Relative impact of diagnosis and clinical stage on response to electroconvulsive therapy: a retrospective cohort

Objectives: Electroconvulsive therapy (ECT) is commonly indicated for refractory psychiatric disorders. However, little research has compared response across diagnoses. Here, we aimed to evaluate the relative impact of diagnosis and clinical staging as response predictors in a cross-diagnostic sample. Methods: In a retrospective cohort of adult inpatients (n=287) who underwent at least six sessions of ECT, we investigated predictors of complete response (a clinical global impression of 1) to ECT. We use adjusted regression models to estimate the impact of clinical diagnosis and staging on complete response and dominance analysis to assess the relative importance of these predictors. Results: Those for whom a depressive episode was a primary indication for treatment were the most likely to have complete improvement, while those with psychosis were the least likely; clinical stage had a significant influence on outcome in all diagnoses. A diagnosis of psychosis was the strongest predictor of non-response. Conclusions: A diagnosis of psychosis (mainly schizophrenia) was the strongest predictor of non-response. We also found that clinical staging can aggregate information on ECT response that is independent of clinical diagnosis.

Relative impact of diagnosis and clinical stage on response to electroconvulsive therapy: a retrospective cohort.

OBJECTIVE: Electroconvulsive therapy (ECT) is commonly indicated for refractory psychiatric disorders. However, response comparison across diagnoses is scantly investigated. Here, we aimed to evaluate the relative impact of diagnosis and clinical staging as response predictors in a cross-diagnostic sample. METHODS: We investigate, in a retrospective cohort of adult inpatients (N=287) who underwent at least six sessions of ECT, predictors of complete response (a clinical global impression of 1) to ECT. We use adjusted regression models to estimate the impact of clinical diagnosis and staging on complete response and dominance analysis to assess the relative importance of these predictors. RESULTS: Those with a depressive episode as a primary indication for treatment were more likely than all the other groups to have complete improvement, while those with psychosis were the least likely; clinical stage had a significant influence on outcome in all diagnoses. A diagnosis of psychosis stood as the strongest predictor of non-response. CONCLUSION: An indication of ECT for psychosis (mostly schizophrenia) had a dominant impact in our cohort, indicating a worse chance of response. We also demonstrate that clinical staging can aggregate information on response to electroconvulsive therapy that is independent of clinical diagnosis.

Gender-related and non-gender-related female homicide in Porto Alegre, Brazil, from 2010 to 2016.

Female homicide is a global phenomenon with a higher prevalence in countries in Asia, Africa, and the Americas. Life expectancy in Brazil is compromised by the high risk of death from male and female homicides, a growing social problem. This study aimed to integrate different public datasets and describe the sociodemographic, criminal, and medicolegal characteristics of the homicides of girls and women occurring in Porto Alegre, southern Brazil, from 2010 to 2016. The data were obtained from autopsy reports, police reports, and records from crime scenes. During this period, there was a significant increase in overall standardized rates of female homicides (4.98 to 10.85), with a pronounced increase in non-gender-related deaths, especially due to urban violence, such as involvement in drug trafficking and other crimes and robbery resulting in death. Young (15-29 years of age), non-White women were the most affected. Increased female homicide rates due to non-gender-related factors is a new and worrying phenomenon in Brazil. Obtaining specific data on the profile of victims and characteristics of violence is a crucial step in facing the problem and directing public policies.

A Qualitative Study on Traumatic Experiences of Suicide Survivors.

The suicide of a loved one can be a traumatic experience. The objective of this study was to investigate trauma-related experiences of suicide survivors. This is a qualitative study with people who had recently lost a family member or a close one to suicide, conducted at least two months after the event. Forty-one participants agreed to take part in the study and were interviewed. The interviewees' perception was that suicide brought harm, symptoms, and suffering. Traumatic experiences can begin immediately after the event, with many reporting symptoms lasting many months and persistent impact, both personal and to the family. Postvention models after suicide should incorporate such findings, and investigate trauma consistently.

Socioeconomic and substance use changes in emerging adults and their relationship with mood disorders in a population-based cohort.

