Discuss Bipolar
Blog to discuss being Bipolar
A novel scale is able to identify the key features of mixed states in bipolar disorder, and reinforces the notion that the mixed state is a distinct clinical entity, conclude UK researchers.
The received view of bipolar disorder regards the mixed state as merely the sum of its parts, yet a mixture of symptoms is often present in predominantly manic or depressive episodes. There is little consensus as to the diagnosis or measurement of mixed states, and there is no scale for specifically assessing the phenomenon.
A novel scale, developed by Jonathan Cavanagh, from the University of Glasgow, and colleagues, aimed to address this gap. The scale included items on physical activity, verbal activity, thought process, voice level, mood, self-esteem, social contact, sleep, sexual interest, eating habits, weight change, meaning in life, anxiety, feelings of pressure, passage of time, future plans, pain sensitivity, and work capacity.
Each pole of the scale ranged from 1 to 4 and respondents were asked to recall their last manic episodes. It was made clear that they could endorse more than one of the manic and depressive symptoms, as both types may apply at different times during an episode.
The clinical sample consisted of 189 bipolar disorder patients with a confirmed diagnosis, ?1 previous manic episode, ?1 affective episode, and age 18??”65 years. In addition, a community sample of 220 bipolar affective disorder patients were posted the scale, resulting in 122 usable replies.
The average age of the clinical and community samples was 36.7 years and 43.0 years, respectively, the average number of mania episodes was 11.45 and 5.8, respectively, and the average number of depressive episodes was 15.24 and 5.8, respectively.
Factor analysis for the sum total manic plus depression item scores indicated the presence of a two-factor solution for the manic and depressed items, with factor 1 representing physical activity, verbal activity, thought processes, and mood and factor 2 representing eating habits, weight change, passage of time, and pain sensitivity. The two factors accounted for 61.2% in the variance in scores.
The team concludes: “It is important to pursue the question of whether mixed states represent a separate category or are an important dimension on the spectrum of symptoms that constitute bipolar affective disorder. Either way, it is a challenge to the existing nosology of bipolar.”
They add in the journal Clinical Psychology and Psychotherapy: “If mixed states are a variant within the bipolar spectrum, it raises the question as to whether such patients should be treated with mood stabilizers rather than antidepressants.”
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
Unipolar and bipolar mood disorders are more common in adolescence and young adulthood than previously assumed, says an international team of scientists that also found conversion from unipolar to bipolar disorder is not particularly high.
There have been a number of large, community-based surveys on the occurrence of mood disorders and conversion from unipolar to bipolar disorders, but they have commonly been limited by their cross-sectional design and the inclusion of a broad age spectrum, which introduces the possibility of recall bias.
To circumvent these problems, Katja Beesdo, from Technische University Dresden in Germany, and colleagues administered the Munich-Composite International Diagnostic Interview to a representative sample of 3021 individuals aged 14??”24 years at baseline. The participants were then followed-up three times during the subsequent 10 years, when they were aged 21??”34 years.
At age 33 years, the age-specific cumulative incidence of manic episodes was 2.9%, while the incidence of hypomanic episodes, major depressive episodes, and minor depressive episodes was 4.0%, 29.4%, and 19.0%, respectively, the team reports in the journal Bipolar Disorders.
The estimated cumulative incidence up to age 33 years of unipolar mania, unipolar hypomania, unipolar major depression, and bipolar depression was 1.5%, 3.6%, 26.0%, and 4.0%, respectively. Excluding patients with minor depressive episodes, the results indicate that the strictly defined incidence of unipolar mania and unipolar hypomania was 0.6% and 1.8%, respectively.
Among patients with primary unipolar (hypo)mania, the conversion rate to bipolar depression was 29.2%, and the rate was greater among those with primary manic episodes than those with primary hypomanic episodes, at 49.6% and 15.8%, respectively, yielding an odds ratio of 5.2. The conversion rate to bipolar depression among manic episode patients when minor depressive episodes were also included was 75.6%, compared with 44.3% among hypomanic episode patients.
