Z. Rihmer

The International Society for Bipolar Disorders (ISBD) Task Force Report on Antidepressant Use in Bipolar Disorders

OBJECTIVEnThe risk-benefit profile of antidepressant medications in bipolar disorder is controversial. When conclusive evidence is lacking, expert consensus can guide treatment decisions. The International Society for Bipolar Disorders (ISBD) convened a task force to seek consensus recommendations on the use of antidepressants in bipolar disorders.nnnMETHODnAn expert task force iteratively developed consensus through serial consensus-based revisions using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new or reworded items and items that needed to be rerated. This process resulted in the final ISBD Task Force clinical recommendations on antidepressant use in bipolar disorder.nnnRESULTSnThere is striking incongruity between the wide use of and the weak evidence base for the efficacy and safety of antidepressant drugs in bipolar disorder. Few well-designed, long-term trials of prophylactic benefits have been conducted, and there is insufficient evidence for treatment benefits with antidepressants combined with mood stabilizers. A major concern is the risk for mood switch to hypomania, mania, and mixed states. Integrating the evidence and the experience of the task force members, a consensus was reached on 12 statements on the use of antidepressants in bipolar disorder.nnnCONCLUSIONSnBecause of limited data, the task force could not make broad statements endorsing antidepressant use but acknowledged that individual bipolar patients may benefit from antidepressants. Regarding safety, serotonin reuptake inhibitors and bupropion may have lower rates of manic switch than tricyclic and tetracyclic antidepressants and norepinephrine-serotonin reuptake inhibitors. The frequency and severity of antidepressant-associated mood elevations appear to be greater in bipolar I than bipolar II disorder. Hence, in bipolar I patients antidepressants should be prescribed only as an adjunct to mood-stabilizing medications.

Temperament and Personality Dimensions in Suicidal and Nonsuicidal Psychiatric Inpatients

Background: Suicide is a serious public health problem. In the international literature there is evidence to support the notion that certain temperaments and personality traits are often associated with suicidal behavior. Sampling and Methods: In this study, 150 psychiatric inpatients were investigated using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego autoquestionnaire, the Minnesota Multiphasic Personality Inventory, 2nd edition (MMPI-2) and the Beck Hopelessness Scale and evaluated for suicide risk by means of the critical items of the Mini International Neuropsychiatric Interview. Results: Statistical analysis, including logistic regression analysis and multiple regression analysis, showed that suicide risk contributed to the prediction of hopelessness. Among the temperaments, only the hyperthymic temperament, as a protective factor, and the dysthymic/cyclothymic/anxious temperament contributed significantly to the prediction of hopelessness. Irritable temperament and social introversion were predictive factors for suicidal risk. Hopelessness and depression were associated with higher suicidal behavior and ideation, but, unexpectedly, depression as measured by the MMPI did not contribute significantly to the multiple regressions. Conclusions: The present study indicated that, although suicidal psychiatric patients have MMPI-2 profiles in the pathological range, they exhibit several differences from nonsuicidal patients. Patients at risk of suicide have specific temperaments as well as personality and defense mechanism profiles. They are more socially introverted, depressed and psychasthenic, and use hysterical and schizoid mechanisms more often. Generalizability of the findings was limited by the small sample size and the mix of bipolar disorder I, bipolar disorder II, major depressive disorder and psychotic disorder patients.

Towards a genetically validated new affective temperament scale: A delineation of the temperament ʻphenotype' of 5-HTTLPR using the TEMPS-A