In this report, we aim to assess the interaction of bipolar disorder and major depressive disorder with the evolution of social roles, economic classification, and substance misuse in emerging adults. This is a longitudinal population-based study (n = 231 at baseline), in which participants were reassessed at a mean of 5 years after baseline. A structured clinical interview was used to diagnose the participants with bipolar disorder and major depression; a control group without mood disorders was included. Men with mood disorders were less likely to be married in the beginning of the study and less likely to work in the follow-up. Women with major depression were less likely to study and more likely to be in a lower economic class at the beginning of the study. In comparison, women with bipolar disorder were less likely to live with their parents and more likely to live with their children in the first wave of the study. Substance misuse was more likely in people with mood disorders, especially in men, and women with bipolar disorder had the highest likelihood in the follow-up. Albeit longitudinal analyses were limited by a possibly insufficient sample size and mediating mechanisms for change, such as stigma, were not explored, the study suggests sex-related specificities regarding the change in social roles and substance use in people with mood disorders. Emerging adults, especially those with mood disorders, are in a period of change and instability and at a greater risk for substance use and abuse.

Characteristics of suicides of young people in Porto Alegre, Southern Brazil, from 2010 to 2016.

The purpose of this study was to describe demographic, toxicological, criminal, and medicolegal characteristics of suicides of young people aged up to 24 years examined by the Porto Alegre Medicolegal Office, from 2010 to 2016. This cross-sectional study collected data from the Porto Alegre Medicolegal Office and the Rio Grande do Sul State Police Department. The information was obtained from death certificates, toxicological analyses and police reports. Rates were calculated according to sex and age range (under 15 years old, 15 to 19 years old, and 20 to 24 years old) for comparing local with national data. There were 143 people who died by suicide in the period, 120 males and 23 females. Hanging was the most frequently used method, but in the range of 10 to 14 years old, firearm use was the predominant method. Fifty percent of male victims and 30% of female victims had some criminal history. Suicide rates in the study groups generally followed national trends. The relative frequency of suicide by firearm in this study diverged from international findings, as it was relatively more frequent in children under 15 years old and less frequent in older ranges. If confirmed, the finding draws attention to access to firearms in this age range. In older age ranges, adolescents and young adults were frequently involved in the criminal system. This finding may be useful for planning interventions involving both mental health education and screening for problems that may be associated with criminal involvement.

Early illness progression in mood disorders: A population-based longitudinal study.

This study is aimed at assessing changes in functioning among young people from the general population with bipolar disorder and major depressive disorder over a period of five years. Specifically, we hypothesized that significant illness progression would take place during euthymia over time in bipolar disorder. We conducted a longitudinal study with 231 people, assessed at baseline and again at a five-year follow-up. A structured clinical interview was used to diagnose participants with mood disorders. A control group without mood disorders was also included. Functioning was assessed with the Functioning Assessment Short Test, and linear mixed models were used to analyze the effect of psychopathology on change in functioning. Mood disorders were associated with significant functional impairment, but functioning significantly improved in both groups over the 5-year follow-up period. Depressive episodes, however, were associated with worse functioning at follow-up, independently of depression severity. In contrast to our initial hypothesis, we found a worsening of functioning in a five-year period associated only with depressive episodes. This suggests that interventions focused on the prevention of mood episodes early in the course of illness may be particularly promising to reduce adverse functioning outcomes.

Factors Associated With Seizure Adequacy Along the Course of Electroconvulsive Therapy.

OBJECTIVES: Eliciting a generalized seizure is essential to electroconvulsive therapy (ECT), but there is still a need to understand how patient and session variables interact to generate a seizure of adequate quality. Here, we investigate factors associated with motor seizure length as a measure of quality in a large database of patients who underwent ECT. METHODS: This is a retrospective cohort including data from all adult inpatients who underwent ECT at a university hospital in Brazil from 2009 to 2015. We used linear mixed models to investigate the effects of patient, session, and medication on seizure length. RESULTS: Session information was available for 387 patients, a total of 3544 sessions and 4167 individual stimulations. Multiple stimulations were necessary in 12.4% of sessions. Median seizure length was 30 seconds. Seizure length was directly correlated with stimulus dosage and inversely correlated with the session number, patient age, prescription of anticonvulsants in the day before and ß-blockers during the session, and the thiopental dose. Use of benzodiazepines was not associated with a shorter seizure duration, irrespective of dose. CONCLUSIONS: We demonstrate here how motor seizure length evolves during a course of ECT. With a large number of sessions, we are able to integrate a host of factors in a prediction model. Seizure quality was influenced by a number of the studied factors, many of which are potentially modifiable and could be assessed before initiating and handled during treatment.

