Gender differences in the phenomenology of bipolar disorder

OBJECTIVES: To investigate gender differences in the phenomenology of episodes in bipolar disorder as according to ICD-10. METHODS: All patients who got a diagnosis of a manic episode/bipolar disorder in a period from 1994 to 2002 at the first outpatient treatment ever or at the first discharge from psychiatric hospitalization ever in Denmark were identified in a nationwide register. RESULTS: Totally, 682 outpatients and 1037 inpatients got a diagnosis of a manic episode/bipolar disorder at the first contact ever. Significantly more women were treated as outpatients than as inpatients. Women were treated for longer periods as inpatients but not as outpatients. In both settings, the prevalence of depressive versus manic/mixed episodes was similar for men and women and the severity of manic episodes (hypomanic /manic without psychosis/manic with psychosis) and the severity of depressive episodes (mild/moderate/severe without psychosis/severe with psychosis) did not differ between genders. The prevalence of psychotic symptoms at first contact was the same for both genders. Among patients treated in outpatient settings more men than women presented with comorbid substance abuse and among patients treated during hospitalization more women than men presented with mixed episodes. CONCLUSIONS: Besides differences in the prevalence of mixed episodes and comorbid substance abuse few gender differences are found among patients presenting with a manic episode/bipolar disorder at first contact in psychiatric inpatient or outpatient hospital settings.     

A comparison of life events in patients with unipolar disorder or bipolar disorder and controls

Objective

The present study aimed to explore the association between stressful life events (LEs) and the development of affective psychopathology.

Method

Thirty patients with unipolar disorder and 30 patients with bipolar disorder were compared to 60 matched healthy controls in regard to the rate of stressful LEs. Assessment measures included the Beck Depression Inventory, the Adult Life Events Questionnaire, and the Childhood Life Events List.

Results

The entire sample of affective patients had more LEs in general, more negative LEs, and more loss-related LEs in the year preceding their first depressive episode as compared with normal controls. Subjects with unipolar disorder had more positive LEs and more achievement LEs, whereas subjects with bipolar disorder had more uncontrollable LEs in the year preceding the first depressive episode. The relationship between LEs and manic episodes was prominent in the year preceding the first manic episode, with subjects with bipolar disorder reporting more LEs in general and more ambiguous events in that year. Almost no significant differences on LE frequency were observed in the year before the last depressive and manic episodes in the patient groups with unipolar and bipolar disorder. A significant relationship was found between childhood LEs and the development of affective disorders in adulthood, with patients with unipolar disorder exhibiting less positive and achievement LEs.

Conclusions

In both the unipolar and the bipolar groups, the major impact of LEs on the onset of affective disorders was found in the year before the first depressive or manic episodes. This suggests that the accumulation of stressful LEs at this crucial period contributes to the precipitation of a pathological response mechanism. Once established, this mechanism would be reactivated in the future by even less numerous and less severe stressors, compatible with the kindling hypothesis.     

双相情感障碍混合相临床特征对照研究

目的:了解双相情感障碍混合相的临床特征。方法:收集42例双相情感障碍混合相患者(混合组)与93例无混合发作的双相情感障碍躁狂相的患者(躁狂组)住院治疗的临床资料进行对比。结果:混合组年龄稍低,多见于女性和独身者,性格多为外向型或中间型,首次发作多为抑郁,多伴有精神病性症状及自杀意念和企图。多元逐步回归分析提示,混合发作与自杀意念和企图、性格、性别、首次发作形式有显著的相关性。混合组具有易被误诊、住院时间长、疗效较差的特点。结论:双相情感障碍混合相临床表现具有特殊性、严重性及相应的难治性,应加强重视。     

The prevalence of mixed episodes during the course of illness in bipolar disorder

Objective: To investigate the prevalence of mixed episodes during the course of illness in bipolar disorder. Method: A total of 1620 patients with an ICD‐10 diagnosis of bipolar affective disorder at the first psychiatric contact were identified in a period from 1994 to 2003 in Denmark and the prevalence of mixed, depressive and hypomanic/manic episodes were calculated at each episode. Results: The prevalence of mixed episodes increased from the first episode to the tenth episode, however, only for women (6.7% of the first episodes leading to psychiatric care compared with 18.2% of the tenth episodes). For men, the prevalence of mixed episodes was constantly low. At all episodes, the presence of a current mixed episode increased the risk substantially of getting a future mixed episode. Conclusion: Clinicians should pay more attention to mixed episodes, especially among women, as they may represent an increasing treatment challenge as the illness progress.     

