Digital depression: a new disease of the millennium?

OBJECTIVE: In the past decade, since the innovation of the smartphone, there has been an increase in depression, anxiety, and suicidality among teenagers and young adults. The objective of this article was to review the current evidence for these associations and to provide initial clinical guidance. METHODS: A narrative review of the available literature on digital technology, social media, and psychiatric outcomes in adolescents. RESULTS: Psychiatric outcomes have worsened in adolescents in the past decade, correlating with the invention of the smartphone and the rise of social media. Depressive symptoms among American teenagers rose rapidly around 2012 and now are reported in 22% of adolescents, which is at least double the rate in adults. Suicide rates have risen, especially among teenage girls in the United States, in whom there has been a doubling of completed suicide in the past decade. A causal relationship between social media use and these harmful psychiatric outcomes is supported by emerging randomized data showing reduced depressive symptoms associated with a decrease in social media use in college students. CONCLUSIONS: Social media and digital technology correlate with harmful psychiatric outcomes in adolescents and young adults. Clinical recommendations should include limitations in social media use.

When and how to use lithium.

BACKGROUND: Lithium is an old proven medication, but it is infrequently used in current practice. This review examines evidence for its benefits and risks and provides clinical guidance to its use. METHOD: Narrative review. RESULTS: Besides its benefit in bipolar illness, lithium has important underappreciated proven benefits in prevention of unipolar depression and suicide. Emerging data support neurobiological benefits for cognition and possible dementia prevention. Likely benefits also exist in low doses for mood temperaments (cyclothymia and hyperthymia). High doses (over 1.0 mmol/L) should be avoided since they increase side effects, complications associated with long-term use, and risk of toxicity. Conversely, low dosing can be legitimate, especially for suicide and dementia prevention. Nuisance side effects of lithium may affect adherence, and medically serious side-effects can occur. Managing strategies are available for side effects. CONCLUSION: Lithium is the most effective medication in psychiatry, because it has disease-modifying, not just symptomatic, effects. It is effective not only for bipolar illness but also for prevention of suicide, episodes of unipolar depression, mood temperaments, and possibly dementia. Its many benefits need better appreciation, while lowered dosing can reduce risks.

The International Mood Network (IMN) Nosology Project: differentiating borderline personality from bipolar illness.

OBJECTIVE: The differential diagnosis of bipolar illness vs. borderline personality is controversial. Both conditions manifest impulsive behavior, unstable interpersonal relationships, and mood symptoms. This study examines whether and which mood clinical features can differentiate between both conditions. METHOD: A total of 260 patients (mean ± standard deviation age 41 ± 13 years, 68% female) attending to a mood clinic were examined for diagnosis of bipolar illness and borderline personality disorder using SCID-I, SCID-II, and clinical mood criteria extracted from Mood Disorder Questionnaire (MDQ). They were analyzed using diagnoses as dependent variables. Predictors of bipolar and borderline diagnoses were identified by multivariable logistic regressions, and predictive validity of models was assessed using ROC curve analysis. RESULTS: Bipolar illness was strongly predicted by elevated mood (OR = 4.02, 95% CI: 1.80-9.15), increased goal-directed activities (OR = 3.90, 95% CI: 1.73-8.96), and episodicity of mood symptoms (OR = 3.48, 95% CI 1.49-8.39). This triad model predicted bipolar illness with 88.7% sensitivity, 81.4% specificity, and obtained an auROC of 0.91 (95% CI: 0.76-0.96) and a positive predictive value of 85.1%. For borderline personality disorder, only female gender was a statistically significant predictor (OR = 3.41, 95% CI: 1.29-13.7), and the predictive model obtained an auROC of 0.67 (95% CI: 0.53-0.74). CONCLUSION: In a mood disorder clinic setting, manic criteria and episodic mood course distinguished bipolar illness from borderline personality disorder.

Bipolar or borderline: a clinical overview.

