Danielle M Bargh

The clinical management of bipolar disorder complexity using a stratified model

Malhi GS, Bargh DM, Cashman E, Frye MA, Gitlin M. The clinical management of bipolar disorder complexity using a stratified model. Bipolar Disord 2012: 14 (Suppl. 2): 66–89.

Balanced efficacy, safety, and tolerability recommendations for the clinical management of bipolar disorder

Malhi GS, Bargh DM, McIntyre R, Gitlin M, Frye MA, Bauer M, Berk M. Balanced efficacy, safety, and tolerability recommendations for the clinical management of bipolar disorder. Bipolar Disord 2012: 14 (Suppl. 2): 1–21.

Modeling bipolar disorder suicidality

To review the psychosocial, neuropsychological, and neurobiological evidence regarding suicide and bipolar disorder (BD), to enable the development of an integrated model that facilitates understanding, and to provide a useful framework for future research.

Predicting bipolar disorder on the basis of phenomenology: implications for prevention and early intervention

Bipolar disorder is a multifaceted illness and there is often a substantial delay between the first onset of symptoms and diagnosis. Early detection has the potential to curtail illness progression and disorder‐associated burden but it requires a clear understanding of the initial bipolar prodrome. This article summarizes the phenomenology of bipolar disorder with an emphasis on the initial prodrome, the evolution of the illness, and the implications for prevention and early intervention.

Differential engagement of the fronto-limbic network during emotion processing distinguishes bipolar and borderline personality disorder.

Differential engagement of the fronto-limbic network during emotion processing distinguishes bipolar and borderline personality disorder

Unlocking the diagnosis of depression in primary care: Which key symptoms are GPs using to determine diagnosis and severity?:

Objective: Diagnosing depression in primary care settings is challenging. Patients are more likely to present with somatic symptoms, and typically with mild depression. Use of assessment scales is variable. In this context, it is uncertain how general practitioners (GPs) determine the severity of depressive illness in clinical practice. The aim of the current paper was to identify which symptoms are used by GPs when diagnosing depression and when determining severity. Method: A total of 1760 GPs participated in the RADAR Program, an educational program focusing on the diagnosis and management of clinical depression. GPs identified a maximum of four patients whom they diagnosed with depression and answered questions regarding their diagnostic decision-making process for each patient. Results: Overall, assessment of depression severity was influenced more by somatic symptoms collectively than emotional symptoms. Suicidal thoughts, risk of self-harm, lack of enjoyment and difficulty with activities were amongst the strongest predictors of a diagnosis of severe depression. Conclusions: The conclusions are threefold: (1) collectively, somatic symptoms are the most important predictors of determining depression severity in primary care; (2) GPs may equate risk of self-harm with suicidal intent; (3) educational initiatives need to focus on key depressive subtypes derived from emotional, somatic and associated symptoms.

Neural Antecedents of Emotional Disorders: A Functional Magnetic Resonance Imaging Study of Subsyndromal Emotional Symptoms in Adolescent Girls

BACKGROUND Emotional symptoms (ES) emerge forme fruste in adolescence, before manifesting as fully fledged emotional disorders. Studies indicate that subsyndromal ES precede the onset of emotional disorders. We hypothesized that adolescents showing subsyndromal ES will show perturbations in the emotion regulatory frontolimbic network (FLN) during emotion processing. METHODS Fifty-eight female adolescents underwent functional magnetic resonance imaging while viewing an image-based emotion-processing task. Within this sample, 33 (56.9%) displayed emotional symptoms and 25 (43.1%) did not. Clinical measures, including assessments of mood and anxiety, were administered and participants were allocated to one of two groups based on the presence (ES+) or absence (ES-) of subsyndromal ES. Group comparisons were used to identify differential patterns of neural engagement and their relationship to clinical variables. RESULTS Groups displayed emotion-specific differences in FLN activity with increased frontal activity in ES+ girls during positive emotion processing and decreased frontal and limbic activity during negative emotion processing. Trait anxiety was the strongest clinical predictor of group membership (ES+ versus ES-) and displayed a significant negative correlation with hippocampal neural activity during negative emotion processing. In addition, between the groups, the hippocampus displayed a pattern of reverse coupling with the amygdala and insula that was also significantly correlated with trait anxiety. CONCLUSIONS There is divergence in the pattern of FLN neural processing in adolescent female subjects determined by emotional symptoms. Future research is needed to corroborate these findings and to underline their implications longitudinally.