The predictive effect of episodes on the risk of recurrence in depressive and bipolar disorders - a life-long perspective

OBJECTIVE: It is generally accepted that one of the most important predictors of recurrence in depressive and bipolar disorders is the number of previous episodes. However, very few studies have considered the individual tendency toward recurrence in analyses of the effect of the number of episodes on the risk of subsequent recurrence in affective disorder. METHOD: Frailty models were used to estimate the effect of the number of episodes on the rate of recurrence taking into account the individual frailty toward recurrence. The study base consisted of 406 patients, 186 patients with depressive disorder and 220 patients with bipolar disorder, who were admitted between 1959 and 1963 to the Psychiatric Hospital University of Zurich with an affective episode and followed up to 1997. RESULTS: The individual rate of subsequent recurrence was found to increase with the number of episodes even when the effect was adjusted for the individual frailty toward recurrence. The effect of episodes was the same in depressive and bipolar disorders and for men and women. CONCLUSION: It seems increasingly valid that in depressive and bipolar disorders, the risk of subsequent recurrence increases with the number of episodes.     

Outcome measures of interepisode bipolar patients in a Turkish sample

Background We aimed to study the correlations of several outcome measures in bipolar patients with the clinical features of interepisode period. Methods Bipolar patients who were diagnosed according to DSM-III-R or IV were contacted and asked for a further evaluation. Interepisode bipolar patients (n = 100) were interviewed with the Schedule for Affective Disorders and Schizophrenia (SADS). In addition the Brief Disability Questionnaire (BDQ), the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Global Assessment Scale (GAS) were administered to assess outcome. They were also asked to check the List of Life Events (LLE) for the last six months. Results Our results can be summarised as follows: (1) quality of life was predicted by current subthreshold depressive symptoms; (2) the number of previous depressive episodes, current subthreshold depressive and manic symptoms predicted disability; (3) the number of previous depressive episodes and the duration of hospitalisation as well as current subthreshold depressive and manic symptoms predicted overall functioning; (4) the number and distress level of life events were correlated with suicidal symptoms. Conclusions Our findings suggest that outcome measures were correlated with subsyndromal disorder, the number of previous depressive episodes and the duration of hospitalisation. Accepted: 2 October 2001     

Changes in insight among patients with bipolar I disorder: a 2-year prospective study

OBJECTIVES: The aim of this 2-year prospective study was to examine changes in insight among bipolar patients with different clinical courses. METHODS: A cohort of 65 patients with bipolar I disorder in remission was recruited for this study. They received six follow-up assessments over a 2-year period. The Schedule of Assessment of Insight-Expanded version (SAI-E) was used to determine their levels of insight, while the Young Mania Rating Scale (YMRS) and the Hamilton Rating Scale for Depression (HAM-D) were used to determine affective symptoms. Types of changes in insight among bipolar patients were analyzed according to the different clinical courses during the 2-year follow-up period. RESULTS: Insight in consistently stable patients was steady during the 2-year period. Insight decreased during the manic period in patients with only a single manic episode as well as in those with repeated manic episodes. However, insight returned to the pre-episode level for patients with only a single manic episode, but did not for most of the patients with repeated episodes. No changes in insight were observed during depressive episodes for either patients with a single or those with repeated depressive episodes. CONCLUSIONS: The types of insight changes among bipolar patients during the 2-year period were various and depended on the different clinical courses. Frequent mood disturbance episodes may cause patient insight to deteriorate.     

Comparison of rapid-cycling and non-rapid-cycling bipolar disorder based on prospective mood ratings in 539 outpatients

