Related Articles

OBJECTIVE: To review new perspectives on diagnosis, clinical features, epidemiology, and treatment of bipolar II and related disorders. QUALITY OF EVIDENCE: Articles were identified by searching MEDLINE and ClinPSYCH from January 1994 to August 2001 using the key words bipolar disorder, type II or 2; hypomania; spectrum; or variants. Reference lists from articles were reviewed. Overall, the quality of evidence was not high; we found no randomized controlled trials that specifically addressed bipolar II or bipolar spectrum disorders (BSDs). MAIN MESSAGE: Characterized by elevated mood cycling with depression, BSDs appear to be much more common than previously thought, affecting up to 30% of primary care patients presenting with anxiety or depressive symptoms. Hypomania, the defining feature of bipolar II disorder, is often not detected. Collateral information, semistructured interviews, and brief screening instruments could improve diagnosis. Antidepressants should be used with caution. The newer mood stabilizers or combinations of mood stabilizers might be the treatments of choice in the future. CONCLUSION: Family physicians, as primary providers of mental health care, should try to recognize and treat BSDs more frequently. These disorders are becoming increasingly common in primary care populations.

Objectives

Family members of patients with bipolar disorder experience high rates of subjective and objective burden which place them at risk for adverse physical health and mental health outcomes. We present preliminary efficacy data from a novel variation of Family Focused Treatment [Miklowitz DJ. Bipolar Disorder: A Family-Focused Treatment Approach (2nd ed.). New York: The Guilford Press, 2008] that aimed to reduce symptoms of bipolar disorder by working with caregivers to enhance illness management skills and self-care.

Methods

The primary family caregivers of 46 patients with bipolar I (n = 40) or II (n = 6) disorder, diagnosed by the Structured Clinical Interview for DSM-IV Axis I Disorders, were assigned randomly to receive either: (i) a 12–15-session family-focused, cognitive-behavioral intervention designed to provide the caregiver with skills for managing the relative’s illness, attaining self-care goals, and reducing strain, depression, and health risk behavior [Family-Focused Treatment-Health Promoting Intervention (FFT-HPI)]; or (ii) an 8–12-session health education (HE) intervention delivered via videotapes. We assessed patients pre- and post-treatment on levels of depression and mania and caregivers on levels of burden, health behavior, and coping.

Results

Randomization to FFT-HPI was associated with significant decreases in caregiver depressive symptoms and health risk behavior. Greater reductions in depressive symptoms among patients were also observed in the FFT-HPI group. Reduction in patients’ depression was partially mediated by reductions in caregivers’ depression levels. Decreases in caregivers’ depression were partially mediated by reductions in caregivers’ levels of avoidance coping.

Conclusions

Families coping with bipolar disorder may benefit from family interventions as a result of changes in the caregivers’ ability to manage stress and regulate their moods, even when the patient is not available for treatment.

Objective

To determine whether UK patients with coronary heart disease (CHD) who also have schizophrenia or bipolar disorder are less likely to receive primary care in accordance with the agreed national standards of the UK than patients without these mental health problems.

Design

Cross‐sectional study.

Setting

485 UK general practices contributing anonymised medical records of over 3.26 million patients to the QRESEARCH database.

Participants

127 932 patients with CHD of whom 701 had a diagnosis of schizophrenia or bipolar disorder.

Main outcome measures

The relative risks of receiving statin medication and each of the CHD care indicators defined in the UK General Medical Services contract, for patients with schizophrenia or bipolar disorder compared with patients with neither condition. The results were adjusted for age, sex, deprivation, diabetes, stroke and smoking status, and allowed for clustering by practice.

Results

Patients with schizophrenia were 15% less likely to have a recent prescription for a statin (95% CI 8% to 20%) and 7% less likely to have a recent record of cholesterol level (95% CI 3% to 11%). There were no significant differences in the adjusted analyses between mental health groups on recording smoking status, advising on smoking cessation, recording blood pressure, achieving target blood pressure or cholesterol values, or prescribing aspirin, antiplatelets, anticoagulants or β blockers.

Conclusions

Although the majority of CHD care indicators are achieved equally for patients who also have a serious mental health problem, there is a shortfall in identifying and treating raised cholesterol among patients with schizophrenia, despite their higher level of risk factors.

