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Patients with bipolar disorder (BD) with an initial mixed mood episode experience greater levels of morbidity over subsequent months than those with an initial episode of mania.
“Mixed-states involve complex admixtures of rapid alternations of mainly excited or mainly depressive states,” explain Ross Baldessarini (Harvard Medical School, Boston, Massachusetts, USA) and team.
They add: “There is growing evidence that early BD mixed states may be followed by particularly severe later morbidity.”
Regarding morbidity after an initial mood episode, they also say that “there appears to be a tendency to consider manic and mixed episodes… as closely related.”
To investigate further, the researchers studied 247 BD patients (54% men), of whom 97 presented with an initial DSM-IV mixed episode and 150 with an initial episode of mania.
Morbidity was assessed on a weekly basis over a follow-up period of 24 months, and included DSM-IV manic, hypomanic, mixed, or major depressive states, as well as less severe dysthymic or dysphoric states that did not meet DSM-IV criteria but appeared to be clinically significant.
The researchers found that patients with an initial mixed episode spent 60.0% of the weeks during follow up in a morbid state compared with 37.8% of follow-up weeks among patients with an initial episode of mania. Indeed, morbidity levels during follow up were 1.59 times greater among patients with an initial mixed episode than among those with an initial episode of mania.
Patients with an initial mixed episode also had 11.9 times more mixed-states, 6.54 times more major depressive episodes, and 1.69 times more dysthymia during follow up than patients presenting with mania.
In contrast, patients with a first episode of mania had significantly more mania and hypomania episodes during follow up than those with an initial mixed episode.
Baldessarini and team summarize: “The present findings indicate strongly that initial mixed-states of DSM-IV type-I BPD were not only followed by more weeks of illness during two years of follow-up, but also much more mixed, depressive, and dysthymic illness, and much less mania, hypomania, or psychotic illness compared to patients presenting initially in relatively pure mania.”
They conclude: “The findings support two markedly dissimilar subtypes of BD, and call for more explicit therapeutic studies of mixed-states.”
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010
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Stressful life events are associated with delays in functional recovery among bipolar disorder patients who have been treated for an episode of mania, US researchers have found.
“There has been considerable research aimed at understanding the clinical course of bipolar disorder… [but] somewhat less research has explored the predictors of psychosocial functioning or the delay between clinical and functional recovery after episodes,” explain Constance Hammen (University of California, Los Angeles) and team.
They add: “Identifying predictors of functional recovery in bipolar disorder is critical to treatment efforts to help patients re-establish premorbid levels of role adjustment following an acute manic episode.”
To investigate the influence of stressful life events on functional recovery after a manic episode, the team studied 65 patients, aged an average of 36.8 years, with bipolar I disorder.
The participants, who had all been treated for a manic episode, were followed-up monthly from the point of clinical recovery until they had attained functional recovery, or for a maximum of 9 months if they did not achieve functional recovery. Stressful life events were assessed every 3 months.
Functional recovery in four domains (friendship, family, home duties, work/school) was assessed using the Life Functioning Questionnaire (LFQ), with individual items scored on a 4-point Likert scale ranging from one (no problems) to four (severe problems). Functional recovery in a domain was defined as a mean score of ?1.5 across items in that domain.
Overall, functional recovery status was attained by 35 (54%) patients in all four domains, and all but three participants reached functional recovery status in at least one of the four domains. Rates of functional recovery did not differ significantly across domains.
The researchers found that delayed recovery of work/school functioning was significantly associated with one or more stressful life events in the previous 3 months (odds ratio [OR=7.93), as was delayed recovery in the domains of friendship (OR=7.99) and family (OR=10.37). There was no significant association between delayed recovery and stressful life events in the home duties domain.
The presence of stressful life events in the previous 3 months was also associated with recovery time.
For example, in the work/school domain, participants who did not experience a stressful life event had a mean time to recovery of 11.4 days compared with 111.7 days among participants who did experience such an event. In the friendship domain, participants who did not experience a stressful life event had a mean time to recovery of 3.8 days compared with a mean recovery time of 58.4 days among participants who did.
