Longitudinal PTSD symptom trajectories: Relative contributions of state anxiety, depression, and emotion dysregulation.

BACKGROUND: Prospective research on the development and trajectory of PTSD symptoms after a traumatic event is crucial for assessment and early intervention. Further, examining predictors of PTSD pathology provides a better conceptualization of the temporal course of PTSD in trauma victims. METHODS: The present study examined PTSD symptom severity in individuals presenting to the emergency department (ED) following a traumatic event. Participants (N = 147) were assessed at four timepoints: 2-weeks, 3-months, between 6 and 9 months, and 12-months after ED admission. Growth curve modeling was conducted to examine changes in PTSD symptom severity over time. Age, sex, state anxiety, trait anxiety, emotion dysregulation, depression, and trauma type (motor vehicle accident [MVA] and assault), and PTSD diagnosis were included as covariates in the model. RESULTS: Results demonstrated that baseline PTSD symptom severity was positively associated with severity of depression and state (but not trait) anxiety, emotion dysregulation, and PTSD diagnosis. Results also revealed significant associations with PTSD symptom changes over time; greater state anxiety and depression symptoms at baseline were associated with steeper declines in PTSD symptoms over time. LIMITATIONS: Data were collected at only four timepoints over the course of 12-months. Results may be different with more measurement points over longer periods and inclusion of pre-, peri- and post-trauma risk factors. CONCLUSIONS: Results illustrate the relevance of assessing state anxiety, depression, and emotion dysregulation in following trauma victims for trauma-related psychopathology over the course of time to alleviate the negative impact of the same.

A Naturalistic Study of Outcomes for Durable Remission in Patients With Bipolar Disorder.

OBJECTIVE: Bipolar disorder is a severe mental illness affecting emotional stability, physical health, and quality of life. In a previous study, we identified medications associated with remission in patients with bipolar disorder. The objective of the current study was to determine the status of the patients after 3 additional years, as well as the medications associated with remission. METHODS: Data were extracted from clinical records. The criteria for remission in both the original study and the follow-up were 12 continuous months of euthymia, mild symptoms, and no clinical relapse. Active illness was defined as <12 months of remission. Statistical comparisons were made between the remitted and active illness groups on demographics and medication regimens. RESULTS: The original study contained 121 patients, 52 of whom were available for follow-up. Of the 121 patients from the original study, 53 (43.8%) were remitted for at least 12 months. Follow-up data were available for 19 of those patients, 15 of whom continued in remission while 4 relapsed. Of the 68 patients who were still ill at the end of the first study, follow-up data were available for 33 patients, 18 of whom had achieved remission at the time of follow-up while 15 continued to be ill. Remitted patients were more likely to be receiving a mood stabilizer (P=0.022) or a combination of a mood stabilizer and an antidepressant (P=0.004). CONCLUSIONS: On the basis of our results, mood stabilizers and antidepressants were associated with remission in long-term follow-up. Remission may ultimately be possible for many patients who did not succeed initially.

Emotion Dysregulation Prospectively Predicts Posttraumatic Stress Disorder Symptom Severity 3 Months After Trauma Exposure.

Despite growing evidence in support of emotion dysregulation as a risk factor for the development of posttraumatic stress disorder (PTSD) following trauma exposure, few studies have examined temporal relations between emotion dysregulation and the onset and/or worsening of PTSD symptoms over time. The aim of the present study was to extend research on temporal associations between emotion dysregulation and PTSD in a sample of individuals recruited from hospital emergency departments soon after a traumatic event. Adult participants (N = 85; 62.4% female) completed self-report measures of emotion dysregulation and PTSD symptoms within 2 weeks of experiencing a traumatic event. Symptoms of PTSD were assessed approximately 3 months posttrauma. The results of a hierarchical linear regression analysis demonstrated that the inclusion of emotion dysregulation accounted for a significant amount of unique variance, ß = .23, ΔR2 = .04, p = .042, in 3-month PTSD symptom severity over and above other risk factors and baseline PTSD symptoms. No specific facet of emotion dysregulation emerged as a significant predictor of 3-month PTSD symptoms when all facets were included on the same step of the model, ßs = -.04-.33, ps = .133-.954. These results demonstrate that posttraumatic emotion dysregulation may predict PTSD symptoms 3 months after trauma exposure. These findings are consistent with a growing body of literature that speaks to the relevance of emotional processes to the onset and maintenance of PTSD following exposure to a traumatic event.

