Cognitive and Behavioral Differentiation of Those With Borderline Personality Disorder and Bipolar Disorder.

The current study sought to identify features offering differentiation of borderline personality disorder (BPD) from bipolar disorder (BP). Participants were clinically assessed and assigned diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders criteria. A 113-item self-report questionnaire was completed, comprising cognitive and behavioral constructs weighted to a borderline personality style. A total of n = 53 participants were assigned to BPD, n = 83 to BP, with comorbid participants excluded. Twenty items were highly endorsed (>95%) by the BPD group, with most of the features capturing emotional dysregulation (ED) and identity disturbance; however, many items were also highly endorsed by the participants with BP. Thirty-eight items offered differentiation of BPD from BP, with identity disturbance overrepresented. The study findings indicate that the transdiagnostic nature of ED (a feature of both conditions) means it is less useful for diagnostic decisions, whereas identity disturbance is both intrinsic to BPD and offers specificity in differentiation from BP.

Depression and poor outcome after an acute coronary event: Clarification of risk periods and mechanisms.

OBJECTIVE: Lifetime depression and depression around the time of an acute coronary syndrome event have been associated with poor cardiac outcomes. Our study sought to examine the persistence of this association, especially given modern cardiac medicine's successes. METHODS: For 332 patients admitted for an acute coronary syndrome, a baseline interview assessed major depression status, and psychological measures were administered. At 1 and 12 months post-acute coronary syndrome event, telephone interviews collected rates of hospital readmission and/or death and major depression status, while biomarker information was examined using medical records. RESULTS: The 12-month mortality rate was 2.3% and cardiac readmission rate 21.0%. Depression subsequent to an acute coronary syndrome event resulted in a threefold and 2.5-fold increase in 1-month and 12-month odds of cardiac readmission or death, respectively. No relationship with past depressive episodes was found. Poor sleep was associated with higher trait anxiety and neuroticism scores and with more severe depression. CONCLUSION: Lifetime depression may increase the risk of depression around the time of an acute coronary syndrome but not influence cardiac outcomes. We suggest that poor sleep quality may be causal or indicate high anxiety/neuroticism, which increases risk to depression and contributes to poor cardiac outcomes rather than depression being the primary causal factor.

Comparative familial aggregation of bipolar disorder in patients with bipolar I and bipolar II disorders.

OBJECTIVE: We sought to quantify the prevalence and differential prevalence of a bipolar disorder among family members of patients with a bipolar I or II disorder. METHODS: The sample comprised 1165 bipolar and 1041 unipolar patients, with the former then sub-typed as having either a bipolar I or II condition. Family history data was obtained via an online self-report tool. RESULTS: Prevalence of a family member having a bipolar disorder (of either sub-type) was distinctive (36.8%). Patients with a bipolar I disorder reported a slightly higher family history (41.2%) compared to patients with a bipolar II disorder (36.3%), and with both significantly higher than the rate of bipolar disorder in family members of unipolar depressed patients (18.5%). CONCLUSIONS: Findings support the view that bipolar disorder is heritable. The comparable rates in the two bipolar sub-types support the positioning of bipolar II disorder as a valid condition with strong genetic underpinnings.

Clinical Characteristics Associated With Treatment-Resistant Bipolar Disorder.

There has been limited consideration and empirical studies on treatment-resistant bipolar disorder (TRBD). This exploratory study was designed to identify factors contributing to TRBD in patients with a bipolar (I or II) disorder. Patients were categorized with "low," "medium," or "high" levels of treatment resistance based on a) the total number of psychiatric medications received and, for a second analysis, b) the number of mood stabilizer medications received. The study identified a number of factors associated with TRBD, such as being female and older and having an older age at illness onset, a higher incidences of family depression, less likelihood of being in paid employment, a higher number of lifetime stressors, medical conditions and comorbid anxiety disorders, a different personality and temperament profile, and more regular use of benzodiazepines. There were few factors associated with TRBD when defined by number of mood stabilizers trialed. Potential explanations for these findings were explored.

Determinants of Treatment-Resistant Depression: The Salience of Benzodiazepines.

