Clinical validation of the BDSx scale with bipolar disorder outpatients.

PURPOSE: The BDSx (Bipolar Disorder Symptom Scale) is a brief self-report instrument designed for repeated measurement of bipolar disorder (BD) symptoms over time. Previous research indicates that the BDSx measures two depression (cognitive and somatic symptoms) and two hypo/mania factors (affrontive symptoms and elation/loss of insight). The purpose of this study was to validate BDSx responses relative to diagnoses of BD mood episodes. METHODS: Sixty BD outpatients attending routine clinic appointments completed the BDSx, the Hamilton Rating Scale for Depression, the Altman Self-Rating Mania Scale, and the Satisfaction with Life Scale. Blind to scale responses by patients, a clinic psychiatrist determined if patients were currently symptomatic. RESULTS: BDSx depression and hypo/mania subscales showed good construct validity vis-à-vis clinical diagnoses, and concurrent/discriminant validity with other self-report scales. And though not designed as a screening measure, sensitivity for the depression subscale is high at 88% (6+, 76% specificity), yet lower at 57% for the hypo/mania subscale (5+, 90% specificity). CONCLUSIONS: The results of this study indicate that BDSx responses distinguish patients experiencing depressive and hypo/manic mood episodes. Findings support the psychometric properties of the Hebrew version of this scale. The BDSx enables those with bipolar disorder to monitor their symptoms, gauge symptom variability, and identify factors that proceed and sustain BD symptoms over time.

[PERSONALITY IN EUTHYMIC BIPOLAR PATIENTS AS MEASURED BY SELF-REPORT INSTRUMENTS].

INTRODUCTION: Simple logic would suggest that there should be some endophenotype for bipolar disorder. Possible endophenotypes could include specific variations in personality. Bagby and Ryder summarized the work up to that point by noting that the related personality traits of high neuroticism and harm avoidance seem to be associated with bipolar disorder as well as with unipolar depression, whereas higher novelty seeking may be associated only with bipolar patients. As these parameters are all very sensitive to the affective state, it is critical to examine the literature that pertains specifically to euthymic patients in order to evaluate the extent to which this signifies underlying personality (trait), and not primarily clinical status (state). Several important studies have been published since the Bagby and Ryder paper, which we review here. We restrict our current review to empirical studies which employed both adequate samples of euthymic (to minimize the state/trait dilemma) bipolar patients as well as healthy comparison subjects. This paper is restricted to frequently used explicit measures of personality - that is, self-report questionnaires: the Temperament and Character Inventory (TCI) based on Cloninger's psychobiological theory of temperament and character, the Revised NEO Personality Inventory based on the five-factor model of Costa & McCrae, and the Barratt Impulsiveness Scale (BIS-11) (23). No single dimension of 'personality' reviewed would qualify as a psychological marker for a bipolar disorder. Earlier findings as reviewed by Bagby and Ryder, of higher novelty seeking, were not replicated in these studies. Of the personality traits considered, the most promising candidate for marker or endophenotype would seem to be "impulsivity" as measured by the BIS-II.

International multi-site survey on the use of online support groups in bipolar disorder.

BACKGROUND: Peer support is an established component of recovery from bipolar disorder, and online support groups may offer opportunities to expand the use of peer support at the patient's convenience. Prior research in bipolar disorder has reported value from online support groups. AIMS: To understand the use of online support groups by patients with bipolar disorder as part of a larger project about information seeking. METHODS: The results are based on a one-time, paper-based anonymous survey about information seeking by patients with bipolar disorder, which was translated into 12 languages. The survey was completed between March 2014 and January 2016 and included questions on the use of online support groups. All patients were diagnosed by a psychiatrist. Analysis included descriptive statistics and general estimating equations to account for correlated data. RESULTS AND CONCLUSIONS: The survey was completed by 1222 patients in 17 countries. The patients used the Internet at a percentage similar to the general public. Of the Internet users who looked online for information about bipolar disorder, only 21.0% read or participated in support groups, chats, or forums for bipolar disorder (12.8% of the total sample). Given the benefits reported in prior research, clarification of the role of online support groups in bipolar disorder is needed. With only a minority of patients using online support groups, there are analytical challenges for future studies.

Living with bipolar disorder: the impact on patients, spouses, and their marital relationship.