Hammen and team conclude in the journal Psychiatry Research: “The experience of stressful life events may create delays in attaining adequate functional outcomes even after symptomatic recovery.
“Thus, even after patients recover symptomatically from mania, clinicians should consider how they can be vigilant and helpful in dealing with the disruptions caused by stressful events, thus promoting patients’ rapid return to adequate levels of functioning in important roles.”
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010
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Results from a systematic review and meta-analysis show that bipolar disorder (BD) patients with a history of psychosis have poorer cognitive functioning than such patients without such a history.
“It has been suggested that patients with psychotic BD might have more severe cognitive deficits than non-psychotic BD,” explain Emre Bora (The University of Melbourne and Melbourne Health, Victoria, Australia) and team.
“However, only a handful of studies have compared cognition between psychotic BD and non-psychotic BD,” they add.
To examine the evidence for cognitive deficits associated with psychosis in BD patients, the researchers searched the literature for relevant studies published between 1987 and 2009.
In total, 11 studies involving 435 BD patients with a history of psychosis and 339 BD patients without such a history met criteria for inclusion in the meta-analysis.
There were no significant differences in gender and duration of illness between the two groups, the researchers note. However, psychotic BD patients had significantly more inpatient admissions, were younger at illness onset, and used antipsychotics more commonly than non-psychotic BD patients.
Analysis of the pooled results revealed that, overall, psychotic BD patients performed significantly worse than non-psychotic patients in four of the six assessed cognitive domains, including planning and reasoning, working memory, verbal memory, and processing speed.
When the analysis was restricted to studies including BD I patients (seven studies), those with psychotic BD remained more impaired than non-psychotic BD patients in the above domains.
However, there were no significant differences between the groups in the cognitive domains of attention and visual memory.
Between-group differences were significant for a number of individual tests, including the List Learning, Delayed Recall, Trail Making B, Wisconsin Card Sorting Test, Digits Backwards, Stroop Interference, and Semantic Fluency tests.
Bora and team conclude: “This meta-analytic study confirms the notion that history of psychosis is associated with poorer cognitive functioning in BD.
They add: “Future studies should examine psychotic and non-psychotic BD samples separately since a history of psychosis affects cognition in BD. The effect of thought disorder and mood congruency on psychosis and cognition in BD should also be examined.”
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010
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Results from an Egyptian study show that remitted bipolar disorder patients with recurrent mood episodes have greater deficits in attention and executive function than first-episode patients.
“There is a growing consensus that persistent cognitive deficits are common in patients with bipolar disorders even when they are euthymic,” explain Ahmed Mansour and colleagues from Ain Shams University in Cairo.
To investigate cognitive deficits among BD patients, and to assess whether the extent of such deficits are greater in BD with recurrent mood episodes, the team enrolled 50 BD patients who had experienced a single manic episode (group I), 50 BD patients who had experienced recurrent mood episodes (group II), and 50 mentally healthy controls.
Patients in group II had experienced a mean of 5.8 previous mood episodes, the researchers note in the Journal of Affective Disorders.
All of the BD patients met criteria for remission at the time of the study, and there were no significant differences between all 3 groups regarding age, gender, religion, marital status, education, and occupation status.
The participants’ cognitive abilities were assessed using a variety of tests, including the Wisconsin Card Sorting Test (WCST), the Trail Making Test (TMT) , the Wechsler Memory Scale-Revised (WMS-R), and the Wechsler Adult Intelligence Scale (WAIS).
The researchers found that patients in group I had poorer attention, executive function, total memory than controls, as indicated by TMT A scores of 94.40 versus 83.70, WCST1 scores of 26.14 versus 10.52, and WMS-R scores for total memory of 62.93 versus 74.51.
Patients in group II, however, had poorer attention and executive function than those in group I, with mean TMT A and WCST1 scores among group II patients of 152.00 and 28.62, respectively.