OBJECTIVE: To examine the empirical literature on diagnostic validators in borderline personality and bipolar illness. METHOD: Using principles of evidence-based medicine, the highest levels of evidence were emphasized in interpretation of similarities or differences between bipolar illness and borderline personality on the five standard diagnostic validators in psychiatric nosology: symptoms, course, genetics, treatment response, and neurobiology. RESULTS: Bipolar illness and borderline personality were found to be similar in the nosological validator of symptoms of mood lability and impulsivity, but differed notably on all other diagnostic validators, especially the course validator of past sexual abuse and the genetic validator of a bipolar family history. They also differ notably in the symptom validator of parasuicidal self-harm. Treatment response and neurobiological differences were also present and consistent. CONCLUSION: This review of the literature indicates that these two conditions, bipolar illness and borderline personality, are different and can be distinguished. The much stronger biological and genetic evidence for bipolar illness in particular suggests that the two conditions can be reasonably seen as different kinds of clinical entities, namely a biological disease versus a psychosocially caused clinical picture. If this interpretation is correct, similarities between the two conditions, such as mood lability and impulsivity, are superficial, while differences are profound. Further, true comorbidity may be much less common than often presumed.

Diagnostic validity of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review.

OBJECTIVE: At least 50% of bipolar disorder (BD) patients have an additional diagnosis, one of the most difficult to manage being obsessive-compulsive disorder (OCD). Defining the nosology of BD-OCD comorbidity has important clinical implications, given that treatments for OCD can worsen BD outcomes. METHOD: A systematic review was conducted on: i) BD-OCD comorbidity lifetime prevalence and ii) on standard diagnostic validators: phenomenology, course of illness, heredity, biological markers, and treatment response. Relevant papers published through March 30th 2013 were identified searching the electronic databases MEDLINE, Embase, PsycINFO, and the Cochrane Library. RESULTS: Sixty-four articles met inclusion criteria. Lifetime comorbidity prevalence was 11-21% in BD patients and 6-10% in OCD patients. Compared to non-comorbid subjects, BD-OCD has a more episodic course of OC symptoms (up to 75% vs. 3%), typically with worsening during depression (78%) and improvement during mania/hypomania (64%), as well as a higher total mean number of depressive episodes (8.9±4.2 vs. 4.1±2.7) and perhaps more antidepressant-induced mania/hypomania (39% vs. 9%). CONCLUSION: In this first systematic review of BD-OCD comorbidity, it appears that OC symptoms are usually secondary to BD, rather than representing a separate disease.

The mistaken claim of bipolar 'overdiagnosis': solving the false positives problem for DSM-5/ICD-11.

OBJECTIVE: For psychiatric diagnoses, solving the problem of false positives is thought to be a matter of tightening diagnostic criteria. But low prevalence illnesses by their nature have high false positive rates. A recent study of bipolar disorder found the predictive value of bipolar diagnoses to be <50%. Is it possible to achieve much higher diagnostic accuracy for psychiatric diagnoses? METHOD: We calculate predictive values while varying diagnostic sensitivity and holding specificity constant, and vice versa, for a given prevalence of illness. We then calculate predictive values while holding sensitivity and specificity constant, but varying prior probability (clinically feasible by assessing other factors associated with bipolar outcomes, such as family history and degree of recurrence). RESULTS: Assuming a sample in which the prevalence of illness is 10%, achieving positive predictive values (PPV) >50% requires diagnostic specificity of >95%. Holding specificity at a level already achieved clinically (86%), increasing prior probability yields predictive values as high as 83%. CONCLUSION: Systematic assessment of clinical factors that increase the prior probability of illness, before applying DSM/ICD criteria, could raise PPV substantially compared with targeting greater specificity via more stringent diagnostic criteria.

Predictors of response to ziprasidone: results from a 6-week randomized double-blind, placebo-controlled trial for acute depressive mixed state.

INTRODUCTION: The present study is aimed at investigating possible predictors of response to ziprasidone in a sample of patients with mixed depressive state. METHODS: 72 patients were randomized to either ziprasidone or placebo and treated prospectively for 6 weeks. The clinical response and remission were defined with various clinical variables including Montgomery Asberg Depression Rating Scale. Further outcome measures included predictors of remission and other clinical variables over time. RESULTS: None of the variables under investigation were significantly associated with response or remission at 6 weeks (all p-values>0.003, respectively). CONCLUSIONS: Further investigations are warranted due to clear limitations, mostly small sample size and use of concomitant medications.

