Marc Bourgeois

Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP)

BACKGROUND This paper presents the methodology and clinical data in mid-stream from a French multi-center study (EPIDEP) in progress on a national sample of patients with DSM-IV major depressive episode (MDE). The aim of EPIDEP is to show the feasibility of validating the spectrum of soft bipolar disorders by practising clinicians. In this report, we focus on bipolar II (BP-II). METHOD EPIDEP involves training 48 French psychiatrists in 15 sites; construction of a common protocol based on the criteria of DSM-IV and Akiskal (Soft Bipolarity), as well as criteria modified from the work of Angst (Hypomania Checklist), the Ahearn-Carroll Bipolarity Scale, HAM-D and Rosenthal Atypical Depression Scale; Semi-Structured Interview for Evaluation of Affective Temperaments (based on Akiskal-Mallya), self-rated Cyclothymia Scale (Akiskal), family history (Research Diagnostic Criteria); and prospective follow-up. RESULTS Results are presented on 250 (of the 537) MDE patients studied thus far during the acute phase. The rate of BP-II disorder which was 22% at initial evaluation, nearly doubled (40%) by systematic evaluation. As expected from the selection of MDE by uniform criteria, inter-group comparison between BP-II vs unipolar showed no differences on the majority of socio-demographic parameters, clinical presentation and global intensity of depression. Despite such uniformity, key characteristics significantly differentiated BP-II from unipolar: younger age at onset of first depression, higher frequency of suicidal thoughts and hypersomnia during index episode, higher scores on Hypomania Checklist and cyclothymic and irritable temperaments, and higher switching rate under current treatment. Eighty-eight percent of cases assigned to cyclothymic temperament by clinicians (with a cut-off of 10/21 items on self-rated cyclothymia) were recognized as BP-II. Evaluation of this temperament by clinician and patient correlated at a highly significant level (r=0.73; p <0.0001). Cyclothymia and hypomania were also correlated significantly (r=0.51; p < 0.001). LIMITATION In a study conducted in diverse clinical settings, it was not possible to assure that clinicians making affective diagnoses were blind to the various temperamental measures. However, bias was minimized by the systematic and/or semi-structured nature of all evaluations. CONCLUSION With a systematic search for hypomania, 40% of major depressive episodes were classified as BP-II, of which only half were known to the clinicians at study entry. Cyclothymic temperamental dysregulation emerged as a robust clinical marker of BP-II disorder. These data indicate that clinicians in diverse practice settings can be trained to recognize soft bipolarity, leading to changes in diagnostic practice at a national level.

A Randomized Controlled Trial of Cognitive Therapy versus Intensive Behavior Therapy in Obsessive Compulsive Disorder

Background: The study was designed to compare cognitive therapy (CT) with intensive behavior therapy (BT) in obsessive-compulsive disorder (OCD) and to study their change process. Methods: Sixty-five outpatients with DSM-4 OCD were randomized into 2 groups for 16 weeks of individual treatment in 3 centers. Group 1 received 20 sessions of CT. Group 2 received a BT program of 20 h in two phases: 4 weeks of intensive treatment (16 h), and 12 weeks of maintenance sessions (4 h). No medication was prescribed. Results: Sixty-two patients were evaluated at week 4, 60 at week 16 (post-test), 53 at week 26 and 48 at week 52 (follow-up). The response rate was similar in the 2 groups. The Beck Depression Inventory (BDI) was significantly more improved by CT (p = 0.001) at week 16. The baseline BDI and Obsessive Thoughts Checklist scores predicted a therapeutic response in CT, while the baseline BDI score predicted a response in BT. At week 16, only the changes in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and a scale measuring the interpretation of intrusive thoughts correlated in CT, while the changes in Y-BOCS, BDI, and interpretation of intrusive thoughts correlated in BT. Improvement was retained at follow-up without a between-group difference. The intent-to-treat analysis (last observation carried forward) found no between-group differences on obsessions, rituals and depression. Conclusions: CT and BT were equally effective on OCD, but at post-test CT had specific effects on depression which were stronger than those of BT. Pathways to improvement may be different in CT and BT. The outcomes are discussed in the light of an effect size analysis.

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders, Part III: Maintenance Treatment

Summary As with the two preceding guidelines of this series, these practice guidelines for the pharmacological maintenance treatment of bipolar disorder were developed by an international task force of the World Federation of Societies of Biological Psychiatry (WFSBP). Their purpose is to supply a systematic overview of all scientific evidence relating to maintenance treatment. The data used for these guidelines were extracted from a MEDLINE and EMBASE search, from recent proceedings from key conferences and various national and international treatment guidelines. The scientific justification of support for particular treatments was categorised into four levels of evidence (A-D). As these guidelines are intended for clinical use, the scientific evidence was not only graded, but also reviewed by the experts of the task force to ensure practicality.