Treatment-resistant depression (TRD) lacks consensus regarding its definition, despite being common in clinical practice. This study was designed to identify factors contributing to TRD in patients diagnosed with a major depressive disorder. Patients were grouped into "low," "medium," and "high" treatment-resistant (TR) groups based on the number of medications that had been prescribed for their depression. We identified a number of factors linked to TRD. The high TR group was generally older, had a longer depressive episode duration, a higher number of comorbid medical and anxiety disorders, a lower education, and were less likely to be in full-time employment. They also reported less trait irritability and were more likely to view medication as being a contributor to their current depression. Some differences between non-melancholic and melancholic subsets were evident and point to the benefits in research on TRD analyzing the two diagnostic groups separately. The most striking finding was benzodiazepine use, which was significantly more common in the high TR group and within both the melancholic and non-melancholic subsets. Some potential explanations for this finding are offered.

The impact of being newly diagnosed with a bipolar disorder and the short-term outcome of disorder-specific management.

OBJECTIVES: The aim of the study was to determine the impact of a first-time diagnosis of bipolar disorder in patients previously generally managed as having a unipolar disorder, and to quantify the impact of disorder-specific management strategies for such newly diagnosed patients over the following three months. METHODS: A total of 157 patients receiving a diagnosis of bipolar disorder for the first time by a psychiatrist at a specialist depression clinic completed a research interview and questionnaires, with 106 (68%) also completing 12-week quantitative and qualitative evaluations. Assessing psychiatrists undertook baseline and follow-up assessments recording management changes, reactions to the diagnosis and global changes in functioning over time. RESULTS: The majority of patients had a positive response to receiving a diagnosis of bipolar disorder, and most implemented a number of clinician-suggested bipolar management strategies. Patients showed improvement on five of the six self-report measures over the three-month study period. Multivariate analyses quantified lamotrigine as making the most distinctive contribution to 'improver' status, particularly for the bipolar II disorder subset. CONCLUSIONS: Results are encouraging in identifying a generally positive acceptance of a diagnosis of bipolar disorder, improved outcome following the introduction of diagnostic-specific management components, and a distinctive contribution of lamotrigine to improved three-month outcome.

Coping profiles in bipolar disorder.

OBJECTIVE: As coping responses have the capacity to distinctly influence the illness course in affective disorders, they form targets for psychological intervention. Beneficial effects have been reported for interventions incorporating adaptive coping in bipolar disorder. Identification of differential coping preferences in bipolar disorder sub-types has etiological and clinical implications. As most studies to date have focused exclusively on bipolar I disorder, the current study examines coping profiles in those with a bipolar I or II disorder, contrasted with unipolar depressive and healthy controls. METHODS: Groups were derived on the basis of agreement between clinician and DSM-IV diagnoses. Participants (94 bipolar I, 114 bipolar II, 109 unipolar recurrent depression, 100 healthy controls) completed coping style measures including the Brief Cope, Responses to Positive Affect questionnaire, Response Styles Questionnaire, the Coping Inventory for Prodromes of Mania, and the Cognitive Emotion Regulation Questionnaire. RESULTS: Bipolar (I and II) participants were more likely than unipolar participants to ruminate about positive affect, and engage in risk taking when faced with negative affect. Medication status and current mood symptoms influenced risk-taking scores in the bipolar sub-sets, however rumination about positive affect appeared to represent a trait-like response in those with a bipolar II disorder. Behavioral coping strategies differentiated bipolar sub-types, with bipolar II participants being less likely to seek support when faced with stress, and less likely to engage in strategies to down-regulate hypomania. CONCLUSION: Coping style differences were observed between bipolar sub-types. Further consideration of such differentiating characteristics should serve to direct the focus towards specific targets for clinical intervention, reflecting nuances integral to the differing conditions.

Bipolar II disorder--diagnostic and management lessons for health practitioners from a coronial inquest.

