The Burden of Repeated Mood Episodes in Bipolar I Disorder: Results From the National Epidemiological Survey on Alcohol and Related Conditions.

The aim of this study was to examine the association between previous mood episodes and clinical course/functioning in a community sample (National Epidemiological Survey on Alcohol and Related Conditions [NESARC]). Subjects (n = 909) met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria for bipolar I disorder and provided data on number of previous episode recurrences. Number of previous mood episodes was used to predict outcomes at wave 1 and wave 2 of the NESARC. Previous mood episodes accounted for small but unique variance in outcomes. Recurrence was associated with poorer functioning, psychiatric and medical comorbidity, and increased odds of suicidality, disability, unemployment, and hospitalization at wave 1. Recurrences were associated with greater risk for new onset suicidality, psychiatric comorbidity, disability, unemployment, and poor functioning by wave 2. The course of bipolar disorder does worsen with progressive mood episodes but is attenuated in community, relative to clinical samples. Interventions to prevent future relapse may be particularly important to implement early in the course of illness.

Epidemiology and course of unipolar mania: results from the national epidemiologic survey on alcohol and related conditions (NESARC).

BACKGROUND: Unipolar mania (UM), in which only manic episodes occur during the course of illness, may be an important clinical manifestation of bipolar disorder that is under-recognized and understudied. The aim of this study is, for the first time, to examine the prevalence of UM and its clinical characteristics in the community. METHODS: Among a total of 1,411 subjects with bipolar I disorder, we evaluated the prevalence of UM using three different criteria proposed in previous studies. We compared the clinical characteristics of subjects with UM to those with a more classic bipolar presentation with mania and lifetime major depressive episode (MDE). We additionally explored the proportion of subjects with UM who later experience at least one MDE during a 3-year follow-up period and determined risk factors for converting from UM to classic bipolar disorder. RESULTS: The prevalence rate of UM among those with bipolar disorder ranged from 5.0 to 7.2% depending on the criteria. UM was more common in male and nonwhite subjects. About half of individuals with UM experienced subthreshold depression. Individuals with UM had lower rates of comorbid anxiety disorders or attention deficit hyperactivity disorder (ADHD). During the follow-up, about 18% of subjects with UM experienced MDEs. Male, nonwhite, comorbid generalized anxiety disorder and ADHD predicted an increased transition from UM to classic bipolar disorder. Subthreshold depression was not associated with the risk of the transition. CONCLUSIONS: UM is an infrequent but clinically distinct subtype of bipolar I disorder. Further research delineating the characteristics of UM is warranted.

Smoking and suicidality in subjects with bipolar disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

BACKGROUND: Smoking in patients with bipolar disorder is known to be related to suicidality. This link has not been investigated, however, in community-based samples. The aim of this study is to delineate the sociodemographic and clinical characteristics of bipolar smokers and examine the relationship between these characteristics and suicidal ideation or attempts in an epidemiologic database, the National Epidemiological Survey on Alcohol and Related Conditions (NESARC). METHODS: Subjects (n = 1,643) with bipolar disorder I and II, defined by the DSM-IV criteria, who had a history of low moods lasting more than 2 weeks were included in our analysis. Current smokers, former smokers, and lifetime nonsmokers were compared in terms of demographic, clinical characteristics, and functional level. Suicidality, evaluated by a history of suicide ideation and attempts while in low mood were compared. RESULTS: Current smokers with bipolar disorder showed a greater number of DSM-IV symptoms while in acute episodes, higher rate of alcohol, and drug use disorders, as well as poorer functional levels than nonsmokers. Previous smokers displayed intermediate characteristics between current smokers and nonsmokers. The logistic regression analysis revealed that current smoking status predicted the risk of having a history of attempted suicide (Odds ratio 1.35, 95% CI: 1.05-1.76) after adjusting for age, sex, race, bipolar subtype, lifetime axis II/anxiety/alcohol use/substance use disorder; however, lifetime smoking status did not. CONCLUSIONS: The present study confirms that current cigarette smoking can predict attempted suicide in a community representative sample of people with bipolar disorder.

Elevated expectancies among persons diagnosed with bipolar disorder.

