specific diagnostic category would imply an increased diagnostic sensitivity, would help to foster early identification of symptoms and ensure specific treatment, as well as play a role in suicide prevention in this population.

Download Full-text

Deficits in explicit emotion regulation in bipolar disorder: a systematic review

International Journal of Bipolar Disorders ◽

10.1186/s40345-021-00221-9 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Marcel Kurtz ◽

Pia Mohring ◽

Katharina Förster ◽

Michael Bauer ◽

Philipp Kanske

Keyword(s):

At Risk ◽

Bipolar Disorder ◽

Emotion Regulation ◽

Mood State ◽

Bipolar Disorders ◽

Protective Measure ◽

Behavioral Measures ◽

Increased Risk ◽

Regulation Strategies ◽

Depressive Episodes

Abstract Background This study aimed to compile and synthesize studies investigating explicit emotion regulation in patients with bipolar disorder and individuals at risk of developing bipolar disorder. The importance of explicit emotion regulation arises from its potential role as a marker for bipolar disorders in individuals at risk and its potent role in therapy for bipolar disorder patients. Methods To obtain an exhaustive compilation of studies dealing specifically with explicit emotion regulation in bipolar disorder, we conducted a systematic literature search in four databases. In the 15 studies we included in our review, the emotion-regulation strategies maintenance, distraction, and reappraisal (self-focused and situation-focused) were investigated partly on a purely behavioral level and partly in conjunction with neural measures. The samples used in the identified studies included individuals at increased risk of bipolar disorder, patients with current affective episodes, and patients with euthymic mood state. Results In summary, the reviewed studies' results indicate impairments in explicit emotion regulation in individuals at risk for bipolar disorder, patients with manic and depressive episodes, and euthymic patients. These deficits manifest in subjective behavioral measures as well as in neural aberrations. Further, our review reveals a discrepancy between behavioral and neural findings regarding explicit emotion regulation in individuals at risk for bipolar disorders and euthymic patients. While these groups often do not differ significantly in behavioral measures from healthy and low-risk individuals, neural differences are mainly found in frontostriatal networks. Conclusion We conclude that these neural aberrations are a potentially sensitive measure of the probability of occurrence and recurrence of symptoms of bipolar disorders and that strengthening this frontostriatal route is a potentially protective measure for individuals at risk and patients who have bipolar disorders.

Download Full-text

The Challenges of Children with Bipolar Disorder

Medicina ◽

10.3390/medicina57060601 ◽

2021 ◽

Vol 57 (6) ◽

pp. 601

Author(s):

Robert M. Post ◽

Heinz Grunze

Keyword(s):

Bipolar Disorder ◽

Early Recognition ◽

Childhood Onset ◽

Traditional Treatment ◽

Treatment As Usual ◽

Treatment Regimens ◽

Oppositional Defiant ◽

Treatment Of Depression ◽

The Common ◽

Depressive Episodes

Childhood onset bipolar disorder (CO-BD) presents a panoply of difficulties associated with early recognition and treatment. CO-BD is associated with a variety of precursors and comorbidities that have been inadequately studied, so treatment remains obscure. The earlier the onset, the longer is the delay to first treatment, and both early onset and treatment delay are associated with more depressive episodes and a poor prognosis in adulthood. Ultra-rapid and ultradian cycling, consistent with a diagnosis of BP-NOS, are highly prevalent in the youngest children and take long periods of time and complex treatment regimens to achieve euthymia. Lithium and atypical antipsychotics are effective in mania, but treatment of depression remains obscure, with the exception of lurasidone, for children ages 10-17. Treatment of the common comorbid anxiety disorders, oppositional defiant disorders, pathological habits, and substance abuse are all poorly studied and are off-label. Cognitive dysfunction after a first manic hospitalization improves over the next year only on the condition that no further episodes occur. Yet comprehensive expert treatment after an initial manic hospitalization results in many fewer relapses than traditional treatment as usual, emphasizing the need for combined pharmacological, psychosocial, and psycho-educational approaches to this difficult and highly recurrent illness.

Download Full-text

Treatment of bipolar depression with supraphysiologic doses of levothyroxine: a randomized, placebo-controlled study of comorbid anxiety symptoms

International Journal of Bipolar Disorders ◽

10.1186/s40345-019-0155-y ◽

2019 ◽

Vol 7 (1) ◽

Author(s):

Maximilian Pilhatsch ◽

Thomas J Stamm ◽

Petra Stahl ◽

Ute Lewitzka ◽

Anne Berghöfer ◽

...