A coronial inquest into the suicide of television newsreader Charmaine Dragun identified that a likely contributory factor to her death was the failure of many health practitioners to diagnose a bipolar II disorder and to provide more specific treatment for her condition. Lack of awareness about bipolar II disorder among practitioners and the public, as well as screening and detection problems, may have contributed to the failure to diagnose this disorder over the course of a decade. Detection and management of bipolar II disorder generally differs from that for a unipolar disorder, in that mood stabilisers rather than antidepressants are more often a priority. The diagnosis therefore has distinctive implications for management and course of the illness. The Coroner recommended "increased awareness by health professionals of the need to exclude a bipolar disorder in all patients presenting with signs and symptoms of depression" and highlighted the need for "readily available" screening tools.

Measurement of well-being in the workplace: the development of the work well-being questionnaire.

Because there has been a lack of a single comprehensive measure for assessing workplace well-being, we elected to develop such a self-report measure. Provisional items were extracted from the literature on "positive psychology" and were adapted to capture their workplace application. The provisional 50-item set was completed by a nonclinical sample of 150 adults. A second and third sample was recruited to examine its reliability and any impact of depressed mood and sociodemographic and work-related variables, respectively. Factor analysis identified four domains, "Work Satisfaction," "Organizational Respect for the Employee," "Employer Care," and a negative construct-"Intrusion of Work into Private Life." High test-retest reliability was demonstrated for the final 31-item measure, whereas there was no distinct impact of depressed mood on the scale scores. Work Satisfaction scale scores were influenced by job type. Gender effects were found for two of the four scales, whereas a longer period of employment inversely linked to Organizational Respect for the Employee and Employer Care scores and was conversely associated with higher Intrusion of Work into Private Life scores. The refined measure should enable individuals and employers to quantify the levels of support and well-being provided by employing organizations.

Who picks psychiatry? Perceptions, preferences and personality of medical students.

OBJECTIVES: This study aimed to characterise the personality profiles of junior medical students most likely to choose psychiatry as a career, determine aspects of psychiatry that most attract potential recruits, and identify misperceptions about psychiatry that may dissuade students from pursuing this specialism. METHOD: A total of 580 second-year medical students from the University of New South Wales, Australia completed a set of questionnaires that measured the likelihood with which various medical specialties were being considered as careers, personality traits using the NEO Five-Factor Inventory (NEO-FFI), and the degree to which students perceived each specialty as attractive across a number of parameters. RESULTS: Only 86 students (15%) indicated a strong likelihood of choosing psychiatry, compared to other specialties which attracted higher proportions of students (range 19-49%). These 86 students had significantly higher openness scores than those who indicated a lesser likelihood of pursuing psychiatry. Students who were highly interested in psychiatry ranked it as very attractive in respect to providing interesting and challenging subject matter, and relatively attractive in respect to financial reward, work enjoyment, good lifestyle, having a bright and interesting future, and association with colleagues. However, psychiatry remained less attractive with respect to prestige, perceived low effectiveness of treatments, degree to which it draws upon aspects of medical training, and lack of reliable scientific foundation. Within the entire sample, psychiatry was ranked most unattractive compared to the other specialties across eight of the 13 parameters assessed. CONCLUSIONS: Students interested in psychiatry are more likely to be 'open' and view the specialty as interesting and challenging. Such characteristics should be promoted more widely along with countering myths that as a specialty, psychiatry lacks a scientific foundation or is somehow different from mainstream medicine in terms of training and outcomes. Championing psychiatry in this manner may attract more recruits and enhance its prestige.

The impact of differing anxiety disorders on outcome following an acute coronary syndrome: time to start worrying?