Onset of (hypo)manic episodes occurred in 3.6% of patients with primary major depressive episodes, with rates highest among those with onset of major depressive episodes before 17 years of age, at 9.0%. Rates of (hypo)mania among patients aged 17??”20 years, 21??”25 years, and ?26 years at major depressive episode onset were 0.5%, 0.7%, and 0.0%, respectively.
There were no significant differences between unipolar (hypo)mania cases and bipolar cases in terms of clinical disease course, severity of impairment, and likelihood of receiving treatment. In contrast, bipolar cases had more adverse clinical and course depression characteristics than unipolar depressed patients, as well as higher treatment rates.
The team concludes: “Overall, our study suggests that both unipolar and bipolar mood disorders seem to be more frequent than previously thought in adolescence and young adulthood, a time period when both the recognition and the intervention rates by the healthcare system have remained relatively low.”
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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Obesity appears to be associated with a history of suicide attempts in patients with bipolar disorder, study findings show.
The researchers point out that this association remained significant even after taking into account well-established risk factors for suicide attempt such as lifetime comorbid anxiety, alcohol use disorders, and depressive symptoms.
“Clinicians must be aware that obesity may be a severity feature relevant not only to pharmacological treatment decisions but also to the comprehensive management of bipolar disorder,” say Flávio Kapczinski, from Hospital de Clínicas de Porto Alegre in Brazil, and colleagues.
The team examined the association between suicide attempts and obesity in 250 outpatients with bipolar disorder, of whom 133 (52.2%) had a history of suicide attempt and 80 (31.4%) were obese (body mass index [BMI]?30). The majority (87.8%) of the patients were taking mood stabilizers alone or in combination, 20.4% were taking atypical antipsychotics, and 23.5% were receiving antidepressants.
As reported in the journal Acta Neuropsychiatrica, bipolar disorder patients who were obese were nearly twice as likely to have a history of suicide attempts as patients of normal weight.
The suggest that depression may be a possible link between obesity and suicide in bipolar disorder patients. Depressive episodes are related to changes in appetite and eating behavior that contribute to obesity, and bipolar disorder with predominant depressive polarity is strongly related to suicidal behavior.
Alternatively, recent data have suggested common features in the underlying pathophysiology of obesity and bipolar disorder.
Specifically, leptin, a key hormone in the regulation of adiposity, has been shown to be positively associated with the risk for depression. Also, disturbances in metabolic pathways such as insulin-mediated glucose homeostasis, overactivation of the hypothalamic??”pituitary??”adrenal axis, dysregulated immune and inflammatory processes, and adipocytokine profiles are present in both adiposity and depression.
Obesity may therefore be a correlate of allostatic load in bipolar disorder, the researchers suggest.
They caution about generalizing their findings, noting that most of their patients were recruited from the Bipolar Disorder Program and so were considered difficult to treat.
Kapczinski and team conclude: “It is plausible to speculate that therapeutic interventions targeted to obesity may be of potential benefit in the course 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; 2010
Patients with bipolar disorder often experience intrusive memories of the past that become more distressing during depressive episodes, UK study findings show.
The results also showed that bipolar depression was associated with seeing vivid images focussed on death and suicide.
In contrast, intrusive memories were rare in hypomanic states, and these episodes were more associated with vivid, enjoyable images of future events.
“Behaviors and emotions in different bipolar states may be amplified by characteristic intrusive memories and images, suggesting novel opportunities for therapeutic intervention,” say Chris Brewin, from University College London, and colleagues.
The researchers studied the presence of memory and image intrusions in 29 euthymic patients with bipolar disorder. Intrusive memories were defined as visual images of a particular event or episode from the past that were recalled spontaneously and repeatedly, while intrusive images were scenes that came to mind repeatedly but that did not correspond directly to an event from the past and could be an imaginary situation.
The participants were asked to report on intrusive memories and images from the previous week when they were euthymic and from their most recent episode of depression and hypomania.
In all, 17 (59%), 22 (76%), and four (14%) participants reported experiencing intrusive memories during euthymia, depression, and hypomania, respectively.
For intrusive images, none were reported during euthymia, and 13 (45%) and 19 (66%) patients reported experiencing them during depression and hypomania, respectively.