OBJECTIVES: Patients with bipolar disorder are characterized by an unusually high divorce rate. As such, the purpose of the present study was to uncover information relating specifically to the impact of bipolar disorder on patients and spouses individually, and on the marital relationship from the perspectives of both patients and spouses. METHODS: Eleven patients with bipolar disorder and ten spouses were interviewed separately about the impact of bipolar disorder on their lives and on their marital relationship. Data were analyzed using the grounded theory method. RESULTS: The impact of bipolar disorder for spouses included self-sacrifice, caregiving burden, emotional impact, and a sense of personal evolution. The impact of bipolar disorder on patients included an emotional impact, responsibility for self-care, and struggling socially and developmentally. When comparing patient and spouse perspectives on the impact of the disorder, neither the patient nor the spouse was able to accurately assess the impact of the disorder on their partner's lives. The impact of bipolar disorder on the relationship included volatility in the relationship, strengthening the relationship, weakening the relationship, and family planning. CONCLUSIONS: The research indicated that patients and partners alike struggle with the tremendous impact of bipolar disorder on their lives and on their relationships. Given the high rates of divorce and volatility in these relationships, healthcare professionals can provide (or refer to) emotional and practical support both to patients and spouses on their own, and as a couple in their clinics.

Normobaric hyperoxia treatment of schizophrenia.

Several studies of normobaric hyperoxia in neurological conditions have found positive results. The impaired energy metabolism due to mitochondrial dysfunction and frontal lobe hypofunction in schizophrenia might be improved by increasing O2 supply to the brain. Normobaric hyperoxia may be a potential treatment for schizophrenia. Participants in this study, outpatients with chronic schizophrenia and inhabitants of community-based psychiatric institutions (hostels), underwent baseline psychiatric/cognitive assessment and were randomly assigned to either a treatment intervention of oxygen-enriched air inhalation (normobaric hyperoxia of 40% fraction of inspired oxygen) or regular air inhalation (21% fraction of inspired oxygen), through a nasal tube, for 4 weeks. Patients were given the air/oxygen inhalations during the night (mainly while sleeping) for at least 7 hours a night. After completing 4 weeks of treatment, patients were switched (crossed over) to the other treatment intervention. Fifteen patients completed the entire study. Five additional patients completed phase A only. There was significant improvement in total Positive and Negative Symptoms Scale score of patients who received oxygen compared with the control group. There were positive effects of oxygen on memory and attention in neuropsychological performance tests. The effect size is small despite the statistical significance, but the patient group was extremely chronic and severely impaired. These results are a proof of concept, and normobaric hyperoxia should be studied in patients with milder forms of the illness and earlier in the course of illness.

Perceived cognitive failures and quality of life for older adults with bipolar disorder.

BACKGROUND: Older adults with bipolar disorder (BD) commonly present with cognitive deficits (e.g., attention, memory, verbal fluency). Concomitantly, older adults with BD commonly report subjective or perceived cognitive failures. For this study, we confirmed a 3-factor model of cognitive failures first validated with older adults free of mental illness (i.e., forgetfulness, distractibility, false triggering). We then computed a structural equation model (SEM) demonstrating the construct validity of perceived cognitive errors in relation to quality of life with BD. Use of SEM enabled us to measure quality of life broadly and germane to BD (i.e., well-being, life satisfaction, alcohol misuse, sleep quality). METHODS: We obtained responses from an international sample of 350 older adults with BD (M = 61.26 years of age, range 50-87), recruited via micro-targeted social media advertising. Most lived in Canada, the U.S., U.K., Ireland, Australia and South Africa. RESULTS: As hypothesized, perceived cognitive failures were predicted by BD symptoms (depression and hypo/mania). And cognitive failures directly and indirectly predicted quality of life. LIMITATIONS: Future research is needed to replicate this QoL model over time with younger patients and those recruited using more traditional methods. CONCLUSIONS: Perceived cognitive failures may not be strongly correlated with objective indices of cognitive deficits; nonetheless perceived cognitive failures are significantly associated with quality of life for older adults with BD. For both cognitive errors and BD symptoms, their indirect effect on quality of life (via suicide ideation) is greater than the direct effect.

The new lithium clinic.

