The effect of episodes on recurrence in affective disorder: a case register study.

BACKGROUND: The risk of recurrence has been found to increase with the number of episodes in both unipolar and bipolar affective disorder. The present study compared the effect of the number of episodes on the risk of recurrence in the two disorders. METHOD: A case register study including all hospital admissions with primary affective disorder in Denmark during 1971-1993. The effect of the number of prior episodes on the rate of recurrence following the first discharge after 1984 was estimated. A total of 7925 unipolar patients and 2011 bipolar patients were included in the study. RESULTS: The rate of recurrence was, on average, 1.6 times greater for bipolar patients than for unipolar patients. Nevertheless, the effect of the number of episodes was greatest for unipolar patients. Thus, the rate of recurrence increased, on average, 15% with every episode for unipolar patients and 9% with every episode for bipolar patients, when adjusted for differences in age and gender. CONCLUSION: The risk of recurrence increases with every new episode in affective disorder. The effect of episodes is greater for unipolar disorder than for bipolar disorder. LIMITATIONS: The data relate to re-admissions rather than recurrence. CLINICAL RELEVANCE: The study shows that the prognosis worsens more for unipolar than for bipolar patients with each new episode and suggests the relevance of earlier and more sustained intervention.     

The effect of comorbid alcoholism on recurrence in affective disorder: a case register study.

BACKGROUND: Studies of the effect of comorbid alcoholism on the risk of recurrence in affective disorder have given contradictory results. METHOD: Using survival analysis, the rate of recurrence was calculated in a case register study including all hospital admissions with primary affective disorder in Denmark during 1971-1993. The rate of recurrence was estimated following each new affective episode. RESULTS: In all, 20 350 patients were discharged after first admission with a main diagnosis of affective disorder of depressive or manic/circular type. Among these, 518 patients (2.6%) had an auxiliary diagnosis of alcoholism. Patients with a current auxiliary diagnosis of alcoholism had increased rate of recurrence following the first three affective episodes but not following subsequent episodes compared with patients without auxiliary diagnoses. The effect of alcoholism declined with the number of episodes. In contrast, no effect was found of other auxiliary diagnoses on the rate of recurrence. CONCLUSION: Rehospitalisation data suggest that concurrent alcoholism increases the risk of recurrence of affective episodes during the initial course of unipolar and bipolar disorder but has no effect on recurrence later in the course of the illnesses. LIMITATION: The data relate to re-admissions rather than recurrence. CLINICAL RELEVANCE: The study emphasises that alcoholism has a deteriorating effect on the course of affective disorder.     

Obsessive-compulsive disorder in bipolar disorder patients with first manic episode

BACKGROUND: Evidence indicates that obsessive--compulsive disorder (OCD) co-occurs with schizophrenia and bipolar disorder (BD) at a higher rate than in the general population. The inflated rate of comorbidity may result from chronic illness, antipsychotic therapy or treatment-seeking behavior. To control for these factors we evaluated the prevalence of OCD in patients with first-episode acute mania who met DSM-IV criteria for BD-I, and compared them with our previously reported group of first-episode schizophrenia patients. METHOD: Fifty-six BD-I patients with a first-episode of acute mania were screened for OCD and additional comorbid disorders using the Structured Clinical Interview for DSM-IV Axis-I disorders and appropriate rating scales. RESULTS: Only one patient (1.8%) met DSM-IV criteria for OCD, and two (3.6%) met criteria for sub-threshold OCD. In contrast, there was a substantial aggregation of substance use disorders 32.1% (N=8), anxiety disorders, other than OCD 26.8% (N=15) and eating disorders 14.3% (N=8). LIMITATIONS: Small sample size, cross-sectional nature of the assessments and the inclusion of only BD-I patients. CONCLUSION: The rate of OCD in first-episode BD-I patients did not differ significantly from that found in the general population and was substantially lower than in previously reported first-episode schizophrenia patients (1.8% vs. 14%). We suggest that a preferential association of OCD with schizophrenia early in the course of illness represents a pathophysiological linkage between the two disorders, and putatively a specific schizo-obsessive subtype. In contrast, OCD in BD-I may stand for "true" comorbidity. Large-scale parallel comparative evaluations of comorbidity in BD-I and schizophrenia may contribute to the search for specific pathophysiological mechanisms of distinct comorbid-related subsets in either disorder.     

