Rumination,gender, and depressive symptoms associated with caregiving strain in bipolar disorder

Perlick DA, Gonzalez J, Michael L, Huth M, Culver J, Kaczynski R. Calabrese J. Miklowitz DJ. Rumination, gender, and depressive symptoms associated with caregiving strain in bipolar disorder. Objective: To evaluate the associations between indices of caregiving strain, ruminative style, depressive symptoms, and gender among family members of patients with bipolar disorder. Method: One hundred and fifty primary caregivers of patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP‐BD) participated in a cross‐sectional study to evaluate the role of ruminative style in maintaining depressive symptoms associated with caregiving strain. Patient lifetime diagnosis and current episode status were evaluated by the Affective Disorder Evaluation and the Clinical Monitoring Form. Caregivers were evaluated within 30 days of the patient on measures of family strain, depressive symptoms, and ruminative style. Results: Men and women did not differ on depression, caregiver strain, or ruminative style scores. Scores suggest an overall mild level of depression and moderate caregiver strain for the sample. Greater caregiver strain was significantly associated (P < 0.05) with rumination and level of depressive symptoms, controlling for patient clinical status and demographic variables. Rumination reduced the apparent association between strain and depression by nearly half. Gender was not significantly associated with depression or rumination. Conclusion: Rumination helps explain depressive symptoms experienced by both male and female caregivers of patients with bipolar disorder. Interventions for caregivers targeted at decreasing rumination should be considered.     

Early psychosocial intervention for youth at risk for bipolar I or II disorder: a one-year treatment development trial

Miklowitz DJ, Chang KD, Taylor DO, George EL, Singh MK, Schneck CD, Dickinson LM, Howe ME, Garber J. Early psychosocial intervention for youth at risk for bipolar I or II disorder: a one‐year treatment development trial.
Bipolar Disord 2011: 13: 67–75. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objectives: Previous studies have identified behavioral phenotypes that predispose genetically vulnerable youth to a later onset of bipolar I or II disorder, but few studies have examined whether early psychosocial intervention can reduce risk of syndromal conversion. In a one‐year open trial, we tested a version of family‐focused treatment adapted for youth at high risk for bipolar disorder (FFT‐HR). Methods: A referred sample of 13 children (mean 13.4 ± 2.69 years; 4 boys, 9 girls) who had a parent with bipolar I or II disorder participated at one of two outpatient specialty clinics. Youth met DSM‐IV criteria for major depressive disorder (n = 8), cyclothymic disorder (n = 1), or bipolar disorder not otherwise specified (n = 4), with active mood symptoms in the past month. Participants were offered FFT‐HR (12 sessions in four months) with their parents, plus psychotropic medications as needed. Independent evaluators assessed depressive symptoms, hypomanic symptoms, and global functioning at baseline and then every four months for one year, with retrospective severity and impairment ratings made for each week of the follow‐up interval. Results: Families were mostly adherent to the treatment protocol (85% retention), and therapists administered the FFT‐HR manual with high levels of fidelity. Youth showed significant improvements in depression, hypomania, and psychosocial functioning scores on the Adolescent Longitudinal Interval Follow‐up Evaluation. They also showed significant improvements in Young Mania Rating Scale and Children’s Depression Rating Scale scores. Conclusions: FFT‐HR is a promising intervention for youth at high risk for BD. Larger‐scale randomized trials that follow youth into young adulthood will be necessary to determine whether early psychosocial intervention can reduce the probability of developing bipolar I or II disorder among genetically vulnerable youth.     