Background

Bipolar disorders affect between 3–5% of the population and are associated with considerable lifelong impairment. Since much of the morbidity associated with bipolar disorder is caused by recurrent depressive symptoms, which are often only poorly responsive to antidepressants, there is a need to develop alternative, non-pharmacological interventions. Psychoeducational interventions have emerged as promising long-term therapeutic options for bipolar disorder.

Methods/design

The study is an exploratory, individually randomised controlled trial. The intervention known as 'Beating Bipolar' is a psychoeducational programme which is delivered via a novel web-based system. We will recruit 100 patients with a diagnosis of DSM-IV bipolar disorder (including type I and type II) currently in clinical remission. The primary outcome is quality of life. This will be compared for those patients who have participated in the psychoeducational programme with those who received treatment as usual. Quality of life will be assessed immediately following the intervention as well as 10 months after randomisation. Secondary outcomes include current depressive and manic symptoms, number of episodes of depression and mania/hypomania experienced during the follow-up period, global functioning, functional impairment and insight. An assessment of costs and a process evaluation will also be conducted which will explore the feasibility and acceptability of the intervention as well as potential barriers to effectiveness.

Discussion

Bipolar disorder is common, under-recognised and often poorly managed. It is a chronic, life-long, relapsing condition which has an enormous impact on the individual and the economy. This trial will be the first to explore the effectiveness of a novel web-based psychoeducational intervention for patients with bipolar disorder which has potential to be easily rolled out to patients.

Trial registration

Current Controlled Trials ISRCTN81375447

Little longitudinal research has examined progression to more severe bipolar disorders in individuals with “soft” bipolar spectrum conditions. We examine rates and predictors of progression to bipolar I and II diagnoses in a non-patient sample of college-age participants (n = 201) with high General Behavior Inventory scores and childhood or adolescent onset of “soft” bipolar spectrum disorders followed longitudinally for 4.5 years from the Longitudinal Investigation of Bipolar Spectrum (LIBS) project. Of 57 individuals with initial cyclothymia or bipolar disorder not otherwise specified (BiNOS) diagnoses, 42.1% progressed to a bipolar II diagnosis and 10.5% progressed to a bipolar I diagnosis. Of 144 individuals with initial bipolar II diagnoses, 17.4% progressed to a bipolar I diagnosis. Consistent with hypotheses derived from the clinical literature and the Behavioral Approach System (BAS) model of bipolar disorder, and controlling for relevant variables (length of follow-up, initial depressive and hypomanic symptoms, treatment-seeking, and family history), high BAS sensitivity (especially BAS Fun Seeking) predicted a greater likelihood of progression to bipolar II disorder, whereas early age of onset and high impulsivity predicted a greater likelihood of progression to bipolar I (high BAS sensitivity and Fun-Seeking also predicted progression to bipolar I when family history was not controlled). The interaction of high BAS and high Behavioral Inhibition System (BIS) sensitivities also predicted greater likelihood of progression to bipolar I. We discuss implications of the findings for the bipolar spectrum concept, the BAS model of bipolar disorder, and early intervention efforts.

Objective

Rapid cycling (RC) affects 13–30% of bipolar patients. Most of the data regarding RC have been obtained in tertiary care research centers. Generalizability of these findings to primary care populations is thus questionable. We examined clinical and demographic factors associated with RC in both primary and tertiary care treated populations.

Method

Clinical data were obtained by interview from 240 bipolar I disorder (BDI) or bipolar II disorder (BDII) community-treated patients and by chart reviews from 119 bipolar patients treated at an outpatient clinic of a teaching hospital.

Results

Lifetime history of rapid cycling was present in 33.3% and 26.9% of patients from the primary and tertiary care samples, respectively. Among community-treated patients, lifetime history of RC was significantly associated with history of suicidal behavior and higher body mass index. There was a trend for association between RC and BDII, psychiatric comorbidity, diabetes mellitus, as well as lower age of onset of mania/hypomania. In the tertiary care treated sample there was a trend for association between lifetime history of RC and suicidal behavior. Tertiary versus primary care treated subjects with lifetime history of RC demonstrated markedly lower response to mood stabilizers.

