Introduction
Mixed states in bipolar disorder (BD) are characterized by the simultaneous occurrence of both manic and depressive features. Growing evidence suggests that they are associated with ...longer duration of illness, increased relapse risk, and higher prevalence of comorbidities. Suicide risk among BD patients is up to 20–30 times greater than in the general population, although there is not a univocal consensus in whether mixed states should be considered as a high-risk state for suicide.
Objectives
The objective of this study was to identify whether depressive and hypo/manic episodes with mixed features, are associated with more frequent suicidal behavior or ideation when compared to pure hypo/manic and depressive ones. We hypothesized that suicidal ideation or behavior would be more common in those experiencing mixed symptoms. We subsequently also tested whether gender or bipolar subtype moderated the relation between mood and suicidality.
Methods
In a naturalistic study, 903 adult BD outpatients participating in the Stanley Foundation Bipolar Network were followed longitudinally across 14,213 visits for 7 years. The scores at the Inventory of Depressive Symptomatology–Clinician-Rated Version (IDS-C) and at the Young Mania Rating Scale (YMRS), administered at each visit, were used to define the mood episode. Given partial overlap of items between these scales, analyses were also conducted by removing overlapping items. The presence of suicidality was evaluated through the 18th item of the IDS-C (Suicidal Ideation).
Results
During the observation period, up to 60.7% of subjects had at least one visit with suicidal ideation or behavior, broadly defined as a score ≥ 1 at the 18th item of the IDS-C. The distribution of suicidality among visits in different mood states is reported in Figure 1 (N° of visits in which suicidality was detected by mood state at the time of visit). Depressive symptoms were associated with suicidal ideation and behavior either during mixed depression and hypo/mania (p < 0.0001). Hypomanic or manic symptoms appeared to be related to suicidality only during hypo/mania, either pure or mixed (p 0.007). When overlapping items between the two psychometric scales were removed results seemed to confirm these hypotheses. Moreover, male gender appeared to have a protective role against suicidal ideation when hypo/manic (p 0.002).
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Conclusions
The primary role of depressive symptoms in predicting suicidal risk was confirmed by our results, which however suggest that mixed symptoms relate to suicidal ideation and behavior more intensely than pure hypo/manic symptoms. More importantly, hypo/manic symptoms did not appear to have a protective role during mixed episodes. Future studies considering also deaths by suicide are required in order to better clarify the role of mixity on suicidality.
Disclosure of Interest
None Declared
Introduction
Mixed states, the co-occurrence of manic and depressive symptoms, were recognized and described from the time of antiquity. DSM-5 first, and DSM-5-TR after, introduced the ‘’mixed ...features’’ specifier, defined by the presence of at least three non-overlapping opposite-pole symptoms during a syndromic depressive, hypomanic, or manic episode. Various manifestations, including irritability, distractibility, anxiety, psychomotor agitation, were excluded from the specifier, since they can occur during both depressive and hypo/manic episodes and other mental illnesses.
Objectives
The objective of this study was to evaluate the phenomenology and prevalence of mixed states among bipolar disorder (BD) patients. We first assessed the frequency of specific features during different mood states. Then, we estimated the prevalence of mixed states by applying DSM-5 criteria, comparing it qualitatively with the one detected from psychometric questionnaires.
Methods
In a naturalistic study, 903 adult outpatients with BD participating in the Stanley Foundation Bipolar Network were followed longitudinally across 14,213 visits for 7 years. The scores at the Inventory of Depressive Symptomatology–Clinician-Rated Version (IDS-C) and at the Young Mania Rating Scale (YMRS), administered at each visit, were used to define the mood episode and to assess the frequency of specific symptoms. In addition, we applied DSM-5 criteria for “with mixed features” to our sample, to examine a DSM-5-based construct.
Results
Specific symptomatic profiles differentiate mixed states from pure ones (Figure 1 and 2). Mainly, a higher prevalence of irritability was found during mixed episodes, both depressive and hypo/manic, compared to pure depression (0.60 vs. 1.20, p < 0,001) and hypo/mania (0.82 vs. 1.54, p < 0,001), as reported at the 6th item of IDS-C.
