Impact on suicidality of the borderline personality traits impulsivity and affective instability.

BACKGROUND: The aim of this study was to test the impact on suicidality (suicide threats, attempts) of the borderline personality disorder (BPD) traits impulsivity and affective instability in mood disorders. METHODS: In a general psychiatry private practice (nontertiary care), consecutive remitted, non-substance-abusing outpatients--138 with bipolar II disorder (BP II) and 71 with major depressive disorder (MDD)--self-assessed using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) Questionnaire. RESULTS: The frequency (higher in BP II) of suicidality was 14%; impulsivity, 37%; and affective instability, 58%. The suicidality-positive patients (n = 30), when compared with the suicidality-negative patients (n = 179), had more BP II, more impulsivity (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.3 to 13.3), and more affective instability (OR, 2.4; 95% CI, 0.99 to 6.0). Logistic regression of suicidality vs impulsivity and affective instability (controlled for BP II; age; and interactions among BP II, age, impulsivity, and affective instability), showed that impulsivity was a strong independent predictor of suicidality (OR, 4.3; 95% CI, 1.7 to 10.6), and that affective instability was not an independent predictor of suicidality (OR,1.6; 95% 0.6 to 4.1). BP II showed neither confounding nor interactions. CONCLUSION: Results showed a strong independent impact of impulsivity-but not affective instability-on suicidality in BPD. No confounding by mood and substance disorders supported the BPD nature of these associations.

Hypomania: a transcultural perspective.

This study examined the transcultural robustness of a screening instrument for hypomania, the Hypomania Checklist-32, first revised version (HCL-32 R1). It was carried out in 2606 patients from twelve countries in five geographic regions (Northern, Southern and Eastern Europe, South America and East Asia). In addition, GAMIAN Europe contributed data from its members. Exploratory and confirmatory factor analyses were used to examine the transregional stability of the measurement properties of the HCL-32 R1, including the influence of sex and age as covariates. Across cultures, a two-factor structure was confirmed: the first factor (F1) reflected the more positive aspects of hypomania (being more active, elated, self-confident, and cogni-tively enhanced); the second factor (F2) reflected the more negative aspects (being irritable, impulsive, careless, more substance use). The measurement properties of the HCL-32 R1 were largely invariant across cultures. Only few items showed transcultural differences in their relation to hypomania as measured by the test. F2 was higher among men and in more severe manic syndromes; F1 was highest in North and East Europe and lowest in South America. The scores decreased slightly with age. The frequency of the 32 items showed remarkable similarities across geographic areas, with two excep-tions: South Europeans had lower symptom frequencies in general and East Europeans higher rates of substance use. These findings support the interna-tional applicability of the HCL-32 R1 as a screening instrument for hypomania.

Olanzapine/fluoxetine combination for the treatment of mixed depression in bipolar I disorder: a post hoc analysis.

