Bipolar Disorder

LAS VEGAS – A growing body of evidence suggests that a high proportion of men with hypersexual disorder have an axis I psychiatric comorbidity such as attention-deficit/hyperactivity disorder, an association that can easily fly under a clinician’s radar.

"ADHD is very prominent in men with hypersexual disorder who come to see me now, occurring about 45% of the time," Dr. Martin Kafka said at the annual psychopharmacology update held by the Nevada Psychiatric Association. "I spend half of my time trying to get authorizations for them to be prescribed stimulants."

Men with ADHD tend to "look for something novel when they’re feeling dysphoric affect like boredom or when they’re depressed," continued Dr. Kafka, clinical associate professor of psychiatry at Harvard Medical School, Boston, and an authority on hypersexual disorder (HD). "They procrastinate, so when they’re facing stressful events they escape through their sexual behavior. Pornography is very tempting, because it can be viewed with just the click of a button."

He based his remarks on an analysis of medical records from about 150 HD patients he’s treated in recent years, with a goal of expanding that data set to at least 300. Previous studies he published from 1994 to 2002 suggested that the association between HD and ADHD ranged from 17% to 19%. Those studies also found that dysthymia was the most common coexisting axis I disorder in HD patients, occurring 61%-62% of the time, followed by alcohol abuse (25%-39%) and social phobia (22%-25%).

In Dr. Kafka’s current clinical practice, about 26% of men with HD that he counsels also have bipolar spectrum disorder. "What’s interesting is that this tends to occur in patients with cyclothymic disorder or bipolar disorder not otherwise specified," he said. "It’s the ones who have hypomanias lasting 1-2 days, but repetitively, who have a family history of the illness. In community samples, about 5% of the population meets criteria for hypomania if you shorten the duration to 1-2 days. We really need to be sensitive about brief, recurrent hypomanias and things like cyclothymic disorder, where you’re not depressed for that long."

Though one hallmark symptom of major depressive disorder (MDD) is decreased sexual interest, a small body of literature suggests that the opposite might be true. "This sounds counterintuitive, but subgroups of patients with MDD can have increased sexual behavior," Dr. Kafka said. "Some can have chronically increased sexual behavior." In one 1993 study of cognitive therapy in 40 subjects who were having problems with sexual arousal, 28 got better. The 12 who didn’t get better had chronic low-grade depression" (Arch. Gen. Psychiatry 1993;50:24-30).

Other investigators have reported that when men are depressed, they are more likely to respond to dysphoric affect through action and impulsivity (Arch. Sexual Behav. 2003; 32:217-30). "So even though it’s counterintuitive, depressive disorders can be associated with hypersexuality," Dr. Kafka said.

Treatment of axis I disorders, when executed properly, can positively affect outcomes for patients with HD. "Consider doing a thorough diagnostic evaluation," Dr. Kafka advised. "If they’re not getting better with nonpharmacological treatments, or their behavior is endangering them, then medications could be indicated." He went on to note that the medical model "goes a long way to destigmatize behavior in patients with HD. Yes, there are people who do immoral acts. Promiscuous behavior is an immoral act. But it could be embedded in a psychiatric disorder, which makes it much more complex. It makes it much more understandable; it can destigmatize the person. The person is not just a philanderer; the person is somebody who has an affliction, whose symptom is philandering. They will connect with you if you say this is a medical psychiatric disorder and not just a moral issue."

Though no controlled studies exist on treatment strategies for HD, Dr. Kafka recommended integrating psychiatric diagnosis into the treatment of HD. He also recommended proactive communication with other mental health professionals in helping derive "a good diagnostic picture" of certain patients and educating them about subthreshold adult manifestations of psychiatric diagnoses. "Of course, they can’t really help you with identifying bipolar spectrum disorder or ADHD unless they’re educated about it, but it’s helpful when a psychotherapist tells you that a patient looked hypomanic to him," Dr. Kafka explained. "The next time you see that patient, you might want to ask about that."

He also recommended educating HD patients as much as possible about their illness from resources such as the Society for the Advancement of Sexual Health (www.sash.net) "because these are chronic, early-onset disorders. They’re going to have them for the rest of their lives. Unless they understand them, they’re going to use medication inappropriately, they’re not going to be as treatment compliant and collaborative, and they’re going to relapse."

As to treatment approaches for HD itself, Dr. Kafka recommended a "here and now" approach that involves external interventions to limit access to computers and smart phones, such as phone block, Internet filters with kept passwords, moving the computer to a more public location, changing Internet service providers, and removing credit cards. He acknowledged that disclosing HD to an unsuspecting spouse can be "a minefield. Unless a spouse is prepared to find out about this, it’s devastating, because this is a secret disorder. Many times the spouse has no clue. I’m not going to say don’t tell the spouse, I’m going to say be very careful with your patient about what might be a strategy and when a spouse should find out. When the spouse finds out, it’s important that the spouse be in treatment, that they know how to get some help."

Frequent 12-step meetings that include daily contact with a sponsor are typically indicated for patients with HD, he added, along with individual psychotherapy and some cognitive-behavioral therapy.

"Hypersexuality is a dimension of human behavior; it can be treated," Dr. Kafka concluded. "The psychiatrist is an important player in all this."

Dr. Kafka said that he had no relevant financial conflicts to disclose.

[email protected]

LAS VEGAS – A growing body of evidence suggests that a high proportion of men with hypersexual disorder have an axis I psychiatric comorbidity such as attention-deficit/hyperactivity disorder, an association that can easily fly under a clinician’s radar.

"ADHD is very prominent in men with hypersexual disorder who come to see me now, occurring about 45% of the time," Dr. Martin Kafka said at the annual psychopharmacology update held by the Nevada Psychiatric Association. "I spend half of my time trying to get authorizations for them to be prescribed stimulants."

Men with ADHD tend to "look for something novel when they’re feeling dysphoric affect like boredom or when they’re depressed," continued Dr. Kafka, clinical associate professor of psychiatry at Harvard Medical School, Boston, and an authority on hypersexual disorder (HD). "They procrastinate, so when they’re facing stressful events they escape through their sexual behavior. Pornography is very tempting, because it can be viewed with just the click of a button."

He based his remarks on an analysis of medical records from about 150 HD patients he’s treated in recent years, with a goal of expanding that data set to at least 300. Previous studies he published from 1994 to 2002 suggested that the association between HD and ADHD ranged from 17% to 19%. Those studies also found that dysthymia was the most common coexisting axis I disorder in HD patients, occurring 61%-62% of the time, followed by alcohol abuse (25%-39%) and social phobia (22%-25%).

In Dr. Kafka’s current clinical practice, about 26% of men with HD that he counsels also have bipolar spectrum disorder. "What’s interesting is that this tends to occur in patients with cyclothymic disorder or bipolar disorder not otherwise specified," he said. "It’s the ones who have hypomanias lasting 1-2 days, but repetitively, who have a family history of the illness. In community samples, about 5% of the population meets criteria for hypomania if you shorten the duration to 1-2 days. We really need to be sensitive about brief, recurrent hypomanias and things like cyclothymic disorder, where you’re not depressed for that long."

Though one hallmark symptom of major depressive disorder (MDD) is decreased sexual interest, a small body of literature suggests that the opposite might be true. "This sounds counterintuitive, but subgroups of patients with MDD can have increased sexual behavior," Dr. Kafka said. "Some can have chronically increased sexual behavior." In one 1993 study of cognitive therapy in 40 subjects who were having problems with sexual arousal, 28 got better. The 12 who didn’t get better had chronic low-grade depression" (Arch. Gen. Psychiatry 1993;50:24-30).

Other investigators have reported that when men are depressed, they are more likely to respond to dysphoric affect through action and impulsivity (Arch. Sexual Behav. 2003; 32:217-30). "So even though it’s counterintuitive, depressive disorders can be associated with hypersexuality," Dr. Kafka said.

Treatment of axis I disorders, when executed properly, can positively affect outcomes for patients with HD. "Consider doing a thorough diagnostic evaluation," Dr. Kafka advised. "If they’re not getting better with nonpharmacological treatments, or their behavior is endangering them, then medications could be indicated." He went on to note that the medical model "goes a long way to destigmatize behavior in patients with HD. Yes, there are people who do immoral acts. Promiscuous behavior is an immoral act. But it could be embedded in a psychiatric disorder, which makes it much more complex. It makes it much more understandable; it can destigmatize the person. The person is not just a philanderer; the person is somebody who has an affliction, whose symptom is philandering. They will connect with you if you say this is a medical psychiatric disorder and not just a moral issue."

Though no controlled studies exist on treatment strategies for HD, Dr. Kafka recommended integrating psychiatric diagnosis into the treatment of HD. He also recommended proactive communication with other mental health professionals in helping derive "a good diagnostic picture" of certain patients and educating them about subthreshold adult manifestations of psychiatric diagnoses. "Of course, they can’t really help you with identifying bipolar spectrum disorder or ADHD unless they’re educated about it, but it’s helpful when a psychotherapist tells you that a patient looked hypomanic to him," Dr. Kafka explained. "The next time you see that patient, you might want to ask about that."

He also recommended educating HD patients as much as possible about their illness from resources such as the Society for the Advancement of Sexual Health (www.sash.net) "because these are chronic, early-onset disorders. They’re going to have them for the rest of their lives. Unless they understand them, they’re going to use medication inappropriately, they’re not going to be as treatment compliant and collaborative, and they’re going to relapse."

As to treatment approaches for HD itself, Dr. Kafka recommended a "here and now" approach that involves external interventions to limit access to computers and smart phones, such as phone block, Internet filters with kept passwords, moving the computer to a more public location, changing Internet service providers, and removing credit cards. He acknowledged that disclosing HD to an unsuspecting spouse can be "a minefield. Unless a spouse is prepared to find out about this, it’s devastating, because this is a secret disorder. Many times the spouse has no clue. I’m not going to say don’t tell the spouse, I’m going to say be very careful with your patient about what might be a strategy and when a spouse should find out. When the spouse finds out, it’s important that the spouse be in treatment, that they know how to get some help."

Frequent 12-step meetings that include daily contact with a sponsor are typically indicated for patients with HD, he added, along with individual psychotherapy and some cognitive-behavioral therapy.

"Hypersexuality is a dimension of human behavior; it can be treated," Dr. Kafka concluded. "The psychiatrist is an important player in all this."

Dr. Kafka said that he had no relevant financial conflicts to disclose.

[email protected]

LAS VEGAS – A growing body of evidence suggests that a high proportion of men with hypersexual disorder have an axis I psychiatric comorbidity such as attention-deficit/hyperactivity disorder, an association that can easily fly under a clinician’s radar.

"ADHD is very prominent in men with hypersexual disorder who come to see me now, occurring about 45% of the time," Dr. Martin Kafka said at the annual psychopharmacology update held by the Nevada Psychiatric Association. "I spend half of my time trying to get authorizations for them to be prescribed stimulants."

Men with ADHD tend to "look for something novel when they’re feeling dysphoric affect like boredom or when they’re depressed," continued Dr. Kafka, clinical associate professor of psychiatry at Harvard Medical School, Boston, and an authority on hypersexual disorder (HD). "They procrastinate, so when they’re facing stressful events they escape through their sexual behavior. Pornography is very tempting, because it can be viewed with just the click of a button."

He based his remarks on an analysis of medical records from about 150 HD patients he’s treated in recent years, with a goal of expanding that data set to at least 300. Previous studies he published from 1994 to 2002 suggested that the association between HD and ADHD ranged from 17% to 19%. Those studies also found that dysthymia was the most common coexisting axis I disorder in HD patients, occurring 61%-62% of the time, followed by alcohol abuse (25%-39%) and social phobia (22%-25%).