Prevalence and correlates of burden among caregivers of patients with bipolar disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder

OBJECTIVES: Caring for a relative with schizophrenia or dementia is associated with reports of high caregiver burden, symptoms of depression, poor physical health, negligence of the caregiver's own health needs, elevated health service use, low use of social supports, and financial strain. This study presents the design and preliminary data on the costs and consequences of caring for a relative or friend with bipolar disorder from the Family Experience Study, a longitudinal study of the primary caregivers to 500 patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder. METHODS: Subjects were primary caregivers of 500 patients with bipolar disorder diagnosed by the Mini International Neuropsychiatric Interview and the Affective Disorder Evaluation. Caregivers were evaluated within 1 month after patients entered Systematic Treatment Enhancement Program using measures of burden, coping, health/mental health, and use of resources and costs. RESULTS: Eighty-nine percent, 52%, and 61% of caregivers, respectively, experienced moderate or higher burden in relation to patient problem behaviors, role dysfunction, or disruption of household routine. High burden caregivers reported more physical health problems, depressive symptoms, health risk behavior and health service use, and less social support than less burden caregivers. They also provided more financial support to their bipolar relative. CONCLUSIONS: Burdens experienced by family caregivers of people with bipolar disorder are associated with problems in health, mental health, and cost. Psychosocial interventions targeting the strains of caregiving for a patient with bipolar disorder are needed.     

The longitudinal course of bipolar disorder as revealed through weekly text messaging: a feasibility study

Bopp JM, Miklowitz DJ, Goodwin GM, Stevens W, Rendell JM, Geddes JR. The longitudinal course of bipolar disorder as revealed through weekly text messaging: a feasibility study.
Bipolar Disord 2010: 12: 327–334. © 2010 The Authors.
Journal compilation © 2010 John Wiley & Sons A/S. Objectives: To examine the feasibility of collecting course of illness data from patients with bipolar I and II disorder, using weekly text‐messaged mood ratings, and to examine the time trajectory of symptom ratings based on this method of self‐report. Methods: A total of 62 patients with bipolar I (n = 47) or II (n = 15) disorder provided mood data in response to weekly cell phone text messages (n = 54) or e‐mail prompts (n = 8). Participants provided weekly ratings using the Altman Self‐Rating Mania Scale and the Quick Inventory of Depressive Symptoms–Self Report. Patients with bipolar I and II disorder, and men and women, were compared on percentages of time in depressive or manic mood states over up to two years. Results: Participants provided weekly ratings over an average of 36 (range 1–92) weeks. Compliance with the procedure was 75%. Overall, participants reported depressive symptoms 47.7% of the time compared to 7% of entries reflecting manic symptoms, 8.8% reflecting both depressive and manic symptoms, and 36.5% reflecting euthymic mood. Participants with bipolar I disorder reported more days of depression and were less likely to improve with time than participants with bipolar II disorder. Gender differences observed at the beginning of the study were not observed at follow‐up. Conclusions: The results are similar to those of other longitudinal studies of bipolar disorder that use traditional retrospective, clinician‐gathered mood data. Text‐message‐based symptom monitoring during routine follow‐up may be a reliable alternative to in‐person interviews.     

Suicidal ideation and depressive symptoms among bipolar patients as predictors of the health and well‐being of caregivers

Objectives: Few studies have addressed the physical and mental health effects of caring for a family member with bipolar disorder. This study examined whether caregivers’ health is associated with changes in suicidal ideation and depressive symptoms among bipolar patients observed over one year. Methods: Patients (N = 500) participating in the Systematic Treatment Enhancement Program for Bipolar Disorder and their primary caregivers (N = 500, including 188 parental and 182 spousal caregivers) were evaluated for up to one year as part of a naturalistic observational study. Caregivers’ perceptions of their own physical health were evaluated using the general health scale from the Medical Outcomes Study 36‐item Short‐Form Health Survey. Caregivers’ depression was evaluated using the Center for Epidemiological Studies of Depression Scale. Results: Caregivers of patients who had increasing suicidal ideation over time reported worsening health over time compared to caregivers of patients whose suicidal ideation decreased or stayed the same. Caregivers of patients who had more suicidal ideation and depressive symptoms reported more depressed mood over a one‐year reporting period than caregivers of patients with less suicidal ideation or depression. The pattern of findings was consistent across parent caregivers and spousal caregivers. Conclusions: Caregivers, rightly concerned about patients becoming suicidal or depressed, may try to care for the patient at the expense of their own health and well‐being. Treatments that focus on the health of caregivers must be developed and tested.     

