Rebecca Graham

Further examination of the utility and comparative properties of the MSQ and MDQ bipolar screening measures

BACKGROUND Our aim was to further examine the diagnostic utility of the Mood Swings Questionnaire (MSQ) and to compare its properties with the standard bipolar screening measure, the Mood Disorders Questionnaire (MDQ). METHODS A total of 1040 patients attending the Black Dog Institute Depression Clinic and diagnosed with a primary mood disorder (unipolar or bipolar) completed the MSQ and a smaller subset completed the MDQ. All patients underwent clinical assessment by an Institute psychiatrist. RESULTS Based on pre-established cut-off scores, the MSQ demonstrated superior sensitivity and specificity to the MDQ, both for the full version (MSQ-46; 85.1% and 77.9% vs. 63.3% and 70.2%) and the 27-item version (MSQ-27; 81.7 and 77.9% vs. 63.3% and 70.2%). The sensitivity of the MDQ in detecting a bipolar disorder was improved when its impairment criterion was ignored. Optimal cut-off scores derived in the current sample were generally consistent with those quantified previously. The stability of these discriminatory properties across different samples provides encouraging evidence for the utility of the MSQ and MDQ in screening for bipolar disorder in samples of depressed patients. CONCLUSIONS These results provide further positive evidence for the capacity of the MSQ and the MDQ as self-report screening measures to discriminate bipolar and unipolar depressive conditions.

Differentiation of bipolar I and II disorders by examining for differences in severity of manic/hypomanic symptoms and the presence or absence of psychosis during that phase

BACKGROUND DSM-IV criteria for mania/hypomania overlap considerably. We sought to examine the utility of a model differentiating bipolar I and II disorders by weighting the presence or absence of psychosis during manic/hypomanic episodes as opposed to simply weighting symptom severity. METHODS A set of 632 patients with a so-assigned clinical bipolar I or II disorder diagnosis contributed to the principal analyses, and a subset of 210 was included in a comparative analyses of DSM-assigned diagnoses. We also examined the impact of duration of highs on symptom patterns and the extent to which depressive episodes were psychotic or non-psychotic melancholic in type. RESULTS There were no group differences for bipolar I and II patients (clinical or DSM groups) by age, gender, age of onset or age of formal bipolar diagnosis. Clinically assigned bipolar I patients returned higher severity scores than bipolar II patients on manic/hypomanic symptoms, but such differentiation was limited. Clinically-assigned bipolar I patients were more likely than bipolar II patients to be diagnosed with psychotic depression, and had lower rates of non-melancholic depression. Duration of highs had some impact on the phenomenology of highs, but not on the phenomenology of depression. LIMITATIONS We cannot establish the degree to which clinicians validly differentiated those with bipolar disorder, and accurately judged the lifetime presence of psychotic features and of depressive subtype differentiation. CONCLUSIONS Findings support the utility of an alternative model to DSM-IV in weighting the respective presence or absence of psychotic symptoms during highs in differentiating bipolar I and II disorders.

The duration of undiagnosed bipolar disorder: effect on outcomes and treatment response.

INTRODUCTION There are commonly long delays between the onset of bipolar disorder (BP), seeking of treatment and acquiring a bipolar disorder diagnosis. Whether a longer duration of undiagnosed bipolar disorder (DUBP) leads to an inferior treatment response is unclear in the literature. METHOD We conducted two studies with independent samples of BP patients who had received a first-time diagnosis of BP - first investigating whether DUBP was related to clinical and social outcomes at the time of assessment (n=173) and, second, whether response to mood stabiliser medication was affected by DUBP when assessed three months following assessment and intervention (n=64). RESULTS Participants׳ mean DUBP was 18-20 years (from the onset of mood episodes). After controlling for age, a longer DUBP was associated with employment difficulties, whereas a shorter DUBP was associated with a history of engaging in self-harm behaviours, as well as a reduced likelihood of experiencing social costs as consequence of the mood disorder. The majority of study variables were statistically unrelated to DUBP. In a multivariate analysis, age was the only predictor variable to make a significant contribution to the DUBP (33%). Across the 3-month intervention period, participants improved significantly on all but one outcome measure. The participants׳ likelihood to improve, become worse or experience minimal/no change over the study period was not significantly related to the DUBP. LIMITATIONS Self-reporting poses a risk to measurement precision. Being a naturalistic observation, no specific dose of medication was prescribed. The small sample of BP I patients provided insufficient statistical power to undertake meaningful separate analyses of the BP I and BP II participants. CONCLUSION Early detection and intervention remains important for helping to reduce morbidity and risks associated with untreated BP. However, the variation in DUBP was mostly a function of age and did not substantially affect clinical status at assessment, or lead to an inferior response to mood stabilising medication.