In Dr. Kafka’s current clinical practice, about 26% of men with HD that he counsels also have bipolar spectrum disorder. "What’s interesting is that this tends to occur in patients with cyclothymic disorder or bipolar disorder not otherwise specified," he said. "It’s the ones who have hypomanias lasting 1-2 days, but repetitively, who have a family history of the illness. In community samples, about 5% of the population meets criteria for hypomania if you shorten the duration to 1-2 days. We really need to be sensitive about brief, recurrent hypomanias and things like cyclothymic disorder, where you’re not depressed for that long."

Though one hallmark symptom of major depressive disorder (MDD) is decreased sexual interest, a small body of literature suggests that the opposite might be true. "This sounds counterintuitive, but subgroups of patients with MDD can have increased sexual behavior," Dr. Kafka said. "Some can have chronically increased sexual behavior." In one 1993 study of cognitive therapy in 40 subjects who were having problems with sexual arousal, 28 got better. The 12 who didn’t get better had chronic low-grade depression" (Arch. Gen. Psychiatry 1993;50:24-30).

Other investigators have reported that when men are depressed, they are more likely to respond to dysphoric affect through action and impulsivity (Arch. Sexual Behav. 2003; 32:217-30). "So even though it’s counterintuitive, depressive disorders can be associated with hypersexuality," Dr. Kafka said.

Treatment of axis I disorders, when executed properly, can positively affect outcomes for patients with HD. "Consider doing a thorough diagnostic evaluation," Dr. Kafka advised. "If they’re not getting better with nonpharmacological treatments, or their behavior is endangering them, then medications could be indicated." He went on to note that the medical model "goes a long way to destigmatize behavior in patients with HD. Yes, there are people who do immoral acts. Promiscuous behavior is an immoral act. But it could be embedded in a psychiatric disorder, which makes it much more complex. It makes it much more understandable; it can destigmatize the person. The person is not just a philanderer; the person is somebody who has an affliction, whose symptom is philandering. They will connect with you if you say this is a medical psychiatric disorder and not just a moral issue."

Though no controlled studies exist on treatment strategies for HD, Dr. Kafka recommended integrating psychiatric diagnosis into the treatment of HD. He also recommended proactive communication with other mental health professionals in helping derive "a good diagnostic picture" of certain patients and educating them about subthreshold adult manifestations of psychiatric diagnoses. "Of course, they can’t really help you with identifying bipolar spectrum disorder or ADHD unless they’re educated about it, but it’s helpful when a psychotherapist tells you that a patient looked hypomanic to him," Dr. Kafka explained. "The next time you see that patient, you might want to ask about that."

He also recommended educating HD patients as much as possible about their illness from resources such as the Society for the Advancement of Sexual Health (www.sash.net) "because these are chronic, early-onset disorders. They’re going to have them for the rest of their lives. Unless they understand them, they’re going to use medication inappropriately, they’re not going to be as treatment compliant and collaborative, and they’re going to relapse."

As to treatment approaches for HD itself, Dr. Kafka recommended a "here and now" approach that involves external interventions to limit access to computers and smart phones, such as phone block, Internet filters with kept passwords, moving the computer to a more public location, changing Internet service providers, and removing credit cards. He acknowledged that disclosing HD to an unsuspecting spouse can be "a minefield. Unless a spouse is prepared to find out about this, it’s devastating, because this is a secret disorder. Many times the spouse has no clue. I’m not going to say don’t tell the spouse, I’m going to say be very careful with your patient about what might be a strategy and when a spouse should find out. When the spouse finds out, it’s important that the spouse be in treatment, that they know how to get some help."

Frequent 12-step meetings that include daily contact with a sponsor are typically indicated for patients with HD, he added, along with individual psychotherapy and some cognitive-behavioral therapy.

"Hypersexuality is a dimension of human behavior; it can be treated," Dr. Kafka concluded. "The psychiatrist is an important player in all this."

Dr. Kafka said that he had no relevant financial conflicts to disclose.

[email protected]

Overgeneral autobiographical memory – an alteration in the specificity of memory from an individual’s life – is a characteristic of bipolar I disorder and relates to executive function, according to a report published in Comprehensive Psychiatry.

"We found a greater prevalence of overgeneralized [autobiographical memory] in [bipolar disorder] patients compared to healthy controls," wrote lead study author Woo Jung Kim of Yonsei University in Seoul, South Korea, and his associates. "Our results suggest [autobiographical memory] may be a characteristic of [bipolar disorder] along with certain cognitive functions."

The investigators recruited 28 bipolar I disorder patients from inpatient and outpatient clinics at Severance Mental Health Hospital, and 28 healthy age- and sex-matched controls. The patients were between the ages of 20 and 50.The researchers gave all participants the autobiographical memory test (AMT), a word-cuing technique aimed at assessing the degree of specificity of autobiographical memory, and a 2-hour neuropsychological battery to assess general intelligence, attention, verbal memory, verbal fluency, visual memory, and executive functions.

The AMT was adapted to Korean culture, using five positive adjectives (happy, successful, safe, interested, and loved) and five negative adjectives (hurtful, angry, lonely, failed, and dangerous). The words were written on paper cards and shown to participants one at a time, while those administering the test encouraged participants to recall specific memories and describe them in as much detail as possible within 1 minute each.

Each patient was interviewed using the Mini-International Neuropsychiatric Interview. Their residual mania symptoms were assessed using the Young Mania Rating Scale, and their depressive symptoms were assessed by the Montgomery-Asberg Depression Rating Scale. Patients with other medical or psychiatric comorbidities were excluded, as were those with mental retardation or a history of head trauma (Compr. Psychiatry 2014;55:290-7).

The investigators found the total and negative AMT scores to be significantly lower in the patients with bipolar disorder than in healthy controls. For example, among the patients with bipolar disorder, the total autobiographical memory test scores were 3.86 plus or minus 2.85, compared with 5.32 plus or minus 2.57 among the healthy controls. Meanwhile, the negative autobiographical memory test scores were 1.86 plus or minus 1.38 among the patients with bipolar disorder and 2.75 plus or minus 1.40 among the healthy controls.

In addition, the patients with bipolar disorder "tended to report more general and fewer specific positive memories than did the healthy controls, although the difference was not statistically significant." The bipolar disorder group had significantly lower verbal memory, verbal fluency, and visual memory test scores than the healthy controls, but the results of tests for executive function were not different between the groups.

In bipolar disorder patients, the AMT scores correlated significantly with intelligence and perseverative errors. In healthy controls, they correlated with verbal memory and fluency.

The investigators cited several limitations. The sample size was fairly small, but it was similar to that of previous studies of autobiographical memory and bipolar disorder, they said. None of the patients in the study had psychotic symptoms at the time of enrollment, but the investigators did not access the patients’ prior history of such symptoms.

"Future research should investigate the specific [autobiographical memory] neural network in [bipolar disorder] individuals and examine the relationship between [autobiographical memory] and psychosocial functions and quality of life," the authors wrote. This may provide insight into the benefit of additional treatment focusing on overgeneral autobiographical memory in bipolar disorder, they said.

This study was supported by the Korea Healthcare Technology R&D Project of the Ministry of Health & Welfare of the Republic of Korea. The authors reported no relevant financial disclosures.

Overgeneral autobiographical memory – an alteration in the specificity of memory from an individual’s life – is a characteristic of bipolar I disorder and relates to executive function, according to a report published in Comprehensive Psychiatry.

"We found a greater prevalence of overgeneralized [autobiographical memory] in [bipolar disorder] patients compared to healthy controls," wrote lead study author Woo Jung Kim of Yonsei University in Seoul, South Korea, and his associates. "Our results suggest [autobiographical memory] may be a characteristic of [bipolar disorder] along with certain cognitive functions."

The investigators recruited 28 bipolar I disorder patients from inpatient and outpatient clinics at Severance Mental Health Hospital, and 28 healthy age- and sex-matched controls. The patients were between the ages of 20 and 50.The researchers gave all participants the autobiographical memory test (AMT), a word-cuing technique aimed at assessing the degree of specificity of autobiographical memory, and a 2-hour neuropsychological battery to assess general intelligence, attention, verbal memory, verbal fluency, visual memory, and executive functions.

The AMT was adapted to Korean culture, using five positive adjectives (happy, successful, safe, interested, and loved) and five negative adjectives (hurtful, angry, lonely, failed, and dangerous). The words were written on paper cards and shown to participants one at a time, while those administering the test encouraged participants to recall specific memories and describe them in as much detail as possible within 1 minute each.

Each patient was interviewed using the Mini-International Neuropsychiatric Interview. Their residual mania symptoms were assessed using the Young Mania Rating Scale, and their depressive symptoms were assessed by the Montgomery-Asberg Depression Rating Scale. Patients with other medical or psychiatric comorbidities were excluded, as were those with mental retardation or a history of head trauma (Compr. Psychiatry 2014;55:290-7).

The investigators found the total and negative AMT scores to be significantly lower in the patients with bipolar disorder than in healthy controls. For example, among the patients with bipolar disorder, the total autobiographical memory test scores were 3.86 plus or minus 2.85, compared with 5.32 plus or minus 2.57 among the healthy controls. Meanwhile, the negative autobiographical memory test scores were 1.86 plus or minus 1.38 among the patients with bipolar disorder and 2.75 plus or minus 1.40 among the healthy controls.

In addition, the patients with bipolar disorder "tended to report more general and fewer specific positive memories than did the healthy controls, although the difference was not statistically significant." The bipolar disorder group had significantly lower verbal memory, verbal fluency, and visual memory test scores than the healthy controls, but the results of tests for executive function were not different between the groups.

In bipolar disorder patients, the AMT scores correlated significantly with intelligence and perseverative errors. In healthy controls, they correlated with verbal memory and fluency.

The investigators cited several limitations. The sample size was fairly small, but it was similar to that of previous studies of autobiographical memory and bipolar disorder, they said. None of the patients in the study had psychotic symptoms at the time of enrollment, but the investigators did not access the patients’ prior history of such symptoms.

"Future research should investigate the specific [autobiographical memory] neural network in [bipolar disorder] individuals and examine the relationship between [autobiographical memory] and psychosocial functions and quality of life," the authors wrote. This may provide insight into the benefit of additional treatment focusing on overgeneral autobiographical memory in bipolar disorder, they said.

This study was supported by the Korea Healthcare Technology R&D Project of the Ministry of Health & Welfare of the Republic of Korea. The authors reported no relevant financial disclosures.

Overgeneral autobiographical memory – an alteration in the specificity of memory from an individual’s life – is a characteristic of bipolar I disorder and relates to executive function, according to a report published in Comprehensive Psychiatry.

"We found a greater prevalence of overgeneralized [autobiographical memory] in [bipolar disorder] patients compared to healthy controls," wrote lead study author Woo Jung Kim of Yonsei University in Seoul, South Korea, and his associates. "Our results suggest [autobiographical memory] may be a characteristic of [bipolar disorder] along with certain cognitive functions."

The investigators recruited 28 bipolar I disorder patients from inpatient and outpatient clinics at Severance Mental Health Hospital, and 28 healthy age- and sex-matched controls. The patients were between the ages of 20 and 50.The researchers gave all participants the autobiographical memory test (AMT), a word-cuing technique aimed at assessing the degree of specificity of autobiographical memory, and a 2-hour neuropsychological battery to assess general intelligence, attention, verbal memory, verbal fluency, visual memory, and executive functions.