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013

Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Beaulieu S, Alda M, O’Donovan C, MacQueen G, McIntyre RS, Sharma V, Ravindran A, Young LT, Milev R, Bond DJ, Frey BN, Goldstein BI, Lafer B, Birmaher B, Ha K, Nolen WA, Berk M.
Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013.
Bipolar Disord 2012: 00: 000–000. © 2012 John Wiley & Sons A/S.Published by Blackwell Publishing Ltd. The Canadian Network for Mood and Anxiety Treatments published guidelines for the management of bipolar disorder in 2005, with updates in 2007 and 2009. This third update, in conjunction with the International Society for Bipolar Disorders, reviews new evidence and is designed to be used in conjunction with the previous publications.The recommendations for the management of acute mania remain largely unchanged. Lithium, valproate, and several atypical antipsychotic agents continue to be first‐line treatments for acute mania. Monotherapy with asenapine, paliperidone extended release (ER), and divalproex ER, as well as adjunctive asenapine, have been added as first‐line options.For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first‐line options. Lurasidone monotherapy and the combination of lurasidone or lamotrigine plus lithium or divalproex have been added as a second‐line options. Ziprasidone alone or as adjunctive therapy, and adjunctive levetiracetam have been added as not‐recommended options for the treatment of bipolar depression. Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole, risperidone long‐acting injection, and adjunctive ziprasidone continue to be first‐line options for maintenance treatment of bipolar disorder. Asenapine alone or as adjunctive therapy have been added as third‐line options.     

Facilitated Integrated Mood Management for adults with bipolar disorder

Miklowitz DJ, Price J, Holmes EA, Rendell J, Bell S, Budge K, Christensen J, Wallace J, Simon J, Armstrong NM, McPeake L, Goodwin GM, Geddes JR. Facilitated Integrated Mood Management for adults with bipolar disorder.
Bipolar Disord 2012: 14: 185–197. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S. Objectives: We describe the development of a five‐session psychoeducational treatment, Facilitated Integrated Mood Management (FIMM), which contains many of the core elements of longer evidence‐based psychosocial treatments for bipolar disorder. FIMM incorporated a novel mood monitoring program based on mobile phone technology. Methods: Adult patients with bipolar I and II disorders (N = 19) received six sessions (Pilot I: n = 14) or five sessions (Pilot II: n = 5) of FIMM with pharmacotherapy. Treatment facilitators were novice counselors who were trained in a three‐day workshop and supervised for six months. FIMM sessions focused on identifying early signs of recurrence, maintaining regular daily and nightly routines, rehearsing mood management strategies, maintaining adherence to medications, and education about substance abuse. Patients sent daily text messages or e‐mails containing ratings of their mood and sleep, and weekly messages containing self‐ratings on the Quick Inventory of Depressive Symptomatology (QIDS) and the Altman Self Rating Mania Scale (ASRM). Patients also completed a weekly mood management strategies questionnaire. Results: Of the 19 patients, 17 (89.5%) completed FIMM in an average of 9.2 ± 3.4 weeks (Pilot I) and 7.6 ± 0.9 weeks (Pilot II). Patients reported stable moods on the QIDS and ASRM over a 120‐day period, and on average responded to 81% of the daily message prompts and 88% of the weekly QIDS and ASRM prompts. Facilitators maintained high levels of fidelity to the FIMM manual. Patients’ knowledge of mood management strategies increased significantly between the first and last weeks of treatment. Conclusions: Patients with bipolar disorder can be engaged in a short program of facilitated mood management. The effects of FIMM on the course of bipolar disorder await evaluation in randomized trials. The program may be a useful adjunct to pharmacotherapy in community centers that cannot routinely administer full courses of psychosocial treatment.     