OBJECTIVE: Mixed depression (ie, co-occurrence of syndromal depression and subsyndromal mania/hypomania) is a common variant of bipolar depression. However, its treatment is much understudied. The aim of the study was to assess the efficacy of the antipsychotic and mood-stabilizing agent olanzapine and the efficacy of the combination of an antidepressant (fluoxetine) and olanzapine (olanzapine/fluoxetine combination; OFC) for the treatment of bipolar I mixed depression. METHOD: We carried out a post hoc analysis of an 8-week, double-blind trial of adult bipolar I depression treated with placebo (n = 355), olanzapine (5-20 mg/d; n = 351), or OFC (olanzapine/fluoxetine doses: 6/25, 6/50, 12/50 mg/d; n = 82). Studying mixed depression was not a previous goal of the double-blind trial. Subjects in the trial were diagnosed according to DSM-IV and were randomly assigned to treatment during the period June 2000 to December 2001. Mixed depression was defined as the co-occurrence of a major depressive episode and > or = 2 manic/hypomanic symptoms (ie, > or = 2 Young Mania Rating Scale [YMRS] items scoring > or = 2). Response was defined as a > or = 50% reduction in Montgomery-Asberg Depression Rating Scale score and < 2 concurrent manic/hypomanic symptoms. Switching to mania/hypomania was defined as a YMRS score > or = 15. RESULTS: Frequency of mixed depression was 45.1% in the OFC arm, 49.3% in the olanzapine arm, and 46.8% in the placebo arm (P = .705). The most frequent manic/ hypomanic symptoms of mixed depression were irritability, reduced need for sleep, talkativeness, and racing thoughts. Response rates in patients with nonmixed depression versus patients with mixed depression were the following: in the OFC arm, 48.9% versus 43.2% (OR = 1.24; 95% CI, 0.51-2.98); in the olanzapine arm, 39.9% versus 26.6% (OR = 1.84; 95% CI, 1.17-2.90); in the placebo arm, 27.5% versus 16.3% (OR = 1.94; 95% CI, 1.15-3.28). Response rates in the samples of patients with mixed depression were the following: OFC versus olanzapine, OR = 2.00 (95% CI, 0.96-4.19); OFC versus placebo, OR = 3.91 (95% CI, 1.80-8.49); olanzapine versus placebo, OR = 1.95 (95% CI, 1.14-3.34). It was found that no baseline manic/hypomanic symptom of mixed depression predicted treatment response. A higher number of baseline concurrent manic/hypomanic symptoms predicted a lower response rate in the olanzapine and placebo arms, but not in the OFC arm. The rates of switching were the following: in the OFC arm, 8.5%; in the olanzapine arm, 6.8%; and in the placebo arm, 7.9% (P = .808). The rates of dropouts in patients with mixed depression versus patients with nonmixed depression were not significantly different within any of the treatment arms. The rates of dropouts in the samples of patients with mixed depression were the following: in the OFC arm, 29.7%; in the olanzapine arm, 53.8%; and in the placebo arm, 59.6% (olanzapine vs OFC: OR = 2.66; 95% CI, 1.23-5.75; placebo vs OFC: OR = 3.48; 95% CI, 1.61-7.54; placebo vs olanzapine: OR = 1.30; 95% CI, 0.84-2.01). CONCLUSION: Olanzapine/fluoxetine combination may be an effective treatment for bipolar I mixed depression. Statistically, the efficacy of OFC was not significantly different from that of olanzapine, but inspection of the 95% CI showed a trend in favor of a possible superiority of OFC. Supporting the study findings are the similar efficacy of OFC in bipolar mixed depression independent of the number of concurrent manic/hypomanic symptoms, a lower dropout rate, and a similarly low switching rate compared to olanzapine. Contrary to other current limited evidence, an antidepressant (fluoxetine) showed efficacy and did not worsen bipolar mixed depression if combined with a mood-stabilizing agent (olanzapine).

What is hypomania? Tetrachoric factor analysis and kernel estimation of DSM-IV hypomanic symptoms.

BACKGROUND: The DSM-IV definition of hypomania, which relies on clinical consensus and historical tradition, includes several "nonspecific" symptoms. The aim of this study was to identify the core symptoms of DSM-IV hypomania. METHOD: In an outpatient private practice, 266 bipolar II disorder (BP-II) and 138 major depressive disorder (MDD) remitted patients were interviewed by a bipolar-trained psychiatrist, for different study goals. Patients were questioned, using the Structured Clinical Interview for DSM-IV, about the most common symptoms and duration of recent threshold and subthreshold hypomanic episodes. Data were recorded between 2002 and 2006. Four different samples, assessed with the same methodology, were pooled for the present analyses. Tetrachoric factor analysis was used to identify core hypomanic symptoms. Distribution of symptoms by kernel estimation was inspected for bimodality. Validity of core hypomania was tested by receiver operating characteristic (ROC) analysis. RESULTS: The distribution of subthreshold and threshold hypomanic episodes did not show bimodality. Tetrachoric factor analysis found 2 uncorrelated factors: factor 1 included the "classic" symptoms elevated mood, inflated self-esteem, decreased need for sleep, talkativeness, and increase in goal-directed activity (overactivity); factor 2 included the "nonspecific" symptoms irritable mood, racing/crowded thoughts, and distractibility. Factor 1 discriminatory accuracy for distinguishing BP-II versus MDD was high (ROC area = 0.94). The distribution of the 5-symptom episodes of factor 1 showed clear-cut bimodality. Similar results were found for episodes limited to 3 behavioral symptoms of factor 1 (decreased need for sleep, talkativeness, and overactivity) and 4 behavioral symptoms of factor 1 (adding elevated mood), with high discriminatory accuracy. CONCLUSIONS: A core, categorical DSM-IV hypomania was found that included 3 to 5 symptoms, ie, behavioral symptoms and elevated mood. Behavioral symptoms (overactivity domain) could be the basic phenotype of hypomania. This finding could help in probing for hypomania and reduce misdiagnosis. Biologic research could focus more on the underpinnings of the overactivity domain specifically.