Figure 1. Individual YMRS items scores in visits with pure depression, mixed depression, pure hypo/mania and mixed hypo/mania.
Figure 2. Individual IDS-C items scores in visits with pure depression, mixed depression, pure hypo/mania and mixed hypo/mania.
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Conclusions
Preliminary results of the present study showed that symptoms like irritability are strongly prevalent during mixed states. Moreover, the DSM-5 diagnostic criteria for “with mixed features” specifier for any of the mood episodes detected lower rates of mixed states, hence this criteria may yield inadequate sensitivity in recognizing patients suffering from such conditions.
Disclosure of Interest
None Declared
Abstract Introduction Sleep disturbance is a core feature of bipolar disorder. To date there are a limited number of studies that compare subjective and objective measures of sleep in populations of ...subjects with mood disorders. This study evaluated the relationship between subjective and objective measurements of total sleep time (TST) in a bipolar type I disorder (BD I) population. Methods Thirty-nine subjects diagnosed with BD I participated in the study. Mood symptoms were assessed via YMRS and IDS-30-C. Subjects wore an actigraph device and maintained a sleep diary for seven consecutive days. Differences between TST as estimated via sleep diaries and actigraphy were calculated. Results Objective and subjective measures of TST were significantly correlated ( r =0.5151, p =0.0008). Secondary analysis revealed that the severity of depressive symptoms did correlate to this discrepancy ( t =2.65, p =0.01). Limitations The impact that medications have on the accuracy of TST reported was not investigated. Also, sleep diaries may have acted to prompt subjects to pay closer attention to their sleep habits and therefore more accurately report TST than in the average clinical setting. Conclusion The results of the current study demonstrate a significant correlation between the estimation of TST as measured objectively via actigraphy and subjectively via sleep diaries in BD patients. Mood symptomotology might impact the accuracy of TST reported. Further study is warranted.
The present study provides additional data on the psychometric properties of the 30-item Inventory of Depressive Symptomatology (IDS) and of the recently developed Quick Inventory of Depressive ...Symptomatology (QIDS), a brief 16-item symptom severity rating scale that was derived from the longer form. Both the IDS and QIDS are available in matched clinician-rated (IDS-C30; QIDS-C16) and self-report (IDS-SR30; QIDS-SR16) formats.
The patient samples included 544 out-patients with major depressive disorder (MDD) and 402 out-patients with bipolar disorder (BD) drawn from 19 regionally and ethnicically diverse clinics as part of the Texas Medication Algorithm Project (TMAP). Psychometric analyses including sensitivity to change with treatment were conducted.
Internal consistencies (Cronbach's alpha) ranged from 0.81 to 0.94 for all four scales (QIDS-C16, QIDS-SR16, IDS-C30 and IDS-SR30) in both MDD and BD patients. Sad mood, involvement, energy, concentration and self-outlook had the highest item-total correlations among patients with MDD and BD across all four scales. QIDS-SR16 and IDS-SR30 total scores were highly correlated among patients with MDD at exit (c = 0.83). QIDS-C16 and IDS-C30 total scores were also highly correlated among patients with MDD (c = 0.82) and patients with BD (c = 0.81). The IDS-SR30, IDS-C30, QIDS-SR16, and QIDS-C16 were equivalently sensitive to symptom change, indicating high concurrent validity for all four scales. High concurrent validity was also documented based on the SF-12 Mental Health Summary score for the population divided in quintiles based on their IDS or QIDS score.
The QIDS-SR16 and QIDS-C16, as well as the longer 30-item versions, have highly acceptable psychometric properties and are treatment sensitive measures of symptom severity in depression.
Few studies have examined the relative risks of switching into hypomania or mania associated with second-generation antidepressant drugs in bipolar depression.
To examine the relative acute effects ...of bupropion, sertraline and venlafaxine as adjuncts to mood stabilisers.
