Manic symptoms and impulsivity during bipolar depressive episodes

OBJECTIVES: In contrast to the extensive literature on the frequent occurrence of depressive symptoms in manic patients, there is little information about manic symptoms in bipolar depressions. Impulsivity is a prominent component of the manic syndrome, so manic features during depressive syndromes may be associated with impulsivity and its consequences, including increased risk of substance abuse and suicidal behavior. Therefore, we investigated the prevalence of manic symptoms and their relationships to impulsivity and clinical characteristics in patients with bipolar depressive episodes. METHODS: In 56 bipolar I or II depressed subjects, we investigated the presence of manic symptoms, using Mania Rating Scale (MRS) scores from the Schedule for Affective Disorders and Schizophrenia (SADS), and examined its association with other psychiatric symptoms (depression, anxiety, and psychosis), age of onset, history of alcohol and/or other substance abuse and of suicidal behavior, and measures of impulsivity. RESULTS: MRS ranged from 0 to 29 (25th-75th percentile, range 4-13), and correlated significantly with anxiety and psychosis, but not with depression, suggesting the superimposition of a separate psychopathological mechanism. Impulsivity and history of substance abuse, head trauma, or suicide attempt increased with increasing MRS. Receiver-operating curve analysis showed that MRS could divide patients into two groups based on history of alcohol abuse and suicide attempt, with an inflection point corresponding to an MRS score of 6. DISCUSSION: Even modest manic symptoms during bipolar depressive episodes were associated with greater impulsivity, and with histories of alcohol abuse and suicide attempts. Manic symptoms during depressive episodes suggest the presence of a potentially dangerous combination of depression and impulsivity.     

Treatment emergent affective switch: a controlled study

OBJECTIVE: To study the clinical features of treatment emergent affective switch (TEAS) in comparison with spontaneous mania. METHODS: Twelve patients with TEAS within a 12-week period (average) of starting standard antidepressant medication were compared with 12 patients with spontaneous mania. RESULTS: Patients with TEAS were older, had longer duration of illness, more previous episodes, higher prevalence of subclinical hypothyroidism, and reported more previous episodes of mania associated with antidepressant use. TEAS was less severe, with a lower incidence of psychotic symptoms, lower Young Mania Rating Scale index score and rarely required hospitalization. The interval from intervention to response and remission was similar in both groups. CONCLUSION: TEAS was less severe, but had similar duration when compared with spontaneous mania. These results cannot directly answer the question of whether there is a causal relationship between antidepressant use and TEAS. While it is also possible that patients with longer duration of illness and higher cycle frequencies are more likely to experience episodes, it is difficult to attribute lesser severity of TEAS episodes to these clinical factors. Our observations are consistent with the suggestion that patients with longer duration of illness and previous history of TEAS may be at a greater risk of switching to mania during the use of antidepressants.     

Clinical characteristics of familial and non-familial bipolar disorder

Objective: To explore the clinical characteristics of familial and non-familial bipolar disorder.

Method: Twenty subjects with bipolar disorder, who also had a family history of bipolar disorder in a first degree relative, were matched for current age, age of first onset of bipolar disorder and gender with 20 subjects with bipolar disorder who had no family history of any psychiatric disorders in first or second degree relatives.

Results: Fourteen subjects in each group were female. The mean age at interview was 45.2 years and the mean age at first admission was 26 years. Although familial and non-familial probands had an equivalent number of illness episodes, familial probands were significantly more likely to experience mixed states as compared to non-familial probands. The latter experienced significantly more depressive episodes and had significantly higher neuroticism (N) scores on the Eysenck Personality Inventory (EPI; Eysenck H, Eysenck S. Manual of the Eysenck Personality Inventory. London: University of London Press, 1964.).

Conclusions: If the results are replicated, they have important implications. For example, such data may aid decisions about the targeting of additional psychosocial interventions in high N score cases. Researchers will wish to investigate whether mixed states show a stronger association with early age of onset or family history of BD.     