Seasonal variation in affective disorders. A case register study

This paper reports the results of a study on seasonal variation in new episodes of affective disorders, conducted using the South-Verona psychiatric case register. We found evidence for a cyclical pattern in the occurrence of affective psychosis, but this was statistically significant only for the males: there was no cyclical variation in depressive neurosis. The advantages are discussed of case register data over hospital admission statistics for the study of seasonal variation. These are particularly marked in case register areas where community psychiatric care is well developed, as in South-Verona.     

Symptoms and behaviors prior to the first major affective episode of bipolar II disorder. An exploratory study

Background

Few studies have investigated the initial prodrome of bipolar disorders, and none has explicitly addressed bipolar II disorder (BD-II). We explored symptoms and behaviors preceding the first major affective episode (FMAE) of BD-II to generate hypotheses concerning possible clinical targets for early intervention.

Methods

In-depth interviews of 15 BD-II patients and 22 family informants were carried out. Clinical diagnoses were reassessed. The textual data of transcribed interviews were analyzed utilizing qualitative methodology supplemented by quantitative analyses.

Results

All patients experienced clinically significant symptoms and behaviors at an average of more than a decade before the FMAE. Anxiety and depression-type symptoms were the most common. Two distinct subgroups were identified based on prominent and enduring personal characteristics prior to the FMAE. The individuals in one of the subgroups were described as very well-functioning, whereas the individuals in the other subgroup were characterized by neurocognitive deficits, relatively low academic and social functioning, and pronounced irritability and aggressiveness. Furthermore, it is possible that these individuals experience earlier prodromal symptom onset, earlier FMAEs, and more symptoms than individuals without these characteristics.

Limitations

This is a retrospective and hypothesis-generating qualitative study. The hypotheses generated need to be tested in future studies.

Conclusions

Prodromal clinical phenomenology is too nonspecific to predict the occurrence of the FMAE of BD-II. However, identifiable subgroups may exist. We hypothesize that neurocognitive deficits together with pronounced irritability and aggressiveness may constitute a vulnerability marker for a subgroup of individuals who subsequently develop BD-II. This subgroup may be of potential interest for early identification.     

The precipitants of manic/hypomanic episodes in the context of bipolar disorder: a review

Background

Mania/hypomania is the hallmark feature of bipolar disorder. This paper aims to review the current evidence in relation to factors hypothesised to precipitate bipolar mania/hypomania, and suggest areas for future research.

Methods

A selective review of original and review papers was conducted. The electronic databases ‘PsycINFO’ and ‘PubMed’ were searched using the following search strings: “bipolar disorder” or “mania” or “hypomania” or “manic-depression” with “triggers” or “precipitants” or “precedents” or “predictors”.

Results

There is evidence that goal attainment events, antidepressant medication, disrupted circadian rhythms, spring/summer seasonal conditions, and more tentatively, stressful life events and high emotional expression, may precipitate bipolar mania/hypomania in susceptible individuals. Evidence from case reports and clinical observations are also reported.

Discussion

The pathways to bipolar mania/hypomania may be many and varied, and many of these pathways may be outside the awareness of individuals with bipolar disorder. Greater awareness of the broad number of precipitating factors is needed to inform self-management and psycho-educational programs to build resilience to further episodes. Future research is needed to explore what other factors may precipitate bipolar mania/hypomania, and to determine why some factors may precipitate mania/hypomania in some individuals with bipolar I or II disorder but not in others.     

Suicide risk in patients hospitalised because of an affective disorder: a follow-up study, 1973-1993

The aim of this study was to identify risk factors for suicide related to the course of treatment. METHODS: All persons in Denmark hospitalised for the first time because of an affective disorder during the period 1973-1993 were included. RESULTS: In 53466 patients, suicide was the cause of death in 3141 (6%) cases. The risk of suicide was high both immediately after admission and immediately following discharge. Increased risk was also associated with short duration of affective disorder, a history of multiple admissions, male gender, and increasing age. LIMITATIONS: We were not able to distinguish with certainty between manic and depressive episodes in bipolar disorder. Prior suicide attempts could not be included in the analyses. Lack of operationalised diagnostic criteria. CONCLUSIONS: Patients hospitalised because of an affective disorder are a highly relevant target group for suicide prevention. There is a need for improvement of preventive measures during admission and at discharge. Likewise, there is a need for preventive measures which can minimize the risk of relapse in affective disorders.     