OBJECTIVE: Students at risk for bipolar disorder endorse highly ambitious goals. This study examined expectations for the future among people with actual bipolar disorder, versus people with no history of mood disorder and persons with history of unipolar depression. METHODS: One hundred and three students were assessed for Axis I disorders and completed a measure of expected life outcomes. RESULTS: History of mania, but not history of depression, related to higher expectations of achieving popular fame and wealth. CONCLUSIONS: People with history of mania anticipate great success in domains involving public recognition.

Cognitive responses to failure and success relate uniquely to bipolar depression versus mania.

This project examined cognitive responses to failure and success and their association with depression and mania within bipolar disorder. Many cognitive variables that are associated with unipolar depression have been found to be involved in bipolar disorder, more specifically bipolar depression. This research was the first to examine tendencies to hold high standards, engage in self-criticism, and generalize from failure to an overall sense of self-worth. In Study 1, undergraduates were screened for risk of mood disorders and completed structured diagnostic interviews. History of bipolar spectrum disorders and history of depression had separate associations with negative generalization. The association of generalization with bipolar spectrum disorders was accounted for by current depressive symptoms. For Study 2, the authors developed a measure of the tendency to engage in positive generalization following success experiences. In a sample of 276 undergraduates, this measure related uniquely to risk for mania. Results of these 2 studies suggest that responses to failure are associated with a history of depression, whereas responses to success are associated with a risk for mania. Implications for future research and clinical work are discussed.

Simplifying profiles of comorbidity in bipolar disorder.

BACKGROUND: Comorbid psychiatric symptoms in bipolar disorder (BD) predict poorer course of illness and treatment outcome. The sheer number of comorbid symptoms has thwarted developing treatments to address these comorbid concerns. The goal of this study was to develop a more parsimonious approach to understanding clusters of comorbid symptoms within BD. METHOD: Data were collected as part of the National Epidemiologic Survey on Alcohol and Related Conditions. Structured diagnostic interviews were conducted with 43,093 participants using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV (AUDADIS-IV). Analyses were conducted on lifetime symptom counts for the most common 14 comorbid disorders among the 1411 persons who met lifetime criteria for bipolar I disorder. RESULTS: An exploratory factor analysis with promax rotation as well as confirmatory factor analyses revealed a three-factor solution of Externalizing, Anxiety, and Mood syndromes, with a higher order Internalizing factor comprised of the Mood and Anxiety factors. LIMITATIONS: Further research is needed in a clinical sample. CONCLUSIONS: Comorbid symptoms in BD tend to cohere into Internalizing and Externalizing disorders, which could simplify research and treatment on comorbidity in BD.

Dialectical Behavior Therapy Group Skills Training for Bipolar Disorder.

There is growing evidence that the capacity for emotion regulation is compromised in individuals with bipolar disorder. Dialectical behavior therapy (DBT), an empirically supported treatment that specifically targets emotion dysregulation, may be an effective adjunct treatment for improving emotion regulation and residual mood symptoms in patients with bipolar disorder. In this open, proof-of-concept pilot study, 37 participants engaged in a 12-week DBT group skills training program, learning mindfulness, emotion regulation, and distress tolerance skills. Repeated measures mixed models revealed skill acquisition in the areas of mindfulness, emotion regulation and distress tolerance, as well as improved psychological well-being and decreased emotion reactivity. The results of this study support a burgeoning literature that DBT is a feasible adjunct intervention for patients with bipolar disorder.

Differentiating risk for mania and borderline personality disorder: The nature of goal regulation and impulsivity.

Researchers and clinicians have long noted the overlap among features and high comorbidity of bipolar disorder and borderline personality disorder. The shared features of impulsivity and labile mood in both disorders make them challenging to distinguish. We tested the hypothesis that variables related to goal dysregulation would be uniquely related to risk for mania, while emotion-relevant impulsivity would be related to risk for both disorders. We administered a broad range of measures related to goal regulation traits and impulsivity to 214 undergraduates. Findings confirmed that risk for mania, but not for borderline personality disorder, was related to higher sensitivity to reward and intense pursuit of goals. In contrast, borderline personality disorder symptoms related more strongly than did mania risk with threat sensitivity and with impulsivity in the context of negative affect. Results highlight potential differences and commonalities in mania risk versus borderline personality disorder risk.

