US researchers have found that the phenomenon of “mixed hypomania” occurs frequently in pediatric bipolar II patients and tends to go unrecognized in early daytime assessments.

The DSM-IV recognizes mania and mixed phases but not the state of mixed hypomania where mixed features involve hypomania rather than mania.

“Our preliminary observations suggest that the phenomenon described by us is quite common among bipolar children and adolescents presenting in an outpatient setting and should therefore command public health attention and efforts directed at replication,” say Steven Dilsaver (Comprehensive Doctors Medical Group Inc., Arcadia, California) and Hagop Akiskal (University of California, San Diego).

The authors evaluated 47 bipolar patients aged 7??”17 years presenting to an outpatient clinic using a structured instrument designed to detect the presence of major depressive episodes (MDE), hypomania, psychotic disorders, and behavioral disorders. Mixed hypomania was defined as MDE and hypomania occurring over at least a 2-week period.

Overall, 85.2% of patients were classified as either bipolar I mixed or bipolar II mixed (38.3%). Focusing the study on the 18 mixed bipolar II patients, the researchers found that this group tended to experience morning depression and some combination of nocturnal rising or elated mood often presented with spikes of euphoria and increased goal-directed activity between the hours of 1900 and 0300. Furthermore, 27.8% of patients showed an inversion of the sleep??”wake cycle.

The researchers found that when patients were seen in the morning, they appeared depressed and showed no signs for a concurrence of depressive and hypomanic symptoms apart from irritability. Conversely, when seen in the mid-to-late afternoon they exhibited irritability, distractibility, and the emergence of psychomotor activation relative to earlier on in the day.

“It is our impression that patients, when seen in the mid-to-late afternoon, sometimes exhibited a transitional state between depressive and hypomanic syndromes,” write Dilsaver and Akiskal in the Journal of Affective Disorders.

They point out that for diagnosing mixed hypomania the clinician must attune to the behavior and experience of a patient over a 24-hour cycle. Additionally, the misleading lack of features of hypomania other than irritability during early assessments “can mislead clinicians into concluding that a patient has major depressive disorder and that treatment with an antidepressant is indicated,” say the authors.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a part of Springer Science+Business Media. © Current Medicine Group Ltd; 2009

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Long-term poor functional outcome among bipolar disorder patients may be linked to both cognitive impairment and the time spent with subsyndromal depressive symptomatology, Argentinean study findings indicate.

Cognitive impairment has been shown to be negatively associated with measures of disability and social and occupational functioning, but there is a lack of data examining the ability of cognitive impairments to predict long-term functional outcome.

Sergio Strehilevich and colleagues from the Favaloro Foundation in Buenos Aires therefore administered a neurocognitive battery assessing verbal memory, attention, and executive function to 35 patients with euthymic bipolar disorder and 30 mentally healthy controls matched for age and years in education.

The patients were assessed every 1??”4 weeks for ?1 year, with the course of illness documented using a modified life charting technique. The General Assessment to Functioning (GAF) and the Functioning Assessment Short Test (FAST) were used to determine psychosocial functioning at the end of the follow-up period.

Patients had lower performance than healthy controls on measures of verbal memory, attention, and executive function. There were no significant differences between patients and controls in terms of age, gender, years in education, and baseline scores on the Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HDRS).

The team found significant association between GAF scores at the end of follow-up and subsyndromal depressive symptomatology, along with impairments in verbal memory, attention, and executive function. Further analysis revealed that around 43% of the variance in GAF scores was accounted for by subsyndromal depressive symptomatology, and impairments in attention and verbal memory.

Similar results were seen for FAST scores, the researchers note in the Journal of Affective Disorders, with 28% of the variance of scores at the end of follow-up accounted for by impairments in attention and executive function. The results for both functioning assessments were unmodified by YMRS and HDRS scores.

“In summary, our findings bring further evidence that both cognitive impairments as well as subsyndromal depressive symptomatology are illness features associated with long-term functional outcome,” the team says.

“These results point out the importance of in which way developing strategies to improve cognitive impairments and subsyndromal symptomatology may lead to more comprehensive treatments and contribute to enhance the long-term functional outcome in patients with bipolar disorder.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a part of Springer Science+Business Media. © Current Medicine Group Ltd; 2009

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Both bipolar disorder and genetic liability for the condition are characterized by disturbances to the structural integrity within specific intra- and interhemispheric tracts within the brain, conclude scientists.

Previous studies have revealed white matter hyperintensities and volume deficits on structural magnetic resonance imaging in bipolar disorder patients and unaffected relatives at high genetic liability, as well as white matter coherence impairments in frontal regions on diffusion tensor imaging (DTI).

To examine changes in fractional anisotropy in the whole brain, Christopher Chaddock, from the Institute of Psychiatry in London, UK, and colleagues performed DTI on 19 psychotic bipolar I disorder patients, 21 unaffected first-degree relatives, and 18 healthy controls.

Brain voxel-based analysis was used to compare fractional anisotropy for patients, relatives, and controls, and related to findings on a genetic liability scale in unaffected relatives.

The three groups were similar in terms of age, gender, handedness, full-scale IQ, years of education, and parental social class. All patients were in illness remission, despite experiencing subsyndromal symptoms. The average duration of illness was 15.6 years.

Compared with controls, patients had significant fractional anisotropy reductions in a bilateral frontal cluster extending from deep frontal white matter to include the genu of the corpus callosum and a left lateralized portion of the internal capsule, a right temporal cluster extending superiorly toward the parietal lobe, and a superior frontal cluster.

In addition, fractional anisotropy was strongly correlated among brain regions, with the first principal component accounting for 88% of the total variance. The cluster associations were unaffected by gender, current versus no medication, symptom scores, or number of hospitalizations.

In contrast, no significant clusters of either increased or decreased fractional anisotropy were detected between unaffected relatives and controls, the team writes in the British Journal of Psychiatry.

They did find, however, that increasing genetic liability for bipolar disorder was significantly associated with lower fractional anisotropy in 70 distributed clusters incorporating several white matter tracts, including the cerebellum and brainstem, longitudinal fasciculus and unicate, and bilateral deep frontal white matter. This negative correlation was identified in both patients and unaffected relatives, at r values of -0.814 and -0.717, respectively.

The team concludes: “It is not possible to clarify the exact cause of a reduction in fractional anisotropy, as this can be influenced by a change in the organization or orientation of white matter tracts, a reduction in density of white matter fibres or a reduction in myelination.

“In bipolar disorder, there is some evidence pointing to a role of disrupted myelination, with increased apoptosis and necrosis of oligodendrocytes and a downregulation of myelination and oligodendrocyte-related genes previously identified.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a part of Springer Science+Business Media. © Current Medicine Group Ltd; 2009

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