Comments on: Request to euthanase a horse from a client with bipolar disorder

Despite a marked increase in treatment for bipolar disorder among youths, little is known about their pattern of service use. This article describes mental health service use in the year before and after a new clinical diagnosis of bipolar disorder. Claims were reviewed between April 1, 2004, and March 31, 2005, for 1,274,726 privately insured youths (17 years and younger) who were eligible for services at least one year before and after a service claim; 2,907 youths had new diagnosis of bipolar disorder during this period. Diagnoses of other mental disorders and prescriptions filled for psychotropic drugs were assessed in the year before and after the initial diagnosis of bipolar disorder. The one-year rate of a new diagnosis of bipolar disorder was .23%. During the year before the new diagnosis of bipolar disorder, youths were commonly diagnosed as having depressive disorder (46.5%) or disruptive behavior disorder (36.7%) and had often filled a prescription for an antidepressant (48.5%), stimulant (33.0%), mood stabilizer (31.8%), or antipsychotic (29.1%). Most youths with a new diagnosis of bipolar disorder had only one (28.8%) or two to four (28.7%) insurance claims for bipolar disorder in the year starting with the index diagnosis. The proportion starting mood stabilizers after the index diagnosis was highest for youths with five or more insurance claims for bipolar disorder (42.1%), intermediate for those with two to four claims (24.2%), and lowest for those with one claim (13.8%). Most youths with a new diagnosis of bipolar disorder had recently received treatment for depressive or disruptive behavior disorders, and many had no claims listing a diagnosis of bipolar disorder after the initial diagnosis. The service pattern suggests that a diagnosis of bipolar disorder is often given tentatively to youths treated for mental disorders with overlapping symptom profiles and is subsequently reconsidered.

Longitudinal Course of Pediatric Bipolar Disorder

Longitudinal Course of Pediatric Bipolar Disorder

In order to explore valproate's spectrum of efficacy in rapid-cycling bipolar disorder, 55 patients underwent a prospective, open, 7.8-month trial designed to assess the drug's acute and prophylactic properties. Twenty patients received monotherapy, and 35 received combination therapy. Moderate to marked acute antidepressant responses were seen in 47% of the patients, prophylactic antidepressant responses in 76%, acute antimanic responses in 91%, prophylactic antimanic responses in 94%, acute responses in mixed states in 85%, and prophylactic responses in mixed states in 93%. Consistent with other anticonvulsant literature, these data suggest that valproate has marked antimanic and mixed state efficacy, but minimal to moderate antidepressant properties.

Sir: Deciding whether to prescribe antidepressants for the depressed patients with bipolar spectrum disorders remains a challenge for clinicians. Two most-feared potential consequences of using antidepressants in patients with bipolar spectrum disorders are triggering a manic switch and/or generating a rapid cycling course of the disease.1 Experts have long tried to recognize the depressed patients who are at a greater risk for switching to mania; thus, several symptoms have been suggested as “soft signs” of bipolarity, including hypersomnia, psychomotor retardation, young age at onset of depression, family history of bipolar disorder, drug-induced hypomania, seasonality of the episodes, and diurnal variation of the symptoms.2 However, the list is not yet complete, and many cases still cannot be correctly predicted. As a result, clinical findings that could be used as new predictors of bipolar spectrum disorders could be helpful for future interventions. Case report. Ms. A was a 27-year-old married woman who experienced an aggravation of depressive and anxiety symptoms for 6 months beginning in August 2005. Symptoms included depressed mood, loss of interest, repeated crying spells, loss of concentration, insomnia, decreased appetite, irritability, worry, and preoccupation with death. Past history revealed no significant finding other than mild depressive and anxiety symptoms in the previous 4 years and no episodes of mania or hypomania. She had no suggestive symptoms for a bipolar spectrum disorder except for very brief periods (about 30 seconds) of euphoria and inflated self-esteem, which occurred just before falling asleep, in a semiconscious state between wakefulness and sleep. During these periods, she experienced an exuberant sense of power, and she believed that she was able to “move mountains.” Family history for bipolar disorder was negative. The patient met the criteria for major depressive disorder based on DSM-IV-TR and received 5 mg/day of citalopram (February 2006), and after 5 days, the dose was increased to 10 mg/day, in addition to 1.25 mg/day of alprazolam, in 3 divided doses. One week later, the patient showed significant improvement. In addition, alprazolam had reduced the sleep latency, and the patient did not experience or remember any sleep-related hypomanic symptoms. Instead, she reported having distinct periods of euphoria and talkativeness 15 to 20 minutes after taking each dose of alprazolam. These periods would happen after all doses of alprazolam and would completely resolve after about 10 minutes, and the patient would return to her depressed baseline. The patient did not experience any other side effects other than a mild sedation during the day. The alprazolam dose was reduced to 0.75 mg/day to decrease sedation and then tapered to complete cessation in the next 3 weeks, and citalopram was continued. Sleep-related hypomanic symptoms did not recur after reducing or discontinuing alprazolam. The patient was followed for 6 more months and remained euthymic (August 2006). Recent studies suggest that the lifetime prevalence of bipolar spectrum disorders in the general population is more than 6%,3 that is, much higher than what was previously speculated.2 It is also reported that about 12.5% of the patients initially diagnosed as having depression will be reclassified as having a bipolar spectrum disorder in their course of illness.4 This patient reported experiencing distinct brief periods of euphoria and inflated self-esteem before sleep onset, which could potentially be related to bipolar spectrum disorders. Even though we did not have enough evidence to accept it as a new soft sign of bipolar spectrum disorders before starting the medications, transient hypomanic symptoms induced by taking al-prazolam suggested that “sleep-related periods of euphoria” could be assumed as one of the predictors of bipolar spectrum disorders. We are aware that had the patient been followed without decreasing the dose of alprazolam, she might not have developed a bipolar disorder. Obviously, this could not be performed because of ethical considerations. Future studies could tell more about the diagnostic value and effect of each of the soft signs on the long-term course of the disease.

