[Manic polarity of the onset episode of bipolar disorder: clinical and prognostic considerations]. / Polarité maniaque du premier épisode d'un trouble bipolaire: aspects cliniques et pronostiques.

Studies mapping the course of bipolar disorder from the first episode have provided important information with regard to the prognosis of the illness in patients with a manic episode at onset. Two different approaches have been used in these studies. Prospective follow-up studies conducted in the few years following the first episode have emphasized the poor symptomatic and functional short-term outcome of the patients. Retrospective studies, more relevant to address the long-term course of the illness according to the clinical characteristics of the first episode, have consistently evidenced that polarity at onset is predictive of the dominant polarity of the disorder for a given patient. Given the harmful consequences of recurrences on the outcome of the illness and the psychosocial functioning of patients, early diagnosis potentially allowed by the occurrence of a first manic episode is a critical step toward prescribing a mood stabilizer at the beginning of the disorder. Accurate knowledge on the clinical characteristics and the course of illness in patients with a manic episode at illness onset may help clinicians for developing more specific and more relevant therapeutic intervention for these patients.

[Depressive onset episode of bipolar disorder: clinical and prognostic considerations]. / Premier épisode dépressif d'un trouble bipolaire: aspects cliniques et pronostiques.

Both retrospective and high-risk individuals prospective studies show that a high percentage of patients experience one or more depressive episodes previous the diagnosis of bipolar disorder. Depressive onset bipolar disorders begin earlier than the ones with a manic onset, have a higher duration, a chronic course with frequent recurrences, a depressive dominant polarity, a higher lifetime rate of suicidal behaviour, less psychotic symptoms and more rapid cycling. A relation between frequent rapid cycling and previous prescription of antidepressants was suggested but not rigorously demonstrated. Thus, a high percentage of patients presenting a first depressive episode will later develop bipolar disorder. Several risk factors of bipolarity have been identified and might be detected during each depressive episode by using standardised evaluations and family interviews, if necessary. Among them, an early age at first episode, frequent recurrences, a family history of bipolar disorder, atypical features and hypomanic symptoms are particularly associated with the subsequent development of a bipolar disorder. The impact of a high risk of bipolarity on drug prescription is unclear ; however, one can strongly recommend to intensifying clinical monitoring and to proposing adjunctive psychoeducation.

[Treatment of a first manic episode]. / Traitement d'un premier épisode maniaque.

When the first episode of mania is not directly related to a somatic or toxic disease it indicates bipolar disorder. These former possibilities must always be excluded from a laboratory and morphological assessment. They are clinically difficult to identify mostly because the clinical presentation is usually atypical. Whilst they may occur at any age they mostly involve young people, and drug use is common. Psychotic presentations are particularly common as are some symptoms such as irritability. Treatment of the acute phase is no different from that of other manic episodes although the challenges are very different as whilst there is often a risk of functional deterioration after an initial episode this risk increases considerably with repeated episodes. It is therefore essential to establish a quality treatment alliance as soon as possible which will facilitate the introduction, acceptance and adherence to preventative treatment and adherence to the different lifestyle recommendations. Clinical studies are needed in order to provide more information about the most suitable preventative treatment in this population.

[Prodromal phase in bipolar disorder]. / Phase prodromale du trouble bipolaire.

The prodromal phase is generally described as a subsyndromal stage preceding the disease onset. The characterization of such phase found its main purpose in secondary prevention. Up to now, clinical research relating to this topic in mental health has primarily focus on schizophrenic disorders. Over the last years, some studies have applied similar methods in order to characterize a preclinical phase in bipolar disorders. In spite of the fact that this strategy appears less adequate in bipolar disorders, these studies have demonstrated the existence of prodromal signs in a majority of patients. However, these features appear for the moment neither sufficiently characteristic, nor sufficiently specific to allow the construction of suitable assessment instruments, or to suggest precise guidelines in the management of these subjects. Also, these prodromal features show considerable overlap with other psychiatric disorders, especially attention-deficit hyperactivity disorder (ADHD) and schizophrenia Interestingly, a limited number of studies have looked at the number of patients considered in a prodromal phase of schizophrenia which later developed a bipolar disorder and reported substantial proportions of subjects in this case, further highlighting the obvious bias in favor of schizophrenia in the actual prevention politics. In order to identify potential candidates at a prodromal phase of bipolar disorders that could benefit from early intervention, studies have relied on both high genetic risk and symptoms at the boundary of the actual classification. However, even within such approach, pharmacological treatments have not proven obvious advantage in terms of prevention. It is suggested that adopting a more longitudinal vision of the disease and, given the mean age of onset of bipolar disorder and a fortiori of its prodromal phase, a more developmental perspective of individuals, could help lowering the confusion in this field ; Also, given the considerable overlap in prodromal features between different psychiatric disorders, early detection programs could benefit from implementing approach open to multiple diseases assessment, rather than hyper-specialization in a specific disorder.

[Clinical features of suicide occurring in schizophrenia (I). Risk-factors identification]. / Approche clinique du suicide au cours de la schizophrénie (I). Identification des facteurs de risque.