Correlates of subjective and objective burden among caregivers of patients with bipolar disorder

Objective: We examined the relationship between mood symptoms and episodes in patients with bipolar disorder and burden reported by their primary caregivers. Method: Data on subjective and objective burden reported by 500 primary caregivers for 500 patients with bipolar disorder participating in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP‐BD) were collected using semistructured interviews. Patient data were collected prospectively over 1 year. The relationship between patient course and subsequent caregiver burden was examined. Results: Episodes of patient depression, but not mood elevation, were associated with greater objective and subjective caregiver burden. Burden was associated with fewer patient days well over the previous year. Patient depression was associated with caregiver burden even after controlling for days well. Conclusion: Patient depression, after accounting for chronicity of symptoms, independently predicts caregiver burden. This study underscores the important impact of bipolar depression on those most closely involved with those whom it affects.     

Relationship between suicidality and impulsivity in bipolar I disorder: a diffusion tensor imaging study

Mahon K, Burdick KE, Wu J, Ardekani BA, Szeszko PR. Relationship between suicidality and impulsivity in bipolar I disorder: a diffusion tensor imaging study.
Bipolar Disord 2012: 14: 80–89. © 2012 The Authors.
Journal compilation © 2012 John Wiley & Sons A/S. Background: Impulsivity is characteristic of individuals with bipolar disorder and may be a contributing factor to the high rate of suicide in patients with this disorder. Although white matter abnormalities have been implicated in the pathophysiology of bipolar disorder, their relationship to impulsivity and suicidality in this disorder has not been well‐investigated. Methods: Diffusion tensor imaging scans were acquired in 14 bipolar disorder patients with a prior suicide attempt, 15 bipolar disorder patients with no prior suicide attempt, and 15 healthy volunteers. Bipolar disorder patients received clinical assessments including measures of impulsivity, depression, mania, and anxiety. Images were processed using the Tract‐Based Spatial Statistics method in the FSL software package. Results: Bipolar disorder patients with a prior suicide attempt had lower fractional anisotropy (FA) within the left orbital frontal white matter (p < 0.05, corrected) and higher overall impulsivity compared to patients without a previous suicide attempt. Among patients with a prior suicide attempt, FA in the orbital frontal white matter region correlated inversely with motor impulsivity. Conclusions: Abnormal orbital frontal white matter may play a role in impulsive and suicidal behavior among patients with bipolar disorder.     

Identification of bipolar disorder in women with postpartum depression

Sharma V, Khan M. Identification of bipolar disorder in women with postpartum depression.
Bipolar Disord 2010: 12: 335–340. © 2010 The Authors.
Journal compilation © 2010 John Wiley & Sons A/S. Objective: No studies to date have assessed the pharmacological management of treatment‐resistant postpartum depression. We reviewed the pharmacological treatment of postpartum depression in patients diagnosed with treatment‐resistant ‘unipolar’ depression. Methods: We conducted a chart review of patients treated consecutively at a perinatal clinic. Treatment‐resistant postpartum depression was defined as a failure to respond to at least one adequate antidepressant trial. Patients were diagnosed using the DSM‐IV criteria, and the Clinical Global Impression–Improvement (CGI‐I) rating scale was used to assess response to various pharmacological interventions. Results: The majority of patients (57%, 34/60) referred for postpartum depression actually suffered from bipolar disorder. All patients were on antidepressants at the time of referral, but by the end of the study 37% (22/60) continued on antidepressants alone or in combination with other medications. CGI‐I ratings showed appreciable improvement in depression at the end of six months following the initial consultation. Very much improvement was noted in 65% (39/60) of patients, and 22% (13/60) were considered much improved. The most common change in medication was a switch to or addition of an atypical neuroleptic. Limitations: Retrospective design, small sample size, and lack of a control group. Conclusions: Management of treatment resistance in women with postpartum depression should be considered within the context of types of mood disorders. Atypical neuroleptics and mood stabilizers used alone or as adjuncts should be considered in the treatment of resistant postpartum depression in patients with a bipolar diathesis.     