BACKGROUNDnAlthough it has been described that affective temperaments are associated with the 5-HTTLPR, less attention was paid to the association between this polymorphism and subscales and items related to each affective temperament. The aim of our study was to investigate the association of affective temperament subscales and individual items with the s allele of the 5-HTTLPR.nnnMETHODn138 psychiatrically healthy women completed the TEMPS-A questionnaire and were genotyped for 5-HTTLPR. Scores of subjects on the temperament scales, subscales and items in the three genotype and the two phenotype groups were compared using ANOVA. We selected items with significantly different mean scores between the three genotype groups and the two phenotype groups separately and performed item analysis.nnnRESULTSnSubjects in the different 5-HTTLPR genotype and phenotype groups have significantly different score on scales measuring depressive, cyclothymic, irritable and anxious temperaments, and several subscales composing these temperamental scales. Subjects in the three genotype groups scored significantly different on 11 items, 8 of these remained in a derived genotype scale after item analysis. Subjects in the two phenotype groups had significantly different scores on 12 items, 9 of them were retained in a derived phenotype scale after item analysis.nnnLIMITATIONSnOur sample was relatively small and included only women.nnnCONCLUSIONSnOur data provide support for the association of affective temperaments with the s allele. Although the cyclothymic temperament shows the strongest association, all temperaments within the depressive superfactor have a similar share in this association. The newly derived 5-HTTLPR Phenotype Scale shows strong association with 5-HTTLPR genotype and phenotype, therefore this scale should be further investigated in relation to psychiatric disorders, as well as psychological traits and temperaments.

Gender differences in major depressive disorder in a Hungarian community survey

INTRODUCTION: The aim of this study was to investigate the characteristics of Major Depressive Disorder (MDD) in males and females in a sample of the Hungarian adult population. METHOD: 2953 randomly selected subjects between 18 and 64 years old were interviewed using the Hungarian version of the Diagnostic Interview Schedule (DIS), which generated DSM-III-R diagnoses. RESULTS: The lifetime and period prevalences of MDD were more than twice as high in women than in men. The gender difference appeared in early adolescence and continued up until the age of 50. An increased risk for anxiety disorders was found in patients with MDD, irrespective of gender, and in the majority of cases (65%) the anxiety symptoms preceded the onset of MDD. Depressed women tended to have more symptoms and a more marked tendency for recurrence than men. The preponderance of females was twice as high in MDD with comorbid anxiety than in MDD without it, in spite of the fact that the likelihood of the coexistence of MDD and anxiety disorders did not differ by gender. CONCLUSION: The higher MDD prevalence rate in women might be the consequence of a higher rate of pre-existing anxiety disorder(s).

P-225 - Affective temperament profile in patients with hypertension. First results with temps-a in primary care in hungary

Introduction Affective temperaments profoundly determine emotional reactivity and are the main precursors of major affective disorders. Having strong genetic and biological basis, they are relatively stable throughout life. Given the strong and multidimensional relationship between affective and cardiovascular disorders, temperaments may be effective predictors of future cardiovascular risks and events. Objectives The assessment of affective temperament profile of hypertensive patients. Aims Explore affective temperaments, anxiety and depression in a hypertensive population in primary care settings. Methods 214 consecutive hypertensive and 90 control subjects completed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoqestionnaire (TEMPS-A), Hamilton Anxiety Scale (HAM-A) and Beck Depression Inventory (BDI). For comparisons, Mann-Whitney U test was applied. Results Hypertensive patients scored significantly higher in both BDI (Uxa0=xa06854; pxa0=xa00,002) and HAM-A (Uxa0=xa06543; pxa0=xa00,004). Hypertensives also had significantly higher (Uxa0=xa08214; pxa0=xa00,029) irritable temperament scores, while there was no significant difference in case of the other temperaments. Controlling for diagnosed depression rendered the effect of irritable temperament on hypertensives only marginally significant (Uxa0=xa05836; pxa0=xa00,053). Conclusions Our results suggest that BDI and HAM-A could be effectively used in primary care for screening patients with high cardiovascular risk. The more marked presence of the irritable temperament in the hypertensive group reveals new information, since it may mediate susceptibility to behavioural risk factors and reaction to stressful life events known to play a role in cardiovascular risk. Exploration the relationship between irritable temperament and Type A behaviour needs further studies.