Until the early 1950s, no effective pharmacological treatment existed for bipolar affective disorder. By the early 1960s, specialty clinics were being set up to dispense lithium carbonate to bipolar patients. By the late 1980s, a new body of knowledge was influencing the perception of bipolar disorder and how the disease should be treated. The authors' lithium clinic from 1974 has grown and evolved from a lithium blood level monitoring model into a comprehensive care model with polypharmacy, psychoeducation, rehabilitation, cognitive therapy, social rhythm therapy, and employment counseling as well as a staff of 2 part-time psychiatrists and 1 clinical psychologist. This service delivery model may benefit both treatment and research in bipolar disorder. The evolution of psychopharmacological and psychosocial knowledge in treating bipolar illness has been integrated into our clinic. Case vignettes are presented to illustrate these points. The comparative cost of this model is discussed.

Is the 6-item, self-report HAM-D an effective depression screening measure with bipolar disorder?

PURPOSE: Brief and effective screening measures are required to detect clinical depression in bipolar disorder (BD) patients. The purpose of this study was to demonstrate the clinical utility of a six-item, self-report Hamilton Depression Rating Scale (HAMD-6). DESIGN AND METHOD: Sixty BD outpatients completed questionnaires including the HAMD-6 before regular psychiatric appointments. FINDINGS: A 7+ HAMD-6 cut-off score correctly identified six of eight depressed patients, indicating 75% sensitivity and 84% specificity. PRACTICE IMPLICATIONS: The results of this study suggest the HAMD-6 is an effective depression screening measure with BD patients living in the community. This brief self-report scale can be used in clinical settings to quickly identify those requiring more thorough clinical attention.

Neuropsychological correlates of homocysteine levels in euthymic bipolar patients.

BACKGROUND: We have previously reported that homocysteine levels are elevated in euthymic bipolar patients with functional deterioration. The current study was designed to extend this finding by examining the relationship between neuropsychological functioning and homocysteine levels in euthymic bipolar patients. METHODS: Fifty-seven euthymic bipolar outpatients were assessed for serum levels of homocysteine, folic acid, and vitamin B-12 and administered a battery of neuropsychological tests. RESULTS: We found that male bipolar subjects showed higher average homocysteine levels than a comparison group of normal subjects, that poorer functioning on a task of executive function (Wisconsin Card Sort) was related to higher homocysteine levels, and that folic acid or vitamin B-12 levels did not significantly affect neuropsychological functioning. LIMITATIONS: These results, while suggesting some relationship between higher homocysteine levels, bipolar illness, and impairment in cognitive function do not establish any causative effects. CONCLUSIONS: The findings of this study confirm that in euthymic bipolar patients, higher homocysteine levels are associated with poorer performance in some neuropsychological tests. Treatment trials will be required before it will be known if the putative decrements in the executive function of bipolar patients can be reversed, or at least retarded, if homocysteine levels are reduced (as, for example, by dietary addition of B vitamin supplements).

Homocysteine-reducing strategies improve symptoms in chronic schizophrenic patients with hyperhomocysteinemia.

BACKGROUND: An elevated homocysteine level is reported to be a risk factor for several diseases, including Alzheimer's and cerebrovascular disease. Recently, several studies have reported that homocysteine levels are elevated in many schizophrenic patients. Homocysteine levels can be lowered by oral folic acid, B-12, and pyridoxine. METHODS: Forty-two schizophrenic patients with plasma homocysteine levels >15 micromol/L were treated with these vitamins for 3 months and placebo for 3 months in a study with a randomized, double-blind, placebo-controlled, crossover design. RESULTS: Homocysteine levels declined with vitamin therapy compared with placebo in all patients except for one noncompliant subject. Clinical symptoms of schizophrenia as measured by the Positive and Negative Syndrome Scale declined significantly with active treatment compared with placebo. Neuropsychological test results overall, and Wisconsin Card Sort (Categories Completed) test results in particular, were significantly better after vitamin treatment than after placebo. CONCLUSIONS: A subgroup of schizophrenic patients with hyperhomocysteinemia might benefit from the simple addition of B vitamins.

Clinical trials of PUFAs in depression: State of the art.