Mansour and team conclude: “In the current study, patients with a single manic episode showed impairment in attention, executive function and total memory score compared to control subjects [and] patients with BD with recurrent episodes in remission performed worse than those with a single episode in attention and executive function.”
They add: “Attention and executive dysfunction is deteriorated by the recurrence of bipolar episodes.”
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010
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Bipolar disorder (BD) patients can be divided into three groups based on age-at-onset (AAO) distributions, with patients in the earliest AAO group at greatest risk for suicide attempts, research shows.
In BD, “the ability to identify clinical variables capable of explaining some of the disease heterogeneity could improve the identification of the underlying pathophysiological bases of the disease,” explain Federica Tozzi (GlaxoSmithKline R&D, Verona, Italy) and team.
They add: “As for other neuropsychiatric diseases, AAO has been proposed as a promising criterion by which to select more homogeneous subgroups of BD patients.”
To investigate further, the team studied data on 964 patients with BD, aged an average of 47.2 years (range 18-84 years), recruited from three hospitals in Canada and the UK.
Data on clinical variables and AAO were collected from interviews with the patients using the Schedules for Clinical Assessment in Neuropsychiatry.
The researchers found that the mean AAO was 21.4 years, with AAO showing a peak frequency between the ages of 15 and 17 years, and a steady decrease after 21 years.
Admixture analysis revealed three distinct distributions of AAO, with age means of 16.1, 25.4, and 32.2 years, representing 64%, 6%, and 30% of the patients, respectively.
Further analysis showed that patients in the earliest onset group were 2.54 times more likely to have had depression at onset, 1.78 times more likely to have bipolar I disorder rather than bipolar II disorder, and 1.47 times more likely to have attempted suicide than those in the later-onset groups.
The risk for suicide attempts decreased with increasing AAO and was not affected by duration of illness, the researchers note in the journal Psychiatry Research.
Tozzi and team conclude: “Our results indicate that the AAO distribution in BD patients can be subdivided by admixture analysis into three normal distributions.”
They add: “The evidence of AAO subgroups characterized by distinct clinical traits has implications for future research, suggesting AAO as a variable to consider in the investigation of biological and environmental risk factors for BD.”
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2011
Family income is associated with self-reported mood symptoms in patients with bipolar disorder, researchers have found.
“Investigations of a wide range of diseases and populations using diverse methodologies have found an inverse relation between socioeconomic status (SES) and health,” explain Michael Bauer (Technische Universität Dresden, Germany) and team.
“However, relatively little is understood about the impact of income on treatment response and outcome for patients with bipolar disorder,” they add.
To investigate whether there is a link between median family income and daily self-reported mood symptoms in such patients, the team studied 284 individuals with bipolar disorder, aged at least 18 years, who provided daily self-reported mood ratings for 6 months.
Data obtained for the census tract where each patient lived was used to estimate median family income, which ranged from $14,100 (€10,907) to $257,200 (€198,964). The participants were divided into low (29.5%), middle (42.0%), and high (28.5%) income groups based on median family incomes of $64,000 (€49,476) or less, $64,001-$103,999 (€49,464-€80,377), and $104,000 (€80,341) or higher, respectively.
Using income as both a continuous and categorical variable, the researchers found a significant positive association between income and euthymia, and a significant negative association between income and manic/hypomanic symptoms.
Overall, patients in the lower-income group spent 12.4% and 9.7% fewer days in a euthymic state than those in the upper- and middle-income groups, respectively. Patients in the lower-income group also spent 7.1% and 4.1% more days with manic/hypomanic symptoms than those in the upper- and middle-income groups, respectively.
However, there was no significant association between income and depressive symptoms among the participants.
Bauer and team conclude: “The results of this study suggest a clear association between family income and mood in bipolar disorder.”
They add: “Inclusion of income as a measure of SES is recommended for future studies of treatment response and outcome in bipolar disorder in the United States.”
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2011
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Results from a Chinese study show that bipolar disorder (BD) patients have abnormalities in white matter tracts connecting the frontal cortex with the temporal and parietal cortices and the fronto-subcortical circuits.