Clozapine and the Course of Bipolar Disorder in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

OBJECTIVE: The potential of clozapine in severe bipolar disorder is suggested by its efficacy in refractory schizophrenia, but the evidence is limited thus far. This report utilizes data from the standard care pathway of the Systematic Treatment Enhancement Program to examine the clinical impact of clozapine in bipolar disorder, comparing it to two groups, one that received olanzapine and an additional group that received neither drug. METHOD: A total of 4,032 outpatients were available for this analysis. Groups for longitudinal analyses are based on the medication used at each visit. Outcomes assessed were clinical status, symptoms subscales, hospitalizations, and death. We utilized mixed models and generalized estimating equations to adjust for baseline differences and investigate longitudinal differences in symptoms, clinical status, and hospitalization rates between groups. RESULTS: During the study, 1.1% (n = 43) of the patients used clozapine at any time. Those on clozapine had significantly fewer manic and depressive symptoms during follow-up as compared with those on neither clozapine nor olanzapine, while those on olanzapine had more symptoms. The use of clozapine was not associated with an increased risk of hospitalization. No deaths were recorded for clozapine group during the trial. CONCLUSIONS: Although prescribed to very few patients, the impact of clozapine was notable, with fewer symptoms in patients who had more severe illnesses at baseline. Clozapine could prove to be as successful an intervention for late-stage bipolar disorder as it has been in schizophrenia.

Barriers and facilitators perceived by people with bipolar disorder for the practice of exercise: a qualitative study.

INTRODUCTION: Exercising regularly has benefits for people with bipolar disorder. Nevertheless, as a group, these patients tend to be less physically active than the general population and little is known from the viewpoint of the patients about the barriers and facilitators to such a practice. OBJECTIVE: To know the barriers and facilitators perceived by people with bipolar disorder for the practice of exercise. METHODS: This study had a descriptive, qualitative, exploratory nature. The investigation method used for data collection was a semi-structured in-depth interview, using grounded theory as theoretical framework. RESULTS: The data analysis generated two main areas of interest: adherence to regular physical exercise (barriers and facilitators) and the participants' exercise history and perception of disease management, as described below. The main findings were: most of our sample did not exercise regularly, nor knew how exercise can positively influence their disorder; with regard to adherence to physical exercise, the presence of symptoms and stigma were the most important barriers to the practice of physical exercise. Social support, especially from family and friends, could be a facilitator to the practice of exercise. CONCLUSIONS: Even considering the limitations for generalization of qualitative and exploratory studies, understanding perceived barriers and facilitators for the practice of exercise among people who suffer with bipolar disorder may contribute to the promotion of activities in which people with mental illness can participate.

Barriers and facilitators perceived by people with bipolar disorder for the practice of exercise: a qualitative study / Barreiras e facilitadores percebidos por pessoas com transtorno bipolar para a prática de exercício físico: um estudo qualitativo

Abstract Introduction Exercising regularly has benefits for people with bipolar disorder. Nevertheless, as a group, these patients tend to be less physically active than the general population and little is known from the viewpoint of the patients about the barriers and facilitators to such a practice. Objective To know the barriers and facilitators perceived by people with bipolar disorder for the practice of exercise. Methods This study had a descriptive, qualitative, exploratory nature. The investigation method used for data collection was a semi-structured in-depth interview, using grounded theory as theoretical framework. Results The data analysis generated two main areas of interest: adherence to regular physical exercise (barriers and facilitators) and the participants' exercise history and perception of disease management, as described below. The main findings were: most of our sample did not exercise regularly, nor knew how exercise can positively influence their disorder; with regard to adherence to physical exercise, the presence of symptoms and stigma were the most important barriers to the practice of physical exercise. Social support, especially from family and friends, could be a facilitator to the practice of exercise. Conclusions Even considering the limitations for generalization of qualitative and exploratory studies, understanding perceived barriers and facilitators for the practice of exercise among people who suffer with bipolar disorder may contribute to the promotion of activities in which people with mental illness can participate.