Pharmacologial Prevention of Suicide

Pharmacological prevention of suicide in patients with mood disorder Zoltan Rihmer Semmelweis University National Institute of Psychiatry and Addictions In spite of the fact that around two-thirds of suicide victims have current major depressive episode, and up-to half of them contact different levels of health-care services during the last 4 weeks of their life, over 80% of depressed suicides are untreated or inadequately treated. However, several large-scale, naturalistic, observational follow-up studies show that successful acute and long-term treatment of major depression (with antidepressants) and bipolar disorders (with mood stabilizers, antidepressants and/or antipsychotics) markedly reduces the risk of further suicide attempts and committed suicide. Suicidal behaviour in unipolar depressives taking antidepressants is relatively most frequent among nonresponders and in the first 10-14 days of the treatment, several days before the start of action of the drug. Register based cohort studies also found that continuous treatment with antidepressants or mood stabilizers substantially reduced the risk of subsequent suicidal behaviour in unipolar or bipolar patients compared to those who were not pharmacologically treated. The marked decline of national suicide rates in countries where antidepressant utilization increased by three-to-eightfold recently also supports the antisuicidal effect of antidepressants, even on the level of general population. As anxiety, insomnia and psychotic features markedly increase the suicide risk among depressives, supplementary medication with anxiolytics in the case of insommnia or comorbid anxiety and with atypical antipsychotics in patients with psychotic depression is also necessary at least for short-time. However, psychosocial interventions, including psycho-education are allways needed.

Spatial and temporal distribution of suicidal behaviour with a special focus on Hungary: Understanding the variations

This article challenges the traditional viewpoint of attempted suicide as a generic term. It argues that greater use could be made, by both medical and nursing staff, of the terms parasuicide and attempted suicide, and that therapeutic intervention could be improved if both terms are considered when making a diagnosis.Part I: Theoretical Underpinnings 1.Conceptualizing Suicidal Behaviour: Understanding and Prevention Hardeep Lal Joshi, Vijay Parkash and Updesh Kumar 2.Genetics of Suicidal Behaviour Marco Sarchiapone and Miriam Iosue 3.Suicidality and Personality: Linking Pathways Vijay Parkash and Updesh Kumar 4.Role of Emotion Dysregulation in Suicidality Michael D. Anestis 5.The Role of Aggression and Impulsivity in Suicide Attempts and In Suicide Completion Yari Gvion and Alan Apter 6.Psychosocial Stress and Suicidal Behaviour Vsevolod A. Rozanov 7.From Social Adversity to Psychological Pain: A Pathway to Suicide Emilie Olie and Philippe Courtet 8.Clustering and Contagion of Suicidal Behaviour Ella Arensman and Carmel McAuliffe Part II: Varied Research Evidences & Assessment Perspectives 9.Suicidal Ideation and Behaviour among Sexual Minority Youth: Correlates, Vulnerabilities, and Protective Factors Samantha Pflum, Peter Goldblum, Bruce Bongar, Kaitlin Venema and Joseph Tomlins 10.Spatial and Temporal Distribution of Suicidal Behaviour with a Special Focus on Hungary - Understanding the Variations Zoltan Rihmer, Xenia Gonda and Peter Dome 11.Suicide in the United States Military Tracy A. Clemans and Craig J. Bryan 12.Contribution of Alcohol in Suicide Mortality in Eastern Europe Yury E. Razvodovsky 13.Media Representation of Suicide in Various Societies: A Critical Review Qijin Cheng and Paul Yip Siu Fai 14.Formal Assessment of Suicide Risk Bruce Bongar, Elvin Sheykhani, Uri Kugel and David Giannini 15.Cultural Competent Suicide Assessment Uri Kugel, Lori Holleran, Kasie Hummel, Joyce Chu, Peter Goldblum and Bruce Bongar 16.Ethical and Legal Issues in Dealing with Suicidal Behaviour Swati Mukherjee and Updesh Kumar

EPA-1314 - Affective temperaments in the background of acute cardiac complications in primary hypertension