A 15-year prospective follow-up of bipolar affective disorders: comparisons with unipolar nonpsychotic depression

Goldberg JF, Harrow M. A 15‐year prospective follow‐up of bipolar affective disorders: comparisons with unipolar nonpsychotic depression.
Bipolar Disord 2011: 13: 155–163. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objectives: Outcome studies have previously documented substantial functional disability among individuals with bipolar disorder, although few follow‐up studies have examined the prospective course of illness beyond 10 years’ duration. Methods: A total of 95 patients with mood disorders (46 with bipolar I disorder and 49 with unipolar nonpsychotic depression) were assessed 15 years after index hospitalization. Logistic and linear regression models were used to identify predictors of global functioning, work disability, and social adjustment. Results: At 15‐year follow‐up, good overall functioning was significantly less common among subjects with bipolar disorder (35%) than unipolar depression (73%) (p < 0.001). Work disability was significantly more extensive in bipolar than unipolar disorder subjects (p < 0.001). Logistic regression indicated that good outcome 15 years after index hospitalization was significantly predicted by a unipolar rather than bipolar disorder diagnosis and the absence of a depressive episode in the preceding year. Past‐year depressive, but not past‐year manic, syndromes were associated with poorer global outcome and greater work disability. In addition, subsyndromal depression was significantly associated with poorer global, work, and social outcome among bipolar, but not unipolar disorder subjects. Conclusions: A majority of individuals with bipolar I disorder manifest problems with work and global functioning 15 years after an index hospitalized manic episode Recurrent syndromal and subsyndromal depression disrupts multiple domains of functional outcome more profoundly in bipolar than unipolar mood disorders. The prevalence, and correlates, of impaired long‐term outcome parallel those reported in shorter‐term functional outcome studies of bipolar disorder.     

The relationship between religious involvement and clinical status of patients with bipolar disorder

Cruz M, Pincus HA, Welsh DE, Greenwald D, Lasky E, Kilbourne AM. The relationship between religious involvement and clinical status of patients with bipolar disorder.
Bipolar Disord 2010: 12: 68–76. © 2010 The Authors.
Journal compilation © 2010 John Wiley & Sons A/S. Objective: Religion and spirituality are important coping strategies in depression but have been rarely studied within the context of bipolar disorder. The present study assessed the association between different forms of religious involvement and the clinical status of individuals treated for bipolar disorder. Methods: A cross‐sectional observation study of follow‐up data from a large cohort study of patients receiving care for bipolar disorder (n = 334) at an urban Veterans Affairs mental health clinic was conducted. Bivariate and multivariate analyses were performed to assess the association between public (frequency of church attendance), private (frequency of prayer/meditation), as well as subjective forms (influence of beliefs on life) of religious involvement and mixed, manic, depressed, and euthymic states when demographic, anxiety, alcohol abuse, and health indicators were controlled. Results: Multivariate analyses found significant associations between higher rates of prayer/meditation and participants in a mixed state [odds ratio (OR) = 1.29; 95% confidence interval (CI) = 1.10–1.52, chi square = 9.42, df = 14, p < 0.05], as well as lower rates of prayer/meditation and participants who were euthymic (OR = 0.84; 95% CI = 0.72–0.99, chi square = 4.60, df = 14, p < 0.05). Depression and mania were not associated with religious involvement. Conclusions: Compared to patients with bipolar disorder in depressed, manic, or euthymic states, patients in mixed states have more active private religious lives. Providers should assess the religious activities of individuals with bipolar disorder in mixed states and how they may complement/deter ongoing treatment. Future longitudinal studies linking bipolar states, religious activities, and treatment‐seeking behaviors are needed.     