Conclusions

Lifetime history of RC is highly prevalent in both primary and tertiary settings. Even primary care treated subjects with lifetime history of RC seem to suffer from a more complicated and less treatment-responsive variant of bipolar disorder. Our findings further suggest relatively good generalizability of data from tertiary to primary care settings.

Outcome in bipolar patients is affected by comorbidity. Comorbid personality disorders are frequent and may complicate the course of bipolar illness. This pilot study examined a series of 40 euthymic bipolar patients (DSM-IV criteria) (bipolar I disorder 31, bipolar II disorder 9) to assess the effect of clinical variables and the influence of comorbid personality on the clinical course of bipolar illness. Bipolar patients with a diagnosis of comorbid personality disorder (n = 30) were compared with “pure” bipolar patients (n = 10) with regard to demographic, clinical, and course of illness variables. Comorbid personality disorder was diagnosed in 75% of patients according to ICD-10 criteria, with obsessive-compulsive personality disorder being the most frequent type. Sixty-three per cent of subjects had more than one comorbid personality disorder. Bipolar patients with and without comorbid personality disorder showed no significant differences regarding features of the bipolar illness, although the group with comorbid personality disorder showed a younger age at onset, more depressive episodes, and longer duration of bipolar illness. In subjects with comorbid personality disorders, the number of hospitalizations correlated significantly with depressive episodes and there was an inverse correlation between age at the first episode and duration of bipolar illness. These findings, however, should be interpreted taking into account the preliminary nature of a pilot study and the contamination of the sample with too many bipolar II patients.

Background

The Provisional Diagnostic Instrument (PDI-4) is a brief, adult self-report instrument for 4 common psychiatric diagnoses in primary care patients: major depressive episode (MDE), generalized anxiety disorder (GAD), attention deficit hyperactivity disorder (ADHD), and bipolar I disorder based on past or present mania. Our objective was to assess validity of the PDI-4 in a population independent of the study population originally used to develop the scale.

Methods

An online version of the 17-item PDI-4 was administered to 1,047 adults in the US; respondents also completed the PHQ-9, HADS-A, CAARS-S, and MDQ within the online survey. Respondents self-reported diagnosis by a healthcare professional with the terms depression (n=221), anxiety (n=218), attention deficit disorder (n=206), bipolar or manic depressive disorder (n=195), or none of these (n=207). Statistical analyses examined convergent and discriminant validity, and operating characteristics of the PDI-4 relative to the individual, validated, self-rated scales PHQ-9, HADS-A, CAARS-S, and MDQ, for each PDI-4 diagnosis.

Results

Convergent validity of the PDI-4 was supported by strong correlations with the corresponding individual scales (range of 0.63 [PDI-4 and MDQ] to 0.87 [PDI-4 and PHQ-9]). Operating characteristics of the PDI-4 were similar to results in the previous site-based study. The scale exhibited moderate sensitivities (0.52 [mania] to 0.70 [ADHD]) and strong specificities (0.86 [mania] to 0.92 [GAD]) using the individual scales as the gold standards. ANOVAs demonstrated that PDI-4 discriminated between subsets of patients defined by pre-specified severity level cutoff scores of the individual scales. However, overlapping symptoms and co-morbidities made differentiation between mental diagnoses much weaker than differentiation from the control group with none of the diagnoses.

Conclusions

The PDI-4 appears to be a suitable, brief, self-rated tool for provisional diagnoses of common mental disorders. However, the high level of symptom overlap between these diagnoses emphasizes that such brief scales are not a replacement for thorough diagnostic evaluation by trained medical providers.

The present paper provides an overview of child and adolescent bipolar disorder for paediatricians. Epidemiology, premorbid characteristics, clinical characteristics, differential diagnosis, comorbidity, course, prognosis and multimodal treatment are reviewed. The rate of child and adolescent bipolar disorder appears to be increasing. It manifests with symptoms consistent with the developmental level of the patient, which can make diagnosis difficult. Compounding the diagnostic difficulty is the frequent presence of comorbid conditions. Early recognition and treatment are critical given the severe morbidity associated with this condition. Thus, it is essential that paediatricians and other primary care physicians are familiar with this disorder to recognize its presence and activate appropriate multimodal treatment.