OBJECTIVE: To detect risk factors for rapid cycling in bipolar disorder, the authors compared characteristics of rapid-cycling and non-rapid-cycling patients both from a categorical and a dimensional perspective. METHOD: Outpatients with bipolar I disorder (N=419), bipolar II disorder (N=104), and bipolar disorder not otherwise specified (N=16) were prospectively evaluated with daily mood ratings for 1 year. Subjects were classified as having rapid cycling (defined by the DSM-IV criterion of four or more manic or depressive episodes within 1 year) or not having rapid cycling, and the two groups' demographic and retrospective and prospective illness characteristics were compared. Associated factors were also evaluated in relationship to episode frequency. RESULTS: Patients with rapid cycling (N=206; 38.2%) significantly differed from those without rapid cycling (N=333) with respect to the following independent variables: history of childhood physical and/or sexual abuse, bipolar I disorder subtype, number of lifetime manic or depressive episodes, history of rapid cycling, and history of drug abuse. The prevalence of these characteristics increased progressively with episode frequency. The proportion of women was greater than the proportion of men only among patients with eight or more episodes per year. The average time spent manic/hypomanic increased as a function of episode frequency, but the average time spent depressed was comparable in patients with one episode and in those with more than one episode. Brief episodes were as frequent as full-duration DSM-IV-defined episodes. CONCLUSIONS: A number of heterogeneous risk factors were progressively associated with increasing episode frequency. Depression predominated in all bipolar disorder patients, but patients with rapid cycling were more likely to be characterized by manic features. The findings overall suggest that rapid cycling is a dimensional course specifier arbitrarily defined on a continuum of episode frequency.     

Update on quetiapine in the treatment of bipolar disorder: results from the BOLDER studies

The essential features of bipolar affective disorder involve the cyclical occurrence of high (manic or hypomanic episodes) and low mood states. Depressive episodes in both bipolar I and II disorder are more numerous and last for longer duration than either manic or hypomanic episodes. In addition depressive episodes are associated with higher morbidity and mortality. While multiple agents, including all 5 atypical antipsychotics, have demonstrated efficacy and earned US FDA indication for manic phase of bipolar illness, the acute treatment of bipolar depression is less well-studied. The first treatment approved by the US FDA for acute bipolar depression was the combination of the atypical antipsychotic olanzapine and the antidepressant fluoxetine. Recently, quetiapine monotherapy has demonstrated efficacy in the treatment of depressive episodes associated with both bipolar I and II disorder and has earned US FDA indication for the same.     

重性抑郁障碍或双相障碍患者抑郁发作伴随躁狂症状的临床特征

目的:了解重性抑郁障碍(MDD)或双相障碍抑郁发作患者出现躁狂症状的频率和程度。方法:对52例经简明国际神经精神访谈(MINI)、符合《美国精神障碍诊断与统计手册》第4版(DSMIV)重性抑郁障碍或双相障碍抑郁发作的患者,采用情感障碍评估量表(ADE)评估患者本次抑郁发作中出现的躁狂症状。结果:52例患者中有36例重性抑郁障碍,16例为双相障碍抑郁发作。至少有1条躁狂症状的患者达86.5%(n=45),至少有3条躁狂症状的患者占32.7%(n=17),而没有任何躁狂症状的患者仅占13.5%(n=7)。结论:抑郁发作患者大多存在不同程度的躁狂症状,及时识别这些症状,对诊断与治疗有指导意义。情感障碍评估量表是一个值得应用的评估情感发作的工具。     

Sleep disturbance in bipolar disorder: therapeutic implications

In this review, the authors detail our current understanding of the crucial role that sleep and its disturbances play in bipolar disorder. Multiple lines of evidence suggest that impaired sleep can induce and predict manic episodes. Similarly, treatment of sleep disturbance may serve as both a target of treatment and a measure of response in mania. The depressive phase of bipolar illness is marked by sleep disturbance that may be amenable to somatic therapies that target sleep and circadian rhythms. Residual insomnia in the euthymic period may represent a vulnerability to affective relapse in susceptible patients. Given the importance of sleep in all phases of bipolar disorder, appropriate evaluation and management of sleep disturbance in patients with bipolar illness is further detailed.     

Sex difference in symptomatology of manic episode

Objective

Studies addressing sex differences in the symptoms and course of bipolar affective disorder had been investigated across different phase of bipolar affective disorder. There are few studies in manic phase that have reported inconsistent results. Therefore, we investigated sex difference in symptom presentation of manic episode.

Methods

A total of 150 male and 50 female subjects meeting criteria for manic episode according to International Statistical Classification of Diseases, 10th Revision Diagnostic Criteria for Research, giving written informed consent, were included for the study. Those with comorbid major medical or psychiatric disorders were excluded. All the patients were assessed on Scale for Manic States.