Impulsivity across the course of bipolar disorder

Strakowski SM, Fleck DE, DelBello MP, Adler CM, Shear PK, Kotwal R, Arndt S. Impulsivity across the course of bipolar disorder.
Bipolar Disord 2010: 12: 285–297. © 2010 The Authors.
Journal compilation © 2010 John Wiley & Sons A/S. Objective: To determine whether abnormalities of impulse control persist across the course of bipolar disorder, thereby representing potential state markers and endophenotypes. Methods: Impulse control of 108 bipolar I manic or mixed patients was measured on three tasks designed to study response inhibition, ability to delay gratification, and attention; namely, a stop signal task, a delayed reward task, and a continuous performance task, respectively. Barrett Impulsivity Scale (BIS‐11) scores were also obtained. Patients were then followed for up to one year and reassessed with the same measures if they developed depression or euthymia. Healthy comparison subjects were also assessed with the same instruments on two occasions to assess measurement stability. Results: At baseline, bipolar subjects demonstrated significant deficits on all three tasks as compared to healthy subjects, consistent with more impulsive responding in the bipolar manic/mixed group. In general, performance on the three behavioral tasks normalized upon switching to depression or developing euthymia. In contrast, BIS‐11 scores were elevated during mania and remained elevated as bipolar subjects developed depression or achieved euthymia. Conclusions: Bipolar I disorder patients demonstrate deficits on laboratory tests of various aspects of impulsivity when manic, as compared to healthy subjects, that largely normalize with recovery and switching into depression. However, elevated BIS‐11 scores persist across phases of illness. These findings suggest that impulsivity has both affective‐state dependent and trait components in bipolar disorder.     

Fibromyalgia and bipolar disorder: a potential problem?

Wilke WS, Gota CE, Muzina DJ. Fibromyalgia and bipolar disorder: a potential problem?
Bipolar Disord 2010: 12: 514–520. © 2010 The Authors. Journal compilation © 2010 John Wiley & Sons A/S. Objective: To screen patients with fibromyalgia for bipolar disorder and to determine if there were any clinical clues, other than the Mood Disorders Questionnaire (MDQ), which might suggest a diagnosis of comorbid bipolar disorder. Methods: A total of 128 consecutive new fibromyalgia patients referred to a tertiary care center rheumatology practice were enrolled and assessed using a standard clinical protocol that included the completion of four screening questionnaires: (i) MDQ for bipolar disorder, (ii) Beck Depression Inventory (BDI) for depression, (iii) Epworth Sleepiness Scale (ESS) for daytime sleepiness, and (iv) Fibromyalgia Impact Questionnaire Disability Index (FIQ‐DI) to assess for functional capacity. Results: A quarter of the fibromyalgia subjects, 25.19%, had a positive screen for bipolar disorder (MDQ ≥ 7); 78.12% were clinically depressed (BDI ≥ 10); and 52.13% reported daytime sleepiness (ESS ≥ 10). Fibromyalgia subjects who screened positive for bipolar disorder had more severe depression than those with a negative screen [median BDI: 26.0 (19.0, 32.0) versus 15.0 (9.0, 24.0), p < 0.001]. Conclusions: We report a high prevalence of positive testing for bipolar disorder in this fibromyalgia cohort. Clinical data and questionnaire instruments other than nonspecific high depression severity failed to identify these patients. Since the norepinephrine serotonin reuptake inhibitors duloxetine and milnacipran have been recently approved by the U.S. Food and Drug Administration for the treatment of fibromyalgia, and because patients with bipolar disorder may experience destabilization of mood when treated with such agents, patients with fibromyalgia should be systematically screened for bipolar disorder prior to treatment.     

Cognitive styles in hypomanic episodes of bipolar I disorder

Lex C, Hautzinger M, Meyer TD. Cognitive styles in hypomanic episodes of bipolar I disorder.
Bipolar Disord 2011: 13: 355–364. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objectives: Cognitive vulnerability‐stress theories have recently been extended to bipolar disorder by suggesting that an activation of negative cognition might lead to depressive mood episodes and an activation of positive cognition might lead to manic mood episodes. Alternatively, the manic defense hypothesis claims that hypomanic and manic states are not the opposite of depression but rather contain similar underlying negative cognitions. The objective of this study was to further evaluate these theories by examining the cognitive patterns in bipolar I hypomania. Methods: We compared 15 hypomanic bipolar I disorder patients, 26 remitted bipolar I disorder patients, and 21 healthy individuals in a cross‐sectional study. All participants completed the Dysfunctional Attitude Scale, the Attributional Style Questionnaire, the Emotional Stroop Task, and the Emotional Auditory Verbal Learning Test. Results: Hypomanic bipolar disorder individuals showed cognitions associated with depressive states as well as cognitions associated with manic states. The results for the remitted bipolar disorder patients paralleled those for the control group. Conclusion: Dysfunctional cognition in bipolar disorder seems to relate to state rather than to trait. Hypomania includes depression‐related as well as mania‐related cognitions and can therefore not be considered as the mere opposite of depression.     