Background

The anterior insula cortex is considered to be both the structural and functional link between experience, affect, and behaviour. Magnetic resonance imaging (MRI) studies have shown changes in anterior insula gray matter volume (GMV) in psychosis, bipolar, depression and anxiety disorders in older patients, but few studies have investigated insula GMV changes in young people. This study examined the relationship between anterior insula GMV, clinical symptom severity and neuropsychological performance in a heterogeneous cohort of young people presenting for mental health care.

Methods

Participants with a primary diagnosis of depression (n = 43), bipolar disorder (n = 38), psychosis (n = 32), anxiety disorder (n = 12) or healthy controls (n = 39) underwent structural MRI scanning, and volumetric segmentation of the bilateral anterior insula cortex was performed using the FreeSurfer application. Statistical analysis examined the linear and quadratic correlations between anterior insula GMV and participants’ performance in a battery of clinical and neuropsychological assessments.

Results

Compared to healthy participants, patients had significantly reduced GMV in the left anterior insula (t = 2.05, p = .042) which correlated with reduced performance on a neuropsychological task of attentional set-shifting (ρ = .32, p = .016). Changes in right anterior insula GMV was correlated with increased symptom severity (r = .29, p = .006) and more positive symptoms (r = .32, p = .002).

Conclusions

By using the novel approach of examining a heterogeneous cohort of young depression, anxiety, bipolar and psychosis patients together, this study has demonstrated that insula GMV changes are associated with neurocognitive deficits and clinical symptoms in such young patients.

Objective: Several findings suggest that some patients with depressive or bipolar disorder may be at increased risk of developing dementia. The present study aimed to investigate whether the risk of developing dementia increases with the number of affective episodes in patients with depressive disorder and in patients with bipolar disorder.

Methods: This was a case register study including all hospital admissions with primary affective disorder in Denmark during 1970–99. The effect of the number of prior episodes leading to admission on the rate of readmission with a diagnosis of dementia following the first discharge after 1985 was estimated. A total of 18 726 patients with depressive disorder and 4248 patients with bipolar disorder were included in the study.

Results: The rate of a diagnosis of dementia on readmission was significantly related to the number of prior affective episodes leading to admission. On average, the rate of dementia tended to increase 13% with every episode leading to admission for patients with depressive disorder and 6% with every episode leading to admission for patients with bipolar disorder, when adjusted for differences in age and sex.

Conclusion: On average, the risk of dementia seems to increase with the number of episodes in depressive and bipolar affective disorders.

Background

Severe mental illness is a serious and potentially life changing set of conditions. This paper describes and analyses patient characteristics and service usage over one year of a representative cohort of people with a diagnosis of severe mental illness across England, including contacts with primary and secondary care and continuity of care.

Methods and Findings

Data were collected from primary care patient notes (n = 1150) by trained nurses from 64 practices in England, covering all service contacts from 1st April 2008 to 31st March 2009. The estimated national rate of patients seen only in primary care in the period was 31.1% (95% C.I. 27.2% to 35.3%) and the rates of schizophrenia and bipolar disorder were 56.8% (95% C.I. 52.3% to 61.2%) and 37.9% (95% C.I. 33.7% to 42.2%). In total, patients had 7,961 consultations within primary care and 1,993 contacts with mental health services (20% of the total). Unemployed individuals diagnosed more recently were more likely to have contact with secondary care. Of those seen in secondary care, 61% had at most two secondary care contacts in the period. Median annual consultation rates with GPs were lower than have been reported for previous years and were only slightly above the general population. Relational continuity in primary care was poor for 21% of patients (Modified Modified Continuity Index  = <0.5), and for almost a third of new referrals to mental health services the primary care record contained no information on the referral outcome.

Conclusions

Primary care is centrally involved in the care of people with serious mental illness, but primary care and cross-boundary continuity is poor for a substantial proportion. Research is needed to determine the impact of poor continuity on patient outcomes, and above all, the impact of new collaborative ways of working at the primary/secondary care interface.

Objectives

To determine changes in prescribing patterns in primary care of antipsychotic and mood stabiliser medication in a representative sample of patients with bipolar disorder in the United Kingdom over a fifteen year period and association with socio-demographic factors.

Methods

We identified 4700 patients in the Health Improvement Network (THIN) primary care database, who had received treatment for bipolar disorder between 1995 and 2009. The proportion of time for which each individual was prescribed a particular medication was studied, along with variation by sex, age and social depravation status (quintiles of Townsend scores). The number of drugs an individual was taking within a particular year was also examined.