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Parsing the association between bipolar, conduct, and substance use disorders: a familial risk analysis

Hormonal fluctuations associated with female reproductive life events may precipitate or worsen affective episodes in women with bipolar disorder (BD). Previous studies have shown that women with BD report higher rates of premenstrual dysphoric disorder (PMDD) than controls. Further, bipolar women who report premenstrual worsening of mood display a worse course of their bipolar illness. Despite this, the neural correlates of comorbid BD and PMDD have not been investigated. Eighty-five [CTRL, n = 25; PMDD, n = 20; BD, n = 21; BD with comorbid PMDD (BDPMDD), n = 19], regularly cycling women, not on hormonal contraception, underwent two MRI scans: during their mid-follicular and late luteal menstrual phases. We investigated resting-state functional connectivity (Rs-FC), cortical thickness, and subcortical volumes of brain regions associated with the pathophysiology of BD and PMDD between groups, in the mid-follicular and late luteal phases of the menstrual cycle. All BD subjects were euthymic for at least 2 months prior to study entry. Women in the BDPMDD group displayed greater disruption in biological rhythms and more subthreshold depressive and anxious symptoms through the menstrual cycle compared to other groups. Rs-FC was increased between the L-hippocampus and R-frontal cortex and decreased between the R-hippocampus and R-premotor cortex in BDPMDD vs. BD (FDR-corrected, p < 0.05). Cortical thickness analysis revealed decreased cortical thickness of the L-pericalcarine, L-superior parietal, R-middle temporal, R-rostral middle frontal, and L-superior frontal, as well as increased cortical thickness of the L-superior temporal gyri in BDPMDD compared to BD. We also found increased left-caudate volume in BDPMDD vs. BD (pCORR < 0.05). Women with BD and comorbid PMDD display a distinct clinical and neurobiological phenotype of BD, which suggests differential sensitivity to endogenous hormones.

Improving Medical and Psychiatric Outcomes Among Individuals With Bipolar Disorder: A Randomized Controlled Trial

PurposeThe Swedish National Quality Register for bipolar affective disorder, BipoläR, was established in 2004 to provide nationwide indicators for quality assessment and development in the clinical care of individuals with...

Anxiety disorders are among the most common comorbid conditions in youth with bipolar disorder. We aimed to examine the prevalence and correlates of comorbid anxiety disorders among youth with bipolar disorder. As part of the Course and Outcome of Bipolar Youth study, 446 youth, ages 7 to 17 years, who met DSM-IV criteria for bipolar I disorder (n = 260) or bipolar II disorder (n = 32) or met operationalized criteria for bipolar disorder not otherwise specified (n = 154) were included. Subjects were evaluated for current and lifetime Axis I psychiatric disorders at intake using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime version, and standardized instruments were used to assess functioning and family history. Forty-four percent (n = 194) of the sample met DSM-IV criteria for at least 1 lifetime anxiety disorder, most commonly separation anxiety (24%) and generalized anxiety disorders (16%). Nearly 20% met criteria for 2 or more anxiety disorders. Overall, anxiety disorders predated the onset of bipolar disorder. Subjects with bipolar II disorder were more likely than subjects with bipolar I disorder or bipolar disorder not otherwise specified to have a comorbid anxiety disorder. After adjusting for confounding factors, youth with bipolar disorder with anxiety were more likely to have bipolar II disorder; longer duration of mood symptoms; more severe ratings of depression; and family history of depression, hopelessness, and somatic complaints during their worst lifetime depressive episode than those without anxiety. Comorbid anxiety disorders are common in youth with bipolar disorder, and they most often predate bipolar disorder onset. Bipolar II disorder, a family history of depression, and more severe lifetime depressive episodes distinguish youth with bipolar disorder with comorbid anxiety disorders from those without. Careful consideration should be given to the assessment of comorbid anxiety in youth with bipolar disorder.