Clinical and personality correlates of a new measure of depression: a general practice study

OBJECTIVE: There is a need for a brief, efficient depression screening measure for general practice settings, particularly for identifying those who are at high risk of depression. We therefore test the usefulness of a measure developed in a sample of medically ill hospitalized patients. METHOD: More than 600 patients attending six Sydney general practices completed the Depression in the Medically Ill (DMI-10) measure, in conjunction with sociodemographic, depression history and personality profile measures. The impacts of sociodemographic, personality and lifetime depression variables on DMI-10 scores (and identified 'cases') were examined as a measure of its usefulness. RESULTS: Gender did not influence depression scores, while there were slight associations between DMI-10 scores and age, marital and occupational status. Higher scores were returned by those with more severe, lengthier and perceived stressful medical illnesses. Using a predetermined cut-off score, 36% rated as putative 'cases', a prevalence almost identical to our general hospital study. 'Cases' were distinctly more likely to have had previous depressive episodes, to have sought help for such episodes and to have received antidepressant medication. They also scored higher on measures of anxious (anxious worrying and irritability) and self-critical ('depressive personality') personality styles. CONCLUSIONS: The DMI-10 appears useful as a brief and acceptable screen for depression in a general practice setting, both identifying those who are likely to be currently depressed and those with a background of previous depression.     

Comparison of clinical characteristics in trichotillomania and obsessive-compulsive disorder

Fifteen patients with trichotillomania (TM) and 25 patients with obsessive-compulsive disorder (OCD) were studied. All patients were evaluated using the structured clinical interview for DSM-III-R (SCID-P). TM and OCD patients were compared with respect to demographic variables and the scores obtained from the various scales. The TM group had a greater percentage of women and showed an earlier age at onset. There was no significant difference for depression and anxiety assessed with the STAI, HRSA, and HRSD between the groups. Compared to OCD patients, TM patients had significantly lower scores on the Y-BOCS. The two groups were similar on the measures of resistance to and control of the hair pulling/compulsive symptoms. We found significantly higher incidence of anxiety and depressive disorders, and Axis II personality disorders for OCD patients. These findings are discussed in the view of results from earlier reports.     

Prevalence of typus melancholicus in healthy germans

BACKGROUND: There have been few studies concerning the prevalence of Typus melancholicus (TM) in healthy volunteers based on age or sex. To our knowledge, no such studies have been performed in healthy Germans, but several in healthy Japanese people. Therefore, it is necessary to also determine the prevalence of TM in healthy Germans, in order to know whether the prevalence of TM is cross-culturally constant. SUBJECTS AND METHODS: We examined the prevalence of TM in 121 healthy German volunteers (62 men and 59 women with a mean age +/- SD of 43.9 +/- 16.8 years and 47.4 +/- 15.9 years, respectively). Kasahara's Inventory for the Melancholic Type Personality (KIMTP) and von Zerssen's F-List (F-List) were used to identify TM. The subjects were divided by age into three groups: those aged 40 years or less (group A), those aged 41-60 years (group B), and those aged 61 years or more (group C). Mean total KIMTP and F-List scores were calculated. In addition, we also calculated mean scores of the two KIMTP TM factors ['harmony in personal relationships' (factor 1) and 'social norms' (factor 2)]. Differences in scores between men and women were analyzed by Student's t test. Differences in scores between the three age groups were evaluated by one-way analysis of variance and Scheffé's test. RESULTS: The KIMTP and F-List scores increased with age in both men and women. In the women, the KIMTP and F-List scores were significantly higher in groups B and C than in group A. In the women, the group C KIMTP factor 1 score was significantly higher than the group A KIMTP factor 1 score. The KIMTP and F-List scores tended to be higher for the women than for the men. Within groups B and C, the KIMTP and F-List scores and the KIMTP factor 1 score were significantly higher for the women than for the men. CONCLUSION: Overall, the sex and age distributions of scores for both questionnaires were similar to those obtained in previous studies in Japanese people. It is of note that our German subjects and previous Japanese subjects were not demographically controlled and, clearly, cultural backgrounds differed. Thus, KIMTP and the F-List may discriminate the TM personality with some degree of universality despite cultural differences and might be useful in cross-cultural comparisons of TM.     