Pain and rejection sensitivity in bipolar depression

Ehnvall A, Mitchell PB, Hadzi‐Pavlovic D, Loo C, Breakspear M, Wright A, Roberts G, Frankland A, Corry J. Pain and rejection sensitivity in bipolar depression.
Bipolar Disord 2011: 13: 59–66. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objectives: Little is known regarding the correlates of pain in bipolar disorder. Recent neuroimaging studies support the contention that depression, as well as pain distress and rejection distress, share the same neurobiological circuits. In a recently published study, we confirmed the hypothesis that perception of increased pain during treatment‐refractory depression, predominantly unipolar, was related to increased rejection sensitivity. In the present study, we aimed to test this same hypothesis for bipolar depression. Methods: The present study analysed data from 67 patients presenting to the Black Dog Institute Bipolar Disorders Clinic in Sydney, Australia. The patients all met DSM‐IV criteria for bipolar disorder and had completed a self‐report questionnaire regarding perceived pain and rejection sensitivity during depression. Results: A significant increase in the experience of headaches (p = 0.003) as well as chest pain (p = 0.004) during bipolar depression was predicted by a major increase in rejection sensitivity when depressed, i.e., state rejection sensitivity. Being rejection sensitive in general, i.e., trait rejection sensitivity, did not predict pain during depression. Conclusions: The experience of increased headaches and chest pain during bipolar depression is related to increased rejection sensitivity during depression. Research to further elucidate this relationship is required.     

Evidence‐based treatment strategies for treatment‐resistant bipolar depression: a systematic review

Sienaert P, Lambrichts L, Dols A, De Fruyt J.
Evidence‐based treatment strategies for treatment‐resistant bipolar depression: a systematic review.
Bipolar Disord 2012: 00: 000–000. © 2012 John Wiley & Sons A/S.Published by Blackwell Publishing Ltd. Objectives: Treatment resistance in bipolar depression is a common clinical problem that constitutes a major challenge for the treating clinician as there is a paucity of treatment options. The objective of this paper was to review the evidence for treatment options in treatment‐resistant bipolar depression, as found in randomized controlled trials and with special attention to the definition and assessment of treatment resistance. Methods: A Medline search (from database inception to May 2012) was performed using the search terms treatment resistance or treatment refractory, and bipolar depression or bipolar disorder, supplemented with 43 separate searches using the various pharmacologic agents or technical interventions as search terms. Results: Only seven studies met our inclusion criteria. These studies examined the effects of ketamine (n = 1), (ar)modafinil (n = 2), pramipexole (n = 1), lamotrigine (n = 1), inositol (n = 1), risperidone (n = 1), and electroconvulsive therapy (ECT) (n = 2). Conclusions: The available level I evidence for treatment strategies in resistant bipolar depression is extremely scarce, and although the response rates reported are reassuring, most of the strategies remain experimental. There is an urgent need for further study in homogeneous patient samples using a clear concept of treatment resistance.     