Smoking and suicidality in subjects with major depressive disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

BACKGROUND: Detailed characteristics of depressive smokers and its association with suicidality were still less investigated. The aim of this study was to delineate characteristics of smokers with major depressive disorder (MDD) and examine the relationship between these characteristics and suicidality using an epidemiologic database, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). METHODS: A total of 5695 subjects with MDD, defined by the DSM-IV criteria, were included in our analysis. Current smokers, former smokers, and lifetime nonsmokers were compared in terms of demographic, clinical characteristics, and functional level. Suicidality, evaluated by history of suicide ideation and attempts while in a low mood was evaluated and compared among the groups. RESULTS: Current smokers with MDD showed a greater number of DSM-IV symptoms while in acute episodes, a higher rate of alcohol and drug-use disorders, and poorer functional levels than nonsmokers. Previous smokers displayed intermediate characteristics between current smokers and nonsmokers. The logistic regression analysis revealed that both current and former smoking status predicted the risk of having a history of attempted suicide (current smokers: odds ratio 1.62, 95% C.I. 1.42-1.86; former smokers: odds ratio 1.37, 95% C.I. 1.13-1.66) after adjusting for demographic data, a history of subthreshold hypomania, and a lifetime axis II/anxiety/alcohol use/substance-use disorder. LIMITATIONS: Retrospective, cross-sectional evaluation; suicidality assessed only in the most severe depressive episode. CONCLUSIONS: The present study corroborates that smokers with MDD showed distinct clinical characteristics, and cigarette smoking can predict attempted suicide in a community representative sample of people with MDD.

Mindfulness-based cognitive therapy for nonremitted patients with bipolar disorder.

INTRODUCTION: Bipolar disorder is characterized by recurrent episodes of depression and/or mania along with interepisodic mood symptoms that interfere with psychosocial functioning. Despite periods of symptomatic recovery, many individuals with bipolar disorder continue to experience substantial residual mood symptoms that often lead to the recurrence of mood episodes. AIMS: This study explored whether a new mindfulness-based cognitive therapy (MBCT) for bipolar disorder would increase mindfulness, reduce residual mood symptoms, and increase emotion-regulation abilities, psychological well-being, positive affect, and psychosocial functioning. Following a baseline clinical assessment, 12 individuals with DSM-IV bipolar disorder were treated with 12 group sessions of MBCT. RESULTS: At the end of treatment, as well as at the 3 months follow-up, participants showed increased mindfulness, lower residual depressive mood symptoms, less attentional difficulties, and increased emotion-regulation abilities, psychological well-being, positive affect, and psychosocial functioning. CONCLUSIONS: These findings suggest that treating residual mood symptoms with MBCT may be another avenue to improving mood, emotion regulation, well-being, and functioning in individuals with bipolar disorder.

Mindfulness-based cognitive therapy for bipolar disorder: effects on cognitive functioning.

Bipolar disorder is associated with impairments in cognition, including difficulties in executive functioning, even when patients are euthymic (neither depressed nor manic). The purpose of this study was to assess changes in self-reported cognitive functioning in patients with bipolar disorder who participated in an open pilot trial of mindfulness-based cognitive therapy (MBCT). Following MBCT, patients reported significant improvements in executive functioning, memory, and ability to initiate and complete tasks, as measured by the Behavior Rating Inventory of Executive Function (BRIEF) and the Frontal Systems Behavior Scale (FrSBe). Changes in cognitive functioning were correlated with increases in mindful, nonjudgmental observance and awareness of thoughts, feelings, and sensations, and were not associated with decreases in depression. Improvements tended to diminish after termination of treatment, but some improvements, particularly those in executive functioning, persisted after 3 months. These results provide preliminary evidence that MBCT may be a treatment option that can be used as an adjunct to medication to improve cognitive functioning in bipolar disorder.

Assessment Tools for Adult Bipolar Disorder.