The AMT was adapted to Korean culture, using five positive adjectives (happy, successful, safe, interested, and loved) and five negative adjectives (hurtful, angry, lonely, failed, and dangerous). The words were written on paper cards and shown to participants one at a time, while those administering the test encouraged participants to recall specific memories and describe them in as much detail as possible within 1 minute each.

Each patient was interviewed using the Mini-International Neuropsychiatric Interview. Their residual mania symptoms were assessed using the Young Mania Rating Scale, and their depressive symptoms were assessed by the Montgomery-Asberg Depression Rating Scale. Patients with other medical or psychiatric comorbidities were excluded, as were those with mental retardation or a history of head trauma (Compr. Psychiatry 2014;55:290-7).

The investigators found the total and negative AMT scores to be significantly lower in the patients with bipolar disorder than in healthy controls. For example, among the patients with bipolar disorder, the total autobiographical memory test scores were 3.86 plus or minus 2.85, compared with 5.32 plus or minus 2.57 among the healthy controls. Meanwhile, the negative autobiographical memory test scores were 1.86 plus or minus 1.38 among the patients with bipolar disorder and 2.75 plus or minus 1.40 among the healthy controls.

In addition, the patients with bipolar disorder "tended to report more general and fewer specific positive memories than did the healthy controls, although the difference was not statistically significant." The bipolar disorder group had significantly lower verbal memory, verbal fluency, and visual memory test scores than the healthy controls, but the results of tests for executive function were not different between the groups.

In bipolar disorder patients, the AMT scores correlated significantly with intelligence and perseverative errors. In healthy controls, they correlated with verbal memory and fluency.

The investigators cited several limitations. The sample size was fairly small, but it was similar to that of previous studies of autobiographical memory and bipolar disorder, they said. None of the patients in the study had psychotic symptoms at the time of enrollment, but the investigators did not access the patients’ prior history of such symptoms.

"Future research should investigate the specific [autobiographical memory] neural network in [bipolar disorder] individuals and examine the relationship between [autobiographical memory] and psychosocial functions and quality of life," the authors wrote. This may provide insight into the benefit of additional treatment focusing on overgeneral autobiographical memory in bipolar disorder, they said.

This study was supported by the Korea Healthcare Technology R&D Project of the Ministry of Health & Welfare of the Republic of Korea. The authors reported no relevant financial disclosures.

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

Statewide health care reform in Massachusetts did not increase inpatient admissions for behavioral diagnoses among adolescents and young adults, as some had feared. Instead, reform led to a decrease in such admissions, a report published online Feb. 19 in JAMA Psychiatry showed.

This suggests nationwide health care reform might have a similar effect, at least in states that, like Massachusetts, offer robust hospital-based mental health services.

©AndreyPopov/thinkstockphotos.com

One major goal of health care reform is to extend insurance coverage to populations least likely to have it, such as young adults. Given that most behavioral health disorders emerge in adolescence and young adulthood, some experts were concerned that newly acquired insurance coverage for this age group might lead to increases in hospital and emergency department admissions for behavioral issues, said Ellen Meara, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, N.H., and her associates.

To assess whether the enactment of national health care reform might lead to a sharp increase in such hospital and ED admissions, the investigators examined the experience in Massachusetts after statewide health care reform was enacted there in 2006.

They analyzed the records of 2,533,307 admissions for any diagnosis and 6,817,855 ED visits for any diagnosis and focused on young adults aged 19-25 years – "a group with relatively high behavioral health needs and low rates of insurance coverage prior to reform" (JAMA Psychiatry 2014 Feb. 19 [doi:10.1001/jamapsychiatry.2013.3972]).

Dr. Meara and her associates found that the uninsured rate fell from 26% to 10% among this population after health reform. The increase in insurance coverage was accompanied by a decline in patient admission rates and ED visits for young adults with behavioral health diagnoses. The drop was fueled primarily by a decrease in admissions and ED visits for substance use disorders. This pattern suggests that most of these patients are being redirected – appropriately – to outpatient services, Dr. Meara and her associates said.

The findings are reassuring in that they appear to show that young people with behavioral health issues will now find the care they need to be more accessible and affordable, without increasing the burden on hospitals or raising inpatient costs, they said.

Dr. Meara and her associates cited a few limitations. For example, outpatient treatment for mental illness or substance use disorders was not observed. "Thus, we cannot infer whether use of hospital-based care for mental illness and substance use disorders represents lower rates of morbidity in the population, effective care in outpatient settings, or restrictions on use of hospital-based settings," they wrote. In addition, they did not look at admissions to psychiatric or alcohol or chemical-dependency facilities.

Still, the data "offer a snapshot of one aspect of policies to improve access to behavioral health treatment, expanded insurance coverage," they said.

The study was supported by the National Institutes of Health and the National Institute of Drug Abuse. No financial conflicts of interest were reported.

Statewide health care reform in Massachusetts did not increase inpatient admissions for behavioral diagnoses among adolescents and young adults, as some had feared. Instead, reform led to a decrease in such admissions, a report published online Feb. 19 in JAMA Psychiatry showed.

This suggests nationwide health care reform might have a similar effect, at least in states that, like Massachusetts, offer robust hospital-based mental health services.

©AndreyPopov/thinkstockphotos.com

One major goal of health care reform is to extend insurance coverage to populations least likely to have it, such as young adults. Given that most behavioral health disorders emerge in adolescence and young adulthood, some experts were concerned that newly acquired insurance coverage for this age group might lead to increases in hospital and emergency department admissions for behavioral issues, said Ellen Meara, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, N.H., and her associates.

To assess whether the enactment of national health care reform might lead to a sharp increase in such hospital and ED admissions, the investigators examined the experience in Massachusetts after statewide health care reform was enacted there in 2006.

They analyzed the records of 2,533,307 admissions for any diagnosis and 6,817,855 ED visits for any diagnosis and focused on young adults aged 19-25 years – "a group with relatively high behavioral health needs and low rates of insurance coverage prior to reform" (JAMA Psychiatry 2014 Feb. 19 [doi:10.1001/jamapsychiatry.2013.3972]).

Dr. Meara and her associates found that the uninsured rate fell from 26% to 10% among this population after health reform. The increase in insurance coverage was accompanied by a decline in patient admission rates and ED visits for young adults with behavioral health diagnoses. The drop was fueled primarily by a decrease in admissions and ED visits for substance use disorders. This pattern suggests that most of these patients are being redirected – appropriately – to outpatient services, Dr. Meara and her associates said.

The findings are reassuring in that they appear to show that young people with behavioral health issues will now find the care they need to be more accessible and affordable, without increasing the burden on hospitals or raising inpatient costs, they said.

Dr. Meara and her associates cited a few limitations. For example, outpatient treatment for mental illness or substance use disorders was not observed. "Thus, we cannot infer whether use of hospital-based care for mental illness and substance use disorders represents lower rates of morbidity in the population, effective care in outpatient settings, or restrictions on use of hospital-based settings," they wrote. In addition, they did not look at admissions to psychiatric or alcohol or chemical-dependency facilities.

Still, the data "offer a snapshot of one aspect of policies to improve access to behavioral health treatment, expanded insurance coverage," they said.

The study was supported by the National Institutes of Health and the National Institute of Drug Abuse. No financial conflicts of interest were reported.

Statewide health care reform in Massachusetts did not increase inpatient admissions for behavioral diagnoses among adolescents and young adults, as some had feared. Instead, reform led to a decrease in such admissions, a report published online Feb. 19 in JAMA Psychiatry showed.

This suggests nationwide health care reform might have a similar effect, at least in states that, like Massachusetts, offer robust hospital-based mental health services.

©AndreyPopov/thinkstockphotos.com

One major goal of health care reform is to extend insurance coverage to populations least likely to have it, such as young adults. Given that most behavioral health disorders emerge in adolescence and young adulthood, some experts were concerned that newly acquired insurance coverage for this age group might lead to increases in hospital and emergency department admissions for behavioral issues, said Ellen Meara, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, N.H., and her associates.

To assess whether the enactment of national health care reform might lead to a sharp increase in such hospital and ED admissions, the investigators examined the experience in Massachusetts after statewide health care reform was enacted there in 2006.

They analyzed the records of 2,533,307 admissions for any diagnosis and 6,817,855 ED visits for any diagnosis and focused on young adults aged 19-25 years – "a group with relatively high behavioral health needs and low rates of insurance coverage prior to reform" (JAMA Psychiatry 2014 Feb. 19 [doi:10.1001/jamapsychiatry.2013.3972]).

Dr. Meara and her associates found that the uninsured rate fell from 26% to 10% among this population after health reform. The increase in insurance coverage was accompanied by a decline in patient admission rates and ED visits for young adults with behavioral health diagnoses. The drop was fueled primarily by a decrease in admissions and ED visits for substance use disorders. This pattern suggests that most of these patients are being redirected – appropriately – to outpatient services, Dr. Meara and her associates said.

The findings are reassuring in that they appear to show that young people with behavioral health issues will now find the care they need to be more accessible and affordable, without increasing the burden on hospitals or raising inpatient costs, they said.

Dr. Meara and her associates cited a few limitations. For example, outpatient treatment for mental illness or substance use disorders was not observed. "Thus, we cannot infer whether use of hospital-based care for mental illness and substance use disorders represents lower rates of morbidity in the population, effective care in outpatient settings, or restrictions on use of hospital-based settings," they wrote. In addition, they did not look at admissions to psychiatric or alcohol or chemical-dependency facilities.

Still, the data "offer a snapshot of one aspect of policies to improve access to behavioral health treatment, expanded insurance coverage," they said.

The study was supported by the National Institutes of Health and the National Institute of Drug Abuse. No financial conflicts of interest were reported.

Whole brain tractography imaging shows decreased white matter integrity in patients with bipolar I disorder, compared with individuals without the disorder, a study published online in JAMA Psychiatry shows.

This effect was even more pronounced in bipolar patients with a history of psychotic features, defined as the patient having had at least one manic or depressive episode with delusions or hallucinations, wrote Samuel Sarrazin and his colleagues.

The investigators compared generalized fractional anisotropy (GFA) values in 118 bipolar I patients recruited from multiple university-affiliated centers in France, Germany, and the United States, with a control group of 86 participants who had no personal or family history of Axis I mood disorders, schizophrenia, or schizoaffective disorder. A lower GFA value suggests loss of integrity or coherence of white matter, the authors said.

At all of the sites, the Montgomery-Åsberg Depression Rating Scale or the Hamilton Depression Rating Scale were administered, in addition to the Young Mania Rating Scale, and the National Adult Reading Test, reported Mr. Sarrazin, who is affiliated with several French medical institutions, including the Assistance Publique–Hôpitaux de Paris.

The mean age of disease onset among the patients with bipolar I was about 20.8 years, and the mean age at MRI was about 36.3 years. For the healthy controls, the mean age at MRI was 37.2 years (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4513]).

In a linear mixed-model analysis comparing the two groups, patients with bipolar I disorder had an average GFA value of 0.101 in the body of the corpus callosum, 0.113 in the splenium, and 0.079 in the anterior segment of the left hemisphere, compared with values of 0.102, 0.115, and 0.081, respectively, in the control group. Results remained significant when adjusting for false discovery rate (P = .03), and were consistent when researchers removed patients from the sample who had confounding factors such as elevated or mixed symptoms, the taking of lithium, and the existence of past alcohol abuse.

Bipolar I patients with a history of psychotic features had even lower GFA values than did bipolar patients with no psychotic history, with a mean GFA value of 0.100 in the body of the corpus callosum. This difference remained significant after adjusting for false discovery rate (P = .03).