Results

Multivariate analysis of variance using all the items of Scale for Manic Symptoms showed significant sex difference (Pillai's Trace F_20,179 = 5.154, P < .001), with large effect size (η² = .365). In men, there was significantly higher motor activity, psychosis, grandiosity, contact, and humor, whereas mood lability, depressed mood, guilt, suicide, anxiety, and dress scores were higher in women. Discriminant analysis showed that 84% of men and 72% of women could be correctly classified using the Scale for Manic Symptoms. Stepwise logistic regression analysis showed anxiety, guilt, and dress positively predicted female sex and the model explained 24% to 36% of variance.

Conclusion

Symptom presentation of mania differs across sex and a predominance of anxiety and depressive symptoms was found in women, whereas increased psychomotor activity was prevalent in men.     

Does the risk of developing dementia increase with the number of episodes in patients with depressive disorder and in patients with bipolar disorder?

OBJECTIVE: Several findings suggest that some patients with depressive or bipolar disorder may be at increased risk of developing dementia. The present study aimed to investigate whether the risk of developing dementia increases with the number of affective episodes in patients with depressive disorder and in patients with bipolar disorder. METHODS: This was a case register study including all hospital admissions with primary affective disorder in Denmark during 1970-99. The effect of the number of prior episodes leading to admission on the rate of readmission with a diagnosis of dementia following the first discharge after 1985 was estimated. A total of 18,726 patients with depressive disorder and 4248 patients with bipolar disorder were included in the study. RESULTS: The rate of a diagnosis of dementia on readmission was significantly related to the number of prior affective episodes leading to admission. On average, the rate of dementia tended to increase 13% with every episode leading to admission for patients with depressive disorder and 6% with every episode leading to admission for patients with bipolar disorder, when adjusted for differences in age and sex. CONCLUSION: On average, the risk of dementia seems to increase with the number of episodes in depressive and bipolar affective disorders.     

Mania with associated organic factors

Thirty-nine patients with bipolar illness preceded by organic factors were compared to age and sex matched bipolar controls. The patients with pre-existing organic factors were older at onset of their bipolar illness, had fewer depressive episodes, less family history of affective disorder, and were symptomatically different in a number of respects. The nosology of such disorders is discussed and the literature reviewed.     

The importance of measures of affective temperaments in genetic studies of mood disorders

Collaboration between the University of Pisa, Italy, and the University of Tennessee, Memphis, U.S.A., on patients presenting with major depressive episodes (in the absence of nonaffective psychiatric illness) focused on the detection of depressive and hyperthymic temperaments. From our data on symptomatology, family history and course of 538 such patients, several findings emerge of cardinal relevance to genetic studies. Hyperthymic temperament, observed more commonly in men, appears as one pole of an attenuated form of manic-depressive illness. Thus, major depressives with this temparament have high rates of bipolar family history, even in the absence of hypomanic and manic episodes. The depressive temperament, more prevalent in women, is correlated with earlier onset and higher number of depressive episodes, greater severity of the Hamilton Rating Scale for Depression (HAM-D), as well as higher familial loading for mood disorders, compared with major depressives without this temperament. Building on Akiskal's latest model on the multifactorial origin of mood disorders, we submit that these temperamental dysregulations constitute the intermediate step between predisposing familial-genetic factors in affective illness and gender-related clinical expressions of mood disorders. The authors recommend that future high-risk prospective studies and genetic investigations should include measures of affective temperament.     

Diagnostic subtypes of bipolar disorder in older versus younger adults

OBJECTIVE: To investigate differences in diagnostic subtypes of bipolar disorder as according to ICD-10 between patients whose first contact with psychiatric health care occurs late in life (over 50 years of age) and patients who have first contact earlier in life (50 years of age or below). METHODS: From 1994 to 2002 all patients who received a diagnosis of a manic episode or bipolar disorder at initial contact with the mental healthcare system, whether outpatient or inpatient, were identified in Denmark's nationwide register. RESULTS: A total of 852 (49.6%) patients, who were over age 50, and 867 patients, who were 50 or below, received a diagnosis of a manic episode or bipolar disorder at the first contact ever. Older inpatients presented with psychotic symptoms (35.4%) significantly less than younger inpatients (42.6%) due specifically to a lower prevalence of manic episodes with psychotic symptoms. Conversely, older inpatients more often presented with severe depressive episodes with psychotic symptoms than younger inpatients (32.0% versus 17.0%). Among outpatients, no significant differences were found between patients older than 50 years and patients 50 years of age or younger. However, a bimodal distribution of age at first outpatient contact was found with an intermode of 65 years and outpatients older than 65 years more often presented with severe depressive episodes with psychosis. CONCLUSIONS: Bipolar patients who are older at first psychiatric hospitalization (>50 years) present less with psychotic manic episodes and more with severe depressive episodes with psychosis than younger patients. The distribution of age at first outpatient contact is bimodal with an intermode of 65 years and outpatients older than 65 years more often present with severe depressive episodes with psychosis.     