Introduction/Objectives Recent research on depression treatment of cardiac patients indicated that there are depressive subtypes at higher risk for cardiovascular complications and exploring personality types with negative affect may help to identify them. Aims To explore the association of affective temperaments with cardiac complications in primary hypertensive (HT) outpatients. Methods Data of 228 HT patients, controlled monthly for hypertension by their GPs, was analysed. TEMPS-A and BDI was applied to measure stable affective temperamental traits and depressive symptoms. ICD-10 diagnosed depression, antidepressant medication and cardiac complications (CC) required acute coronary intervention (acute coronary syndrome or acute myocardial infarction) was checked from patients’ medical records. Results Mean age was 64 (SD±14) years and mean duration of hypertension was 14 (SD±7) years. 16 patients out of 228 developed cardiac complications (CC+). Age, gender, systolic blood pressure, BMI, smoking, HDL cholesterol level, years of hypertension, ICD-10 diagnosed depression, BDI point score and family history of cardiovascular diseases (CVD) did not reveal significant differences between those with or without CC. However, serum cholesterol level was significantly lower (U=997, p=0.01) and bigger proportion of three or more CVDs was found (χ 2 (1)=24.4, p Conclusion Cyclothymic temperament with lability and rapid mood shifts as main characteristics may help to identify hypertensive patients in greater risk of cardiovascular complications irrespective of depression.

EPA-1065 – There is a method in madness: are affective disorders and affective temperaments evolutionally adaptive?

In spite of the great burden and adaptive disadvantage associated with them, psychiatric illnesses do not become extinct over time with evolution. The most investigated and accepted explanation for this is that the genes encoding for risk of psychiatric illnesses also encode for traits determining greater adaptational and evolutionary success, most observable in healthy first degree relatives of psychiatric patients, sharing overlapping genotypes and exhibiting attenuated manifestations of the relevant endophenotypes. Besides the burden associated with affective illness, the advantage of genes and related (endo)phenotypes is observable on the individual and group/social level aiding several aspects of survival and reproduction. In order to gain deeper insight into the advantageous and disadvantageous sides of mood disorders as distinct integral entities, decomposing these illnesses into smaller and more easily characterizable phenomena such as their affective temperamental bases may reveal how these disorders carry multiple possibly adaptive aspects. Furthermore, in a recent paper, a parallel pattern of distribution was found between the relative frequency of certain dominant affective temperaments and relative scores on Hofstedes cultural indexes investigating data from six countries. Matching distributions for scores were identified for depressive temperament and individualism-collectivism, hyperthymic temperament and uncertainty avoidance, and irritable temperament and power distance. These findings indicate an important relationship between affective temperaments and cultural dimensions, suggesting that these phenomena may be the manifestations of the same genetically determined predispositions in different forms, and that affective temperaments, also considered the precursors of affective illness, play a role on social-cultural evolution and adaptation as well.

P-177 - Hopelessness and suicidality in major depressive disorder in patients with cyclothymic temperament

Background The aim of the present study was to assess sociodemographic and clinical differences between BD patients, pure MDD patients, and MDD patients with cyclothymic temperament (MDD-CYC). Methods Participants were 281 adult inpatients (134 men and 147 women) consecutively admitted to the Department of Psychiatry of the SantAndrea University Hospital in Rome, Italy, between January 2008 and June 2010. The patients completed the Hamilton Scale for Depression (HAMD 17 ), the Young Mania Rating Scale, the TEMPS-A (Temperament Evaluation of the Memphis, Pisa, Paris and San Diego - Autoquestionnaire) and the Beck Hopelessness Scale. Results 38.7% of the MDD patients met criteria to be included in the MDD-CYC group. Above 93% of the MDD-CYC reported suicidal ideation (27.6% suicide attempts) at the item 3 of the HAMD 17 .Furthermore, MDD-CYC patients reported higher hopelessness compered to other patients. Limitations Our results are potentially limited by the small number of MDD-CYC patients included in the sample. Conclusions Our results support the clinical usefulness of the concept of soft bipolar spectrum. Patients with unipolar depression and cyclothymic temperament differ from pure MDD patients and BD patients in terms of temperamental profile and clinical variables.