Keyword(s):

Bipolar Disorder ◽

Rating Scale ◽

Bipolar Depression ◽

Phenotypic Expression ◽

Anxiety Symptoms ◽

Controlled Study ◽

Double Blind ◽

Comorbid Anxiety ◽

Depressed Patients ◽

Depressive Episodes

Abstract Background Symptoms of anxiety co-occur in a variety of disorders including in depressive episodes of bipolar disorder and in patients with thyrotoxicosis. Treatment of refractory bipolar disorder with supraphysiologic doses of levothyroxine (L-T4) has been shown to improve the phenotypic expression of the disorder and is associated with an increase of circulating thyroid hormones. However, it might be associated with somatic and mental adverse effects. Here we report the investigation of the influence of treatment with supraphysiologic doses of L-T4 on symptoms of anxiety in patients with refractory bipolar depression. Methods Post-hoc analysis from a 6-week, multi-center, randomized, double-blind, placebo-controlled study of the effects of supraphysiologic L-T4 treatment on anxiety symptoms in bipolar depression. Anxiety symptoms were measured weekly with the Hamilton anxiety/somatization factor (HASF) score of the Hamilton Depression Rating Scale (HAMD) and the State- and Trait Anxiety Inventory (STAI). Results Treatment of both groups was associated with a significant reduction in anxiety symptoms (p < 0.001) with no statistical difference between groups (LT-4: from 5.9 (SD = 2.0) at baseline to 3.7 (SD = 2.4) at study end; placebo: from 6.1 (SD = 2.4) at baseline to 4.4 (SD = 2.8) at study end; p = 0.717). Severity of anxiety at baseline did not show a statistically significant correlation to the antidepressive effect of treatment with supraphysiologic doses of L-T4 (p = 0.811). Gender did not show an influence on the reduction of anxiety symptoms (females: from 5.6 (SD = 1.7) at baseline to 3.5 (SD = 2.4) at study end; males: from 6.1 (SD = 2.3) at baseline to 4.0 (SD = 2.4) at study end; p = 0.877). Conclusions This study failed to detect a difference in change of anxiety between bipolar depressed patients treated with supraphysiologic doses of L-T4 or placebo. Comorbid anxiety symptoms should not be considered a limitation for the administration of supraphysiologic doses of L-T4 refractory bipolar depressed patients. Trial registration ClinicalTrials, ClinicalTrials.gov identifier: NCT01528839. Registered 2 June 2012—Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT01528839

Download Full-text

The Rapid Mood Screener: A Novel and Pragmatic Screener Tool for Bipolar I Disorder

CNS Spectrums ◽

10.1017/s1092852920002709 ◽

2021 ◽

Vol 26 (2) ◽

pp. 167-168

Author(s):

C. Brendan Montano ◽

Mehul Patel ◽

Rakesh Jain ◽

Prakash S. Masand ◽

Amanda Harrington ◽

...

Keyword(s):

Risk Factors ◽

Primary Care ◽

Health Outcomes ◽

Screening Tool ◽

Clinical Interview ◽

Clinical Practices ◽

Predictive Values ◽

Bipolar I Disorder ◽

Manic Symptoms ◽

Depressive Episodes

AbstractIntroductionApproximately 70% of patients with bipolar disorder (BPD) are initially misdiagnosed, resulting in significantly delayed diagnosis of 7–10 years on average. Misdiagnosis and diagnostic delay adversely affect health outcomes and lead to the use of inappropriate treatments. As depressive episodes and symptoms are the predominant symptom presentation in BPD, misdiagnosis as major depressive disorder (MDD) is common. Self-rated screening instruments for BPD exist but their length and reliance on past manic symptoms are barriers to implementation, especially in primary care settings where many of these patients initially present. We developed a brief, pragmatic bipolar I disorder (BPD-I) screening tool that not only screens for manic symptoms but also includes risk factors for BPD-I (eg, age of depression onset) to help clinicians reduce the misdiagnosis of BPD-I as MDD.MethodsExisting questionnaires and risk factors were identified through a targeted literature search; a multidisciplinary panel of experts participated in 2 modified Delphi panels to select concepts thought to differentiate BPD-I from MDD. Individuals with self-reported BPD-I or MDD participated in cognitive debriefing interviews (N=12) to test and refine item wording. A multisite, cross-sectional, observational study was conducted to evaluate the screening tool’s predictive validity. Participants with clinical interview-confirmed diagnoses of BPD-I or MDD completed a draft 10-item screening tool and additional questionnaires/questions. Different combinations of item sets with various item permutations (eg, number of depressive episodes, age of onset) were simultaneously tested. The final combination of items and thresholds was selected based on multiple considerations including clinical validity, optimization of sensitivity and specificity, and pragmatism.ResultsA total of 160 clinical interviews were conducted; 139 patients had clinical interview-confirmed BPD-I (n=67) or MDD (n=72). The screening tool was reduced from 10 to 6 items based on item-level analysis. When 4 items or more were endorsed (yes) in this analysis sample, the sensitivity of this tool for identifying patients with BPD-I was 0.88 and specificity was 0.80; positive and negative predictive values were 0.80 and 0.88, respectively. These properties represent an improvement over the Mood Disorder Questionnaire, while using >50% fewer items.ConclusionThis new 6-item BPD-I screening tool serves to differentiate BPD-I from MDD in patients with depressive symptoms. Use of this tool can provide real-world guidance to primary care practitioners on whether more comprehensive assessment for BPD-I is warranted. Use of a brief and valid tool provides an opportunity to reduce misdiagnosis, improve treatment selection, and enhance health outcomes in busy clinical practices.FundingAbbVie Inc.

Download Full-text