BACKGROUND: Both depression and anxiety have been implicated as influencing survival following an acute coronary syndrome (ACS). Studies evaluating the contribution of anxiety have produced varying results, perhaps reflecting the use of dimensional self-report measures of state anxiety and failure to control for co-morbid depression. We sought to assess the impact of anxiety on outcome in ACS patients using DSM-IV diagnoses, in addition to self-report measures, controlling for effects of concurrent depressive diagnosis as well as medical and socio-demographic variables. METHODS: Some 489 patients hospitalized with an ACS were assessed for lifetime and current DSM-IV anxiety disorders using both Composite International Diagnostic Interview (CIDI) decisions and such decisions complemented by clinical judgments of impairment. Patients were re-interviewed over the next 12 months to assess cardiac outcome (ACS readmission and cardiac mortality). RESULTS: Univariate analyses revealed a trend for those with a lifetime history of agoraphobia to experience poorer cardiac outcome and for those with a lifetime diagnosis of generalized anxiety disorder (GAD) to experience a superior cardiac outcome. After controlling for post-ACS depression and key medical and demographic covariates, agoraphobia was a significant predictor of poorer cardiac outcome while the trend for those with a history of GAD to experience a superior cardiac outcome remained. CONCLUSIONS: Any impact of "anxiety" on post-ACS outcome appears to be influenced by the clinical sub-type. The seemingly paradoxical finding that GAD might improve outcome may reflect "apprehensive worrying" being constructive, by improving self-management of the individual's cardiac problems.

What happens after diagnosis? Understanding the experiences of patients with newly-diagnosed bipolar disorder.

UNLABELLED: Bipolar disorder is chronic condition involving episodes of both depression and elevated mood, associated with significant disability and high relapse rates. Recent estimates suggest a lifetime prevalence of 5%. Little is known about the subjective experiences of patients after receiving a diagnosis of bipolar disorder, and the impact of these experiences on patients' willingness and ability to work with their health professionals to find the most effective combination of treatments and to set up self-management plans. OBJECTIVE: This paper describes a qualitative study exploring the experiences and difficulties faced by patients after they have received a diagnosis of bipolar disorder, as expressed online to expert patients trained to provide informed support. DESIGN: Qualitative study. SETTING: Online communication within a public health service setting. PARTICIPANTS: Twenty-six participants with recently-diagnosed bipolar disorder communicated online with 'Informed Supporters', people who had been managing their bipolar disorder effectively for 2 years or more, as part of an online psycho-education programme. RESULTS: Participants cited unwanted side-effects of medication, coping with unpleasant symptoms, positive and negative reactions to the diagnosis, identifying early warning signs and triggers of the illness, the loss of a sense of self, uncertainty about their future and stigma as issues of major importance after diagnosis. CONCLUSIONS: Personal concerns and difficulties following diagnosis can undermine effective treatment, thwart self-management efforts and interfere with effective functioning. Such data are important for clinicians to take into account when they work in partnership with their patients to fine-tune treatments and help them set up self-management plans.

Management of depression by general practitioners: impact of physician gender.

OBJECTIVE: The aim of the present study was to determine whether anecdotal claims of gender differences in the treatment of depression by general practitioners (GPs) existed in practice. METHOD: Referral letters from 100 GPs to a specialized psychiatric depression clinic were analysed by word count and gender of referrer. Second, a Web-based survey of 517 participants examined the impact of GP gender in terms of levels of management nuances. RESULTS: The first study established that female GPs wrote distinctly longer referral letters. The second study identified that female GPs were seen as distinctly more caring over a range of parameters and identified the impact of some GP-patient gender differences. CONCLUSIONS: Reasons why female GPs are viewed as more caring - and any impact on the management of those with a depressive disorder - would benefit from refined investigation.

Examining age effects on prototypic melancholic symptoms as a strategy for refining definition of melancholia.

BACKGROUND: Melancholic depression appears to have a later age of onset than the non-melancholic disorders, and its phenotypic picture also appears to change with age. The latter phenomenon allows clarification of key symptoms of melancholia by examining for age effects on putative melancholic symptoms, thus enabling identification and refinement of the melancholic sub-type. METHODS: We studied 158 patients receiving a diagnosis of unipolar depression (65 melancholic: 93 non-melancholic), dichotomised by age and with a higher representation of those with melancholia in the older age band. The severity of individual DSM-IV-TR melancholic candidate symptom constructs were quantified across age groups and diagnostic sub-type. RESULTS: Symptom constructs identified as most clearly associated with age effects in those with melancholia were anhedonia, non-reactivity, diurnal mood variation and, to a lesser degree, psychomotor slowing. When melancholic and non-melancholic patients were compared, non-reactivity, psychomotor slowing and diurnal mood variation were the most differentiating in the older age group. CONCLUSIONS: The capacity of certain symptoms to mark the changing phenotypic expression of melancholia with age may not only assist refined definition of melancholia but inform about underlying causes and, of key importance, explain the suggested differential impact of narrow-action and broad-action antidepressant on those with melancholia across differing age groups.