Omega fatty acid treatment of depression is an unusual story in psychopharmacology in that the use and study of these compounds were advanced in cardiovascular disease before becoming of interest in psychiatry. Given the absence of an easily patentable derivative it is a tribute to the field that enough studies have accumulated for a reasonable review of omega-3 treatment of depression at this time. On the other hand, it is clearly not possible to compare the number of studies, variety of studies and the number of participants in each study with Federal Drug Administration style registration trials of patented antidepressant drugs. Most of the available studies of omega-3 in depression have been investigator initiated and use add-on design. This paper reviews 12 published and as yet unpublished clinical trials (all but one double-blind placebo-controlled) of polyunsaturated fatty acids in unipolar depression, bipolar disorder, and special populations with affective/depressive disorders. While overall results up to this point are encouraging, they are not unanimously positive. Outstanding issues that have not as yet been resolved include the dose of omega-3 necessary and the length of time required for significant response. Moreover, the complex issue of the relationship between two possible active ingredients, eicosapentaenoic acid and docosahexaenoic acid, remains unresolved.

Online information seeking by patients with bipolar disorder: results from an international multisite survey.

BACKGROUND: Information seeking is an important coping mechanism for dealing with chronic illness. Despite a growing number of mental health websites, there is little understanding of how patients with bipolar disorder use the Internet to seek information. METHODS: A 39 question, paper-based, anonymous survey, translated into 12 languages, was completed by 1222 patients in 17 countries as a convenience sample between March 2014 and January 2016. All patients had a diagnosis of bipolar disorder from a psychiatrist. Data were analyzed using descriptive statistics and generalized estimating equations to account for correlated data. RESULTS: 976 (81 % of 1212 valid responses) of the patients used the Internet, and of these 750 (77 %) looked for information on bipolar disorder. When looking online for information, 89 % used a computer rather than a smartphone, and 79 % started with a general search engine. The primary reasons for searching were drug side effects (51 %), to learn anonymously (43 %), and for help coping (39 %). About 1/3 rated their search skills as expert, and 2/3 as basic or intermediate. 59 % preferred a website on mental illness and 33 % preferred Wikipedia. Only 20 % read or participated in online support groups. Most patients (62 %) searched a couple times a year. Online information seeking helped about 2/3 to cope (41 % of the entire sample). About 2/3 did not discuss Internet findings with their doctor. CONCLUSION: Online information seeking helps many patients to cope although alternative information sources remain important. Most patients do not discuss Internet findings with their doctor, and concern remains about the quality of online information especially related to prescription drugs. Patients may not rate search skills accurately, and may not understand limitations of online privacy. More patient education about online information searching is needed and physicians should recommend a few high quality websites.

Internet use by patients with bipolar disorder: Results from an international multisite survey.

There is considerable international interest in online education of patients with bipolar disorder, yet little understanding of how patients use the Internet and other sources to seek information. 1171 patients with a diagnosis of bipolar disorder in 17 countries completed a paper-based, anonymous survey. 81% of the patients used the Internet, a percentage similar to the general public. Older age, less education, and challenges in country telecommunications infrastructure and demographics decreased the odds of using the Internet. About 78% of the Internet users looked online for information on bipolar disorder or 63% of the total sample. More years of education in relation to the country mean, and feeling very confident about managing life decreased the odds of seeking information on bipolar disorder online, while having attended support groups increased the odds. Patients who looked online for information on bipolar disorder consulted medical professionals plus a mean of 2.3 other information sources such as books, physician handouts, and others with bipolar disorder. Patients not using the Internet consulted medical professionals plus a mean of 1.6 other information sources. The percentage of patients with bipolar disorder who use the Internet is about the same as the general public. Other information sources remain important.

Omega-3 eicosapentaenoic acid in bipolar depression: report of a small open-label study.

INTRODUCTION: Epidemiologic studies have suggested that consumption of cold water fish oils may have some protective function against depression. This proposition is supported by a series of biochemical and pharmacologic studies that have suggested that fatty acids may modulate neurotransmitter metabolism and cell signal trans-duction in humans and that abnormalities in fatty acid and eicosanoid metabolism may play a causal role in depression. Aware of the critical need for antidepression treatments that might not carry the risk of precipitating a manic episode in bipolar patients, we decided to conduct an open-label add-on trial of eicosapentaenoic acid (EPA) in bipolar depression. METHOD: Twelve bipolar I outpatients with depressive symptoms diagnosed by DSM-IV were treated with 1.5 to 2 g/day of the omega-3 fatty acid EPA for up to 6 months. The study was conducted between September 2001 and January 2003. RESULTS: Eight of the 10 patients who completed at least 1 month of follow-up achieved a 50% or greater reduction in Hamilton Rating Scale for Depression scores within 1 month. No patients developed hypomania or manic symptoms. No significant side effects were reported. LIMITATIONS: This study is limited both by the open-label design and by the small sample size. As in all previous reported studies, patients in this study were treated in an outpatient setting, so that the most severely depressed bipolar patients (requiring hospitalization) are not represented. CONCLUSIONS: Although the ultimate utility of omega-3 fatty acids in bipolar depression is still an open question, we believe that these initial results are encouraging, especially for mild to moderate bipolar depression, and justify the continuing exploration of its use.