Psychosocial Factors and Comorbidity Associated with Suicide Attempts: Findings in Patients with Bipolar Disorder.

BACKGROUND: Suicidal attempts occur more frequently in patients with bipolar disorder compared to other mood disorders. The goal of this study is to identify psychosocial factors and comorbidity associated with this serious and life-threatening behavior. SAMPLING AND METHODS: Subjects were 121 patients evaluated and treated at a university outpatient psychiatric clinic. The patients' charts were examined to determine history of suicide attempts, demographic and psychosocial variables, and comorbid symptoms. RESULTS: Forty-one percent of the subjects had attempted suicide. Patients who were younger at onset of illness (p = 0.02) and those who had been abused (p = 0.003) were more likely to attempt suicide. Suicide attempts were also more common in subjects with a history of alcohol abuse (p = 0.003) and those with psychotic symptoms (p = 0.02). CONCLUSIONS: Based on the results of this study, it is recommended that increased emphasis be placed on the psychosocial history and comorbid symptoms in patients with bipolar disorder. While asking about previous suicide attempts is the most accurate way to predict suicidal behavior, age of onset, past abuse, and overuse of alcohol may also be helpful. Since suicidal behavior in patients with bipolar disorder is relatively common, intensified efforts to predict this behavior may be life-saving.

Hypertriglyceridemia-Induced Pancreatitis in Psychiatric Patients: A Case Report and Review of Literature.

Hypertriglyceridemia is a known cause of 2%-7% of cases of acute pancreatitis. Although there are numerous potential causes, the use of atypical antipsychotics has been linked to elevated triglycerides and pancreatitis. Here, we present the case of a 42-year-old male patient with a diagnosis of schizoaffective disorder who presented to our hospital with acute pancreatitis due to hypertriglyceridemia, which was exacerbated after he was started on quetiapine.

A Descriptive Analysis of Factors Leading to a 1-Year Remission in Bipolar Disorder.

BACKGROUND: Bipolar spectrum disorders are associated with symptomatic and functional disability in many patients. Other studies have examined predictors of outcome with variable results. The goal of this retrospective study was to identify medications associated with a minimum of 12 consecutive months of symptomatic, functional, and syndromal remission. METHODS: The charts of 121 patients with confirmed bipolar disorder were reviewed. Data on medical regimen and demographic and adherence factors were gathered using standardized data collection sheets approved by the University of Toledo Institutional Review Board. The criterion for improvement was set at 12 consecutive months of Clinical Global Impressions Improvement ratings of ≤2, which is a far higher standard of syndromal and functional remissions than the usual 8 consecutive weeks used by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. RESULTS: In this sample of 121 patients, 43.8% achieved a minimum of 12 consecutive months of remission, whereas 56.2% did not. When bipolar disorder was divided into its subtypes, 45.5% of our cohort were diagnosed with bipolar I disorder, 27.3% were diagnosed with bipolar II disorder, and 27.3% were diagnosed with bipolar disorder, not otherwise specified. Of the 55 patients with bipolar I disorder, 27 remitted and 28 did not. Of the 33 patients with bipolar II disorder, 12 remitted and 21 did not. Of the 33 patients with bipolar disorder, not otherwise specified, 14 remitted and 19 did not. The treatment regimen that was most closely associated with remission was a combination of atypical antipsychotics (primarily aripiprazole), mood stabilizers (primarily lamotrigine), and an antidepressant. In addition, the patients who achieved remission were more likely to be adherent to medication and with appointments. CONCLUSIONS: The chart review showed that 12 consecutive months of symptomatic remission was achieved in our clinic in 43.8% of patients with bipolar disorder when they were treated with tailored medication regimens. The remainder (56.2%) failed to achieve 12 consecutive months of remission based on real-time Clinical Global Impressions Improvement ratings. The combination of an atypical antipsychotic, a mood stabilizer, and an antidepressant was highly correlated with 1-year remission.