"These results highlight the role of interhemispheric disconnectivity" in bipolar I disorder and suggest that bipolar I disorder with psychotic features "could be a relevant subtype of bipolar disorder with specific pathophysiological features," the investigators wrote. Additional large, multicenter studies are needed to compare bipolar I disorder with other psychotic disorders, and to further study such neuroimaging biomarkers, they added.

In an accompanying editorial, Dr. Kathryn R. Cullen and Dr. Kelvin O. Lim said that the latest findings advance the diffusion imaging literature in that the sample was large enough to address two important questions: "where [white matter] deficits are most consistent and how abnormalities vary across subtypes of [bipolar disorder]."

Furthermore, they said, the findings "conclusively affirm prior reports suggesting impaired [fractional anisotropy] in [white matter] tracts ... using state-of-the-art methods. Exciting contributions are the documentation of a more severe biological abnormality in the subgroup of patients with psychosis and additional evidence supporting an interhemispheric disconnectivity theory in [bipolar disorder]," wrote Dr. Cullen and Dr. Lim, both of the University of Minnesota, Minneapolis (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4638]).

Mr. Sarrazin and his colleagues cited several limitations to their study. First, they "did not explore the interrater and intersite reliability of the scales used in the study." Second, they did not include a "phantom procedure" to check the intercenter quality of the acquisitions. Third, the authors cannot exclude a possible effect of past medication use on the results. Fourth, given the large number of tracts to assess, the authors did not exploit other metrics from the orientation distribution function. Last, mean GFA values were calculated along each tract to perform comparisons, and localized decreases in GFA values might have gone undetected.

Neither Mr. Sarrazin nor his colleagues reported conflicts of interest. The study was funded by Alliance Nationale pour les Sciences de la Vie et de la Santé (aviesan), the Agence Nationale pour la Recherche, the Deutsche Forschungsgemeinschaft, the National Institute of Mental Health, and the Agence Régionale de Santé Ile-de-France.

[email protected]

Whole brain tractography imaging shows decreased white matter integrity in patients with bipolar I disorder, compared with individuals without the disorder, a study published online in JAMA Psychiatry shows.

This effect was even more pronounced in bipolar patients with a history of psychotic features, defined as the patient having had at least one manic or depressive episode with delusions or hallucinations, wrote Samuel Sarrazin and his colleagues.

The investigators compared generalized fractional anisotropy (GFA) values in 118 bipolar I patients recruited from multiple university-affiliated centers in France, Germany, and the United States, with a control group of 86 participants who had no personal or family history of Axis I mood disorders, schizophrenia, or schizoaffective disorder. A lower GFA value suggests loss of integrity or coherence of white matter, the authors said.

At all of the sites, the Montgomery-Åsberg Depression Rating Scale or the Hamilton Depression Rating Scale were administered, in addition to the Young Mania Rating Scale, and the National Adult Reading Test, reported Mr. Sarrazin, who is affiliated with several French medical institutions, including the Assistance Publique–Hôpitaux de Paris.

The mean age of disease onset among the patients with bipolar I was about 20.8 years, and the mean age at MRI was about 36.3 years. For the healthy controls, the mean age at MRI was 37.2 years (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4513]).

In a linear mixed-model analysis comparing the two groups, patients with bipolar I disorder had an average GFA value of 0.101 in the body of the corpus callosum, 0.113 in the splenium, and 0.079 in the anterior segment of the left hemisphere, compared with values of 0.102, 0.115, and 0.081, respectively, in the control group. Results remained significant when adjusting for false discovery rate (P = .03), and were consistent when researchers removed patients from the sample who had confounding factors such as elevated or mixed symptoms, the taking of lithium, and the existence of past alcohol abuse.

Bipolar I patients with a history of psychotic features had even lower GFA values than did bipolar patients with no psychotic history, with a mean GFA value of 0.100 in the body of the corpus callosum. This difference remained significant after adjusting for false discovery rate (P = .03).

"These results highlight the role of interhemispheric disconnectivity" in bipolar I disorder and suggest that bipolar I disorder with psychotic features "could be a relevant subtype of bipolar disorder with specific pathophysiological features," the investigators wrote. Additional large, multicenter studies are needed to compare bipolar I disorder with other psychotic disorders, and to further study such neuroimaging biomarkers, they added.

In an accompanying editorial, Dr. Kathryn R. Cullen and Dr. Kelvin O. Lim said that the latest findings advance the diffusion imaging literature in that the sample was large enough to address two important questions: "where [white matter] deficits are most consistent and how abnormalities vary across subtypes of [bipolar disorder]."

Furthermore, they said, the findings "conclusively affirm prior reports suggesting impaired [fractional anisotropy] in [white matter] tracts ... using state-of-the-art methods. Exciting contributions are the documentation of a more severe biological abnormality in the subgroup of patients with psychosis and additional evidence supporting an interhemispheric disconnectivity theory in [bipolar disorder]," wrote Dr. Cullen and Dr. Lim, both of the University of Minnesota, Minneapolis (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4638]).

Mr. Sarrazin and his colleagues cited several limitations to their study. First, they "did not explore the interrater and intersite reliability of the scales used in the study." Second, they did not include a "phantom procedure" to check the intercenter quality of the acquisitions. Third, the authors cannot exclude a possible effect of past medication use on the results. Fourth, given the large number of tracts to assess, the authors did not exploit other metrics from the orientation distribution function. Last, mean GFA values were calculated along each tract to perform comparisons, and localized decreases in GFA values might have gone undetected.

Neither Mr. Sarrazin nor his colleagues reported conflicts of interest. The study was funded by Alliance Nationale pour les Sciences de la Vie et de la Santé (aviesan), the Agence Nationale pour la Recherche, the Deutsche Forschungsgemeinschaft, the National Institute of Mental Health, and the Agence Régionale de Santé Ile-de-France.

[email protected]

Whole brain tractography imaging shows decreased white matter integrity in patients with bipolar I disorder, compared with individuals without the disorder, a study published online in JAMA Psychiatry shows.

This effect was even more pronounced in bipolar patients with a history of psychotic features, defined as the patient having had at least one manic or depressive episode with delusions or hallucinations, wrote Samuel Sarrazin and his colleagues.

The investigators compared generalized fractional anisotropy (GFA) values in 118 bipolar I patients recruited from multiple university-affiliated centers in France, Germany, and the United States, with a control group of 86 participants who had no personal or family history of Axis I mood disorders, schizophrenia, or schizoaffective disorder. A lower GFA value suggests loss of integrity or coherence of white matter, the authors said.

At all of the sites, the Montgomery-Åsberg Depression Rating Scale or the Hamilton Depression Rating Scale were administered, in addition to the Young Mania Rating Scale, and the National Adult Reading Test, reported Mr. Sarrazin, who is affiliated with several French medical institutions, including the Assistance Publique–Hôpitaux de Paris.

The mean age of disease onset among the patients with bipolar I was about 20.8 years, and the mean age at MRI was about 36.3 years. For the healthy controls, the mean age at MRI was 37.2 years (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4513]).

In a linear mixed-model analysis comparing the two groups, patients with bipolar I disorder had an average GFA value of 0.101 in the body of the corpus callosum, 0.113 in the splenium, and 0.079 in the anterior segment of the left hemisphere, compared with values of 0.102, 0.115, and 0.081, respectively, in the control group. Results remained significant when adjusting for false discovery rate (P = .03), and were consistent when researchers removed patients from the sample who had confounding factors such as elevated or mixed symptoms, the taking of lithium, and the existence of past alcohol abuse.

Bipolar I patients with a history of psychotic features had even lower GFA values than did bipolar patients with no psychotic history, with a mean GFA value of 0.100 in the body of the corpus callosum. This difference remained significant after adjusting for false discovery rate (P = .03).

"These results highlight the role of interhemispheric disconnectivity" in bipolar I disorder and suggest that bipolar I disorder with psychotic features "could be a relevant subtype of bipolar disorder with specific pathophysiological features," the investigators wrote. Additional large, multicenter studies are needed to compare bipolar I disorder with other psychotic disorders, and to further study such neuroimaging biomarkers, they added.

In an accompanying editorial, Dr. Kathryn R. Cullen and Dr. Kelvin O. Lim said that the latest findings advance the diffusion imaging literature in that the sample was large enough to address two important questions: "where [white matter] deficits are most consistent and how abnormalities vary across subtypes of [bipolar disorder]."

Furthermore, they said, the findings "conclusively affirm prior reports suggesting impaired [fractional anisotropy] in [white matter] tracts ... using state-of-the-art methods. Exciting contributions are the documentation of a more severe biological abnormality in the subgroup of patients with psychosis and additional evidence supporting an interhemispheric disconnectivity theory in [bipolar disorder]," wrote Dr. Cullen and Dr. Lim, both of the University of Minnesota, Minneapolis (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4638]).

Mr. Sarrazin and his colleagues cited several limitations to their study. First, they "did not explore the interrater and intersite reliability of the scales used in the study." Second, they did not include a "phantom procedure" to check the intercenter quality of the acquisitions. Third, the authors cannot exclude a possible effect of past medication use on the results. Fourth, given the large number of tracts to assess, the authors did not exploit other metrics from the orientation distribution function. Last, mean GFA values were calculated along each tract to perform comparisons, and localized decreases in GFA values might have gone undetected.

Neither Mr. Sarrazin nor his colleagues reported conflicts of interest. The study was funded by Alliance Nationale pour les Sciences de la Vie et de la Santé (aviesan), the Agence Nationale pour la Recherche, the Deutsche Forschungsgemeinschaft, the National Institute of Mental Health, and the Agence Régionale de Santé Ile-de-France.

[email protected]

Borderline personality disorder and bipolar II disorder share some common features, but the illnesses can be distinguished by patients’ differences in emotion regulation strategies and perceptions of how their parents raised them, according to a report published online in the Journal of Affective Disorders.

Forty-eight psychiatric outpatients, half with borderline personality disorder and half with bipolar II, were recruited by Kathryn Fletcher of the University of New South Wales, Sydney, and the Black Dog Institute, Randwick, and her colleagues. The mean age of the outpatients was 33 years. Those with borderline reported a younger age of depression onset, and a higher proportion of patients in that group had more lifetime suicide and attempts at self-harm.

The participants completed the Cognitive Emotion Regulation Questionnaire and the Difficulties in Emotion Regulation Scale, both 36-item tests aimed at assessing strategies to regulate emotion. They also completed the Measure of Parental Style, a test that seeks to assess perceived parent abuse, indifference, and overcontrol.

Overall, the investigators found that the outpatients with borderline personality disorder scored "significantly higher than those with [bipolar II] on a number of maladaptive emotion regulation strategies, including difficulty controlling impulsive behaviors, having limited access to emotion regulation strategies, and a tendency to self-blame, catastrophize, and blame others," Ms. Fletcher and her colleagues wrote (J. Affect. Disord. 2014;157:52-9).

They found that the outpatients with borderline personality disorder were "significantly less likely than those with [bipolar II] to use adaptive cognitive emotion regulation strategies, including planning, positive reappraisal, and putting things into perspective."

Those with borderline also scored significantly higher on most perceived parental style subscales, "indicating a maternal relationship characterized by indifference, abuse, and overcontrol and a paternal relationship characterized by abuse and overcontrol."

Identifying "maladaptive strategies to regulate emotion highlights specific targets for psychological intervention," the authors said. "However, given that those with [borderline personality disorder] and [bipolar II] displayed differing patterns of emotion dysregulation, there may be a need to tailor intervention strategies," such as positive reappraisal and promotion of acceptance in borderline.

Psychological therapies focusing on lessening the impact of "toxic childhood experiences" might help patients with both disorders, they said.