Some studies have suggested that oxcarbazepine has a role in preventing episode recurrence in bipolar affective disorder. This review attempted to investigate the existing evidence from randomised controlled trials for its use in the maintenance treatment of this illness. To review the efficacy of oxcarbazepine, relative to placebo and other agents, in the prevention of affective episodes of bipolar affective disorder. The efficacy of oxcarbazepine was considered in terms of episode recurrence, general and social functioning. Adverse effects, overall acceptability to participants and mortality were also considered. CCDANCTR-Studies and CCDANCTR-References were searched on 7/11/2007. Medline, CENTRAL, EMBASE and PsycINFO were searched in March 2007. Specialist journals and conference proceedings were handsearched. Reference lists of relevant papers and major textbooks of affective disorder were checked. Authors, experts in the field and pharmaceutical companies were contacted requesting information on published or unpublished trials. Randomised controlled trials comparing oxcarbazepine with placebo or alternative agents, where the stated intent of intervention was the maintenance treatment of bipolar affective disorder were sought. Participants with bipolar disorder, male and female, of all ages, were included. Data were extracted from the original reports individually by two review authors. The methodological quality of included studies was assessed individually by two review authors. The main outcomes were the efficacy of oxcarbazepine maintenance treatment in preventing or attenuating further episodes of bipolar affective disorder (including its efficacy in rapid cycling disorder), the acceptability of oxcarbazepine treatment to participants, the prevalence of side-effects, and mortality, if any, on oxcarbazepine treatment. Where appropriate, data concerning outcome measures and adverse effects were to be extracted from the studies and analysed using Review Manager software. Two randomised controlled trials were found that met the methodological criteria for inclusion in the review. However, they did not report data with sufficient clarity to allow their confident extraction for inclusion in the meta-analysis. Findings from the two studies were presented descriptively. There is an insufficient methodologically rigorous evidence base to provide guidance on the use of oxcarbazepine in the maintenance treatment of bipolar disorder. Given the need for more efficacious therapeutic agents, there is a need for good quality randomised controlled trials examining the therapeutic potential of this and related agents in bipolar disorder.

Treatments for late-life bipolar disorder

L’évaluation cognitive permet-elle de distinguer la schizophrénie du trouble bipolaire ?

The diagnostic distinction of bipolar affective disorder and schizophrenia in current classification systems ICD10 and DSM IV is based on Kraepelin's definition of “dementia praecox” and “maniodepressive psychosis”. However, the validity of the diagnostic distinction is challanged by an accumulating amount of various independent findings. The authors review the similarities and distinctins between both disorders in a range from psychopathology to neuroimaging methods with an emphasis on genetic findings as a major source of evidence of an overlap between bipolar disorder and schizophrenia. Both bipolar disorder and schizophrenia demonstrate several similar psychopathological and epidemiologic characteristics. Both disorders are strongly influenced by genetic factors, e.g., results of linkage studies show a partial overlap of susceptibility loci. Two relatively common chromosomal aberations are associated with both bipolar disorder and schizophrenia. Association studies of candidate genes in either disorder identified several genes apparently involved in both disorders, such as NRG1, DISC1, and G72/G30. Emerging gene functions possibly involved in both schizophrenia and bipolar disorder include neurogenesis, synaptogenesis, myelinization, and neurotransmition. Bipolar disorder and schizophrenia also demonstrate some similarities in neurotransmitter dysfunction and share some, but not all, pharmacological mechanisms. Cognitive impairment in schizophrenia is well established during acute episodes as well as during remission and is more obvious compared to bipolar disorder. Moreover, children who developed schizophrenia in adulthood are characterised by cognitive, social, emotional, and behavioral impairments, in contrast to an impairment of a lesser degree found in children who later developed bipolar disorder. Also, patients with schizophrenia have more extensive structural brain abnormalities than those with bipolar disorder.