Writing in the Journal of Affective Disorders, Fuchun Lin (Chinese Academy of Sciences, Wuhan) and colleagues explain that “abnormalities in white matter have previously been demonstrated in the patients with BD with region-of-interest and voxel-based analyses.”
But they add: “The lack of any diffusion tensor imaging (DTI) tractography studies on bipolar disorder has lead to uncertainty about which specific white matter tracts are affected by this disorder.”
To address this, the team studied 18 patients with BD, aged an average of 28.5 years, and 16 age- and gender-matched mentally healthy controls.
None of the BD patients were younger than eighteen years or had any concurrent psychiatric or medical illness, including substance addiction.
All of the participants underwent DTI brain scans, and tractography was used to reconstruct images of the frontal cortex white matter tracts, including the anterior thalamic radiation (ATR), uncinate fasciculus (UF), superior longitudinal fasciculus (SLF), cingulum, and inferior fronto-occipital fasciculus (IFO).
Fractional anisotropy (FA) values for each white matter tract were compared between BD patients and controls.
After accounting for age and gender, the researchers found that BD patients showed significantly lower FA values in the ATR and UF, and a trend towards lower FA values in the SLF and cingulum. However, there were no significant differences between the groups regarding FA values in the IFO.
Lin and team conclude: “DTI tractography analysis in this study revealed evidence of abnormalities in white matter tract connectivity between the frontal cortex and the temporal and parietal cortices and the fronto-subcortical circuits in BD.”
They add: “Our findings support that abnormal white matter tracts which connect with the frontal lobe may be involved in the neuropathology of bipolar disorder.”
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2011
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Patients with bipolar disorder and comorbid
obsessive-compulsive disorder (OCD) are more likely to have a
history of suicide attempts, rapid cycling, and alcohol dependence
compared with their peers without anxiety comorbidities, study
results show.
“The data in this report support the notion that comorbid OCD is
fairly common, is associated with disease severity, and has
important consequences regarding symptom- and patient-rated
outcomes,” comment Flávio Kapczinski (Hospital de
Clínicas de Porto Alegre, Brazil) and colleagues.
The prominence of anxiety in general and OCD in particular among
patients with bipolar disorder has long been acknowledged. Recent
studies have tried to investigate the illness burden of OCD, but
comparisons have usually been made between those with and without
OCD comorbidity.
“This is little informative because those patients with any
comorbidity tend to differ in a number of measures from those with
‘pure’ bipolar disorder,” the researchers explain in the journal
Comprehensive Psychiatry.
To address this, they performed a cross-sectional study of
lifetime comorbidities in 259 patients with bipolar disorder, using
anxiety comorbidities as a “more rigorous control group with the
aim of uncovering more specific correlates of OCD comorbidity in
bipolar disorder.”
Kapczinski et al report that lifetime prevalence of any
anxiety disorder was 55.6%, and of OCD, 12.4%. Current prevalence
of OCD was 8.5%; although no cases were detected during mania, it
was diagnosed in 8.4% of those in a euthymic phase, 13.9% of those
depressed, and 13.0% of those with mixed episodes.
The researchers note that this fits with recent studies showing
that obsessions or compulsions may remit during mania to reappear
in depression.
Compared with patients with no anxiety comorbidity, those with
lifetime OCD were more likely to be women (61.8% vs 84.4%), to have
a longer period of untreated illness (8 vs 13 years), have a
lifetime history of suicide attempts (35% vs 70%), rapid cycling
(14% vs 39%), and alcohol dependence (10% vs 31%).
Patients with OCD also had higher depression and anxiety symptom
scores than those without anxiety comorbidity, but fewer manic
symptoms.
Meanwhile, when compared with patients with other lifetime
anxiety disorders, those with OCD comorbidity had a lower quality
of life on the social domain.
Kapczinski et al comment: “Patients with OCD are troubled
by thoughts and behaviors, which seem frequently repugnant and
further restrict their social functioning.
“They also often incite friends or family members to engage in
their illness-related behaviors, which may result in conflict.”