The superiority of antidepressant medication to cognitive behavior therapy in melancholic depressed patients: a 12-week single-blind randomized study

To pursue the previously long‐standing but formally untested clinical view that melancholia is preferentially responsive to antidepressant medication in comparison with psychotherapy [specifically Cognitive Behavior Therapy (CBT)]. Second, to determine whether a broader action antidepressant medication sequencing regimen is superior to a Selective Serotonin Reuptake Inhibitor (SSRI) alone.

Is there consensus across international evidence-based guidelines for the management of bipolar disorder?

To examine the level of agreement across professionally auspiced evidence‐based guidelines for managing the bipolar disorders.

The re-labelling of dysthymic disorder to persistent depressive disorder in DSM-5: old wine in new bottles?

Purpose of review Dysthymic disorder and other chronic depressive disorders have recently been merged in DSM-5 into a ‘persistent depressive disorder’ category. As its introduction in DSM-III, the validity of dysthymic disorder has long been challenged, posing concerns regarding the validity of its successor – persistent depressive disorder. This review aims to present recent findings regarding the validity and utility of dysthymic disorder. Recent findings Several recent studies raise questions regarding the validity of dysthymic disorder, namely, results indicating a significant overlap between dysthymic disorder and other mood and/or anxiety disorders, failure of such a diagnosis to predict illness outcome and the lack of any validation strategy identifying that it is a depressive entity or subtype. Summary Research findings indicate that dysthymic disorder is a heterogeneous diagnosis encompassing many different depressive (and anxiety or personality weighted) conditions, and without clear evidence of its validity as a diagnostic entity. As dysthymic disorder is a key component of DSM-defined persistent depressive disorder – the latter is at similar risk of providing a heterogeneous domain diagnosis, and thus limiting identification of specific causative factors and preferential treatment modality.

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

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.

Clinical Characteristics Associated With Treatment-Resistant Bipolar Disorder.

Abstract 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.

Seasonal variations in rates of hospitalisation for mania and hypomania in psychiatric hospitals in NSW.

BACKGROUND A number of studies have established that manic patients have higher rates of hospitalization in spring. There appears to be no data evaluating whether there is any seasonal variation in hospitalization for those with hypomania. METHODS Data were obtained for 27,255 individuals hospitalized in NSW psychiatric hospitals over a 14-year period (2000-2014) for ICD-10 diagnosed mania or hypomania. Graphical analyzes examined rates of hospitalisation for hypomania and mania separately, using monthly and seasonal averages. RESULTS Admission rates were higher for mania compared to hypomania and there was a similar pattern across seasons - with admissions being at their lowest in autumn, increasing in winter, and at their highest for spring. Monthly percentage scores were similar for mania and hypomania and indicated lower admission rates in the first six months of the year (January-June), with a sudden increase in July, and followed by a more gradual increase until December. LIMITATIONS Hospitalization rates do not necessarily provide an accurate estimate of the onset of hypo/manic episodes, while the validity of those assigned a diagnosis of hypomania could not be established, allowing the possibility that many may have had manic episodes. CONCLUSIONS Findings indicate that hypomania shows a similar seasonal pattern to mania.

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

Abstract 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.