High homocysteine serum levels in young male schizophrenia and bipolar patients and in an animal model.

Elevated plasma homocysteine has been found to be a risk factor for Alzheimer's disease as well as cerebral vascular disease, suggesting that some risk factors can accelerate or increase the severity of several CNS disease processes. We screened plasma total homocysteine levels of 193 schizophrenic patients vs. 762 controls for plasma homocysteine levels. The effect of schizophrenia was marked (p<0.0001) and mean homocysteine level was 16.3+/-12 (S.D.) microM in schizophrenic patients vs. 10.6+/-3.6 (S.D.) microM in healthy controls. The increase was almost entirely in young male schizophrenic patients. It seemed important to determine if this finding is already present in newly admitted schizophrenic patients. Serum homocysteine levels were studied in 184 consecutively admitted schizophrenic patients and 305 control subjects. Homocysteine levels were markedly increased in this population of newly admitted schizophrenic patients, especially in young males. However, no difference was found for CSF homocysteine levels between schizophrenia patients and controls. We also examined homocysteine levels in 41 euthymic outpatients with bipolar disorder. Functional deterioration in patients was rated as 'present' or 'absent' by consensus of two treating clinicians. Young male bipolar patients were found to have higher homocysteine levels than controls. Among the male subjects, bipolar patients showing deterioration had homocysteine levels which were significantly higher than other patients. We attempted to develop a model of homocysteine neurotoxicity in mice. Mice were fed homocysteine in water at a dose of 200 mg/kg per mouse per day. Independent samples of animals were studied at 2 to 6 months with behavioral tests including apomorphine-induced stereotypy and spatial learning and memory in the Morris Water Maze. Homocysteine levels were elevated up to 800% at months 5 and 6 by this procedure. No homocysteine-induced defects were found in any behavioral test until month 5 when mild but statistically significant abnormalities in the Morris Water Maze were detected.

Lithium nephrotoxicity.

Reports of toxic effects on the kidney of lithium treatment emerged very soon after lithium therapy was introduced. Lithium-induced nephrogenic diabetes insipidus is usually self-limiting or not clinically dangerous. Some reports of irreversible chronic kidney disease and renal failure were difficult to attribute to lithium treatment since chronic kidney disease and renal failure exist in the population at large. In recent years, large-scale epidemiological studies have convincingly shown that lithium treatment elevates the risk of chronic kidney disease and renal failure. Most patients do not experience renal side effects. The most common side effect of polyuria only weakly predicts increasing creatinine or reduced kidney function. Among those patients who do experience decrease in creatinine clearance, some may require continuation of lithium treatment even as their creatinine increases. Other patients may be able to switch to a different mood stabilizer medication, but kidney function may continue to deteriorate even after lithium cessation. Most, but not all, evidence today recommends using a lower lithium plasma level target for long-term maintenance and thereby reducing risks of severe nephrotoxicity.

Effect of bipolar disorder on lymphocyte inositol monophosphatase mRNA levels.

The activity of inositol monophosphatase (IMPase), the lithium (Li)-inhibitable enzyme in the phosphatidylinositol (PI) signal transduction system, has recently been found significantly lower in lymphoblastoid cell lines from bipolar (BP) patients, particularly in Li-responders. To probe for possible quick detection of the disease and prediction of the therapeutic response we repeated our study in fresh lymphocytes. Since IMPase in fresh lymphocytes is inhibited in vivo by ongoing Li treatment and its pre-Li activity cannot be evaluated, IMPase mRNA levels were measured. Relative (to beta-actin) mRNA levels were quantified by reverse transcriptase (RT)-PCR in 5 drug-free and 31 drug-treated BP patients compared with 36 control subjects in fresh lymphocytes. In agreement with our findings with IMPase activity, the small group of drug-free BP patients exhibited approximately 2/3 reduction in IMPase relative mRNA levels compared to control subjects. Approximately 2-fold elevation of these levels toward control values was found for patients treated with Li and other mood stabilizers. The study further suggests the possible importance of IMPase in the aetiology of BP disorder and in the mediation of the therapeutic efficacy of Li. It may be that chronic inhibition of IMPase activity by Li results in up-regulation of its gene at the transcriptional level.