This article reviews the current state of the literature on the assessment of bipolar disorder in adults. Research on reliable and valid measures for bipolar disorder has unfortunately lagged behind assessment research for other disorders, such as major depression. We review diagnostic tools, self-report measures to facilitate screening for bipolar diagnoses, and symptom severity measures. We briefly review other assessment domains, including measures designed to facilitate self-monitoring of symptoms. We highlight particular gaps in the field, including an absence of research on the reliable diagnosis of bipolar II and milder forms of disorder, a lack of empirical data on the best ways to integrate data from multiple domains, and a shortage of measures targeting a broader set of illness-related constructs relevant to bipolar disorder.

Positive affect regulation in anxiety disorders.

Although individual differences exist in how people respond to positive affect (PA), little research addresses PA regulation in people with anxiety disorders. The goal of this study was to provide information about responses to PA in people with symptoms of social phobia, generalized anxiety disorder, panic disorder, agoraphobia, and obsessive-compulsive disorder. The tendency to dampen PA and the ability to savor PA were examined in an undergraduate sample. Analyses examined the unique links between these reactions and symptoms of anxiety disorders, controlling for a history of depression. Given the high comorbidity of depression and anxiety, exploratory analyses further controlled for generalized anxiety disorder. Results demonstrated that one or both measures of affect regulation made a unique and substantial contribution to predicting each anxiety disorder except agoraphobia, above and beyond prediction afforded by symptoms of depression and generalized anxiety disorder. Clinical implications and areas for future research are discussed.

An acceptance-based psychoeducation intervention to reduce expressed emotion in relatives of bipolar patients.

Expressed emotion (EE) is a robust predictor of outcome in bipolar disorder. Despite decades of research, interventions to reduce EE levels have had only modest effects. This study used an expanded model of EE to develop an intervention. Research has demonstrated a strong link between attributions and EE in families of patients with psychiatric disorders. There is also substantial research to suggest that anger can drive blaming attributions. Combining these ideas, this study built on previous psychoeducation interventions through the addition of an acceptance component designed to decrease anger and blaming attributions among family members of those with bipolar disorder. Twenty-eight family members attended a 1-day or 2-evening multifamily group workshop and completed a follow-up assessment 1 week later. At follow-up, participants demonstrated more knowledge about bipolar disorder. Anger, blaming attributions, and number of criticisms remained unchanged. Results of this study are consistent with others in that it is difficult to change EE. Implications for future clinical research in this area are addressed.

A double-blind, placebo-controlled trial of adjunctive donepezil in treatment-resistant mania.

INTRODUCTION: Because there is a high rate of partial response to standard thymoleptic medication, novel augmentation strategies for treatment-resistant bipolar disorder are needed. In an open trial, donepezil augmentation was associated with improvement in manic symptoms in 9 of 11 subjects. METHOD: We conducted a 6-week, double-blind, placebo-controlled trial of donepezil for treatment-resistant bipolar mania. Eligible subjects had a Young Mania Rating Scale (YMRS) score of at least 15 despite two or more weeks of proven therapeutic levels of lithium or valproate. Subjects who completed the trial were eligible for an 8-week open trial of donepezil. Subjects were started on donepezil 5 mg/day and were eligible for dose increase to 10 mg/day after 4 weeks. RESULTS: Twelve subjects were enrolled. Eleven subjects received at least 1 week of study medication and were included in the analysis. No subjects in the donepezil group (0/6) and 60% (3/5) in the placebo group met response criteria of >30% reduction in YMRS score (Fisher's Exact p = 0.061). YMRS scores were higher at trial endpoint in the donepezil group 20.17 (3.66) compared with the placebo group [11.20 (4.60), Z = -2.476, p = 0.01]. There were no differences at trial endpoint in Hamilton Rating Scale for Depression (HAM-D) or Brief Psychiatric Rating Scale (BPRS) scores in either the intent-to-treat or the completer analyses. CONCLUSIONS: Donepezil does not appear to be an effective adjunctive treatment for refractory manic symptoms. The strength of the conclusion of this trial is limited by the possibility of a false-negative result due to the small sample.

Mirtazapine in the treatment of mood and anxiety disorders.

Mirtazapine is a new antidepressant whose effects on presynaptic adrenergic receptors leads to increased serotonergic transmission, and thus its antidepressant and antianxiety effects. It is equal in practical effectiveness to any currently marked antidepressant but may exert its effects earlier than some others. It is safe, well-tolerated and a useful addition to the drugs currently available for the treatment of mood and anxiety disorders.