The modified SCID Hypomania Module (SCID-Hba): a detailed systematic phenomenologic probing.

Diagnosing past hypomania is a difficult task. Current structured interviews (e.g. CIDI, SCID) limit the ability to probe for hypomania. A modified SCID Hypomania Module was published by us (Benazzi and Akiskal, J Affect Disord 2003; Akiskal and Benazzi, J Clin Psychiatry 2005) in order to overcome the limitations of structured interviewing. Our papers outlined the framework of the modified SCID. In response to requests from many readers of this journal and other clinicians and investigators, we are hereby providing a more explicit step-by-step phenomenologic probing interview. DSM-IV criteria have to be met, but the probing for hypomania is very different from that of the SCID. All past hypomanic symptoms are assessed. No negative meaning is given to symptoms, as hypomania often improves functioning and it is seen by patients as a state of well being. The first step is probing for overactivity (increase in goal-directed activity), because observable behaviors are easier to remember by patients and key informants. There is no gold-standard for overactivity: each person becomes his/her own standard to 'measure' a clear-cut departure form the usual behavior. Questions, correspondingly, can change from patient to patient. The emotions associated with behavioral change are easier to be remembered than asking them first, as in the structured interviews. Structured interviews have mood change (elation, irritability) as stem question (corresponding to the criterion A of DSM-IV, which postulates that it must always be present). However, apart from a likely recall bias of past emotions, the description of mood change appears more or less negative in structured interviews (to increase specificity but by much reducing sensitivity, i.e. the false-negatives). Presenting mood change as simply having been more elated/irritable than usual can easily be interpreted as normal mood fluctuations, while presenting mood change as much more than usual could be understood as a severe mental disorder. Both ways are likely to lead to a negative response, moving the interviewers to unipolar disorders (the skip-out instruction). Our modified SCID is a fully semi-structured interview: many questions are asked about each symptom to make the question understandable according to each patient, and, very importantly, examples of the 'events' are systematically asked to check understanding and clinical relevance. Our interview follows DSM-IV criteria (apart from the minimum duration, 2 days versus DSM-IV 4 days), i.e. mood change must always been present, but our probing detects more hypomanic episodes than the SCID.

Cyclothymic temperament: the impact of age.

BACKGROUND: Cyclothymic temperament (CT) is a more or less 'permanent' instability of mood, thinking and activity (behaviour), which is frequent in bipolar disorders. Testing the impact of age on CT items, as has been done in many mood disorders, could further define its features. The aim of the study was to test the relationship between age and CT items. METHODS: During follow-up visits in a private practice, 209consecutive remitted bipolar II (BP-II, n = 138) and major depressive disorder (MDD, n = 71) outpatients were re-diagnosed by a mood disorder specialist psychiatrist, using the Structured Clinical Interview for DSM-IV (blind to patients), and self-assessed CT was evaluated by the TEMPS-A questionnaire (blind to interviewer). RESULTS: Mean (SD) age was 39.1 (10.0) years (median 39, range 16-63 years). BP-II had significantly more CT items. Logistic regression tested the association between each CT item and age. Of the 17 CT items, 8 showed a trend (p < 0.10) or significant association with age. Among these items, there were items suggested to be core features of CT, i.e. instability of mood and energy: 'moods and energy either high or low', 'constantly switching between being lively and sluggish' and 'being sad and happy at the same time'. However, other CT items related to mood and energy instability, i.e. 'sudden shifts in mood and energy' and 'mood often changing for no reason', were not significantly associated with age. DISCUSSION: Study findings suggest that age may have an impact on some CT items related to mood and energy, which might become more common with age (according to the item's wording), and that many CT items may not be impacted by age, suggesting more stability.