Follow-up tests indicated that there was no difference in the frequency of intrusive memories between euthymia and depressed states, but they occurred significantly more during these times than during hypomania.
Intrusive images were equally prevalent during depression and hypomania, and were significantly more common during these episodes than during euthymia.
The characteristics of intrusive cognitions differed according to mood states. During euthymia and depression they appeared to encapsulate past-focused negative experiences, which were more distressing and interfered more with daily activities during depression.
Depression was also associated with vivid and distressing future-focused images that typically involved death or suicide.
In contrast, intrusive images in hypomania rarely featured past-focused negative experience; instead, they tended to be vivid positive future-oriented events involving goal-oriented events that were interpersonal in nature.
Brewin and team suggest in the journal Behavior Research and Therapy that treatments that have shown promise for reducing intrusive memories in patients with unipolar depression may also be effective for bipolar disorder patients.
The two possibilities they cite are: imagery rescripting to create an alternative representation that will compete effectively with the intruding image or memory to prevent the amplification of an unwanted mood state; and more general, meta-cognitive strategies such as detached mindfulness in response to intruding memories and images.
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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The children of bipolar disorder parents face the highest risk for mood episodes during adolescence, with depression almost always the index episode, the results of a Canadian and Czech study indicate.
There is currently little information on the early clinical stages of bipolar disorder, with descriptions of onset and early course reliant largely on patient recall, explain Anne Duffy, from Dalhousie University in Halifax, Canada, and colleagues.
To investigate further, the team studied 207 children aged 8??”25 years from 105 families with parents who had known bipolar disorder. The children completed the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version at enrolment, annually, and at any time symptoms developed until their 30th birthday, with each child followed-up for 1??”15 years.
In all, 67 participants met the criteria for one or more major mood episodes. The average age at analysis was 24 years and the average age of onset was 17 years, with no child experiencing onset before 12 years of age.
In 90% of cases, the first episode was major depression, and 61 patients had a remitting or partially remitting episode course. Among remitting patients, 89% of first episodes were depressive, compared with 68% of second episodes, 78% of third episodes, and 58% of fourth episodes.
The average duration of first depressive episodes among remitting or partially remitting patients was 6.1 months, compared with 1.7 months for the first hypomanic/manic or mixed episode. The average cycle length was 26.3 months.
Analysis revealed an increase risk for new onsets of major mood episodes from age 12 years that continued to 30 years of age. A similar pattern was seen for recurrence risk, at a risk for recurrence of 61% by 5 years.
The researchers write in the British Journal of Psychiatry: “These findings emphasize the need to identify children at familial risk for bipolar disorder and to provide continuity of expert psychiatric surveillance and assessment over this period.
“This involves programs spanning child and adult institutions, and close collaboration between child and adult psychiatry services.”
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; 2009
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The availability of striatal dopamine transporter (DAT) is increased in bipolar disorder patients compared with healthy individuals, even in patients in the euthymic state, the results of a Taiwanese study indicate.
DAT activity is thought to reflect the general state of dopamine function in the brain, and previous research has shown that euthymic bipolar disorder patients have regions of abnormal brain activation.
To investigate striatal DAT availability in bipolar disorder, Yen Kuang Yang, from National Cheng Kung University Hospital in Tainan, and colleagues used single photon emission computed tomography (SPECT) with [99mTc] TRODAT-1 to approximate DAT availability in 17 drug-free euthymic bipolar disorder patients and 17 healthy controls matched for age, gender, and education level.
The team reports in the journal Bipolar Disorders that there was no correlation between the DAT ratio and the duration of bipolar disorder, number of manic episodes, or number of depressive episodes.
Patients were found to have a significantly higher binding availability of DAT in the striatum than healthy controls, at an average effect size of 1.04. There were no significant differences in DAT availability between the seven patients with bipolar I disorder and the 10 with bipolar II disorder.
While noting that the study has several limitations, the team concludes: “The present results suggest that an upregulation of DAT may be the primary alteration which progressively leads to lowered intrasynaptic dopamine concentration and then influences the emotional process and cognition in euthymic bipolar patients.”
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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