Comparing treatment outcomes of bipolar patients between psychiatry residents and attending physicians.

OBJECTIVE: The authors sought to compare the outcomes of patients treated by psychiatric residents and attending psychiatrists. METHOD: Charts of 121 outpatients meeting criteria for bipolar spectrum disorder were analyzed. Residents treated 41, and attending physicians 80, of 121 patients. Improvement was defined as at least 12 consecutive months of the following: Remission--euthymic mood; Response--much improved mood, not meeting DSM-IV criteria for mild illness; Relapse--remission or response followed by recurrence. The Active Illness group contained patients who did not have 12 months of Remission or Response. RESULTS: The percentage of improved patients was similar between residents (46.3%; 19/41) and attending physicians (42.5%; 34/80). There was a significant difference in the number of patients in the Remission or Response categories between attending physicians: (26.5%; 21/80) and residents (12.2%; 5/41). CONCLUSION: Similar numbers of residents' and attending physicians' patients achieved improvement for 12 months, but twice the number of attending physicians' patients achieved and maintained euthymia.

Effectiveness of adjunctive antidepressant treatment for bipolar depression.

BACKGROUND: Episodes of depression are the most frequent cause of disability among patients with bipolar disorder. The effectiveness and safety of standard antidepressant agents for depressive episodes associated with bipolar disorder (bipolar depression) have not been well studied. Our study was designed to determine whether adjunctive antidepressant therapy reduces symptoms of bipolar depression without increasing the risk of mania. METHODS: In this double-blind, placebo-controlled study, we randomly assigned subjects with bipolar depression to receive up to 26 weeks of treatment with a mood stabilizer plus adjunctive antidepressant therapy or a mood stabilizer plus a matching placebo, under conditions generalizable to routine clinical care. A standardized clinical monitoring form adapted from the mood-disorder modules of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, was used at all follow-up visits. The primary outcome was the percentage of subjects in each treatment group meeting the criterion for a durable recovery (8 consecutive weeks of euthymia). Secondary effectiveness outcomes and rates of treatment-emergent affective switch (a switch to mania or hypomania early in the course of treatment) were also examined. RESULTS: Forty-two of the 179 subjects (23.5%) receiving a mood stabilizer plus adjunctive antidepressant therapy had a durable recovery, as did 51 of the 187 subjects (27.3%) receiving a mood stabilizer plus a matching placebo (P=0.40). Modest nonsignificant trends favoring the group receiving a mood stabilizer plus placebo were observed across the secondary outcomes. Rates of treatment-emergent affective switch were similar in the two groups. CONCLUSIONS: The use of adjunctive, standard antidepressant medication, as compared with the use of mood stabilizers, was not associated with increased efficacy or with increased risk of treatment-emergent affective switch. Longer-term outcome studies are needed to fully assess the benefits and risks of antidepressant therapy for bipolar disorder. (ClinicalTrials.gov number, NCT00012558 [ClinicalTrials.gov].).

A 20-month, double-blind, maintenance trial of lithium versus divalproex in rapid-cycling bipolar disorder.

