Norma Verdolini

The State of the Art of the DSM-5 “with Mixed Features” Specifier

The new DSM-5 “with mixed features” specifier (MFS) has renewed the interest of the scientific community in mixed states, leading not only to new clinical studies but also to new criticisms of the current nosology. Consequently, in our paper we have reviewed the latest literature, trying to understand the reactions of psychiatrists to the new nosology and its epidemiological, prognostic, and clinical consequences. It seems that the most widespread major criticism is the exclusion from the DSM-5 MFS of overlapping symptoms (such as psychomotor agitation, irritability, and distractibility), with a consequent reduction in diagnostic power. On the other hand, undoubtedly the new DSM-5 classification has helped to identify more patients suffering from a mixed state by broadening the narrow DSM-IV-TR criteria. As for the clinical presentation, the epidemiological data, and the therapeutic outcomes, the latest literature does not point out a univocal point of view and further research is needed to fully assess the implications of the new DSM-5 MFS. It is our view that a diagnostic category should be preferred to a specifier and mixed states should be better considered as a spectrum of states, according to what was stated many years ago by Kraepelin.

Assessing and staging bipolar disorder

We congratulate Duffy et al on their paper.[1][1] We have long argued that bipolar disorder is often underdiagnosed by community mental health teams, and that the reason for this is often failure to assess the longitudinal trajectory of patients with recurrent depression.[2][2],[3][3] We have

Depressive mood and circadian rhythms disturbances as outcomes of seasonal affective disorder treatment: A systematic review

BACKGROUND The present systematic review was aimed at critically summarizing the evidence about interventions focused on circadian rhythms and mood symptoms in seasonal affective disorder (SAD). METHODS A systematic search of the electronic databases PUBMED, PsycINFO and Web of Science was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Original papers reporting data about the effects of treatments on both mood and circadian rhythms disturbances in SAD patients were considered for inclusion. The quality of the evidence provided by the eligible studies was assessed using the Revised Cochrane Risk of Bias Tool (RoB 2.0) and the Cochrane Risk of Bias in Non-Randomized Studies of Interventions Tool (ROBINS-I). RESULTS Forty papers were deemed eligible for the systematic review. The evidence of treatment outcomes referring to circadian disturbances was not robust. Despite this, bright light therapy (BLT) demonstrates to phase-advance delayed rhythms and to improve sleep-wake disorders. As for mood symptoms, both BLT and selective serotonin reuptake inhibitors (SSRIs) show evidence of efficacy. The possible connection between improvements of mood symptoms and changes in circadian outcomes seems controversial. LIMITATIONS The included studies presented considerable methodological heterogeneity, small sample sizes and non-optimal sample selection. CONCLUSIONS The effectiveness of BLT in depressive symptoms and circadian disturbances of SAD was outlined by the present systematic review. The evidence about other biological and pharmacological treatments, although promising, should be replicated. A multifactorial etiopathogenesis could explain the heterogeneous clinical presentations of SAD and the complex link between mood and circadian symptoms.

The Clinical Assessment of Prognostic Factors in Bipolar Disorder- an Audit

Introduction Prognostic staging is one of the most important current psychiatrical challenges. Objectives Bipolar prognostic factors must be identified to assist in staging. Aims To assess prognostic factors, to describe any correlation with the disease outcome and to recommend that psychiatrists assess bipolar patients, determining their stage of disease in order to identify possible high-risk groups of patients. Methods We collected data from the clinical notes of 70 bipolar outpatients seen at the initial psychiatric assessment clinic about socio-demographic and clinical factors. Results The sample comprised 16 bipolar I (22.9%) and 54 bipolar II (77.1%) outpatients; 60.9% reported anxiety, 71.7 % mixed state features and 72.7% rapid cycling. A comparison between 12 prognostic factors found that only the correlations between current illicit drug use/previous illicit drug use, current alcohol use/previous alcohol use, and current illicit drug use/anxiety were statistically significant; the correlation between previous illicit drug use/previous alcohol use, previous alcohol use/family history and mixed state features/anxiety were almost significant. 17 patients were assigned to a care coordinator; we found no statistically significant differences between the patients with or without a care coordinator on the basis of the presence of 12 possible prognostic factors. Conclusions In our sample, some patients were found not to have information available so we suggest that a questionnaire to remind clinicians of potentially useful information would be helpful to aid in prognostication. Specific features of the disease (family history, age at onset, features of depressive episodes and mixed state, rapid cycling) may be highlighted.

Bipolar disorder comorbid with borderline personality disorder and treatment with mood stabilisers

Crawford and colleagues discuss the difficulty in deciding whether patients with borderline personality disorder (BPD) should be treated with mood stabilisers.1 This decision is affected by the fact that patients can have two comorbid but distinct conditions—bipolar disorder and BPD. Bipolar disorder has an important genetic component, often with a family history of the disease, whereas BPD is mostly related …