The InterSePT scale for suicidal thinking reliability and validity

BACKGROUND The InterSePT Scale for Suicidal Thinking (ISST) is a 12-item instrument for the assessment of current suicidal ideation in patients with schizophrenia and schizoaffective disorders. We report the psychometric characteristics of this new scale based on two studies. METHOD In Study 1, 22 inpatients with schizophrenia and schizoaffective disorders, who had recently attempted suicide or engaged in suicidal ideation, were rated by three trained independent raters to examine interrater reliability. In Study 2, a total of 980 patients with schizophrenia or schizoaffective disorder with a history of suicidal ideation in the past 36 months were enrolled in a 2-year industry-sponsored suicide prevention study. At baseline, these patients were administered the ISST and the Clinical Global Impression Scale for Severity of Suicidality (CGI-SS) by the Principal Investigator (PI) and by a blinded rater (BR), who also administered the Positive and Negative Symptom Scale (PANSS), the Calgary Depression Scale (CDS), and the Scale of Functioning (SOF). Indices of internal reliability, construct and discriminant validity were examined. RESULTS The intraclass correlation coefficient (ICC) for the total ISST score for the 22 subjects in Study 1 was 0.90 and mean weighted item kappa coefficients ranged from 0.66 to 0.92. In Study 2, internal reliability (Cronbach alpha) was high, ranging from 0.86 to 0.89 for the individual items, and the overall Cronbach alpha coefficient for all items was 0.88. The ISST (PI) total score was highly correlated with the CGI-SS by the blind rater (r = 0.61, p < 0.0001). ISST total scores significantly differentiated the different levels of CGI-SS (F = 519.2; p < 0.0001). Results of construct and discriminant validity analyses are also presented. CONCLUSION The ISST is a reliable and valid instrument for the assessment of current suicidal thinking in patients with schizophrenia and schizoaffective disorder by both clinicians and researchers.

A comparative study of obstetric history in schizophrenics, bipolar patients and normal subjects

Information on pregnancy and birth complications was collected for 46 patients with DSM-IIIR schizophrenia or bipolar disorder and for 23 normal controls. Pregnancy complications were more frequent and birth complications more frequent and more severe in schizophrenics than in bipolar patients or in normal controls. In contrast with other findings in the literature, more obstetric complications (OCs) were found in female than male schizophrenic patients.

Criminal acts among schizophrenics in French mental hospitals.

Veterans Administration Medical Center, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California. Send reprint requests to Dr. Yesavage, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California 94305. This paper reports a questionaire study of 116 schizophrenic subjects. A group without history of crime (N = 53) was found to have considerably better relations with their families than a group with histories of criminal acts (N = 63). An interesting finding was that negative relations with the father were reported more frequently in the noncriminal group than in the criminal group, whereas negative relations with the mother were more frequent in the criminal group than in the noncriminal group. Within the criminal group several differences were found between the criminal behavior of chronic undifferentiated and paranoid schizophrenics. Although subjects of both diagnoses often acted with premeditation, paranoid schizophrenics were more likely to commit crimes against persons, to be under the influence of their illness during the crime, to be secretive about plans, to admit their guilt, and to cite vengeance as a motive than chronic undifferentiated schizophrenic subjects.

A survey of prescribing practice of antipsychotic maintenance treatment for manic-depressive outpatients

Survey questionnaires were mailed to public hospital psychiatrists practising in a French region to obtain information on the manic-depressive outpatients they personally followed up. Data were collected on 222 manic-depressive outpatients managed by 43 separate psychiatrists. More than two thirds were receiving at least one antipsychotic, and 17% were prescribed a depot-neuroleptic. Predictors of antipsychotic prescription were a history of psychotic features (OR = 3.4; 95%CI 1.7-6.9), early age at onset (OR = 2.1; 95%CI 1.0-4.8) and low educational level (OR = 3.1; 95%CI 1.5-6.3). Similar predictors were found for depot-neuroleptic prescription. Although these indicate that the prescription of antipsychotic for manic-depressive outpatients is not random, only 14% of patients were receiving mood stabilizers only. Owing to the potential side effects of antipsychotics, the benefit-to-risk ratio of antipsychotic use in the maintenance treatment of manic-depressive patients has to be carefully taken into account.

Violence in the mentally ill : A study of 547 patients at a French hospital for the criminally insane

This is a study of 547 patients hospitalized in a French hospital for the criminally insane over the past 10 years. This chart review study correlates diagnosis with criminal act and other psychological and sociological parameters. It is of note that the diagnosis of paranoia is strongly associated with violent crimes against persons, especially murder, whereas personality disorders are more associated with criminal acts involving property.

Analysis of the seasonal variation of schizophrenic births using a Kolmogorov-Smirnov type statistic.

Previous studies have shown that schizophrenic patients are more likely to be born in winter or early spring months than the general population. Data on 4,207 patients with a hospital diagnosis of schizophrenia were obtained from a mailed survey to public departments of adult psychiatry in metropolitan France. For each year from 1900 to 1965, the expected monthly number of schizophrenic births was calculated and any seasonal variation of live births in the general population was taken into account. Cumulative distributions of the observed and expected number of schizophrenic births were compared using a Kolmogorov-Smirnov type statistic. The seasonal distribution of schizophrenic births was significantly different from that of the general population (P < 0.01). An excess of schizophrenic births was found in the first half of the year, with a peak in April (+ 13%).

Focus on social functioning in depression

Depressive disorders represent a significant global health burden. By the year 2020 the contribution of psychiatric and neurological conditions to the global burden of disease is predicted to reach 15%. Despite this, depression is frequently unrecognized and undertreated; most depressed people do not seek treatment for their depression, and of those who do, most do not receive adequate treatment. Depression is a debilitating condition and the effects of the illness extend beyond the classically defined symptoms to almost every facet of an individuals life, including their social interactions; and even beyond the individual, to close relatives. The treatment of impaired social functioning has not been widely adopted as a therapeutic principle in depression, although it is recognized as an important part of the treatment of schizophrenia. However, depressed individuals experience more functional impairment than patients with other chronic medical conditions such as diabetes and hypertension. Early studies have suggested that antidepressants, in addition to improving the core symptoms of depression, are effective in the treatment of impaired social functioning; but few studies have directly compared different classes of antidepressants. This paper seeks to raise awareness of the key issues relating to the treatment of impaired social functioning in depression and to provide a basis for wider discussion of the topic prior to the establishment of treatment guidelines.