OBJECTIVE: The authors tested the hypothesis that divalproex would be more effective than lithium in the long-term management of patients with recently stabilized rapid-cycling bipolar disorder. METHOD: A 20-month, double-blind, parallel-group comparison was carried out in recently hypomanic/manic patients who had experienced a persistent bimodal response to combined treatment with lithium and divalproex. Sixty patients were randomly assigned to lithium or divalproex monotherapy in a balanced design after stratification for illness type (bipolar I versus bipolar II disorder). RESULTS: Of the 254 patients enrolled in the open-label acute stabilization phase, 76% discontinued the study prematurely (poor adherence: 28%; nonresponse: 26% [of whom 74% remained depressed and 26% remained in a hypomanic/manic/mixed episode], intolerable side effects: 19%). Of the 60 patients (24%) randomly assigned to double-blind maintenance monotherapy, 53% relapsed (59% into depression and 41% into a hypomanic/manic/mixed episode), 22% completed the study, 10% had intolerable side effects, and 10% were poorly adherent. The rates of relapse into any mood episode for those given lithium versus divalproex were 56% and 50%, respectively; the rates were 34% and 29% for a depressive relapse and 19% and 22% for a hypomania/mania relapse. There were no significant differences in time to relapse. The proportion discontinuing prematurely because of side effects was 16% for lithium and 4% for divalproex. CONCLUSIONS: The hypothesis that divalproex is more effective than lithium in the long-term management of rapid-cycling bipolar disorder is not supported by these data. Preliminary data suggest highly recurrent refractory depression may be the hallmark of rapid-cycling bipolar disorder.

Gender differences in criminality: bipolar disorder with co-occurring substance abuse.

Outpatient interviews to collect criminal history data were conducted with 55 women and 77 men who had the dual diagnosis of rapid-cycling bipolar disorder with co-morbid substance abuse disorders (DD-RCBD), to ascertain gender-related similarities and differences. Fifty-three percent of women and 79 percent of men reported that they had been charged with a crime, and nearly half of those charged had been incarcerated. Men with DD-RCBD were more likely to have committed a felony and had a trend of committing more misdemeanors. Although women with DD-RCBD were less likely to have a criminal history than their male counterparts, they were far more likely to have a criminal history than were women in the general population. Implications from this pilot study include the need for earlier identification of bipolar disorder and for the increased availability of psychiatric and substance abuse services within correctional facilities.

Long-term treatment of bipolar disorder with lamotrigine.

Bipolar depression is as debilitating as mania in bipolar disorder, but the treatment of bipolar depression has historically received less attention. To date, there is no mood stabilizer (liberally defined as a medication that decreases episode severity, duration, or frequency in one phase of bipolar illness without producing a negative effect in other phases) that demonstrates similar efficacy in both the depressive and the manic phases of bipolar disorder. However, bipolar depression--which is prevalent, sometimes chronic, and associated with a low quality of life and a high risk of suicide--must be addressed as energetically as mania. Recent research into the long-term treatment of bipolar disorder has raised several questions about the generalizability of early lithium studies, as a result of these studies' designs. Researchers conducting more recent studies of mood stabilizers in the long-term treatment of bipolar disorder have attempted to clarify their results by, for example, performing survival analyses of the data. Until pharmacotherapy has been found that is equally efficacious in the treatment of both manic and depressive episodes in bipolar disorder, the use of combination therapy to manage bipolar disorder is advised. Lithium and divalproex sodium remain the first-line treatments for mania. Lamotrigine has been found to have acute efficacy in treating episodes of bipolar depression without increasing cycling or provoking a switch into mania, as well as a long-term role in delaying relapse and recurrence of depressive episodes.

Bipolar disorders and the effectiveness of novel anticonvulsants.

The discovery that valproic acid is helpful in the management of patients with rapid-cycling bipolar disorder led to an explosion of research culminating in the third-generation anticonvulsants. Refractory depressive phases are frequent in bipolar disorders. No studies to date have shown that gabapentin is effective in bipolar mania or hypomania. Lamotrigine may have a role in treating bipolar depressive episodes, but it is not a particularly effective antimanic agent. Topiramate has shown encouraging results in both depressed and manic bipolar patients, and it may also promote weight loss. The new anticonvulsants are promising agents for the treatment of bipolar disorders, but they are heterogeneous with regard to their efficacy, target symptoms, and adverse event profiles.