Ms. Fletcher and her colleagues cited several limitations. Among them were a relatively small sample size and the absence of statistical control for numerous sociodemographic and clinical characteristics that differed between the groups.

This study was supported by the National Health and Medical Research Council, Australia’s main funding body for medical research. The authors reported no relevant financial conflicts of interest.

Borderline personality disorder and bipolar II disorder share some common features, but the illnesses can be distinguished by patients’ differences in emotion regulation strategies and perceptions of how their parents raised them, according to a report published online in the Journal of Affective Disorders.

Forty-eight psychiatric outpatients, half with borderline personality disorder and half with bipolar II, were recruited by Kathryn Fletcher of the University of New South Wales, Sydney, and the Black Dog Institute, Randwick, and her colleagues. The mean age of the outpatients was 33 years. Those with borderline reported a younger age of depression onset, and a higher proportion of patients in that group had more lifetime suicide and attempts at self-harm.

The participants completed the Cognitive Emotion Regulation Questionnaire and the Difficulties in Emotion Regulation Scale, both 36-item tests aimed at assessing strategies to regulate emotion. They also completed the Measure of Parental Style, a test that seeks to assess perceived parent abuse, indifference, and overcontrol.

Overall, the investigators found that the outpatients with borderline personality disorder scored "significantly higher than those with [bipolar II] on a number of maladaptive emotion regulation strategies, including difficulty controlling impulsive behaviors, having limited access to emotion regulation strategies, and a tendency to self-blame, catastrophize, and blame others," Ms. Fletcher and her colleagues wrote (J. Affect. Disord. 2014;157:52-9).

They found that the outpatients with borderline personality disorder were "significantly less likely than those with [bipolar II] to use adaptive cognitive emotion regulation strategies, including planning, positive reappraisal, and putting things into perspective."

Those with borderline also scored significantly higher on most perceived parental style subscales, "indicating a maternal relationship characterized by indifference, abuse, and overcontrol and a paternal relationship characterized by abuse and overcontrol."

Identifying "maladaptive strategies to regulate emotion highlights specific targets for psychological intervention," the authors said. "However, given that those with [borderline personality disorder] and [bipolar II] displayed differing patterns of emotion dysregulation, there may be a need to tailor intervention strategies," such as positive reappraisal and promotion of acceptance in borderline.

Psychological therapies focusing on lessening the impact of "toxic childhood experiences" might help patients with both disorders, they said.

Ms. Fletcher and her colleagues cited several limitations. Among them were a relatively small sample size and the absence of statistical control for numerous sociodemographic and clinical characteristics that differed between the groups.

This study was supported by the National Health and Medical Research Council, Australia’s main funding body for medical research. The authors reported no relevant financial conflicts of interest.

Borderline personality disorder and bipolar II disorder share some common features, but the illnesses can be distinguished by patients’ differences in emotion regulation strategies and perceptions of how their parents raised them, according to a report published online in the Journal of Affective Disorders.

Forty-eight psychiatric outpatients, half with borderline personality disorder and half with bipolar II, were recruited by Kathryn Fletcher of the University of New South Wales, Sydney, and the Black Dog Institute, Randwick, and her colleagues. The mean age of the outpatients was 33 years. Those with borderline reported a younger age of depression onset, and a higher proportion of patients in that group had more lifetime suicide and attempts at self-harm.

The participants completed the Cognitive Emotion Regulation Questionnaire and the Difficulties in Emotion Regulation Scale, both 36-item tests aimed at assessing strategies to regulate emotion. They also completed the Measure of Parental Style, a test that seeks to assess perceived parent abuse, indifference, and overcontrol.

Overall, the investigators found that the outpatients with borderline personality disorder scored "significantly higher than those with [bipolar II] on a number of maladaptive emotion regulation strategies, including difficulty controlling impulsive behaviors, having limited access to emotion regulation strategies, and a tendency to self-blame, catastrophize, and blame others," Ms. Fletcher and her colleagues wrote (J. Affect. Disord. 2014;157:52-9).

They found that the outpatients with borderline personality disorder were "significantly less likely than those with [bipolar II] to use adaptive cognitive emotion regulation strategies, including planning, positive reappraisal, and putting things into perspective."

Those with borderline also scored significantly higher on most perceived parental style subscales, "indicating a maternal relationship characterized by indifference, abuse, and overcontrol and a paternal relationship characterized by abuse and overcontrol."

Identifying "maladaptive strategies to regulate emotion highlights specific targets for psychological intervention," the authors said. "However, given that those with [borderline personality disorder] and [bipolar II] displayed differing patterns of emotion dysregulation, there may be a need to tailor intervention strategies," such as positive reappraisal and promotion of acceptance in borderline.

Psychological therapies focusing on lessening the impact of "toxic childhood experiences" might help patients with both disorders, they said.

Ms. Fletcher and her colleagues cited several limitations. Among them were a relatively small sample size and the absence of statistical control for numerous sociodemographic and clinical characteristics that differed between the groups.

This study was supported by the National Health and Medical Research Council, Australia’s main funding body for medical research. The authors reported no relevant financial conflicts of interest.

Total sleep deprivation and light therapy relieve depression in bipolar patients but do not improve overall cognitive function, according to an Italian study published in the Journal of Affective Disorders.

In addition, bipolar patients "do not experience the well-known worsening of performance observed in healthy controls after sleep loss," said Sara Poletti, Ph.D., of the Scientific Institute and University Vita-Salute San Raffaele Turro, Milan, and her associates (J. Affect. Disord. 2014;156:144-9 [doi:10.1016/j.jad.2013.11.023]).

The investigators administered the Brief Assessment of Cognition in Schizophrenia (BACS) to 100 depressed bipolar I patients (DSM-IV) and 100 healthy controls, and then retested 42 subjects with bipolar disorder who underwent total sleep deprivation (TSD) and light therapy (LT), during which they were kept awake for three 36-hour periods over the course of a week, with bright lights shone on them for 30 minutes at 3 a.m. on TSD nights and in the morning after recovery sleep. The Hamilton Depression Rating Scale (HDRS) was administered to assess depression.

The mean age was 47 years in the bipolar group and 44 years in the control group. Both groups were made up of a majority of women. A quarter of the patients with bipolar disorder reported previous psychotic symptoms. Most of the TSD/LT patients were taking lithium, and some were taking other mood stabilizers, benzodiazepines, and antidepressants.

As expected from previous investigations, the 100 bipolar patients had significantly lower baseline cognitive function scores, showing impairment in verbal memory, working memory (digit sequencing), psychomotor coordination (token motor task), verbal fluency, selective attention (symbol coding), and executive function (Wisconsin Card Sorting Test).

Also in keeping with past studies, TSD/LT treatment caused an overall significant decrease in HDRS scores: 31 of the patients with bipolar (74%) achieved the strict remission criterion of HDRS score of less than 8 at day 7 and could be rated as full responders to treatment.

Regarding cognitive function, TSD and light therapy "showed a significant difference only for symbol coding (P less than 0.004). No significant differences were found for the remaining variables," Dr. Poletti and her associates said.

"Although most of the patients responded to TSD treatment reporting a clinical improvement of depressive symptomatology, cognitive deficits persisted in almost each function. The only improvement we observed was in symbol coding, confirming a positive effect of TSD on speed-of-information processing in bipolar patients," they wrote.

Also "in agreement with the literature, we found that as medication load decreases, cognitive performance improves. However, medication effects alone are not likely to fully account for the deficits described in these patients. We can hypothesize that TSD and LT act on cognitive functions through their effect on brain structures and neurotransmitter system[s]. Studies are needed to understand if remediation strategies such as those used for schizophrenia treatment could be introduced for bipolar patients," the investigators said.

Among the study limitations is that "the use and reporting of medications varied between patients, and it was very difficult to control for the potentially negative effect of medication on neurocognitive function, especially as the control group was not taking any medication," Dr. Poletti and her associates noted.

The study received no outside funding. The investigators said that they had no financial conflicts.

[email protected]

Total sleep deprivation and light therapy relieve depression in bipolar patients but do not improve overall cognitive function, according to an Italian study published in the Journal of Affective Disorders.

In addition, bipolar patients "do not experience the well-known worsening of performance observed in healthy controls after sleep loss," said Sara Poletti, Ph.D., of the Scientific Institute and University Vita-Salute San Raffaele Turro, Milan, and her associates (J. Affect. Disord. 2014;156:144-9 [doi:10.1016/j.jad.2013.11.023]).

The investigators administered the Brief Assessment of Cognition in Schizophrenia (BACS) to 100 depressed bipolar I patients (DSM-IV) and 100 healthy controls, and then retested 42 subjects with bipolar disorder who underwent total sleep deprivation (TSD) and light therapy (LT), during which they were kept awake for three 36-hour periods over the course of a week, with bright lights shone on them for 30 minutes at 3 a.m. on TSD nights and in the morning after recovery sleep. The Hamilton Depression Rating Scale (HDRS) was administered to assess depression.

The mean age was 47 years in the bipolar group and 44 years in the control group. Both groups were made up of a majority of women. A quarter of the patients with bipolar disorder reported previous psychotic symptoms. Most of the TSD/LT patients were taking lithium, and some were taking other mood stabilizers, benzodiazepines, and antidepressants.

As expected from previous investigations, the 100 bipolar patients had significantly lower baseline cognitive function scores, showing impairment in verbal memory, working memory (digit sequencing), psychomotor coordination (token motor task), verbal fluency, selective attention (symbol coding), and executive function (Wisconsin Card Sorting Test).

Also in keeping with past studies, TSD/LT treatment caused an overall significant decrease in HDRS scores: 31 of the patients with bipolar (74%) achieved the strict remission criterion of HDRS score of less than 8 at day 7 and could be rated as full responders to treatment.

Regarding cognitive function, TSD and light therapy "showed a significant difference only for symbol coding (P less than 0.004). No significant differences were found for the remaining variables," Dr. Poletti and her associates said.

"Although most of the patients responded to TSD treatment reporting a clinical improvement of depressive symptomatology, cognitive deficits persisted in almost each function. The only improvement we observed was in symbol coding, confirming a positive effect of TSD on speed-of-information processing in bipolar patients," they wrote.

Also "in agreement with the literature, we found that as medication load decreases, cognitive performance improves. However, medication effects alone are not likely to fully account for the deficits described in these patients. We can hypothesize that TSD and LT act on cognitive functions through their effect on brain structures and neurotransmitter system[s]. Studies are needed to understand if remediation strategies such as those used for schizophrenia treatment could be introduced for bipolar patients," the investigators said.

Among the study limitations is that "the use and reporting of medications varied between patients, and it was very difficult to control for the potentially negative effect of medication on neurocognitive function, especially as the control group was not taking any medication," Dr. Poletti and her associates noted.

The study received no outside funding. The investigators said that they had no financial conflicts.

[email protected]

Total sleep deprivation and light therapy relieve depression in bipolar patients but do not improve overall cognitive function, according to an Italian study published in the Journal of Affective Disorders.

In addition, bipolar patients "do not experience the well-known worsening of performance observed in healthy controls after sleep loss," said Sara Poletti, Ph.D., of the Scientific Institute and University Vita-Salute San Raffaele Turro, Milan, and her associates (J. Affect. Disord. 2014;156:144-9 [doi:10.1016/j.jad.2013.11.023]).

The investigators administered the Brief Assessment of Cognition in Schizophrenia (BACS) to 100 depressed bipolar I patients (DSM-IV) and 100 healthy controls, and then retested 42 subjects with bipolar disorder who underwent total sleep deprivation (TSD) and light therapy (LT), during which they were kept awake for three 36-hour periods over the course of a week, with bright lights shone on them for 30 minutes at 3 a.m. on TSD nights and in the morning after recovery sleep. The Hamilton Depression Rating Scale (HDRS) was administered to assess depression.