Dissuasion: the Elaboration Likelihood Model and young children

Purpose The Elaboration Likelihood Model (ELM) proposes two routes to persuasion – the central route (persuasion occurs via information) and the peripheral route (persuasion occurs via visual cues, attractive actors and other source characteristics). The central route is typically used for high-involvement decisions and the peripheral route is used in low involvement situations. The ELM has received extensive support when tested with adults; however, its ability to explain young children’s responses to persuasive communications has not been fully tested. Hence, the purpose of this research is to assess whether the standard tenets of the ELM apply to children’s processing of persuasive messages. Design/methodology/approach This study involved 84 preschool children, ages three to six. It used a 2 (involvement) × 2 (argument strength) × 2 (source attractiveness) design to test children’s responsiveness to advertisements for a novel breakfast cereal. Findings The findings suggest that children are naturally inclined to be persuaded by advertising messages, regardless of their level of involvement. It is the weak arguments and weak peripheral cues that dissuade children who are highly involved with a message. Originality/value This research makes an original contribution to the existing literature by testing the extent to which the ELM applies to children’s processing of persuasive advertisements. The finding that weak peripherals dissuade children from believing an ad’s message has strong implications for advertising practitioners.

Severity alone should no longer determine therapeutic choice in the management of depression in primary care: Findings from a survey of general practitioners

BACKGROUND The treatment of depression in primary care remains suboptimal for reasons that are complex and multifactorial. Typically GPs have to make difficult decisions in limited time and therefore, the aim of this study was to examine the management of depression of varying severity and the factors associated with treatment choices. METHOD Nested within a primary care educational initiative we conducted a survey of 1760 GPs. The GPs each identified four patients with clinical depression whom they had treated recently and then answered questions regarding their diagnosis and management of each patient. RESULTS Comorbid anxiety, sadness and decreased concentration appeared to direct the management of depression toward psychological therapy, whereas comorbid pain and a patients overall functioning, such as the ability to do simple everyday activities, directed the initiation of pharmacological treatment. The use of antidepressants with a broader spectrum of actions (acting on multiple neurotransmitters) increased from mild to severe depression, whereas this did not occur with the more selective agents. SSRIs were prescribed more frequently compared with all other antidepressants, irrespective of depression severity. LIMITATIONS GPs chose the RADAR programme and therefore they were potentially more likely to have an interest in mental health compared to GPs who did not participate. CONCLUSIONS GPs do not appear to be determining pharmacological treatment based on depression subtype and specificity, but rather on the basis of the total number of symptoms and overall severity. While acknowledging important differences between primary care and specialist practice, it is suggested that guidelines to assist GPs in matching treatment to depression subtype may be of practical assistance in decision-making, and the delivery of more effective treatments.

Psychiatric tertiary referral and clinical decision making.

It is little news to any of us that psychiatry is a difficult exercise. Core diagnoses around which we built our practice, such as major depression and generalised anxiety, have turned out to have ‘questionable’ and ‘unacceptable’ reliability when formally assessed by the very organisation that proposed them (Regier et al., 2013). Our best efforts at painstaking diagnosis are often unstable over time, as illness evolves and psychosocial circumstances and phenomenology shift the face of the presentation (Ruggero et al., 2010). Even more concerning, landmark studies such as CATIE and STAR*D demonstrate the limitations of current treatment, and highlight the concern that appropriate and diligent treatment simply does not produce remission in large groups of patients (Insel and Wang, 2009; Lieberman et al., 2005). Given these constraints, it is inevitable that we will both become stuck and make mistakes, not as a function of inattentiveness or incompetence, but rather, as an unavoidable consequence of the nature of our profession. Further, this is substantially more common than we think. Diagnostic error occurs in approximately 15% of general medicine cases (Berner and Graber, 2008), and is likely more frequent in psychiatry, particularly in contested areas such as bipolarity, where approximately half of patients are misdiagnosed at some point (Smith and Ghaemi, 2010; Zimmerman, 2010). Options for addressing our own fallibility are, of course, well described, and nearly every treatment guideline suggests we consider a second opinion or a tertiary referral in the face of treatment resistance (Malhi and Adams, 2009). However, while we all overtly endorse this, in the case of tertiary referral, this principle may be more honoured in the breach than in the observance. At the two major academic centres in Sydney that offer tertiary outpatient mood disorder assessment, most referrals come from GPs (Table 1). Fewer than 100 patients are referred by a psychiatrist annually, a number likely less than the number of psychiatrists in our shared catchment areas. There are numerous possible reasons for this apparent gap between the likely frequency of diagnostic difficulty and the engagement of tertiary expertise. It is possible, for example, that it is simply a parochial issue, or that it is due to factors unrelated to clinical decision making, such as awareness, or service capacity. The large proportion of GP referrals suggests a structural gap may also be present, with direct tertiary referrals filling some of the gulf between the public sector’s focus on severe mental illness and the private sector’s financial constraints. However, the relative underuse of tertiary expertise by psychiatrists may also reflect a broader failure to clarify the nature of tertiary assessment, and we therefore aim to use this paper to reflect on the way in which tertiary assessment intersects with psychiatric decision making.