Design limitations to bipolar II treatment efficacy studies: A challenge and a revisionist strategy.

BACKGROUND: Trials examining medication efficacy for bipolar II disorder commonly employ a set of standardized interval measures to assess outcomes. The key issue is whether such interval measures pick up changes in the severity, duration and frequency of depressive, hypomanic and euthymic episodes. METHOD: We examine the application of measures most commonly used to monitor progress in nine studies involving participants with a bipolar II disorder and published in journals with a moderate to high impact factor. RESULTS: Studies rarely provided interval details for assessing depressive and hypomanic symptoms. None specified whether ratings of depressive and hypomanic symptoms were based on severity, duration or number of symptoms, and none recorded any data on euthymic periods. LIMITATIONS: Our sample of reviewed studies was small and our analyses focused only on the three most commonly used outcome measures. We advocate for complementary subjective daily mood monitoring strategies but recognize that such strategies need to be validated in future studies. CONCLUSIONS: We argue that interval ratings undertaken weekly or over longer periods may compromise efficacy data. We recommend that userguides be developed to ensure standard outcome measures are employed consistently across trials, and that specific details be published in trial papers about how measures were employed and what mood episode characteristics were measured at each assessment. We also argue for daily ratings to be used as an outcome measure to provide data on severity, frequency and duration of depressive, hypomanic and euthymic periods in intervention studies of those with a bipolar II disorder.

Is there consensus across international evidence-based guidelines for the psychotropic drug management of bipolar disorder during the perinatal period?

BACKGROUND: Clinicians treating a patient with bipolar disorder who is pregnant or breastfeeding may seek advice from bipolar management guidelines that provide recommendations for perinatal treatment. We examine the consistency of such recommendations across several evidence-based guidelines. METHODS: A literature search in the National Guideline Clearinghouse, the Cochrane Database of Systematic Reviews, PsycInfo and PubMed was undertaken using the search terms "bipolar disorder" and "guidelines," which generated 11 sets of evidence-based guidelines published by professional organizations during the 2005-2015 period. Information relevant to management during the perinatal period was reviewed by two independent reviewers, with key themes qualitatively analysed. RESULTS: There was a moderate level of agreement across guidelines regarding the potential teratogenic effects of lithium, sodium valproate and carbamazepine, with most highlighting caution in using these medications during the perinatal period. There was less agreement regarding the safety risks associated with lamotrigine, antipsychotics, and antidepressants, and little agreement regarding the risks and recommendations of medications during breastfeeding. LIMITATIONS: Some differences in recommendations are likely due to varying publication dates, with recent guidelines having more up-to-date evidence available to use when formulating recommendations. Further, due to ethical issues surrounding pregnancy and infant research, the evidence used to formulate perinatal recommendations is largely based on retrospective reports and/or case studies. It is therefore unrealistic to expect such recommendations to be entirely consistent and based on rigorous evidence. CONCLUSIONS: While there was some consistency across guidelines on key recommendations, there were also substantial inconsistencies, with the latter risking compromising clinical management.

Is 'subthreshold' bipolar II disorder more difficult to differentiate from borderline personality disorder than formal bipolar II disorder?