The mean age was 47 years in the bipolar group and 44 years in the control group. Both groups were made up of a majority of women. A quarter of the patients with bipolar disorder reported previous psychotic symptoms. Most of the TSD/LT patients were taking lithium, and some were taking other mood stabilizers, benzodiazepines, and antidepressants.

As expected from previous investigations, the 100 bipolar patients had significantly lower baseline cognitive function scores, showing impairment in verbal memory, working memory (digit sequencing), psychomotor coordination (token motor task), verbal fluency, selective attention (symbol coding), and executive function (Wisconsin Card Sorting Test).

Also in keeping with past studies, TSD/LT treatment caused an overall significant decrease in HDRS scores: 31 of the patients with bipolar (74%) achieved the strict remission criterion of HDRS score of less than 8 at day 7 and could be rated as full responders to treatment.

Regarding cognitive function, TSD and light therapy "showed a significant difference only for symbol coding (P less than 0.004). No significant differences were found for the remaining variables," Dr. Poletti and her associates said.

"Although most of the patients responded to TSD treatment reporting a clinical improvement of depressive symptomatology, cognitive deficits persisted in almost each function. The only improvement we observed was in symbol coding, confirming a positive effect of TSD on speed-of-information processing in bipolar patients," they wrote.

Also "in agreement with the literature, we found that as medication load decreases, cognitive performance improves. However, medication effects alone are not likely to fully account for the deficits described in these patients. We can hypothesize that TSD and LT act on cognitive functions through their effect on brain structures and neurotransmitter system[s]. Studies are needed to understand if remediation strategies such as those used for schizophrenia treatment could be introduced for bipolar patients," the investigators said.

Among the study limitations is that "the use and reporting of medications varied between patients, and it was very difficult to control for the potentially negative effect of medication on neurocognitive function, especially as the control group was not taking any medication," Dr. Poletti and her associates noted.

The study received no outside funding. The investigators said that they had no financial conflicts.

[email protected]

The DSM criteria requiring a duration of 4 or more days for the diagnosis of a hypomanic episode are unnecessary for the clinical definition of bipolar II disorder. These criteria probably also exclude patients who truly have the condition, according to an Australian study published in the Journal of Affective Disorders.

The investigators compared responses on the Mood Swings Questionnaire (MSQ) and the Mood Disorders Questionnaire (MDQ) from 315 adult patients diagnosed with bipolar II (BP II) disorder whose hypomanic episodes lasted less than 4 days, and 186 whose episodes met the DSM criteria of lasting 4 or more days. The mean age of both groups was about 35 years, and about 60% of each were women (J. Affect. Disord. 2014;156:87-91).

The mean total MSQ score was 49.6 in the brief-episode group and 57.0 in the standard-duration group, with the brief group also reporting slightly lower scores on most MSQ subscales. Results were similar on the MDQ among those who completed it, with the brief-duration group returning significantly lower scores on 6 of the 13 items, and a somewhat lower total score (9.5 vs. 10.3; P less than .05).

Overall, patients whose hypomania lasts less than 4 days scored 14% lower on the MSQ and 8% lower on the MDQ, "which, while formally significant, are relatively slight differences ... . A plausible explanation is that those with BP II disorder experiencing longer episodes tend to also have somewhat more severe hypomanic episodes," said Dr. Gordon Parker, of the University of New South Wales in Sydney, Australia, and his associates.

"Our study findings are strongly consistent with previous studies arguing that the clinical phenotype of BP II disorder ... is not dependent on a minimum duration of 4 days as imposed by DSM-IV and DSM-5, but further advanced by validation against a number of clinical correlates and not simply by examining phenomenological expression," Dr. Parker and his associates wrote.

"The current DSM-5 imposition therefore continues to risk those with a true bipolar disorder being excluded from receiving such a diagnosis. If our sample is indicative, the duration criterion may exclude the majority – in that 63% of our sample comprised the ‘brief’ group."

The two groups did not differ significantly in age of onset of depression and hypomania, age at formal diagnosis, and other key variables. Rates of bipolar disorder in first-degree relatives were comparable across the two groups, at a bit under 40% in each. "We interpret [that] finding ... as being a distinctive one, and supporting the validity of brief BP II states," the investigators said.

However, "the possibility of false positive BP II diagnoses, especially with brief hypomanic episodes, must be conceded while our examination of clinical symptoms was limited to two measures," they wrote, citing one of several limitations.

The authors said they had no relevant financial disclosures. The study was funded by the National Health and Medical Research Council of Australia and the New South Wales Department of Health.

[email protected]

The DSM criteria requiring a duration of 4 or more days for the diagnosis of a hypomanic episode are unnecessary for the clinical definition of bipolar II disorder. These criteria probably also exclude patients who truly have the condition, according to an Australian study published in the Journal of Affective Disorders.

The investigators compared responses on the Mood Swings Questionnaire (MSQ) and the Mood Disorders Questionnaire (MDQ) from 315 adult patients diagnosed with bipolar II (BP II) disorder whose hypomanic episodes lasted less than 4 days, and 186 whose episodes met the DSM criteria of lasting 4 or more days. The mean age of both groups was about 35 years, and about 60% of each were women (J. Affect. Disord. 2014;156:87-91).

The mean total MSQ score was 49.6 in the brief-episode group and 57.0 in the standard-duration group, with the brief group also reporting slightly lower scores on most MSQ subscales. Results were similar on the MDQ among those who completed it, with the brief-duration group returning significantly lower scores on 6 of the 13 items, and a somewhat lower total score (9.5 vs. 10.3; P less than .05).

Overall, patients whose hypomania lasts less than 4 days scored 14% lower on the MSQ and 8% lower on the MDQ, "which, while formally significant, are relatively slight differences ... . A plausible explanation is that those with BP II disorder experiencing longer episodes tend to also have somewhat more severe hypomanic episodes," said Dr. Gordon Parker, of the University of New South Wales in Sydney, Australia, and his associates.

"Our study findings are strongly consistent with previous studies arguing that the clinical phenotype of BP II disorder ... is not dependent on a minimum duration of 4 days as imposed by DSM-IV and DSM-5, but further advanced by validation against a number of clinical correlates and not simply by examining phenomenological expression," Dr. Parker and his associates wrote.

"The current DSM-5 imposition therefore continues to risk those with a true bipolar disorder being excluded from receiving such a diagnosis. If our sample is indicative, the duration criterion may exclude the majority – in that 63% of our sample comprised the ‘brief’ group."

The two groups did not differ significantly in age of onset of depression and hypomania, age at formal diagnosis, and other key variables. Rates of bipolar disorder in first-degree relatives were comparable across the two groups, at a bit under 40% in each. "We interpret [that] finding ... as being a distinctive one, and supporting the validity of brief BP II states," the investigators said.

However, "the possibility of false positive BP II diagnoses, especially with brief hypomanic episodes, must be conceded while our examination of clinical symptoms was limited to two measures," they wrote, citing one of several limitations.

The authors said they had no relevant financial disclosures. The study was funded by the National Health and Medical Research Council of Australia and the New South Wales Department of Health.

[email protected]

The DSM criteria requiring a duration of 4 or more days for the diagnosis of a hypomanic episode are unnecessary for the clinical definition of bipolar II disorder. These criteria probably also exclude patients who truly have the condition, according to an Australian study published in the Journal of Affective Disorders.

The investigators compared responses on the Mood Swings Questionnaire (MSQ) and the Mood Disorders Questionnaire (MDQ) from 315 adult patients diagnosed with bipolar II (BP II) disorder whose hypomanic episodes lasted less than 4 days, and 186 whose episodes met the DSM criteria of lasting 4 or more days. The mean age of both groups was about 35 years, and about 60% of each were women (J. Affect. Disord. 2014;156:87-91).

The mean total MSQ score was 49.6 in the brief-episode group and 57.0 in the standard-duration group, with the brief group also reporting slightly lower scores on most MSQ subscales. Results were similar on the MDQ among those who completed it, with the brief-duration group returning significantly lower scores on 6 of the 13 items, and a somewhat lower total score (9.5 vs. 10.3; P less than .05).

Overall, patients whose hypomania lasts less than 4 days scored 14% lower on the MSQ and 8% lower on the MDQ, "which, while formally significant, are relatively slight differences ... . A plausible explanation is that those with BP II disorder experiencing longer episodes tend to also have somewhat more severe hypomanic episodes," said Dr. Gordon Parker, of the University of New South Wales in Sydney, Australia, and his associates.

"Our study findings are strongly consistent with previous studies arguing that the clinical phenotype of BP II disorder ... is not dependent on a minimum duration of 4 days as imposed by DSM-IV and DSM-5, but further advanced by validation against a number of clinical correlates and not simply by examining phenomenological expression," Dr. Parker and his associates wrote.

"The current DSM-5 imposition therefore continues to risk those with a true bipolar disorder being excluded from receiving such a diagnosis. If our sample is indicative, the duration criterion may exclude the majority – in that 63% of our sample comprised the ‘brief’ group."

The two groups did not differ significantly in age of onset of depression and hypomania, age at formal diagnosis, and other key variables. Rates of bipolar disorder in first-degree relatives were comparable across the two groups, at a bit under 40% in each. "We interpret [that] finding ... as being a distinctive one, and supporting the validity of brief BP II states," the investigators said.

However, "the possibility of false positive BP II diagnoses, especially with brief hypomanic episodes, must be conceded while our examination of clinical symptoms was limited to two measures," they wrote, citing one of several limitations.

The authors said they had no relevant financial disclosures. The study was funded by the National Health and Medical Research Council of Australia and the New South Wales Department of Health.

[email protected]

NEW YORK – Treating children and teens with refractory bipolar disorder requires both persistence and faith, according to Dr. Gabrielle A. Carlson.

Although new data are trickling out, few of the medications available for treating both mania and depression have been extensively studied in children and teens, Dr. Carlson said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

"The first-generation antipsychotics have been grandfathered in with [Food and Drug Administration] approval. There are very little data for youngsters, and it’s unlikely that there ever will be, since they are generic now and no one will be spending the money" to further investigate them.

A few pediatric trials are in progress for some of the newer, second-generation antipsychotics, but most efficacy data are still from adult studies, said Dr. Carlson, professor of psychiatry and pediatrics at Stony Brook University, New York.

Michele G. Sullivan/Frontline Medical News

Most recently, paloperidone was found effective as an acute treatment for mania in children with bipolar disorder. But the open-label study was very small – just 15 patients – and was terminated early because of the slow enrollment. The study tested two doses (3 mg and 12 mg). There was a significant mean decline of almost 19 points on the Young Mania Rating Scale after 8 weeks of treatment. Children gained a mean of 4 pounds, however (Psychopharmacology [Berl.] 2013;227:449-58).

Sublingual treatment

Asenapine "is the new kid on the block," Dr. Carlson said. It was approved in 2009 for the acute treatment of schizophrenia and manic or mixed bipolar episodes in adults. It’s administered as a sublingual tablet that takes about 10 minutes to dissolve.

"This is good news if you’ve got a kid who has trouble swallowing pills. The bad news is that you have to hold it under your tongue for 10 minutes, and if you’ve got an aggressive, agitated kid – well, good luck with that. If he does it, though, you can get a good treatment response pretty quickly, because it has a peak concentration of 30-90 minutes and a half-life of about 24 hours."