Aripiprazole augmentation in treating comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review.

BACKGROUND: Apparent comorbidity between bipolar disorder (BD) and obsessive-compulsive disorder (OCD) is a common condition in psychiatry, but treatment of BD-OCD remains a clinical challenge. Although serotonin reuptake inhibitors (SRIs) are the first line treatment for OCD, they can induce mood instability in BD. An optimal treatment approach remains to be defined. METHODS: A systematic review was conducted on aripiprazole augmentation in treating comorbid BD-OCD patients. Relevant papers published through August 31st 2018 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library. RESULTS: Aripiprazole augmentation to mood stabilizers (lithium carbonate, valproate), even at low doses (10-15 mg/day), helped to achieve significant remission in affective and obsessive-compulsive symptoms. Aripiprazole was generally safe and well tolerated. LIMITATIONS: Most studies are case reports. Enrolment of subjects mainly from outpatient specialty units might have introduced selection bias and limited community-wide generalizability. CONCLUSIONS: Keeping in mind scantiness and heterogeneity of the available literature, the best interpretation of the available evidence appears to be that aripiprazole augmentation to mood stabilizers, even at low doses, is effective in BD-OCD patients.

Updates in treating comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review.

BACKGROUND: In the last five years, the debate around the comorbidity between bipolar disorder (BD) and obsessive-compulsive disorder (OCD) has flourished within the international psychiatric community and several studies have been published on therapeutic strategies. METHODS: An update of our previous systematic review was conducted on clinical management of comorbid BD-OCD patients. Relevant papers published from July 1st 2013 to September 30th 2018 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library. RESULTS: Fifteen studies were included. In all selected studies BD-OCD patients received mood stabilizers, alone or with second-generation antipsychotics (SGAs). Aripiprazole augmentation demonstrated to be effective as maintenance therapy and for treating obsessive-compulsive symptoms during manic episodes (40% of the studies, 6/15). Addition of antidepressants to mood stabilizers led to clinical remission of both conditions in only one case report. LIMITATIONS: Almost 50% of the selected studies are case reports. Enrolment of subjects mainly from outpatient specialty units might have introduced selection bias and limited community-wide generalizability. CONCLUSIONS: Mood stabilization should be the primary goal in treating BD-OCD patients. Aripiprazole augmentation to lithium carbonate seemed to be the best option in treatment-resistance comorbid patients. Addition of SRIs may be needed only in a minority of BD patients with refractory OCD.

Long-term antidepressant treatment in bipolar disorder: meta-analyses of benefits and risks.

OBJECTIVE: Long-term antidepressant (AD) treatment for depression in bipolar disorder (BPD) patients is highly prevalent, but its benefits and risks remain uncertain, encouraging this meta-analysis of available research. METHOD: We reviewed randomized controlled trials for BPD involving >or=6 months of treatment with AD +/- mood stabilizer (MS) vs. placebo +/- MS, using meta-analyses to compare reported risks of new depression vs. mania. RESULTS: In seven trials (350 BPD patients) involving 12 contrasts, long-term treatments that included ADs yielded 27% lower risk of new depression vs. MS-only or no treatment [pooled relative risk, RR = 0.73; 95% CI 0.55-0.97; number-needed-to-treat (NNT) = 11], but 72% greater risk for new mania [RR = 1.72; 95% CI 1.23-2.41; number-needed-to-harm (NNH) = 7]. Compared with giving an MS-alone, adding an AD yielded neither major protection from depression (RR = 0.84; 95% CI 0.56-1.27; NNT = 16) nor substantial increase in risk of mania (RR = 1.37; 95% CI 0.81-2.33; NNH = 16). CONCLUSION: Long-term adjunctive AD treatment was not superior to MS-alone in BPD, further encouraging reliance on MSs as the cornerstone of prophylaxis.