MedWire (www.medwire-news.md) is an independent clinical news
service provided by Current Medicine Group, a trading division of
Springer Healthcare Limited. © Springer Healthcare Ltd;
2010
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Remitted bipolar disorder patients have unique dysfunctional beliefs compared with unipolar patients and healthy individuals, say UK scientists who believe the findings could help the development of specific behavioral therapies.
To date, cognitive behavioral therapy modified for bipolar disorder has yielded disappointing results. While differences in dysfunctional beliefs noted between unipolar and bipolar patients have been identified that could improve therapeutic approaches, until recently there has been no reliable method of assessing beliefs in remitted bipolar disorder patients.
Y Alatiq and colleagues from the University of Oxford therefore administered the Hypomanic Attitudes and Positive Prediction Inventory (HAPPI), as well as the Dysfunctional Attitudes Scale (DAS) to 40 remitted bipolar disorder patients, 20 remitted unipolar patients, and 20 healthy controls.
There were no significant differences in terms of the history of depression or current depressive mood symptoms between bipolar and unipolar patients, both scoring significantly more than controls. Bipolar patients scored more highly on current manic symptoms than both unipolar patients and controls, with no significant differences between the latter.
There were no significant differences between the groups in DAS scores, whether in terms of total scores of any of the subscales, or after taking age into account, the team reports in the Journal of Affective Disorders.
Bipolar patients had significantly higher HAPPI scores than unipolar patients and controls in terms of total scores as well as scores on the self-catastrophic beliefs, other negative beliefs, and response style, even after controlling for age. There were no significant differences between unipolar patients and controls.
The team writes: “To conclude, the study has confirmed that bipolar patients when in remission hold dysfunctional beliefs related to the elevated mood experience which are found to be specific to bipolar disorder.”
They add: “Further study is now needed to look at whether cognitive behavioural therapy for bipolar disorder might benefit from working on such beliefs.”
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
Children aged 8??”12 years with major mood disorders experience improved outcomes with brief, adjunctive multifamily psychoeducational group psychotherapy, conclude US researchers.
Mood disorders in youth are a major health concern, yet there are few established treatments. Psychosocial treatments are recommended for childhood depression and bipolar disorder; however, evidence to support these recommendations is lacking.
To investigate the benefits of adjunctive multifamily psychoeducational psychotherapy, Mary Fristad, from Ohio State University in Columbus, and colleagues randomly assigned 165 children aged 8??”12 years with depression or bipolar disorder to receive multifamily psychoeducational psychotherapy plus treatment as usual or a wait-list control condition plus treatment as usual.
The treatment consisted of eight 90-minute sessions with the child and at least one parent, combining psychoeducation, family systems, and cognitive behavioral psychotherapy in order to learn about mood disorders and their treatment, gain support from other families, and build skills. Participants were assessed at baseline and after 6, 12, and 18 months, with the intervention applied to the treatment group between baseline and 6 months, and between 12 and 18 months for the control group.
On intention-to-treat analysis, intervention patients experienced a 6.48-point greater decrease in Mood Severity Index (MSI) scores over the first 12 months compared with controls, at an effect size of 0.53. Although control patients experienced a nonsignificant increase in scores over the final 6 months of treatment, the rate of improvement was similar to that seen in the intervention group, at 7.00 and 6.48 points per year, respectively.
Focusing on patients who completed treatment, the team found similar results to those observed on the intention-to-treat analysis, but with a larger effect, such that intervention patients had an 8.17-point greater decrease in MSI scores versus controls over the first 12 months, at an effect size of 0.68.
Noting the benefits of the intervention, the team concludes in the Archives of General Psychiatry: “Clinicians who treat children can incorporate cognitive behavior and family systems components of multifamily psychoeducational psychotherapy into their practice.
“Researchers who investigate psychosocial interventions for mood disorders may consider comparing the relative efficacy of multifamily psychoeducational psychotherapy with that of other psychosocial interventions for children with depression and bipolar disorder as well as possible moderators and mediators of treatment.”
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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