The adult studies of asenapine showed a significant benefit in about 1 week, with many bipolar patients seeing a 50% reduction in symptoms. Two placebo-controlled trials in children are just wrapping up. The first, comprising 400 children, is complete, but no data have yet been published.

The second, a 50-week open-label study, is ongoing; about 300 children are enrolled.

In the adult studies of asenapine, the number needed to treat was about eight. "The NNT for many other drugs is four or five, so to me this looks like a contender, but not anything great. The sublingual route is the biggest benefit," although, Dr. Carlson cautioned, "it does make noncompliance a lot easier, just by swallowing it." The bioavailability when swallowed is only about 35%.

Asenapine is sedating, so it might be a good choice for as-needed treatment; the weight gain profile is similar to that of olanzapine. The twice-daily dosing is weight based, Dr. Carlson said. "Younger children are more sensitive to the initial dose, so they need a lower starting point and shorter up-titration, which isn’t necessary in the older kids."

For children with bipolar depression, there’s little evidence to support the use of quetiapine. There are no data in youngsters and few data to support its use in adults. A 2012 meta-analysis found that the drug is no better than placebo.

The combination of olanzapine and fluoxetine has been examined in children aged 10-17 years. The industry-sponsored placebo-controlled study treated 160 children for 8 weeks.

At the end of the study, remission rates were 59% in the active group and 43% in the placebo group – a significant difference. Children taking the combination gained significantly more weight than those taking placebo – an average of 4 vs. 0.5 kg. There were also significant increases in liver enzymes and prolactin in those taking the drugs, as well as a higher chance of prolonged QTc intervals.

Unpublished results of another study hint that lamotrigine also might be effective in children with bipolar depression, Dr. Carlson said.

The 8-week study looked at what happened to children aged 10-17 years who had lamotrigine withdrawn after they had responded to it. These patients were given the option of continuing the drug or switching to placebo.

"So far they have 250 enrolled," Dr. Carlson said. "Of these, 136 were willing to be randomized, meaning that at least 60% got better in the open-label phase."

There are no published pediatric data on lurasidone or ketamine, although both seem promising. Lurasidone has been approved for adults, and a study being done in youngsters is not specific for bipolar disorder. Children with schizophrenia, psychosis, autism disorders, Asperger’s syndrome, and refractory major depressive disorder also can enroll.

A recently published adult study, PREVAIL 2 (Program to Evaluate the Antidepressant Impact of Lurasidone), comprised 505 patients with bipolar I depression. They were randomized to once-daily, flexibly dosed lurasidone at either 20-60 mg/day or 80-120 mg/day, or to placebo.

After 6 weeks, depression scores fell in both the 20- to 60-mg/day group (–15.4; effect size = 0.51) and the 80- to 120-mg/day group (–15.4; effect size =0.51), compared with placebo (–10.7).

Similarly, lurasidone treatment resulted in significantly greater endpoint reduction in Clinical Global Impressions-Bipolar Scale depression severity scores for both the 20- to 60-mg/day group (–1.8; effect size = 0.61) and the 80- to 120-mg/day group (–1.7; effect size = 0.50), compared with placebo (–1.1). Both lurasidone groups also experienced significant improvements compared with placebo in anxiety symptoms, and in patient-reported measures of quality of life and functional impairment. Response rates were 53% for the active group and 30% for the placebo group, with remission rates of 42% vs. 40%.

"The effect size was similar for the high and low doses, about 0.5, which is not terrible," Dr. Carlson said. "Discontinuation rates were fairly low, suggesting that it may be worth pursuing."

The main side effects were nausea, headache, akathisia, and somnolence, but very few changes were found in weight, lipids, or measures of glycemic control.

"Ketamine is something we’ve been hearing a lot about," Dr. Carlson said. "If we can come up with a way to give it that’s not intravenous and make it last for a while, it could be really valuable."

One study found that adults randomized to ketamine had significantly greater improvements in depression scores after 24 hours than did those who had midazolam.

The study comprised 73 patients. Response rates at 24 hours were 64% vs. 28% for placebo – with patients taking ketamine more than twice as likely to respond in the adjusted analysis.

The response was highest in the first 3 days after infusion; by day 7, it had dropped to about 45%. A review also highlighted ketamine's 'Achilles heel' – it just hasn’t got staying power. The paper looked at effect sizes in two depression studies and found that they peaked around 2 or 3 days after infusion. But 2 weeks later, the effect size was just about the same as with placebo.

"It’s a really interesting drug, and it does appear to hold some promise," Dr. Carlson said.

Dr. Carlson noted that she has received research funding from Bristol-Myers Squibb, GlaxoSmithKline, Merck & Co., Otsuka America Pharmaceutical, Pfizer, and Schering-Plough.

[email protected]

NEW YORK – Treating children and teens with refractory bipolar disorder requires both persistence and faith, according to Dr. Gabrielle A. Carlson.

Although new data are trickling out, few of the medications available for treating both mania and depression have been extensively studied in children and teens, Dr. Carlson said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

"The first-generation antipsychotics have been grandfathered in with [Food and Drug Administration] approval. There are very little data for youngsters, and it’s unlikely that there ever will be, since they are generic now and no one will be spending the money" to further investigate them.

A few pediatric trials are in progress for some of the newer, second-generation antipsychotics, but most efficacy data are still from adult studies, said Dr. Carlson, professor of psychiatry and pediatrics at Stony Brook University, New York.

Michele G. Sullivan/Frontline Medical News

Most recently, paloperidone was found effective as an acute treatment for mania in children with bipolar disorder. But the open-label study was very small – just 15 patients – and was terminated early because of the slow enrollment. The study tested two doses (3 mg and 12 mg). There was a significant mean decline of almost 19 points on the Young Mania Rating Scale after 8 weeks of treatment. Children gained a mean of 4 pounds, however (Psychopharmacology [Berl.] 2013;227:449-58).

Sublingual treatment

Asenapine "is the new kid on the block," Dr. Carlson said. It was approved in 2009 for the acute treatment of schizophrenia and manic or mixed bipolar episodes in adults. It’s administered as a sublingual tablet that takes about 10 minutes to dissolve.

"This is good news if you’ve got a kid who has trouble swallowing pills. The bad news is that you have to hold it under your tongue for 10 minutes, and if you’ve got an aggressive, agitated kid – well, good luck with that. If he does it, though, you can get a good treatment response pretty quickly, because it has a peak concentration of 30-90 minutes and a half-life of about 24 hours."

The adult studies of asenapine showed a significant benefit in about 1 week, with many bipolar patients seeing a 50% reduction in symptoms. Two placebo-controlled trials in children are just wrapping up. The first, comprising 400 children, is complete, but no data have yet been published.

The second, a 50-week open-label study, is ongoing; about 300 children are enrolled.

In the adult studies of asenapine, the number needed to treat was about eight. "The NNT for many other drugs is four or five, so to me this looks like a contender, but not anything great. The sublingual route is the biggest benefit," although, Dr. Carlson cautioned, "it does make noncompliance a lot easier, just by swallowing it." The bioavailability when swallowed is only about 35%.

Asenapine is sedating, so it might be a good choice for as-needed treatment; the weight gain profile is similar to that of olanzapine. The twice-daily dosing is weight based, Dr. Carlson said. "Younger children are more sensitive to the initial dose, so they need a lower starting point and shorter up-titration, which isn’t necessary in the older kids."

For children with bipolar depression, there’s little evidence to support the use of quetiapine. There are no data in youngsters and few data to support its use in adults. A 2012 meta-analysis found that the drug is no better than placebo.

The combination of olanzapine and fluoxetine has been examined in children aged 10-17 years. The industry-sponsored placebo-controlled study treated 160 children for 8 weeks.

At the end of the study, remission rates were 59% in the active group and 43% in the placebo group – a significant difference. Children taking the combination gained significantly more weight than those taking placebo – an average of 4 vs. 0.5 kg. There were also significant increases in liver enzymes and prolactin in those taking the drugs, as well as a higher chance of prolonged QTc intervals.

Unpublished results of another study hint that lamotrigine also might be effective in children with bipolar depression, Dr. Carlson said.

The 8-week study looked at what happened to children aged 10-17 years who had lamotrigine withdrawn after they had responded to it. These patients were given the option of continuing the drug or switching to placebo.

"So far they have 250 enrolled," Dr. Carlson said. "Of these, 136 were willing to be randomized, meaning that at least 60% got better in the open-label phase."

There are no published pediatric data on lurasidone or ketamine, although both seem promising. Lurasidone has been approved for adults, and a study being done in youngsters is not specific for bipolar disorder. Children with schizophrenia, psychosis, autism disorders, Asperger’s syndrome, and refractory major depressive disorder also can enroll.

A recently published adult study, PREVAIL 2 (Program to Evaluate the Antidepressant Impact of Lurasidone), comprised 505 patients with bipolar I depression. They were randomized to once-daily, flexibly dosed lurasidone at either 20-60 mg/day or 80-120 mg/day, or to placebo.

After 6 weeks, depression scores fell in both the 20- to 60-mg/day group (–15.4; effect size = 0.51) and the 80- to 120-mg/day group (–15.4; effect size =0.51), compared with placebo (–10.7).

Similarly, lurasidone treatment resulted in significantly greater endpoint reduction in Clinical Global Impressions-Bipolar Scale depression severity scores for both the 20- to 60-mg/day group (–1.8; effect size = 0.61) and the 80- to 120-mg/day group (–1.7; effect size = 0.50), compared with placebo (–1.1). Both lurasidone groups also experienced significant improvements compared with placebo in anxiety symptoms, and in patient-reported measures of quality of life and functional impairment. Response rates were 53% for the active group and 30% for the placebo group, with remission rates of 42% vs. 40%.

"The effect size was similar for the high and low doses, about 0.5, which is not terrible," Dr. Carlson said. "Discontinuation rates were fairly low, suggesting that it may be worth pursuing."

The main side effects were nausea, headache, akathisia, and somnolence, but very few changes were found in weight, lipids, or measures of glycemic control.

"Ketamine is something we’ve been hearing a lot about," Dr. Carlson said. "If we can come up with a way to give it that’s not intravenous and make it last for a while, it could be really valuable."

One study found that adults randomized to ketamine had significantly greater improvements in depression scores after 24 hours than did those who had midazolam.

The study comprised 73 patients. Response rates at 24 hours were 64% vs. 28% for placebo – with patients taking ketamine more than twice as likely to respond in the adjusted analysis.

The response was highest in the first 3 days after infusion; by day 7, it had dropped to about 45%. A review also highlighted ketamine's 'Achilles heel' – it just hasn’t got staying power. The paper looked at effect sizes in two depression studies and found that they peaked around 2 or 3 days after infusion. But 2 weeks later, the effect size was just about the same as with placebo.

"It’s a really interesting drug, and it does appear to hold some promise," Dr. Carlson said.

Dr. Carlson noted that she has received research funding from Bristol-Myers Squibb, GlaxoSmithKline, Merck & Co., Otsuka America Pharmaceutical, Pfizer, and Schering-Plough.

[email protected]

NEW YORK – Treating children and teens with refractory bipolar disorder requires both persistence and faith, according to Dr. Gabrielle A. Carlson.

Although new data are trickling out, few of the medications available for treating both mania and depression have been extensively studied in children and teens, Dr. Carlson said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

"The first-generation antipsychotics have been grandfathered in with [Food and Drug Administration] approval. There are very little data for youngsters, and it’s unlikely that there ever will be, since they are generic now and no one will be spending the money" to further investigate them.

A few pediatric trials are in progress for some of the newer, second-generation antipsychotics, but most efficacy data are still from adult studies, said Dr. Carlson, professor of psychiatry and pediatrics at Stony Brook University, New York.