Recent research indicates that borderline personality disorder (BPD) can be diagnostically differentiated from the bipolar disorders. However, no studies have attempted to differentiate participants with sub-threshold bipolar disorder or SubT BP (where hypomanic episodes last less than 4 days) from those with a BPD. In this study, participants were assigned a SubT BP, bipolar II disorder (BP II) or BPD diagnosis based on clinical assessment and DSM-IV criteria. Participants completed self-report measures and undertook a clinical interview which collected socio-demographic information, a mood history, family history, developmental history, treatment information, and assessed cognitive, emotional and behavioural functioning. Both bipolar groups, whether SubT BP or BP II, differed to the BPD group on a number of key variables (i.e. developmental trauma, depression correlates, borderline personality scores, self-harm and suicide attempts), and compared to each other, returned similar scores on nearly all key variables. Borderline risk scores resulted in comparable classification rates of 0.74 (for BPD vs BP II) and 0.82 (for BPD vs sub-threshold BP II). Study findings indicate that both SubT BP and BP II disorder can be differentiated from BPD on a set of refined clinical variables with comparable accuracy.

White matter alterations in the internal capsule and psychomotor impairment in melancholic depression.

Emerging evidence suggests that structural brain abnormalities may play a role in the pathophysiology of melancholic depression. We set out to test whether diffusion-derived estimates of white matter structure were disrupted in melancholia in regions underpinning psychomotor function. We hypothesized that those with melancholia (and evidencing impaired psychomotor function) would show disrupted white matter organization in internal capsule subdivisions. Diffusion magnetic resonance imaging (dMRI) data were acquired from 22 melancholic depressed, 23 non-melancholic depressed, and 29 healthy control participants. Voxel-wise fractional anisotropy (FA), radial diffusivity (RD), and axial diffusivity (AD) values were derived for anterior, posterior, and retrolenticular limbs of the internal capsule and compared between groups. Neuropsychological (reaction time) and psychomotor functioning were assessed and correlated against FA. Fractional anisotropy was distinctly increased, whilst RD was decreased, in the right anterior internal capsule in those with melancholia, compared to controls. The right anterior limb of the internal capsule correlated with clinical ratings of psychomotor disturbance, and reduced psychomotor speed was associated with increased FA values in the right retrolenticular limb in those with melancholia. Our findings highlight a distinct disturbance in the local white matter arrangement in specific regions of the internal capsule in melancholia, which in turn is associated with psychomotor dysfunction. This study clarifies the contribution of structural brain integrity to the phenomenology of melancholia, and may assist future efforts seeking to integrate neurobiological markers into depression subtyping.

Personalised relaxation practice to improve sleep and functioning in patients with chronic fatigue syndrome and depression: study protocol for a randomised controlled trial.

BACKGROUND: Chronic fatigue syndrome (CFS) and major depressive disorder (MDD) are both debilitating but heterogeneous conditions sharing core features of fatigue, unrefreshing sleep, and impaired functioning. The aetiology of these conditions is not fully understood, and 'best-practice' treatments are only moderately effective in relieving symptoms. Unrecognised individual differences in the response to such treatments are likely to underlie poor treatment outcomes. METHODS/DESIGN: We are undertaking a two-group, parallel, randomised controlled trial (RCT) comparing the effects of a personalised relaxation intervention on sleep quality, daytime symptoms, and functioning in patients with CFS (n = 64) and MDD (n = 64). Following identification of the method that best enhances autonomic responding (such as heart rate variability), participants randomised to the active intervention will practise their recommended method nightly for 4 weeks. All participants will keep a sleep diary and monitor symptoms during the trial period, and they will complete two face-to-face assessments, one at baseline and one at 4 weeks, and a further online assessment to evaluate lasting effects of the intervention at 2 months. Assessments include self-report measures of sleep, wellbeing, and function and monitoring of autonomic responses at rest, in response to the relaxation method and during nocturnal sleep. Treatment outcomes will be analysed using linear mixed modelling. DISCUSSION: This is the first RCT examining the effects of a personalised relaxation intervention, pre-tested to maximise the autonomic relaxation response, in patients with unrefreshing sleep and fatigue attributed to CFS or MDD. Detailed monitoring of sleep quality and symptoms will enable sensitive detection of improvements in the core symptoms of these debilitating conditions. In addition, repeated monitoring of autonomic functioning can elucidate mechanisms underlying potential benefits. The findings have translational potential, informing novel, personalised symptom management techniques for these conditions, with the potential for better clinical outcomes. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR), ACTRN12616001671459 . Registered on 5 December 2016.