The significance of psychotic features in manic episodes: a report from the NIMH collaborative study

BACKGROUND: Psychotic features in the context of major depressive syndromes have correlates in symptom severity, acute treatment response and long-term prognosis. Little is known as to whether psychotic features have similar importance when they occur within manic syndromes. METHODS: These data derive from a multi-center, long-term follow-up of patients with major affective disorder. Raters conducted follow-up interviews at 6-month intervals for the first 5 years and annually thereafter. A sub-set of probands participated in a family study in which all available, adult, first-degree relatives were interviewed as well. RESULTS: Of 139 who entered the study in an episode of mania, 90 patients had psychotic features. Symptom severity ratings at intake were more severe for this group. Though time to first recovery and time to first relapse did not distinguish the groups, psychotic features were associated with a greater number of weeks ill during follow-up and the strength of this association was similar to that seen for psychotic features within depressed patients described in an earlier publication. Patients with psychotic mania at intake did not differ significantly from those with nonpsychotic mania by response to acute lithium treatment, suicidal behavior during follow-up, or risks for affective disorder among first-degree relatives. Psychotic features within manic syndromes were not associated with high psychosis ratings during follow-up. In contrast, when psychotic features accompanied depressive syndromes, they strongly predicted the number of weeks with psychosis during follow-up, particularly among individuals whose episodes at intake were less acute. CONCLUSIONS: As with major depressive syndromes, psychotic features in mania are associated with greater symptom severity and higher morbidity in the long-term. Psychotic features are much less predictive of future psychosis when they occur within a manic syndrome than when they occur within a depressive syndrome.     

Gender, marital status and treated affective disorders in South Verona: a case register study

Data from the South Verona Psychiatric Case Register were used to test hypotheses about the relationship between age, gender, marital status and the incidence of treated affective disorders. Analysis of the 5-year period 1983-1987 yielded overall rates of affective disorder per 10(5) of 57.7 for males and 78.4 for women. Incidence increased with age both for depressive neurosis and for affective psychosis. Married women had high rates compared with their single counterparts whereas the reverse was true for men. The very low values for incidence are likely to reflect the major role in the treatment of affective disorders carried out by Italian general practitioners, rather than a low population rate of these disorders.     

Rapid cycling affective disorder: a descriptive study from North India.

A series of 33 (4.29%) cases of rapid cycling affective disorder (RCAD ICD-10-DCR) out of a pool of 770 consecutive cases of ICD-10 affective disorder (AD) was collected over a period of 5 years. All cases of RCAD belonged to bipolar affective disorder. RCAD when compared with non-rapid cycling bipolar affective disorder (BPAD) revealed a significantly longer mean duration of illness, greater number of total episodes, greater number of hospitalizations and stronger family loading of bipolar affective disorder. These findings implicate RCAD as a severe form of bipolar affective disorder.     

The initial prodrome to bipolar affective disorder: prospective case studies

BACKGROUND: The initial prodrome to bipolar disorder has received very little attention to date, with most of the available data only addressing the prodrome to relapse. This study presents several prospective case studies of the initial prodrome to bipolar affective disorder. METHODS: Three patients are presented who developed bipolar disorder during their treatment at the Personal Assessment and Crisis Evaluation Clinic (PACE). They were prospectively interviewed over a 12-month period using standard clinical research interviews. RESULTS: These patients met the criteria for bipolar disorder by the end of the treatment period. Depressive symptoms were the main reason for their first clinical presentation, with mania developing at a later date. Other comorbidities were observed before they were diagnosed with bipolar disorder. LIMITATIONS: The generalisability of our findings was constrained because of the small sample size. Furthermore, our findings are likely to be influenced by the intake criteria used at PACE, a clinic that primarily aims at identifying patients at risk of psychosis rather than bipolar disorder. CONCLUSION: Our study provides information about the initial prodrome to bipolar disorder, which has previously been neglected in research studies. We found there were no prodrome features that clearly distinguished between patients who go on to develop bipolar disorder and those who develop schizophrenia. We hope our prospective data will be the starting point for subsequent studies, with the aim of applying these findings to developing suitable preventative interventions for bipolar disorder.     