Is a family history of bipolar disorder a risk factor for migraine among affectively ill patients?

AIMS: The aim was to determine whether having a family history of bipolar disorder (BPD) or unipolar major depressive disorder (MDD) is associated with an increased likelihood of having migraine headaches. METHODS: Latino adults received structured diagnostic interviews. Family history was determined by live interview of first-degree relatives or interview by proxy. All patients met the criteria for major depressive episode (MDE) at the time of assessment. The method of diagnosing migraine had sensitivity and specificity of 87 and 50%, respectively. Logistic regression was used to test for associations and control for confounding. RESULTS: In total, 153 patients met the criteria for MDD and 87 for BPD. Patients with MDD who had a family history of BPD were 4.3 times more likely to have migraine headaches than those who did not (OR=4.34, z=3.02, p=0.003, 95% CI=1.67-11.27). Patients with BPD who had a family history of BPD were 3 times more likely to have migraine than those who did not (OR=2.99, z=2.45, p=0.014, 95% CI=1.25-7.19). Within the entire group of patients, those with a family history of BPD were 4.4 times more likely to have migraine headaches than those who did not (OR = 4.38, p<0.0001, z=4.72, 95% CI=2.37-8.09). A family history of MDD was not associated with an increased risk of having migraine. CONCLUSION: Regardless of a patient's polarity, having a family history of BPD is associated with an increased risk of having migraine headache.

A prediction rule for diagnosing hypomania.

BACKGROUND: Missing the diagnosis of past hypomania, and thus of bipolar II disorder, is common. Study aim was to find a 'prediction rule' for facilitating the diagnosis of past hypomania. METHODS: In an outpatient psychiatry private practice (non-tertiary care), a consecutive sample of 275 bipolar II disorder (BP-II) remitted patients, and consecutive, independent, sample of 138 major depressive disorder (MDD) remitted patients, had been interviewed for different study goals during follow-up visits by a senior bipolar-trained psychiatrist. Using the Structured Clinical Interview for DSM-IV, modified and validated by Benazzi and Akiskal [Benazzi F (2007). Lancet 369: 935-945] to improve the probing for past hypomania, patients had been questioned about the most common symptoms and duration of recent threshold and subthreshold hypomanic episodes. The sample was retrospective in nature. A prediction rule was tested. This is a score resulting from the sum of the weighted scores of each hypomanic symptom which was an independent predictor of hypomania. Its cutoff score for discriminating hypomania was based on the highest figure of correctly classified hypomanias and on the most balanced combination of sensitivity and specificity. A second, independent sample of 138 BP-II and 71 MDD remitted outpatients was tested to replicate the findings. RESULTS: By univariate logistic regression, hypomanic symptoms distinguishing BP-II and MDD included 'increase in goal-directed activity' (overactivity) (OR=28.3), 'elevated mood' (OR=14.9), 'increased talkativeness' (OR=9.2), 'inflated self-esteem', 'decreased need for sleep', 'excessive risky activities', and 'irritable mood'. By multivariable logistic regression, the independent predictors of hypomania resulted 'increase in goal-directed activity' (OR=14.9, weighted score=15), 'elevated mood' (OR=7.5, weighted score=7), 'increased talkativeness' (OR=3.6, weighted score=4); 'irritable mood', 'inflated self-esteem', 'decreased need for sleep', and 'excessive risky activities' had ORs between 2.04 and 2.39, with a weighted score=2. The prediction rule showed that the cutpoint score > or = 21 had the highest figure of correctly classified hypomanias (88%, ROC area=0.94), showing the most balanced combination of sensitivity (87%) and specificity (89%). This prediction rule, tested on the second sample, found that the same cutoff score > or =21 correctly classified the highest figure of hypomanias (94%, ROC area=0.97), showing the most balanced combination of sensitivity (93%) and specificity (95%). To cross this cutoff score, overactivity was always required (as the sum of the scores of elevated mood and of the other symptoms did not reach this cutoff). However, scores 10 to 20 correctly classified only slightly lower figures of hypomanias. CONCLUSIONS: A prediction rule for hypomania was tested. The scores of overactivity plus at least some hypomanic symptom (among elevated mood, irritability, inflated self-esteem, less sleep, talkativeness, excessive risky activities) correctly classified 88% of hypomanias. Instead, elevated mood without overactivity, plus even all the other symptoms, did not reach the best figure of correctly classified. However, lower cutoff scores, up to 10, classified slightly lower figures of hypomanias, but with less balanced combinations of sensitivity and specificity. These findings may have diagnostic utility, because BP-II versus MDD is likely to be a more severe disorder. This prediction rule, if replicated and fine-tuned in different settings, may help clinicians better probing past hypomania, thus reducing the common misdiagnosis of BP-II as MDD.

