A community epidemiological profile based on surveys in 10 diverse countries confirms most but not all current clinically based knowledge on rapid-cycling bipolar disorder (BPD-RC).

Clinical studies suggest that BPD-RC is present in 12-24% of people with BPD, and is more common in women and associated with earlier age at onset, greater illness burden, and relatively higher treatment resistance than non-rapid-cycling bipolar disorder (BPD-nonRC).

However, there have been no community-based epidemiological studies to clarify unresolved issues relating to the disorder, such as whether it is an iatrogenic condition, an arbitrary entity in a dimensional framework of conceptualizing episode frequency in bipolar disorder and, more generally, whether current knowledge about this disorder is biased by a higher probability of help-seeking.

Sing Lee, from the Chinese University of Hong Kong, and colleagues used the Composite International Diagnostic Interview to examine the prevalence, severity, comorbidity, impairment, suicidality, childhood adversity, and treatment of BPD-RC and BPD-nonRC in 54,257 participants in 10 countries (Brazil, Colombia, Mexico, USA, Bulgaria, Romania, India, Japan, Lebanon, and New Zealand).

The 12-month prevalence of BPD-RC was 0.3%. Roughly a third and two-fifths of participants with lifetime and 12-month BPD, respectively, met the criteria for rapid cycling.

Confirming clinical findings, BPD-RC was associated with younger age at onset, higher persistence, more severe depressive symptoms, greater impairment from depressive symptoms, more out-of-role days from mania/hypomania, more anxiety disorders, and an increased likelihood of using health services, compared with BPD-nonRC.

The researchers note that the frequency of BPD-RC was higher in their community study than in some previous clinical studies, which could reflect greater help-seeking in these patients.

But they point out that 83.4% of patients with BPD-RC had received lifetime treatment, suggesting that the condition was indeed very impairing. Also, psychiatrists were not commonly involved in the treatment of BPD-RC patients, refuting the suggestion in some clinical studies that BPD-RC is a primarily drug-induced condition.

In contrast with previous clinical studies of BPD-RC, the present study found that participants with 12-month BPD-RC did not have a significantly elevated risk for suicidality, compared with their peers with BPD-nonRC and there was no association between BPD-RC and gender.

Although both BPD-RC and BPD-nonRC were associated with childhood neglect and abuse, BPD-RC was more strongly associated with childhood neglect than BPD-nonRC, whereas there was no significant difference for abuse.

Writing in the British Journal of Psychiatry, the researchers conclude that the DSM-IV does not fully capture the spectrum of rapid cycling and mixed episodes, and that a refined fully-structured instrument that can validly assess the core characteristics of BPD-RC needs to be developed.

“Dimensional measures of these characteristics are desirable for resolving uncertainty about the optimal boundary distinctions for BPD-RC as rapid cycling may be a dimensional course specifier,” they say.

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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Individuals with bipolar disorder and antisocial personality disorder (ASPD) have increased impulsivity, but the two conditions do not act synergistically to increase further impulsivity, the results of a US study indicate.

It is known that bipolar disorder and cluster B personality disorders, including ASPD, share impulsivity as a trait, but there have been few comparisons of impulsivity and its consequences between the two conditions.

Alan Swann and colleagues from the University of Texas Health Science Center in Houston therefore used the Change version of the Schedule for Affective Disorders and Schizophrenia (SADS-C) and the Barratt Impulsiveness Scale (BIS-11), among other measures, to assess 34 ASPD patients, 61 bipolar disorder patients, 24 patients with APSD and bipolar disorder, and 78 healthy controls.

Scores on the SADS-C demonstrated that patients with bipolar disorder and ASPD had greater depression and psychosis than patients with bipolar disorder alone, the team reports in the journal Acta Psychiatrica Scandinavica.

BIS-11 scores were substantially higher in patients with bipolar disorder than in controls, at an effect size of 1.45. While BIS-11 scores were significantly higher in ASPD patients than in controls, the effect size was smaller, at 0.75.

Patients with bipolar disorder and ASPD had higher BIS-11 scores than patients with ASPD alone, at an effect size of 0.75, but not higher than patients with bipolar disorder alone. BIS-11 scores were associated with conviction for crimes but there was no interaction between impulsivity and the severity of crime, the researchers note.

The co-existence of bipolar disorder with APSD increased the likelihood of substance-related comorbidities, at 20 of 33 ASPD patients without bipolar disorder versus 22 of 24 patients with both bipolar disorder and ASPD. Patients with both conditions were also more likely to attempt suicide than patients with ASPD alone, at 17 of 26 patients versus one of 26 patients.

“These data support other evidence that aspects of cluster B disorders, including but not limited to impulsivity, are related to severity of bipolar disorder,” the researchers conclude.

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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Patient reporting and severity of adverse drug reactions (ADRs) during long-term lithium treatment for bipolar disorder are affected by both serum lithium concentration and mood state, say Dutch researchers.

Compared with randomized controlled studies, the effectiveness of lithium treatment for bipolar disorders is lower in naturalistic follow-up, with nonadherence one of the major contributory factors. Previous studies have indicated that ADRs are a major reason for discontinuing treatment.

To determine the impact of mood state and lithium ADRs, Antoine Egberts, from Utrecht University, and colleagues conducted a 26-year follow-up study of 186 patients aged ?18 years treated at an outpatient lithium clinic between 1973 and 2000.

Information on the presence and severity of nine specific ADRs that frequently occur as a result of lithium treatment and can be identified by patients was gathered by a research nurse at each monthly scheduled visit. Serum lithium level and mood state were also assessed at each visit.

In all, 94.6% of patients had at least two ADR questionnaires completed during follow-up, giving a total of 8056 questionnaires. The median duration of patient follow-up was 5.7 years. At least one ADR was reported by all but two patients.

The serum lithium level at each interview was within the therapeutic range for 62.5% of patients, and mood state was rated as euthymic in 73.4% of cases. Adjusting for mood state, serum lithium level was significantly associated with the number of present ADRs, as well as with the average severity of all present ADRs.

Further adjustment for mood state, age at study inclusion, gender, and duration of lithium use confirmed that serum lithium was significantly associated with the number and severity of reported ADRs. Specifically, patients with a serum lithium level of 0.6 mmol/l, 0.9 mmol/l, and 1.2 mmol/l had an average number of ADRs of 3.3, 3.6, and 3.8, respectively.

When adjusting for serum lithium level, there was a significant association between mood state and the average number and severity of ADRs, with depressed mood, euthymic, and manic patients having an average of 2.0, 3.3, and 4.6 ADRs, respectively.

Interestingly, of the ADRs, tiredness and concentration deficits were most strongly linked to mood state, while polyuria and polydipsia were mostly strongly linked to serum lithium level.

The team writes in the journal Bipolar Disorders: “In conclusion, we found that both mood state and lithium serum level are independently associated with the prevalence and the severity of patient-reported ADRs in patients on lithium 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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