Anorexia nervosa: a psychiatric case register study from Aberdeen

The results of an examination of the 238 cases of anorexia nervosa on the Aberdeen Psychiatric Case Register for the period 1965-82 are reported. A highly significant increase in the number of cases over time was found. The average annual incidence rate for the period 1978-82 was 4.06 per 100 000 population. The case notes of every second patient on the register were inspected to assess diagnostic reliability, to define patient characteristics further and to look for changes in these over time. The diagnosis was highly suspect in 5% of cases. A social class bias was found, with an over-representation of classes I and II but an under-representation of social class III. Few significant changes were noted in the patients over time. The utilization of services was also examined, and it was found that 24% of the patients remained in contact for 4 years or more.     

Efficacy and safety of aripiprazole in subpopulations with acute manic or mixed episodes of bipolar I disorder

BACKGROUND: This analysis was designed to assess the efficacy and safety of aripiprazole compared with placebo in subpopulations of patients with acute manic or mixed episodes of bipolar I disorder. METHODS: Acutely manic patients experiencing DSM-IV manic/mixed episodes of bipolar I disorder were pooled from two randomized, three-week, flexible-dose, double-blind, placebo-controlled trials (N=516) and stratified by disease severity (Young Mania Rating Scale, YMRS), episode type, presence or absence of psychotic features, episode frequency, age, gender, and baseline severity of depressive symptoms. Safety and treatment-emergent adverse-event analyses were also performed. RESULTS: Aripiprazole significantly reduced mean YMRS total scores at end point compared with placebo in patients with more severe or less severe illness, with mixed or manic episodes, with or without psychotic features, or with a history of rapid or non-rapid cycling (p<0.01 for each subpopulation); in men and women (p=0.001 for both); in patients in the 18-40 and 41-55 year age groups (por=5% of patients aged 18-40 years receiving aripiprazole were similar to those reported for the overall population. LIMITATIONS: This post hoc analysis utilized pooled data from two short-term studies. CONCLUSION: Efficacy of the second-generation antipsychotic aripiprazole was noted across a broad range of subpopulations often associated with treatment resistance in patients experiencing manic or mixed episodes of bipolar I disorder.     

Seasonal affective disorder and latitude: a review of the literature.

BACKGROUND: The aim of the study is to investigate the relationship between the prevalence of SAD and latitude. METHODS: An overview of the epidemiological literature on the prevalence of SAD is given and studies relevant for the latitudinal dependency of prevalence will be analyzed and discussed. RESULTS: The mean prevalence of SAD is two times higher in North America compared to Europe. Over all prevalence studies, the correlation between prevalence and latitude was not significant. A significant positive correlation was found between prevalence and latitude in North America. For Europe there was a trend in the same direction. CONCLUSIONS: The influence of latitude on prevalence seems to be small and other factors like climate, genetic vulnerability and social-cultural context can be expected to play a more important role. Additional controlled studies taking these factors into account are necessary to identify their influence.     

Tyrosine hydroxylase polymorphism and phenotypic heterogeneity in bipolar affective disorder: a multicenter association study.

Tyrosine hydroxylase (TH), the rate-limiting enzyme in the metabolism of catecholamines, is considered a candidate gene in bipolar affective disorder (BPAD) and has been the subject of numerous linkage and association studies. Taken together, most results do not support a major gene effect for the TH gene in BPAD. Genetic and phenotypic heterogeneity may partially explain the difficulty of confirming the exact role of this gene using both association and linkage methods. Four hundred one BPAD patients and 401 unrelated matched controls were recruited within a European collaborative project (BIOMED1 project in the area of brain research, European Community grant number CT 92-1217, project leader: J. Mendlewicz) involving 14 centers for a case-control association study with a tetranucleotide polymorphism in the TH gene. Patients and controls were carefully matched for geographical origin. Phenotypic heterogeneity was considered and subgroup analyses were performed with relevant variables: age at onset, family history, and diagnostic stability. No association was observed in the total sample or for subgroups according to age at onset (n = 172), family history alone (n = 159), or high degree of diagnostic stability and a positive family history (n = 131). The results of this association study do not confirm the possible implication of TH polymorphism in the susceptibility to BPAD.