Migraine in affectively ill Mexican adolescents.

The objective of this cross-sectional study was to determine the prevalence of migraine headache among depressed Latino adolescents of Mexican American origin. This is, to the best of our knowledge, the first study of the prevalence of migraine among depressed adolescents of any ethnic/racial background. In a mental health clinic for the indigent, 132 consecutive Latino adolescents fulfilling the DSM-IV criteria for major depressive episode were compared with a sample of adolescents with other mental disorders. Logistic regression was used to test for associations and control for confounding effects. The prevalence of migraine headache among depressed adolescents was 6 times greater than that of the comparison patients (OR = 5.98, z = 2.35, p = 0.019). This finding is consistent with previously published reports involving adult samples, in which the prevalence of migraine was found to exceed that in the general population. However, contrary to what we previously found in Latino adults, the prevalence of migraine was not higher in bipolar than in unipolar adolescents.

Does hypomania distinguish bipolar II disorder from major depressive disorder?

BACKGROUND: Recent epidemiological/clinical studies have not found clear boundaries between bipolar II disorder (BP-II) and major depressive disorder (MDD), as subsyndromalhypomanic episodes were more common than syndromalhypomania. The aim of the study was to test if hypomania could still be used to split categorically BP-II and MDD. METHODS: 274 consecutive remitted BP-II and 129 MDD outpatients were interviewed by the Structured Clinical Interview for DSM-IV on the most common symptoms and duration of hypomanic episodes (lasting at least 2 days, having at least 2 symptoms), in a private practice. RESULTS: As expected by definition, BP-II versus MDD had significantly more episodic hypomanic symptoms. However, MDD had episodes of subsyndromalhypomanic symptoms (median number of symptoms 3). In the entire sample, frequency of episodes of hypomanic symptoms, according to the number of symptoms per episode, was normally, not bimodally,distributed. A grading(r = 0.57, p < 0.001) of the number of episodic hypomanic symptoms was found. DISCUSSION: Findings question the splitting of BP-II and MDD based on hypomania, as hypomania (at least as defined by DSM-IV) seems more a dimensional than a categorical disorder.

Migraine headache in affectively ill latino adults of mexican american origin is associated with bipolarity.