In a 10-week trial, participants receiving out-patient treatment for bipolar disorder (stratified for rapid cycling) were randomly treated with a flexible dose of one of the antidepressants, or their respective matching placebos, as adjuncts to mood stabilisers.
A total of 174 adults with bipolar disorder I, II or not otherwise specified, currently in the depressed phase, were included. All three antidepressants were associated with a similar range of acute response (49-53%) and remission (34-41%). There was a significantly increased risk of switches into hypomania or mania in participants treated with venlafaxine compared with bupropion or sertraline.
More caution appears indicated in the use of venlafaxine rather than bupropion or sertraline in the adjunctive treatment of bipolar depression, especially if there is a prior history of rapid cycling.
Abstract Background There is some controversy but growing evidence that childhood onset bipolar disorder may be more prevalent and run a more difficult course in the United States than some European ...countries. Methods We update and synthesize course of illness data from more than 960 outpatients with bipolar disorder (average age 40) from 4 sites in the U.S. and 3 sites in Netherlands and Germany. After giving informed consent, patients reported on parental history, childhood and lifetime stressors, comorbidities, and illness characteristics. Results Almost all aspects of bipolar disorder were more adverse in patients from the US compared with Europe, including a significantly higher prevalence of: bipolar disorder in one parent and a mood disorder in both parents; childhood verbal, physical, or sexual abuse; stressors in the year prior to illness onset and the last episode; childhood onsets of bipolar illness; delay to first treatment; anxiety disorder, substance abuse, and medical comorbidity; mood episodes and rapid cycling; and nonresponse to prospective naturalistic treatment. Limitations Selection bias in the recruit of patients cannot be ruled out, but convergent data in the literature suggest that this does not account for the findings. Potential mechanisms for the early onset and more adverse course in the U.S. have not been adequately delineated and require further investigation. Conclusions The data suggest the need for earlier and more effective long-term treatment intervention in an attempt to ameliorate this adverse course and its associated heavy burden of psychiatric and medical morbidity.
Objective: Evaluate the efficacy and tolerability of quetiapine (QTP) combined with lithium (Li) or divalproex (DVP) in the treatment of acute mania.
Methods: Patients were randomized to 21 days of ...double‐blind treatment with QTP plus Li/DVP, or placebo (PBO) plus Li/DVP. QTP was rapidly dosed up to a maximum of 800 mg/day; Li was dosed to 0.7–1.0 mEq/L; or DVP to 50–100 μg/mL.
Results: Fifty‐six of 91 (61.5%) individuals in the QTP + Li/DVP group compared with 49 of 100 (49%) taking PBO + Li/DVP completed the study. A significantly greater mean reduction in total Young Mania Rating Scale (YMRS) score was observed at end‐point in patients receiving QTP + Li/DVP compared with those in the PBO + Li/DVP group (−13.76 versus −9.93; p = 0.021). The response rate (≥50% YMRS improvement) was significantly higher in the QTP + Li/DVP group than in PBO + Li/DVP‐treated patients (54.3% versus 32.6%; p = 0.005), as was the proportion of patients achieving clinical remission (YMRS < 12) (45.7% versus 25.8%; p = 0.007). Patients receiving QTP + Li/DVP also had a significantly greater improvement in Clinical Global Impressions‐Bipolar (CGI‐BP) Severity of Illness scores (−1.38 versus −0.78; p = 0.001). The mean last‐week dose of QTP was 584 mg/day in patients meeting response criteria. Common adverse events (at least 10% and twice the rate of Li/DVP) in the QTP + Li/DVP group included somnolence, dry mouth, asthenia, and postural hypotension.
Conclusions: Quetiapine combined with either Li or DVP has superior efficacy compared with Li or DVP monotherapy for treating patients with bipolar mania. Combination therapy was well‐tolerated and most adverse events were mild, withdrawal because of adverse events being only 5% compared with 6% on Li or DVP monotherapy.
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