Results

In 1995, 40.6% of patients with bipolar disorder were prescribed a psychotropic medication at least twice. By 2009 this had increased to 78.5% of patients. Valproate registered with the greatest increase in use (22.7%) followed by olanzapine (15.7%) and quetiapine (9.9%). There were differences by age and sex; with young (18–30 year old) women having the biggest increase in proportion of time on medication. There were no differences by social deprivation status. By 2009, 34.2% of women of childbearing age were treated with valproate.

Conclusions

Lithium use overall remained relatively constant, whilst second generation antipsychotic and valproate use increased dramatically. Changes in prescribing practice preceded published trial evidence, especially with the use of second generation antipsychotics, perhaps with inferences being made from treatment of schizophrenia and use of first generation antipsychotics. Women of childbearing age were prescribed valproate frequently, against best advice.

Abstract

Objective

To describe the prevalence of patients who screen positive for symptoms of bipolar disorder in primary care practice using the validated Mood Disorders Questionnaire (MDQ).

Design

Prevalence survey.

Setting

Fifty-four primary care practices across Canada.

Participants

Adult patients presenting to their primary care practitioners for any cause and reporting, during the course of their visits, current or previous symptoms of depression, anxiety, substance use disorders, or attention deficit hyperactivity disorder.

Main outcome measures

Subjects were screened for symptoms suggestive of bipolar disorder using the MDQ. Health-related quality of life, functional impairment, and work productivity were evaluated using the 12-Item Short-Form Health Survey and Sheehan Disability Scale.

Results

A total of 1416 patients were approached to participate in this study, and 1304 completed the survey. Of these, 27.9% screened positive for symptoms of bipolar disorder. All 13 items of the MDQ were significantly associated with screening positive for bipolar disorder (P < .05). Patients screening positive were significantly more likely to report depression, anxiety, substance use, attention deficit hyperactivity disorder, family history of bipolar disorder, or suicide attempts than patients screening negative were (P < .001). Health-related quality of life, work or school productivity, and social and family functioning were all significantly worse in patients who screened positive (P < .001).

Conclusion

This prevalence survey suggests that more than a quarter of patients presenting to primary care with past or current psychiatric indices are at risk of bipolar disorder. Patients exhibiting a cluster of these symptoms should be further questioned on family history of bipolar disorder and suicide attempts, and selectively screened for symptoms suggestive of bipolar disorder using the quick and high-yielding MDQ.

Background

Although some studies indicate that bipolar disorder causes high health care resources consumption, no study is available addressing a cost estimation of bipolar disorder in Spain. The aim of this observational study was to evaluate healthcare resource utilization and the associated direct cost in patients with manic episodes in the Spanish setting.

Methods

Retrospective descriptive study was carried out in a consecutive sample of patients with a DSM-IV diagnosis of bipolar type I disorder with or without psychotic symptoms, aged 18 years or older, and who were having an active manic episode at the time of inclusion. Information regarding the current manic episode was collected retrospectively from the medical record and patient interview.

Results

Seven hundred and eighty-four evaluable patients, recruited by 182 psychiatrists, were included in the study. The direct cost associated with healthcare resource utilization during the manic episode was high, with a mean cost of nearly €4,500 per patient, of which approximately 55% corresponded to the cost of hospitalization, 30% to the cost of psychopharmacological treatment and 10% to the cost of specialized care.

Conclusions

Our results show the high cost of management of the patient with a manic episode, which is mainly due to hospitalizations. In this regard, any intervention on the management of the manic patient that could reduce the need for hospitalization would have a significant impact on the costs of the disease.

Objective To investigate whether the mortality gap has reduced in recent years between people with schizophrenia or bipolar disorder and the general population.

Design Record linkage study.

Setting English hospital episode statistics and death registration data for patients discharged 1999-2006.

Participants People discharged from inpatient care with a diagnosis of schizophrenia or bipolar disorder, followed for a year after discharge.

Main outcome measures Age standardised mortality ratios at each time, comparing the mortality in people with schizophrenia or bipolar disorder with mortality in the general population. Poisson test of trend was used to investigate trend in ratios over time.