BACKGROUND: The objective of this cross-sectional study was to determine the prevalence of migraine headache among depressed Latino adults of Mexican American origin meeting the criteria for bipolar disorder (BPD) or major depressive disorder (MDD) relative to patients in a psychiatric comparison group. METHOD: In a mental health clinic for the indigent, consecutively and systematically evaluated acutely depressed Latino adults received structured diagnostic psychiatric interviews based on modules extracted from the Structured Clinical Interview for DSM-IV. All were asked as part of routine assessment whether they had headaches "in the last week." Patients with unilateral, pounding, pulsating headache were classified as having migraine headache. The prevalence of migraine headache among the patients with BPD and MDD was contrasted with that of patients in a psychiatric comparison group composed of patients with disorders other than schizophrenia or schizoaffective disorder. Logistic regression was used to test for associations and control for confounding effects. The data were collected between August 2001 and November 2004. RESULTS: Eighty-seven patients had BPD and 123 had MDD. Bipolar patients were 2.9 times more likely to have migraine headaches than patients with MDD (P < .0001). There was a trend for patients with MDD to have a higher prevalence of migraine than patients in the psychiatric comparison group. CONCLUSIONS: Bipolar patients had a high prevalence of migraine headache relative to patients with MDD. This study suggests that migraine is linked to bipolarity.

Does psychomotor agitation in major depressive episodes indicate bipolarity? Evidence from the Zurich Study.

BACKGROUND: Kraepelin's partial interpretation of agitated depression as a mixed state of "manic-depressive insanity" (including the current concept of bipolar disorder) has recently been the focus of much research. This paper tested whether, how, and to what extent both psychomotor symptoms, agitation and retardation in depression are related to bipolarity and anxiety. METHOD: The prospective Zurich Study assessed psychiatric and somatic syndromes in a community sample of young adults (N = 591) (aged 20 at first interview) by six interviews over 20 years (1979-1999). Psychomotor symptoms of agitation and retardation were assessed by professional interviewers from age 22 to 40 (five interviews) on the basis of the observed and reported behaviour within the interview section on depression. Psychiatric diagnoses were strictly operationalised and, in the case of bipolar-II disorder, were broader than proposed by DSM-IV-TR and ICD-10. As indicators of bipolarity, the association with bipolar disorder, a family history of mania/hypomania/cyclothymia, together with hypomanic and cyclothymic temperament as assessed by the general behavior inventory (GBI) [15], and mood lability (an element of cyclothymic temperament) were used. RESULTS: Agitated and retarded depressive states were equally associated with the indicators of bipolarity and with anxiety. Longitudinally, agitation and retardation were significantly associated with each other (OR = 1.8, 95% CI = 1.0-3.2), and this combined group of major depressives showed stronger associations with bipolarity, with both hypomanic/cyclothymic and depressive temperamental traits, and with anxiety. Among agitated, non-retarded depressives, unipolar mood disorder was even twice as common as bipolar mood disorder. CONCLUSION: Combined agitated and retarded major depressive states are more often bipolar than unipolar, but, in general, agitated depression (with or without retardation) is not more frequently bipolar than retarded depression (with or without agitation), and pure agitated depression is even much less frequently bipolar than unipolar. The findings do not support the hypothesis that agitated depressive syndromes are mixed states. LIMITATIONS: The results are limited to a population up to the age of 40; bipolar-I disorders could not be analysed (small N).

Classifying mood disorders by age-at-onset instead of polarity.