Resumo Introdução A prática regular de exercício físico tem benefícios para pessoas com transtorno bipolar. No entanto, como grupo, esses pacientes tendem a ser mais sedentários do que a população geral, e pouco se sabe do ponto de vista dos pacientes sobre as barreiras e facilitadores para tal prática. Objetivo Conhecer as barreiras e facilitadores percebidos por pessoas com transtorno bipolar para a prática de exercício. Métodos Este foi um estudo descritivo, qualitativo e exploratório. O método de investigação utilizado na coleta de dados foi entrevista semiestruturada em profundidade, segundo a grounded theory. Resultados A análise dos conteúdos que surgiram nas entrevistas gerou duas principais áreas de interesse: adesão ao exercício físico regular (barreiras e facilitadores) e a história de exercícios dos participantes e a percepção do manejo da doença. Os principais achados foram: a maioria da nossa amostra não se exercitava regularmente, nem mesmo sabia como a prática regular podia influenciar positivamente sua doença; em relação à adesão ao exercício físico, a presença dos sintomas e do estigma foram as barreiras mais importantes para praticar o exercício físico. O apoio social, especialmente da família e dos amigos, pode ser um facilitador da adesão ao exercício. Conclusões Apesar das limitações de um estudo qualitativo e exploratório, conhecer as barreiras e os facilitadores percebidos para a prática de exercício entre pessoas que sofrem de transtorno bipolar pode facilitar a promoção de atividades onde essas pessoas possam participar e se beneficiar efetivamente.

Functional impairment and cognitive performance in mood disorders: A community sample of young adults.

The aim of this study was to compare the global functioning and cognitive performance in a community sample of young adults with mood disorders versus community controls. This was a cross-sectional study nested in a cohort study with a community sample. Data was collected from February 2012 to June 2014; specifically, at a mean of five years after the first phase, all young adults were invited to participate in a re-evaluation. Mini International Neuropsychiatric Interview - PLUS (MINI-PLUS) was used for the diagnosis of mood disorders. The Functional Assessment Short Test (FAST) and the Montreal Cognitive Assessment (MoCA) were used to assess the global functioning, and cognitive performance, respectively. Were included 1258 subjects. Functional impairment was greater in subjects with bipolar disorder when compared to community controls, and there were no differences between major depressive disorder and community controls. There were no significant differences in cognitive performance between young adults with mood disorders when compared to community controls. Functional impairment is a marker for bipolar disorder in young adults; however, gross cognitive impairment assessed by a screening test is not, possibly because cognition is impaired in more advanced stages of the disorder.

"Why throw away something useful?": Attitudes and opinions of people treated for bipolar disorder and their relatives on organ and tissue donation.

In regard to mental illness, brain donation is essential for the biological investigation of central pathology. Nevertheless, little is known about the thoughts of people with mental disorders on tissue donation for research. Here, our objective was to understand the attitudes and opinions of people treated for bipolar disorder and their relatives regarding donation in general, and particularly donation for research. This is a qualitative study that used in-depth interviews to determine the thoughts of participants regarding tissue donation for research. Theoretical sampling was used as a recruitment method. Grounded theory was used as a framework for content analyses of the interviews. A semi-structured interview guide was applied with the topics: donation in general; donation for research; mental health and body organs; opinion regarding donation; feelings aroused by the topic. Although all participants were aware of organ donation for transplant, they were surprised that tissue could be donated for research. Nevertheless, once they understood the concept they were usually in favor of the idea. Although participants demonstrated a general lack of knowledge on donation for research, they were willing to learn more and viewed it as a good thing, with altruistic reasons often cited as a motive for donation. We speculate that bridging this knowledge gap may be a fundamental step towards a more ethical postmortem tissue donation process.

Antioxidant treatments for schizophrenia.

