Bipolar disorder patients who have high levels of anxiety during an episode are more likely to have greater long-term depressive morbidity, the results of a US study indicate.

It is known that there are differences between bipolar disorder patients with and without comorbid anxiety, but the long-term prognostic significance of comorbid anxiety is unclear, argue William Coryell, from University of Iowa Hospitals and Clinics in Iowa City, and colleagues.

The team therefore studied 427 participants from the National Institute of Mental Health Collaborative Depression Study who were followed-up prospectively for an average of 17.4 years. The manifestations of anxiety at baseline were characterized and related to the proportion of follow-up weeks in episodes of major depression and mania or hypomania.

Overall, 92 patients had mania only at baseline, while 168 had depression only and 167 were cycling. Using the Schedule for Affective Disorders and Schizophrenia, the researchers found that the patients’ somatic anxiety scores were 1.7, 3.2, and 2.8, respectively, while their psychic anxiety scores were 1.9, 4.0, and 3.5, respectively. The global anxiety level was 3.6, 7.2, and 6.3, respectively.

The percentage of weeks in depressive episodes was not predicted by gender, age at intake, age at illness onset, the presence of antisocial personality disorder, alcoholism, or drug dependence.

Patients with past or future manic episodes spent a smaller percentage of weeks in depressive episodes than those with only episodes of hypomania, at 27.4% and 36.5%, respectively. The proportion of weeks spent in depressive episodes was 13.2% for patients with purely manic episodes at baseline, 37.7% for those who had a purely depressive episode at baseline, and 33.0% for those who had a cycling episode.

Time spent in depressive episodes was not predicted by either panic attacks or any anxiety disorder. However, psychic anxiety was significantly associated with time in depressive episodes, while somatic anxiety had borderline significance.

Global anxiety was found to have a continuous relationship with number of weeks in depressive episodes, with no clear threshold for separating anxious and non-anxious patients.

However, the team was able to determine that patients with a purely manic index episode and a global anxiety level below the median value of 7 spent only 12.4% of weeks in depressive episodes, compared with 18.8% for patients with mania and an anxiety score ?7. The rates for patients with depressed or cycling index episodes were 29.7% and 40.4% depending on whether they had anxiety levels below or above the median, respectively.

The team writes in the American Journal of Psychiatry: “The combination of presenting phase and anxiety level appears to offer a potent clinical tool for predicting whether an individual is likely to follow a course dominated by depressive symptoms or one in which mania is more prominent.

“Such prediction is inherently valuable but may also have practical importance in the selection of a mood-stabilizer regimen designed to offer more protection against one or the other pole of bipolar illness.”

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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Correction of excessive goal attainment beliefs in patients with bipolar disorder who enjoy being in a state of “mild hypomania” could help prevent them from assenting to a manic episode, say researchers.

Some individuals with bipolar disorder value the characteristics associated with being in a state of mild hypomania ??” termed a high “sense of hyper-positive self”, D Lam and colleagues from King’s College, London, UK, explain.

These characteristics include being particularly creative, dynamic, entertaining, and outgoing, and make individuals more likely to engage in goal-driven behavior.

Bipolar patients who identify with early warning signs as desirable self-descriptive traits are less inclined to see them as warning signs of a manic relapse, and may therefore engage in activities that cause further stimulation and a greater risk for a manic state, say the researchers.

To investigate, the team asked 54 bipolar I disorder patients to complete a self-report questionnaire that assessed preferred mood state, coping with scenarios, dysfunctional attitudes, and SHPS.

They found that patients’ Sense of Hyper-positive Self Scale (SHPSS) score predicted their preferred internal state of mania, with higher “ideal” scores and lower “usual” scores significantly associated with a higher preferred mania mood.

Indeed, a unit increase in SHPSS-Ideal score produced an increase of 0.169 points on the modified version of the Altman Self-Rating Mania scale (M-ASRM), while a unit increase in SHPSS-Usual score produced a decrease of 0.202 points on the M-ASRM, the researchers report.

Multiple linear regression showed that patients with high scores on the Dysfunctional Attitude Scale (DAS) were more likely than those with low scores to have high SHPSS scores, and the higher the DAS score the greater the tendency for the patient to identify with self-descriptors linked to hypomania.

Moreover, the DAS total score and the DAS Goal-attainment score correlated significantly with mania-escalating activities in response to hypothetical scenarios described in the Scenarios Rating Task, with goal-attainment explaining a further 12.8% of the variance in activity ratings after accounting for mood measures.

“Goal-attainment attitudes, characterized by a desire to strive for success and be admired, were predictive of the extent to which individuals indicated that they would increase their activity, eg, work harder, make more contributions to a project, and be more sociable, in these specified vulnerable situations,” Lam et al report in the journal Psychological Medicine.