Michele G. Sullivan/Frontline Medical News

Most recently, paloperidone was found effective as an acute treatment for mania in children with bipolar disorder. But the open-label study was very small – just 15 patients – and was terminated early because of the slow enrollment. The study tested two doses (3 mg and 12 mg). There was a significant mean decline of almost 19 points on the Young Mania Rating Scale after 8 weeks of treatment. Children gained a mean of 4 pounds, however (Psychopharmacology [Berl.] 2013;227:449-58).

Sublingual treatment

Asenapine "is the new kid on the block," Dr. Carlson said. It was approved in 2009 for the acute treatment of schizophrenia and manic or mixed bipolar episodes in adults. It’s administered as a sublingual tablet that takes about 10 minutes to dissolve.

"This is good news if you’ve got a kid who has trouble swallowing pills. The bad news is that you have to hold it under your tongue for 10 minutes, and if you’ve got an aggressive, agitated kid – well, good luck with that. If he does it, though, you can get a good treatment response pretty quickly, because it has a peak concentration of 30-90 minutes and a half-life of about 24 hours."

The adult studies of asenapine showed a significant benefit in about 1 week, with many bipolar patients seeing a 50% reduction in symptoms. Two placebo-controlled trials in children are just wrapping up. The first, comprising 400 children, is complete, but no data have yet been published.

The second, a 50-week open-label study, is ongoing; about 300 children are enrolled.

In the adult studies of asenapine, the number needed to treat was about eight. "The NNT for many other drugs is four or five, so to me this looks like a contender, but not anything great. The sublingual route is the biggest benefit," although, Dr. Carlson cautioned, "it does make noncompliance a lot easier, just by swallowing it." The bioavailability when swallowed is only about 35%.

Asenapine is sedating, so it might be a good choice for as-needed treatment; the weight gain profile is similar to that of olanzapine. The twice-daily dosing is weight based, Dr. Carlson said. "Younger children are more sensitive to the initial dose, so they need a lower starting point and shorter up-titration, which isn’t necessary in the older kids."

For children with bipolar depression, there’s little evidence to support the use of quetiapine. There are no data in youngsters and few data to support its use in adults. A 2012 meta-analysis found that the drug is no better than placebo.

The combination of olanzapine and fluoxetine has been examined in children aged 10-17 years. The industry-sponsored placebo-controlled study treated 160 children for 8 weeks.

At the end of the study, remission rates were 59% in the active group and 43% in the placebo group – a significant difference. Children taking the combination gained significantly more weight than those taking placebo – an average of 4 vs. 0.5 kg. There were also significant increases in liver enzymes and prolactin in those taking the drugs, as well as a higher chance of prolonged QTc intervals.

Unpublished results of another study hint that lamotrigine also might be effective in children with bipolar depression, Dr. Carlson said.

The 8-week study looked at what happened to children aged 10-17 years who had lamotrigine withdrawn after they had responded to it. These patients were given the option of continuing the drug or switching to placebo.

"So far they have 250 enrolled," Dr. Carlson said. "Of these, 136 were willing to be randomized, meaning that at least 60% got better in the open-label phase."

There are no published pediatric data on lurasidone or ketamine, although both seem promising. Lurasidone has been approved for adults, and a study being done in youngsters is not specific for bipolar disorder. Children with schizophrenia, psychosis, autism disorders, Asperger’s syndrome, and refractory major depressive disorder also can enroll.

A recently published adult study, PREVAIL 2 (Program to Evaluate the Antidepressant Impact of Lurasidone), comprised 505 patients with bipolar I depression. They were randomized to once-daily, flexibly dosed lurasidone at either 20-60 mg/day or 80-120 mg/day, or to placebo.

After 6 weeks, depression scores fell in both the 20- to 60-mg/day group (–15.4; effect size = 0.51) and the 80- to 120-mg/day group (–15.4; effect size =0.51), compared with placebo (–10.7).

Similarly, lurasidone treatment resulted in significantly greater endpoint reduction in Clinical Global Impressions-Bipolar Scale depression severity scores for both the 20- to 60-mg/day group (–1.8; effect size = 0.61) and the 80- to 120-mg/day group (–1.7; effect size = 0.50), compared with placebo (–1.1). Both lurasidone groups also experienced significant improvements compared with placebo in anxiety symptoms, and in patient-reported measures of quality of life and functional impairment. Response rates were 53% for the active group and 30% for the placebo group, with remission rates of 42% vs. 40%.

"The effect size was similar for the high and low doses, about 0.5, which is not terrible," Dr. Carlson said. "Discontinuation rates were fairly low, suggesting that it may be worth pursuing."

The main side effects were nausea, headache, akathisia, and somnolence, but very few changes were found in weight, lipids, or measures of glycemic control.

"Ketamine is something we’ve been hearing a lot about," Dr. Carlson said. "If we can come up with a way to give it that’s not intravenous and make it last for a while, it could be really valuable."

One study found that adults randomized to ketamine had significantly greater improvements in depression scores after 24 hours than did those who had midazolam.

The study comprised 73 patients. Response rates at 24 hours were 64% vs. 28% for placebo – with patients taking ketamine more than twice as likely to respond in the adjusted analysis.

The response was highest in the first 3 days after infusion; by day 7, it had dropped to about 45%. A review also highlighted ketamine's 'Achilles heel' – it just hasn’t got staying power. The paper looked at effect sizes in two depression studies and found that they peaked around 2 or 3 days after infusion. But 2 weeks later, the effect size was just about the same as with placebo.

"It’s a really interesting drug, and it does appear to hold some promise," Dr. Carlson said.

Dr. Carlson noted that she has received research funding from Bristol-Myers Squibb, GlaxoSmithKline, Merck & Co., Otsuka America Pharmaceutical, Pfizer, and Schering-Plough.

[email protected]

Parents with bipolar disorder generally know that their children have an increased risk for the condition, but whether they actively monitor their children for the disorder depends to some extent on how well they manage it themselves, according to a web survey of 266 parents.

Most of the survey respondents were white. Most were female (83.7%), and nearly two-thirds (63.7%) had more than one child. The median age range of the respondents was 41-45.

They rated themselves against statements signaling active monitoring for nascent bipolar disorder, such as "I watch my child’s moods," "I teach my child what to do if his/her moods become bad or unstable," and "I plan for what I would do if I notice symptoms in my child."

In addition, they responded to statements signaling what the researchers called "cognitive distancing" from the possibility that their children might develop bipolar disorder, including "my child’s personality makes him/her less likely to develop a mood disorder" and "the home environment my child has grown up in makes him/her less likely to develop a mood disorder." The parents answered questions about their own illness, as well (Soc. Sci. Med. 2014;104:194-200).

The degree to which parents with bipolar disorder paid attention to their children’s mood was associated with perceived control over the child’s well-being (P less than .005), coping with their own illness (P = .001), and a family history of bipolar disorder (P = .001), among other factors. Cognitive distancing was negatively associated with current mania (P = .007), perceiving bipolar disorder as genetic (P less than .001), and having more children (P = .004), perhaps because parents were more confident that they would spot a problem if they could compare one child to another. The findings were statistically significant.

The investigators said the main limitation of their study is that it used a sample with bipolar disorder that was self-reported. In addition, reports of relatives affected by bipolar were "unexpectedly high, indicating a biased study sample," an unclear survey question, and/or an overreporting of illness in relatives."

Still, the results mean that "health care providers need to move away from a model of parents with mental illness as vehicles of risk to offspring. They should capitalize on parents’ strengths, and help them identify and evaluate their coping strategies," said Holly Landrum Peay of the National Human Genome Research Institute in Bethesda, Md., and her associates.

The National Institutes of Health funded the study. The investigators reported that they have no financial conflicts.

[email protected]

Parents with bipolar disorder generally know that their children have an increased risk for the condition, but whether they actively monitor their children for the disorder depends to some extent on how well they manage it themselves, according to a web survey of 266 parents.

Most of the survey respondents were white. Most were female (83.7%), and nearly two-thirds (63.7%) had more than one child. The median age range of the respondents was 41-45.

They rated themselves against statements signaling active monitoring for nascent bipolar disorder, such as "I watch my child’s moods," "I teach my child what to do if his/her moods become bad or unstable," and "I plan for what I would do if I notice symptoms in my child."

In addition, they responded to statements signaling what the researchers called "cognitive distancing" from the possibility that their children might develop bipolar disorder, including "my child’s personality makes him/her less likely to develop a mood disorder" and "the home environment my child has grown up in makes him/her less likely to develop a mood disorder." The parents answered questions about their own illness, as well (Soc. Sci. Med. 2014;104:194-200).

The degree to which parents with bipolar disorder paid attention to their children’s mood was associated with perceived control over the child’s well-being (P less than .005), coping with their own illness (P = .001), and a family history of bipolar disorder (P = .001), among other factors. Cognitive distancing was negatively associated with current mania (P = .007), perceiving bipolar disorder as genetic (P less than .001), and having more children (P = .004), perhaps because parents were more confident that they would spot a problem if they could compare one child to another. The findings were statistically significant.

The investigators said the main limitation of their study is that it used a sample with bipolar disorder that was self-reported. In addition, reports of relatives affected by bipolar were "unexpectedly high, indicating a biased study sample," an unclear survey question, and/or an overreporting of illness in relatives."

Still, the results mean that "health care providers need to move away from a model of parents with mental illness as vehicles of risk to offspring. They should capitalize on parents’ strengths, and help them identify and evaluate their coping strategies," said Holly Landrum Peay of the National Human Genome Research Institute in Bethesda, Md., and her associates.

The National Institutes of Health funded the study. The investigators reported that they have no financial conflicts.

[email protected]

Parents with bipolar disorder generally know that their children have an increased risk for the condition, but whether they actively monitor their children for the disorder depends to some extent on how well they manage it themselves, according to a web survey of 266 parents.

Most of the survey respondents were white. Most were female (83.7%), and nearly two-thirds (63.7%) had more than one child. The median age range of the respondents was 41-45.

They rated themselves against statements signaling active monitoring for nascent bipolar disorder, such as "I watch my child’s moods," "I teach my child what to do if his/her moods become bad or unstable," and "I plan for what I would do if I notice symptoms in my child."

In addition, they responded to statements signaling what the researchers called "cognitive distancing" from the possibility that their children might develop bipolar disorder, including "my child’s personality makes him/her less likely to develop a mood disorder" and "the home environment my child has grown up in makes him/her less likely to develop a mood disorder." The parents answered questions about their own illness, as well (Soc. Sci. Med. 2014;104:194-200).

The degree to which parents with bipolar disorder paid attention to their children’s mood was associated with perceived control over the child’s well-being (P less than .005), coping with their own illness (P = .001), and a family history of bipolar disorder (P = .001), among other factors. Cognitive distancing was negatively associated with current mania (P = .007), perceiving bipolar disorder as genetic (P less than .001), and having more children (P = .004), perhaps because parents were more confident that they would spot a problem if they could compare one child to another. The findings were statistically significant.

The investigators said the main limitation of their study is that it used a sample with bipolar disorder that was self-reported. In addition, reports of relatives affected by bipolar were "unexpectedly high, indicating a biased study sample," an unclear survey question, and/or an overreporting of illness in relatives."

Still, the results mean that "health care providers need to move away from a model of parents with mental illness as vehicles of risk to offspring. They should capitalize on parents’ strengths, and help them identify and evaluate their coping strategies," said Holly Landrum Peay of the National Human Genome Research Institute in Bethesda, Md., and her associates.

The National Institutes of Health funded the study. The investigators reported that they have no financial conflicts.

[email protected]