BACKGROUND: There is accumulating evidence that progressive changes in brain structure and function take place as schizophrenia unfolds. Among many possible candidates, oxidative stress may be one of the mediators of neuroprogression, grey matter loss and subsequent cognitive and functional impairment. Antioxidants are exogenous or endogenous molecules that mitigate any form of oxidative stress or its consequences. They may act from directly scavenging free radicals to increasing anti-oxidative defences. There is evidence that current treatments impact oxidative pathways and may to some extent reverse pro-oxidative states in schizophrenia. The existing literature, however, indicates that these treatments do not fully restore the deficits in antioxidant levels or restore levels of oxidants in schizophrenia. As such, there has been interest in developing interventions aimed at restoring this oxidative balance beyond the benefits of antipsychotics in this direction. If antioxidants are to have a place in the treatment of this serious condition, the relevant and up-to-date information should be available to clinicians and investigators. OBJECTIVES: To evaluate the effect of antioxidants as add-on treatments to standard antipsychotic medication for improving acute psychotic episodes and core symptoms, and preventing relapse in people with schizophrenia. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials which is based on regular searches of CINAHL, BIOSIS, AMED, Embase, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. There are no language, time, document type, or publication status limitations for inclusion of records in the register. We ran this search in November 2010, and again on 8 January 2015. We also inspected references of all identified studies for further trials and contacted authors of trials for additional information. SELECTION CRITERIA: We included reports if they were randomised controlled trials (RCTs) involving people with schizophrenia who had been allocated to either a substance with antioxidant potential or to a placebo as an adjunct to standard antipsychotic treatment. DATA COLLECTION AND ANALYSIS: We independently extracted data from these trials and we estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE. MAIN RESULTS: The review includes 22 RCTs of varying quality and sample size studying Ginkgo biloba, N-acetyl cysteine (NAC), allopurinol, dehydroepiandrosterone (DHEA), vitamin C, vitamin E or selegiline. Median follow-up was eight weeks. Only three studies including a minority of the participants reported our a priori selected primary outcome of clinically important response. Short-term data for this outcome (measured as at least 20% improvement in scores on Positive and Negative Syndrome Scale (PANSS)) were similar (3 RCTs, n = 229, RR 0.77, 95% CI 0.53 to 1.12, low quality evidence). Studies usually reported only endpoint psychopathology rating scale scores. Psychotic symptoms were lower in those using an adjunctive antioxidant according to the PANSS ( 7 RCTS, n = 584, MD -6.00, 95% CI -10.35 to -1.65, very low quality evidence) and the Brief Psychiatric Rating Scale (BPRS) (8 RCTS, n = 843, MD -3.20, 95% CI -5.63 to -0.78, low quality evidence). There was no overall short-term difference in leaving the study early (16 RCTs, n = 1584, RR 0.73, 95% CI 0.48 to 1.11, moderate quality evidence), or in general functioning (2 RCTs, n = 52, MD -1.11, 95% CI -8.07 to 5.86, low quality evidence). Adverse events were generally poorly reported. Three studies reported useable data for 'any serious adverse effect', results were equivocal (3 RCTs, n = 234, RR 0.65, 95% CI 0.19 to 2.27, low quality evidence). No evidence was available for relapse, quality of life or service use. AUTHORS' CONCLUSIONS: Although 22 trials could be included in this review, the evidence provided is limited and mostly not relevant to clinicians or consumers. Overall, although there was low risk of attrition and selective data reporting bias within the trials, the trials themselves were not adequately powered and need more substantial follow-up periods. There is a need for larger trials with longer periods of follow-up to be conducted. Outcomes should be meaningful for those with schizophrenia, and include measures of improvement and relapse (not just rating scale scores), functioning and quality of life and acceptability and, importantly, safety data.

Functioning in bipolar disorder with substance abuse/dependence in a community sample of young adults.

AIM: To assess the functional impairment of young adults with bipolar disorder with substance abuse/dependence comorbidity. METHOD: Cross-sectional study within a community sample. Bipolar Disorder was assessed by qualified psychologists using The Mini International Neuropsychiatric Interview - PLUS (MINI-PLUS). Substance abuse and dependence was assessed using the "Alcohol, Smoking and Substance Involvement Screening Test" (ASSIST). Functional impairment was assessed using the Functional Assessment Short Test (FAST). RESULTS: The sample included 1259 young adults. The prevalence of Bipolar Disorder (BD) without Substance Abuse/Dependence (SAD) comorbidity was 5.9% (n=74), and the prevalence of bipolar disorder with substance abuse/dependence comorbidity was 1.4% (n=17). Both groups showed higher impairment in overall functioning, interpersonal relationship, and leisure time as compared to controls. In addition, BD+SAD showed higher impairment in the cognitive functioning domain of FAST. LIMITATION: A battery of neuropsychological tests was not performed. CONCLUSION: Functional impairment is associated with BD, independently of substance abuse or dependence. In addition, BD+SAD present a more severe impairment in the cognitive domain of FAST as compared to controls.