Dimension of Typus melancholicus on Kasahara's Inventory for the Melancholic Type Personality

BACKGROUND: Traditionally, Typus melancholicus (TM) was considered, a priori, to represent unidimensionality. Recent studies have suggested that TM is not a personality trait, but rather a constellation of personality traits. The purpose of this study was to examine whether TM on Kasahara's Inventory for the Melancholic Type Personality (KIMTP), considered to represent one of the valid TM questionnaires, is comprised of personality dimensions, and if so, which dimension is essential for distinguishing depressive subjects from control subjects. SUBJECTS AND METHODS: To clarify the dimensionality of TM scores on KIMTP, factor analysis of the TM scores was conducted using principal factor analysis followed by varimax rotation. Comparisons were then made between endogenous depressive patients (n = 38), nonendogenous depressive patients (n = 20), and healthy volunteers (n = 81) for total KIMTP score and factor scores using analysis of covariance, adjusting for sex and age. RESULTS: Factor analysis of KIMTP revealed 2 distinct clusters of items, i.e. 'harmony in personal relationships' (factor 1) and 'social norms' (factor 2). Endogenous and nonendogenous depressive patients showed significantly higher KIMTP total and factor 1 scores than did control subjects. However, no significant differences were observed for KIMTP total score and scores of individual factors between endogenous and nonendogenous depressive patients. CONCLUSIONS: The present results indicate that TM on KIMTP represents a constellation of personality traits, and that the factor 'harmony in personal relationship' possesses the essential meaning for assessing TM.     

Depressive Symptomatology in High School Students: The Role of Age,Gender and Academic Pressure

To clarify the prevalence of depressive symptomatology in high school students in Athens and to evaluate risk factors for depressive symptomatology the CES-D scale was administered to 713 students (age 15–18). Demographic, school performance and extracurricular activities data were collected. A high prevalence (26.2%) of depressive symptomatology (CES-D cut-off score >28) was found. Regression analysis showed depressive symptomatology to be associated to gender (girls had higher scores than boys), school record (students with a better record had lower scores) and the interaction of gender and grade (males were found to have higher depressive symptomatology scores as they grew older).     

Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior

OBJECTIVE: The purpose of the study was to determine if patients with a history of major depressive episode and comorbid posttraumatic stress disorder (PTSD) have a higher risk for suicide attempt and differ in other measures of suicidal behavior, compared to patients with major depressive episode but no PTSD. In addition, to explore how PTSD comorbidity might increase risk for suicidal behavior in major depressive episode, the authors investigated the relationship between PTSD, cluster B personality disorder, childhood sexual or physical abuse, and aggression/impulsivity. METHOD: The subjects were 230 patients with a lifetime history of major depressive episode; 59 also had lifetime comorbid PTSD. The demographic and clinical characteristics of subjects with and without PTSD were compared. Multivariate analysis was used to examine the relationship between suicidal behavior and lifetime history of PTSD, with adjustment for clinical factors known to be associated with suicidal behavior. RESULTS: Patients with a lifetime history of PTSD were significantly more likely to have made a suicide attempt. The groups did not differ with respect to suicidal ideation or intent, number of attempts made, or maximum lethality of attempts. The PTSD group had higher objective depression, impulsivity, and hostility scores; had a higher rate of comorbid cluster B personality disorder; and were more likely to report a childhood history of abuse. However, cluster B personality disorder was the only independent variable related to lifetime suicide attempts in a multiple regression model. CONCLUSIONS: PTSD is frequently comorbid with major depressive episode, and their co-occurrence enhances the risk for suicidal behavior. A higher rate of comorbid cluster B personality disorder appears to be a salient factor contributing to greater risk for suicidal acts in patients with a history of major depressive episode who also have PTSD, compared to those with major depressive episode alone.