INTRODUCTION: Suicide is the leading cause of premature death in schizophrenia. Approximately 10 to 13% of deaths in schizophrenia are explained by suicide, despite widespread availability of generally effective antipsychotic treatments and suicide attempts have been reported among 20 to 50% of patients. This relatively low ratio of attempts/suicide is consistent with greater lethality of means - more violent - and intents - less ambivalence - in this population. LITERATURE FINDINGS: Many studies have focused on risk factors and clinical characteristics for completed and/or attempted suicide. Commonly, sociodemographic risk factors for suicide are male sex, younger age and, among women, being unmarried, divorced or widowed. Previous suicidal behaviour is a strong risk factor for suicide and contrary to the common view, schizophrenic patients often communicate their suicidal intents shortly before death. Moreover, family history of suicide is associated with a heightened risk of suicide and is independent of the diagnosis, according to the growing literature that shows that vulnerability to suicidal behaviour is independent of psychiatric diagnosis. Suicide can occur throughout the entire course of schizophrenia. This is particularly true in those high-risk periods: early phase of the disease, active illness phase, period of relapse or during a depressive episode. The role of insight and positive symptoms remains unclear and probably needs further studies. Although not specifically for people with schizophrenia, hopelessness is a major risk factor and tragic loss is often presented as a trigger for suicide. It has been suggested that treatment side-effects, such as akathisia are associated with suicidal behaviour. CONCLUSION: A better knowledge of risk and protective factors is necessary to prevent suicide and suicidality.

Effect of risperidone versus haloperidol on emotional responding in schizophrenic patients.

RATIONALE: Studies on emotional processing report that schizophrenic patients present a specific pattern of emotional responding that usually includes deficits in emotional expressiveness, increased feelings of unpleasant emotion but decreased feelings of pleasant emotion, and increased physiological reactivity. However, studies have rarely controlled the nature of antipsychotic medication. Yet, the influence of these drugs on emotional response is uncertain and could vary depending on their pharmacological profile. OBJECTIVE: This prospective and randomized study aimed to compare the effects of an atypical antipsychotic, risperidone, to a typical one, haloperidol, on patients' emotional responding during an emotional induction task. MATERIALS AND METHODS: Twenty-five schizophrenic patients underwent two emotional and clinical evaluations: one before treatment initiation and a second 4 weeks after. Emotional states of fear, sadness, anger, joy, and disgust were induced, as well as a neutral baseline state. Video recordings of patients during the induction task allowed for assessment of emotional expressiveness. Self-reports and measures of skin conductance and heart rate were performed to determine both subjective and physiological reactions to emotional experience. RESULTS: Compared to haloperidol, risperidone did not reduce patients' facial expressiveness, decreased physiological reactivity, and decreased experience of unpleasant emotion but maintained experience of pleasant emotion. Emotional expressiveness was negatively correlated to parkisonism. CONCLUSIONS: Our preliminary results suggest that atypical antipsychotics allow for better-adapted patterns of emotional responding than typical ones do. We suggest that this effect is due to reduced striatal D2 blockade, therefore, attenuating akinesia, coupled with increased 5HT and DA levels in prefrontal cortex, which improves emotional regulation.

"Folie circulaire" vs "Folie à double forme": contribution from a French national study.

OBJECTIVE: To check whether the presence or not of free intervals between episodes could help differentiate subtypes of bipolar disorder, as suggested by the seminal controversy between Falret and Baillarger. METHODS: From 1090 bipolar I patients included in a French national study, 981 could be classified as with or without free intervals and assessed for demographic and illness characteristics. RESULTS: Compared with patients with free intervals (n=722), those without (n=259) had an earlier age at onset, more episodes, suicide attempts, cyclothymic and irritable temperaments. The following independent variables were associated with no free intervals: being single or divorced, delay to mood stabilizer treatment, multiple hospitalizations, incongruent psychotic features, panic and generalized anxiety disorder. CONCLUSION: "Folie à double forme" (without free intervals) and "folie circulaire" (with free intervals) may actually refer to early and later onset bipolar subtypes, insofar as most differences we found between them were previously evidenced between the latter two. We cannot, however, exclude that they might simply be two separate subtypes, whose main characteristics could be accounted for by different explanatory factors.

Suicidal behaviour in a French Cohort of major depressive patients: characteristics of attempters and nonattempters.

BACKGROUND: Epidemiological and clinical studies indicate that major depressive disorder is the leading cause of suicidal behaviour and that bipolar II subjects carry the highest risk. Identification of risk factors is therefore essential to prevent suicide in this population. METHODS: As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1month apart, 155 (33.7%) were classified as suicide attempters, and 295 (66.3%) as nonattempters, after exclusion of bipolar I patients. RESULTS: Compared to nonattempters, attempters had a longer duration of illness, longer delays before seeking help and correct diagnosis and a higher number of previous episodes; they were more frequently rapid cyclers, with fewer free intervals between episodes. Lifetime suicide attempts were associated with more comorbid bulimia and substance abuse. Bipolar II spectrum disorders, depressive, cyclothymic and irritable temperaments were overrepresented in attempters, as well as family history of both affective disorder and suicide attempts. The following independent variables were associated with lifetime suicide attempts: higher number of previous depressive episodes, multiple hospitalizations, cyclothymic temperament, rapid cycling and earlier age at onset. LIMITATIONS: Retrospective design, recall bias, lack of sample homogeneity, and insufficient assessment of hypomanic features during index depression. CONCLUSIONS: In major depressive disorders, family history, age at onset, illness course, comorbidity and cyclothymic temperament alongside other indices of bipolarity may help predict suicidal behaviour. Longer delays to seeking help and diagnosis in attempters emphasize the importance of early recognition of bipolar spectrum disorders.