Sleep apnea risk and clinical correlates in patients with bipolar disorder

Soreca I, Levenson J, Lotz M, Frank E, Kupfer DJ. Sleep apnea risk and clinical correlates in patients with bipolar disorder. Bipolar Disord 2012: 14: 672–676. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S. Objective: Despite the high prevalence of risk factors for obstructive sleep apnea (OSA) among individuals with bipolar disorder, the presence of sleep‐disordered breathing has not been systematically assessed in this population. In this study, we sought to determine the level of risk for OSA in a population of remitted individuals with a diagnosis of bipolar I disorder. Methods: A total of 72 individuals with a diagnosis of bipolar I disorder, all of whom were overweight by the World Health Organization criteria, completed the Berlin Questionnaire, a self‐assessment tool to establish risk for OSA. Results: Over half of this study population (54.1%) was found to be in the high‐risk category for OSA. Participants at high risk for OSA scored significantly higher on measures of both depression and mania, even when sleep items were not counted in the total scores. Conclusions: Sleep apnea may be prevalent in patients with bipolar I disorder. Considering the substantial overlap of symptoms between OSA and depression and the potentially harmful effects of sleep disruption in patients with mood disorders, a systematic screening to assess prevalence and associated features of OSA in patients with bipolar disorder is warranted.     

Self‐esteem in remitted bipolar disorder patients: a meta‐analysis

Nilsson KK, Jørgensen CR, Craig TKJ, Straarup KN, Licht RW. Self‐esteem in remitted bipolar disorder patients: a meta‐analysis.
Bipolar Disord 2010: 12: 585–592. © 2010 The Authors.
Journal compilation © 2010 John Wiley & Sons A/S. Objectives: Low self‐esteem has been found to be a risk factor for depression in major depressive disorder (MDD). In contrast, the role of self‐esteem in bipolar disorder (BD) is still uncertain. In order to examine the characteristics of self‐esteem in BD, we synthesized studies comparing self‐esteem in BD patients with self‐esteem in MDD patients and in normal controls. Methods: Database searches and identification of studies were conducted by two of the authors independently. Remission of BD and MDD was a major selection criterion. The results were generated through meta‐analyses. Results: Random‐effects models of 19 between‐group comparisons (N = 1,838) suggested that the self‐esteem of remitted BD patients was significantly lower than that of normal controls (Cohen’s d = ?0.83), while significantly higher than that of remitted MDD patients (Cohen’s d = 0.54). Fail‐safe numbers and tests for funnel plot asymmetry indicated that the results were robust and unlikely to reflect publication biases. Additional studies indicated that self‐esteem may take a fluctuating course during remission of BD. Conclusions: By revealing that BD patients do experience low self‐esteem, the findings implicate a need for further understanding the causes and therapeutic impact of such abnormality in BD.     

Paced finger-tapping abnormalities in bipolar disorder indicate timing dysfunction

Bolbecker AR, Hong SL, Kent JS, Forsyth JK, Klaunig MJ, Lazar EK, O’Donnell BF, Hetrick WP. Paced finger‐tapping abnormalities in bipolar disorder indicate timing dysfunction.
Bipolar Disord 2011: 13: 99–110. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objectives: Theoretical and empirical evidence suggests that impaired time perception and the neural circuitry contributing to internal timing mechanisms may contribute to severe psychiatric disorders, including mood disorders. The structures that are involved in subsecond timing, i.e., cerebellum and basal ganglia, have also been implicated in the pathophysiology of bipolar disorder. However, the timing of subsecond intervals has infrequently been studied in this population. Methods: Paced finger‐tapping tasks have been used to characterize internal timing processes in neuropsychiatric disorders. A total of 42 bipolar disorder patients (25 euthymic, 17 manic) and 42 age‐matched healthy controls completed a finger‐tapping task in which they tapped in time with a paced (500‐ms intertap interval) auditory stimulus (synchronization), then continued tapping without auditory input while attempting to maintain the same pace (continuation). This procedure was followed using the dominant index finger, then with alternating thumbs. Results: Bipolar disorder participants showed greater timing variability relative to controls regardless of pacing stimulus (synchronization versus continuation) or condition (dominant index finger versus alternating thumbs). Decomposition of timing variance into internal clock versus motor implementation components using the Wing–Kristofferson model showed higher clock variability in the bipolar disorder groups compared to controls, with no differences between groups on motor implementation variability. Conclusions: These findings suggest that internal timing mechanisms are disrupted in bipolar disorder patients, independent of symptom status. Increased clock variability in bipolar disorder may be related to abnormalities in cerebellar function.