BACKGROUND: Polarity is the pillar of the current categorical unipolar-bipolar division of mood disorders. However, genetic studies on these polarity-based phenotypes have been largely inconclusive. Recent clinical and epidemiological studies seem to support more of a continuum than a splitting of mood disorders. A reshaping of the classification of mood disorders thus seems required. Age-at-onset and recurrence have been suggested to be more clinically and genetically useful in the phenotyping of mood disorders. STUDY AIM: To test a classification of mood disorders based on age-at-onset, and to delineate its phenotypes. METHODS: A total of 441 consecutive bipolar II disorder (BP-II) and 289 unipolar major depressive disorder (MDD) outpatients, presenting for treatment of a major depressive episode (MDE) in a clinical and research private practice, were assessed by a mood disorder specialist psychiatrist (FB) using a Structured Clinical Interview for the DSM-IV, modified for better probing past hypomania [Benazzi, F. Bipolar disorder-focus on bipolar II disorder and mixed depression. Lancet 2007a;369: 935-945]. The sample was divided according to age-at-onset. Age-at-onset was defined by the age at onset of the first MDE. Early-age-at-onset (EO) was defined as age at onset before 21 years, late-age-at-onset (LO) as onset at or after age 21 years. The study's current goal had not been planned when data were recorded between 1999 and 2006. Variables were compared in EO versus LO mood disorders, investigating phenotype differences. The main focus was on 'classic' diagnostic validators: MDE clinical picture, gender, course, and family history. Age, gender, BP-II, and mania/hypomania family history (possible confounding) were controlled for in the analyses. Logistic regression was used. RESULTS: First, EO was regressed on each variable, one at a time, to find significant associations. Second, EO was regressed on all of the variables whose odds ratio (OR) was statistically significant in the previous analyses in order to find independent predictors. Independent predictors of EO mood disorder were history of hypomania, high recurrence, atypical depression, and family history of mania/hypomania. Controlling for BP-II (in addition to age and gender) did not impact the findings. The highest OR was that between EO and high recurrence (OR=4.00). Distinguishing MDE symptoms of EO mood disorder included hypersomnia and psychomotor agitation when controlling for age and gender, and, by controlling also for BP-II, hypersomnia only. DISCUSSION: A close association among EO mood disorder, high recurrence, and bipolarity (history of hypomania, family history of mania/hypomania) was found. Compared to most previous studies testing EO versus LO in bipolar (mainly BP-I) or in unipolar MDD samples, the present study tested a mixed BP-II and MDD sample and controlled for polarity, reducing, as much as possible, the impact of polarity on the findings. EO (below age 21 years) was distinguished by hypersomnic depression, high recurrence, high history of hypomania, and high history of mania/hypomania. Replications are needed, especially in mixed samples also including BP-I. Results, if replicated, could have implications not only for clinical and genetic studies, but also for treatment (e.g., mood stabilizers could have better long-term effects than antidepressants in EO mood disorders, antidepressants could have negative long-term effects on EO).

Las experiencias disociativas diferencian a pacientes con trastorno bipolar de los deprimidos unipolares: papel mediador de la ciclotimia y la subescala de urgencia e impaciencia para la conducta de tipo A / Dissociative experiences differentiate bipolar-II from unipolar depressed patients: the mediating role of cyclothymia and the type A behaviour speed and impatience subscale

FUNDAMENTO: En pacientes con trastornos delhumor, con frecuencia se observan síntomasdisociativos, pero apenas se dispone de informaciónsobre la posible asociación con los subgrupos ycaracterísticas temperamentales de estos trastornos.MÉTODO: Se aplicó la escala de experienciadisociativa (Dissociative Experience Scale [DES]) a 85pacientes con trastorno depresivo mayor (TDM) otrastorno bipolar II (BP-II) según los criterios delDSM-IV. Se evaluaron tanto la disociación de amplioespectro (puntuación total DES) como las formasclaramente patológicas de disociación (DES-taxón).El temperamento se evaluó utilizando los criterios deAkiskal y Mallya de los temperamentos afectivos y elcuestionario de actividad de Jenkins (Jenkins ActivitySurvey [JAS]) para la conducta de tipo A.RESULTADOS: Proporcionaron respuestas válidaspara la DES 65 pacientes. Utilizando análisis deregresión logística univariable, las puntuacionesmedias DES y DES-T fueron más altas en pacientes elBP-II (16,8 y 12,7, respectivamente) comparado conTDM (9 y 5,7), con odds ratio (OR) = 1,58 (intervalode confianza [IC] del 95%, 1,15-2,18) y OR = 1,6 (ICdel 95%, 1,14-2,25), respectivamente. No se identificóuna diferencia significativa de la puntuación DES enpacientes con (n = 30) y sin temperamento afectivo (n= 35): media (IC del 95%), 13,5 comparado con 10,5(–7,8 a 1,9), p = 0,224. Sin embargo, en el subgrupocon temperamento ciclotímico (n = 18) se obtuvieronmayores puntuaciones DES: media (IC del 95%),17,8 comparado con 9,7 (2,9-13,3), p = 0,003,comparado con pacientes sin dicho temperamento.No se observó una diferencia significativa en laspuntuaciones DES para pacientes con (n = 35) o sin (n= 28) un patrón de conducta de tipo A (JAS > 0):media (IC del 95%), 12,7 comparado con 10,9 (–6,8 a3,3), p = 0,491, pero una puntuación positiva delfactor S en el cuestionario de JAS (subescala deurgencia e impaciencia) se asoció con puntuacionesDES significativamente más altas que una puntuaciónnegativa: media (IC del 95%), 14,9 comparado con 9(1,1-10,7), p = 0,017, y esto siguió siendo significativo(p = 0,005) utilizando una regresión lineal múltiple delas puntuaciones DES comparado con puntuacionesde la subescala JAS. (...)