Reward sensitivity and anger in euthymic bipolar disorder.

According to the hypersensitive behavioral approach system (BAS) model of bipolar disorder (BP), hypersensitivity of the BAS is a trait that should be present even in the euthymic state. This would be expected to result in increased anger and reward sensitivity, both of which are related to the approach system. This study examined these predictions through the use of tasks that assess different aspects of the BAS: reward sensitivity, anger and impulsivity. These characteristics were assessed using the probabilistic classification task (PCT), ultimatum game (UG) and single key impulsivity paradigm (SKIP), respectively. Participants were euthymic adult bipolar disorder patients (BP; N=40) and healthy controls (HC; N=41). In the UG, all participants showed the standard pattern of rejecting overtly unfair offers and accepting clearly fair offers; however, BPs rejected more of the moderately unfair offers than did HCs. BP and HC participants did not differ on their ability to learn, but did show different patterns of learning from reward and punishment. Learning for reward and punishment were negatively correlated in the BP group, suggesting that individuals could learn well either from reward or punishment, but not both. No correlation was found between these forms of learning in the HC group. BP patients show signs of their disorder even in the euthymic state, as seen by the dysbalance between reward and punishment learning and their residual anger in the UG.

Relationship between sunlight and the age of onset of bipolar disorder: an international multisite study.

BACKGROUND: The onset of bipolar disorder is influenced by the interaction of genetic and environmental factors. We previously found that a large increase in sunlight in springtime was associated with a lower age of onset. This study extends this analysis with more collection sites at diverse locations, and includes family history and polarity of first episode. METHODS: Data from 4037 patients with bipolar I disorder were collected at 36 collection sites in 23 countries at latitudes spanning 3.2 north (N) to 63.4 N and 38.2 south (S) of the equator. The age of onset of the first episode, onset location, family history of mood disorders, and polarity of first episode were obtained retrospectively, from patient records and/or direct interview. Solar insolation data were obtained for the onset locations. RESULTS: There was a large, significant inverse relationship between maximum monthly increase in solar insolation and age of onset, controlling for the country median age and the birth cohort. The effect was reduced by half if there was no family history. The maximum monthly increase in solar insolation occurred in springtime. The effect was one-third smaller for initial episodes of mania than depression. The largest maximum monthly increase in solar insolation occurred in northern latitudes such as Oslo, Norway, and warm and dry areas such as Los Angeles, California. LIMITATIONS: Recall bias for onset and family history data. CONCLUSIONS: A large springtime increase in sunlight may have an important influence on the onset of bipolar disorder, especially in those with a family history of mood disorders.

Behavioral addictions in euthymic patients with bipolar I disorder: a comparison to controls.

BACKGROUND: Bipolar disorder may be associated with a hypersensitive behavioral approach system and therefore to increased reward sensitivity. The objective of this study is to explore the interrelationships between bipolar disorder, behavioral addictions, and personality/temperament traits in a group of euthymic outpatients with bipolar I disorder and in a group of comparison subjects. METHODS: Fifty clinically stable patients and 50 comparison subjects matched for age, sex, and educational level were administered the Temperament and Character Inventory-140 and the Behavioral Addiction Scale. RESULTS: The patient group scored significantly higher than comparison subjects for two benign behavioral addictions (music, shopping) as well as for smoking. Comparison subjects scored higher on two harmful behavioral addictions (drugs, alcohol). Novelty Seeking was positively correlated with harmful addictions, and Cooperativeness was negatively correlated with harmful addictions, in both groups. DISCUSSION: The hypersensitive behavioral approach system model of bipolar disorder would predict higher levels of various addictions in bipolar patients as compared to controls. In this study, this was true for three behavioral addictions, whereas controls showed higher levels of behavioral addiction to drugs and alcohol. This may be because the patients in this study are stable, have received considerable psychoeducation, and are relatively adherent to their medication recommendations. Temperament and character traits may play roles both as risk and protective factors regarding behavioral addictions.