Pop, heavy metal and the blues: secondary analysis of persistent organic pollutants (POP), heavy metals and depressive symptoms in the NHANES National Epidemiological Survey.

OBJECTIVES: Persistent environmental pollutants, including heavy metals and persistent organic pollutants (POPs), have a ubiquitous presence. Many of these pollutants affect neurobiological processes, either accidentally or by design. The aim of this study was to explore the associations between assayed measures of POPs and heavy metals and depressive symptoms. We hypothesised that higher levels of pollutants and metals would be associated with depressive symptoms. SETTING: National Health and Nutrition Examination Survey (NHANES). PARTICIPANTS: A total of 15 140 eligible people were included across the three examined waves of NHANES. PRIMARY AND SECONDARY OUTCOME MEASURES: Depressive symptoms were assessed using the nine-item version of the Patient Health Questionnaire (PHQ-9), using a cut-off point of 9/10 as likely depression cases. Organic pollutants and heavy metals, including cadmium, lead and mercury, as well as polyfluorinated compounds (PFCs), pesticides, phenols and phthalates, were measured in blood or urine. RESULTS: Higher cadmium was positively associated with depression (adjusted Prevalence Ratios (PR)=1.48, 95% CI 1.16 to 1.90). Higher levels of mercury were negatively associated with depression (adjusted PR=0.62, 95% CI 0.50 to 0.78), and mercury was associated with increased fish consumption (n=5500, r=0.366, p<0.001). In addition, several PFCs (perfluorooctanoic acid, perfluorohexane sulfonic acid, perfluorodecanoic acid and perfluorononanoic acid) were negatively associated with the prevalence of depression. CONCLUSIONS: Cadmium was associated with an increased likelihood of depression. Contrary to hypotheses, many of persistent environmental pollutants were not associated or negatively associated with depression. While the inverse association between mercury and depressive symptoms may be explained by a protective role for fish consumption, the negative associations with other pollutants remains unclear. This exploratory study suggests the need for further investigation of the role of various agents and classes of agents in the pathophysiology of depression.

Clinical staging in bipolar disorder: focus on cognition and functioning.

OBJECTIVE: Clinical staging has increasingly been considered suitable for psychiatric disorders such as bipolar disorder. A staging model of bipolar disorder could help clinicians understand the mechanisms underlying the course of the illness and guide prognosis and therapy. This study aimed to investigate differences in functional status and cognitive functioning in patients in different clinical stages of bipolar disorder. METHOD: Subjects who met DSM-IV criteria for bipolar disorder (n = 54) were recruited from the Bipolar Disorders Program at Hospital de Clínicas de Porto Alegre (Brazil) from October 2012 to October 2013. All patients had been in remission (score < 7 on the 17-item HDRS and the YMRS) for at least 1 month before assessment. They were classified into 4 clinical stages according to the model described by Kapczinski et al and compared to 43 healthy controls. Functional status was assessed by using the Functioning Assessment Short Test (FAST). Neuropsychological measures were performed to investigate cognitive functioning. RESULTS: Significant differences in functional status were found between patients in all stages compared to controls (F = 33.014, P < .001), except for stage I (P = .104). Additionally, a very strong linear association was found between FAST scores and clinical stages, with FAST scores increasing from stage I to IV (F = 149.55, P < .001). In the bipolar group, stage I was associated with better occupational functioning than stage II (F = 48.344, P = .003). Stage IV patients experienced greater impairment in autonomy than stage III patients (F = 26.646, P = .004), and stage III patients experienced poorer autonomy than those in stage II (P = .004). With regard to cognitive measures, patients in late stages (stages III and IV) were more impaired than healthy controls (P < .001). A similar performance was found between patients in early stages (stages I and II) and healthy controls. DISCUSSION: This study showed progressive functional changes from stage I to stage IV of bipolar disorder, with a greater impairment in patients in later stages of the illness. FAST scores seem to have a good discriminant ability to distinguish between patients in early versus late stages of bipolar disorder and could therefore contribute to the development of a bipolar disorder staging system.