Life events and affective disorders

OBJECTIVE: To summarize research in life events and affective disorders METHOD: Review of the literature. RESULTS AND CONCLUSION: Many studies have shown that episodes of unipolar depression are preceded by life events at higher rates than in control samples. A variety of stressful events are involved with only limited specificity but some relationship to social exit events. Life events also affect remission and relapse of depression. Effects of life events are less when the disorder has already been recurrent, particularly where illness is severe. Effects of life events are also weaker in bipolar disorder than unipolar, but major life events may be important in first onset. Recent evidence suggests a specific role of social rhythm disruption events in manic relapses. Causative chains are multifactorial and complex, and genetic factors can influence life event exposure.     

Humor appreciation in remitted patients with bipolar disorder

The purpose of the present study was to investigate humor appreciation in a group of remitted patients with bipolar disorder. We examined 19 patients (8 men) with bipolar disorder I, currently remitted, and 22 (9 men) healthy controls, matched on age, education, and gender, on a computerized test comprising captionless cartoons, the Penn's Humor Appreciation Test (PHAT). Residual manic symptoms were evaluated with the Young Mania Rating Scale and residual depressive symptoms with the Montgomery-Asberg Depression Rating Scale. Patients with bipolar disorder performed worse than the healthy group on the PHAT, but this difference was not statistically significant. Performance on the PHAT did not significantly correlate with age of onset and duration of illness, or with residual manic or depressive symptoms measured by Young Mania Rating Scale and Montgomery-Asberg Depression Rating Scale, respectively. Humor appreciation, based on captionless cartoons, in bipolar disorder does not seem to be deficient at least during remission, suggesting that this high-order cognitive function may not be considered a trait deficit of the disorder.     

Obesity as a correlate of outcome in patients with bipolar I disorder

OBJECTIVE: This study sought to evaluate the relationship of obesity to demographic and clinical characteristics and treatment outcome in a group of 175 patients with bipolar I disorder who were treated for an acute affective episode and followed through a period of maintenance treatment. METHOD: Data were from participants entering the Maintenance Therapies for Bipolar Disorder protocol between 1991 and 2000. Analyses focused on differences in baseline demographic and clinical characteristics and in treatment outcomes between obese and nonobese patients. RESULTS: A total of 35.4% of the patients met criteria for obesity. Significant differences between the obese and nonobese patients were observed for years of education, numbers of previous depressive and manic episodes, baseline scores on the Hamilton Rating Scale for Depression, and durations of the acute episode. A Kaplan-Meier survival analysis indicated a significantly shorter time to recurrence during the maintenance phase among obese patients. The number of patients experiencing a depressive recurrence was significantly higher in the obese than in the nonobese group. CONCLUSIONS: Obesity is correlated with a poorer outcome in patients with bipolar I disorder. Preventing and treating obesity in bipolar disorder patients could decrease the morbidity and mortality related to physical illness, enhance psychological well-being, and possibly improve the course of bipolar illness. Weight-control interventions specifically designed for patients with bipolar illness should be developed, tested, and integrated into the routine care provided for these patients.     

Tardive dyskinesia associated with depression in a bipolar patient: possible role of melatonin

Several clinical studies have suggested that patients with affective disorder are at high risk for developing tardive dyskinesia (TD). An intriguing aspect of the relationship between TD and affective disorders involves mood dependent alterations in the severity of TD in bipolar patients. In most reported cases, depressive episodes have been reported to be associated with exacerbation of TD, while manic episodes were accompanied by attenuation of TD. Current neurochemical hypotheses of TD do not explain adequately the relationship of TD to depression or mania in bipolar patients. A patient with bipolar illness is presented in whom TD emerged concurrently with the onset of depression that developed during management of an acute manic episode. It is suggested that decline in melatonin secretion with onset of the depression was associated with the emergence of TD. Thus, the increased incidence and risk of TD in bipolar patients may in part be related to decreased melatonin secretion, while increased melatonin secretion during manic episodes may have protective effect against the development of TD.