“However, clinical experience would suggest that an increase in these activities in the scenario would stimulate the patient further, possibly resulting in an assent to a manic episode.”

The researchers therefore conclude that “excessive goal-attainment beliefs should be tackled in therapy.”

They recommend: “Clinicians could implement cognitive techniques to modify these beliefs and find alternatives that are more consistent with relapsed prevention goals.”

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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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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Students who gain higher than average grades at school are at increased risk for developing bipolar disorder, study findings suggest.

The results support the hypothesis that “exceptional intellectual ability is associated with bipolar disorder,” say James MacCabe, from King’s College London in the UK, and colleagues.

They report that individuals with excellent scholastic achievement, defined as grades of two or more standard deviations above the mean, at age 15??”16 years old were almost four times more likely to develop bipolar disorder between the ages of 17 and 31 years than individuals with average grades.

Students with the poorest grades, at two or more standard deviations below the mean, were also at increased risk for bipolar disorder compared with average-grade students, but the risk was only moderately increased at almost two fold.

The study involved 713,596 individuals who finished compulsory schooling in Sweden between 1988 and 1997. The students’ scholastic achievement was assessed alongside hospital admission for bipolar disorder.

The researchers note in the British Journal of Psychiatry that the increased risk for bipolar disorder associated with scholastic achievement remained after accounting for factors such as parental education and socioeconomic status.

Interestingly, they also found that the association between A grades and a heightened risk for bipolar disorder was particularly evident for pupils achieving this grade in subjects such as humanities and Swedish and Music.

“This provides support for the biographic literature which consistently finds associations between linguistic and musical creativity and bipolar disorder,” say MacCabe et al.

They discuss possible explanations for the associations between scholastic achievement and bipolar disorder. Hypomania may be one factor, as it is thought to enhance access to vocabulary, memory and other cognitive resources, helping individuals link successive ideas in innovative ways. It also gives people extraordinary stamina and can considerably enhance concentration. Also, people with bipolar disorder often show exaggerated emotional responses, which may facilitate their talent in art, music, and literature.

Conversely, a predominance of depressive symptoms may explain why individuals with low scholastic achievement might be at increased risk for bipolar disorder, the team suggests.

The study indicated that the association between high grades and risk for later bipolar disorder may be stronger in men than women, but this association did not reach statistical significance and needs further study.

MacCabe makes the important point that, “although having A grades increases your chance of bipolar disorder in later life, we should remember that the majority of people with A grades enjoy good mental health.”

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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Postpartum bipolar II disorder may be mistakenly diagnosed as major depressive disorder, say Canadian and US scientists who make recommendations as to how patients should be treated.

Bipolar postpartum depression is commonly overlooked and mistaken for unipolar major depression. However, while bipolar I disorder is a reliable and relatively stable diagnosis, bipolar II disorder is less easily diagnosed and may be dismissed as a milder form of bipolar I disorder.

To examine the detection, diagnosis, and treatment of bipolar II postpartum depression Verinder Sharma, from the University of Western Ontario in London, Canada, and colleagues conducted a search of the PubMed database and reference lists for relevant articles published between 1998 and 2009.

Estimates of the prevalence of hypomania in non-clinical populations ranged from 9.6% to 20.4% on day 3 postpartum, at an average of approximately 15.0%. Furthermore, almost 20% of patients with hypomanic symptoms at day 3 postpartum developed postpartum depression in one study, with a significant proportion diagnosed with bipolar II disorder or bipolar disorder not otherwise specified (NOS).

Crucially, the team says in the Journal of Affective Disorders that, although there are formal rating scales for assessing bipolar spectrum disorder and unipolar postpartum depression, there are no validated instruments for screening, diagnosing, or monitoring bipolar disorder during pregnancy or postpartum, with even the Highs scale not validated as a diagnostic instrument.

There have only been three randomized controlled trials and six open-label studies of the pharmacologic treatment of postpartum depression, and three studies of the treatment of bipolar disorder during postpartum depression.

While the evidence suggests that postpartum bipolar depression should follow the same guidelines as for non-puerperal bipolar depression, the team says there is a lack of evidence-based treatment options. Women should be monitored closely, they argue, and prophylactic treatment may be considered.

The researchers conclude: “The lack of data on postpartum bipolar II and bipolar disorder NOS is surprising given the high prevalence of hypomanic symptoms immediately after delivery, the unique pharmacologic challenges posed by bipolar depression, and the heightened risk for suicide associated with bipolar spectrum disorder. and illness course that are commonly used to establish the bipolar diathesis of a clinical condition.”

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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