BACKGROUND: Dissociative symptoms are often seenin patients with mood disorders, but there is littleinformation on possible association with subgroupsand temperamental features of these disorders.METHOD: The Dissociative Experience Scale wasadministered to 85 patients with a DSM-IV MajorDepressive Disorder (MDD) or Bipolar-II Disorder(BP-II). Both broad-spectrum dissociation (DES totalscore) and clearly pathological forms of dissociation(DES-Taxon) were assessed. Temperament wasassessed using Akiskal and Mallya’s criteria ofAffective Temperaments and the Jenkins ActivitySurvey (JAS) for Type A Behaviour.RESULTS: Sixty-five patients gave valid answers toDES. The mean DES and DES-T scores were higherin BP-II (16.8 and 12.7 respectively) compared toMDD (9.0 and 5.7); DES odds ratio (OR) = 1.58(95% CI, 1.15-2.18) and DES-T OR = 1.60 (95% CI,1.14-2.25) using univariate logistic regressionanalyses. There was no significant difference in DESscore in patients with (n = 30) and without anaffective temperament (n = 35): mean (95% CI), 13.5vs. 10.5 (–7.8 to 1.9), p = 0.224. However thesubgroup with a cyclothymic temperament (n = 18)had higher DES scores: mean (95% CI): 17.8 vs. 9.7(2.9-13.3), p = 0.003, compared to patients withoutsuch a temperament. There was no significantdifference in DES scores for patients with (n = 35) orwithout (n = 28) a Type A behaviour pattern (JAS >0): mean (95% CI) 12. 7 vs. 10.9 (–6.8 to 3.3), p =0.491, but a positive JAS factor S score (speed andimpatience subscale) was associated withsignificantly higher DES scores than a negative Sscore:mean (95% CI) 14.9 vs. 9 (1.1-10.7), p =0.017), and this was still significant (p = 0.005) usingmultiple linear regression of DES scores vs. the JASsubscale scores. DES-T scores were significantlyhigher in patients with OCD (n = 9): mean (95% CI)18.4 vs. 6.6 (6-17.7), p < 0.001; eating disorder (n =13): 14 vs. 6.8 (1.8-12.6), p = 0.009, psychoticsymptoms during depressions (n = 9): 16.6 vs. 6.9(3.7-15.8), p = 0.002, and in those with a history ofsuicide attempt (n = 28): 11.9 vs. 5.4 (2.2-10.8, p =0.003, but only OCD was an independent predictorafter multiple linear regression of DES-T scores vs.all co-morbid disorders (p = 0.043). (...)

Treating depressive mixed States in bipolar disorders.

Although not recognized as a diagnostic entity in the DSM-IV-TR, mixed depression is a common clinical presentation. To treat depressive mixed states, clinicians in both Europe and the United States have developed valuable, yet different, therapeutic strategies. For example, the European model focuses on resolving patients' hypomanic symptoms, while the American model treats patients in depressive mixed episodes similarly to those who have bipolar II disorder. Common treatment practices between the 2 paradigms include the art of adopting pharmacotherapeutic regimens that are tailored to the needs of each patient and frequent evaluation of the patient's progress.