Results By 2006 standardised mortality ratios in the psychiatric cohorts were about double the population average. The mortality gap widened over time. For people discharged with schizophrenia, the ratio was 1.6 (95% confidence interval 1.5 to 1.8) in 1999 and 2.2 (2.0 to 2.4) in 2006 (P<0.001 for trend). For bipolar disorder, the ratios were 1.3 (1.1 to 1.6) in 1999 and 1.9 (1.6 to 2.2) in 2006 (P=0.06 for trend). Ratios were higher for unnatural than for natural causes. About three quarters of all deaths, however, were certified as natural, and increases in ratios for natural causes, especially circulatory disease and respiratory diseases, were the main components of the increase in all cause mortality.

Conclusions The total burden of premature deaths from natural causes in people with schizophrenia or bipolar disorder is substantial. There is a need for better understanding of the reasons for the persistent and increasing gap in mortality between discharged psychiatric patients and the general population, and for continued action to target risk factors for both natural and unnatural causes of death in people with serious mental illness.

Patients with bipolar disorder spend more time in a depressed than manic state, even with individualized treatment. To date, bipolar depression is often misdiagnosed and ineffectively managed both for acute episodes and residual symptoms. This review attempts to summarize the current status of available treatment strategies in the treatment of bipolar depression. For acute and prophylactic treatment, a substantial body of evidence supports the antidepressive efficacy of lithium for bipolar disorders and its antisuicidal effects. Among numerous anticonvulsants with mood-stabilizing properties, valproate and lamotrigine could be first-line options for bipolar depression. Due to receptor profile, mood-stabilizing properties of second-generation antipsychotics have been explored, and up to date, quetiapine and olanzapine appear to be a reasonable option for bipolar depression. The usefulness of antidepressants in bipolar depression is still controversial. Current guidelines generally recommend the cautious antidepressant use in combination with mood stabilizers to reduce the risk of mood elevation or cycle acceleration. Results from clinical trials on psychosocial intervention are promising, especially when integrated with pharmacotherapy. Most patients with bipolar depression need individualized and combined treatment, although the published evidence on this type of treatment strategy is limited. Future studies on the utility of currently available agents and modalities including psychosocial intervention are required.

Background

There is little published guideline or evidence on treating bipolar affective disorder in patients with renal failure having haemodialysis.

Case

We present two patients with bipolar affective disorder with renal failure having haemodialysis. We used lorazepam in one patient to manage the immediate risk of non-engagement with dialysis. Risperidone was added in the second patient for managing psychotic symptoms. Valproate was started as a mood stabiliser and titrated upwards for long-term management of the illness.

Conclusion

We discuss the similarities in the two cases and the care plan we used to manage them.

Successful treatment of psychiatric disorders, including bipolar disorder and schizophrenia, is complicated and is affected by a broad range of factors associated with the diagnosis, choice of treatment and social factors. In these patients, treatment management must focus on accurate and early diagnosis, to ensure that correct treatment is administered as soon as possible. In both disorders, the treatment of the disease in the acute phase must be maintained long term to provide continuous relief and normal function; the treatment choice in the early stages of the disease may impact on long-term outcomes. In schizophrenia, treatment non-compliance is an important issue, with up to 50% of patients discontinuing treatment for reasons as diverse as efficacy failure, social barriers, and more commonly, adverse events. Treatment non-compliance also remains an issue in bipolar disorder, as tolerability of mood stabilizers, especially lithium, is not always good, and combination treatments are frequent. In order to achieve an optimal outcome in which the patient continues with their medication life-long, treatment should be tailored to each individual, taking into account treatment and family history, and balancing efficacy with tolerability to maximize patient benefit and minimize the risk of discontinuation. These case studies illustrate how treatment should be monitored, tailored and often changed over time to meet these needs.

Objectives

Few studies have addressed the physical and mental health effects of caring for a family member with bipolar disorder. This study examined whether caregivers’ health is associated with changes in suicidal ideation and depressive symptoms among bipolar patients observed over one year.

Methods

Patients (N = 500) participating in the Systematic Treatment Enhancement Program for Bipolar Disorder and their primary caregivers (N = 500, including 188 parental and 182 spousal caregivers) were evaluated for up to one year as part of a naturalistic observational study. Caregivers’ perceptions of their own physical health were evaluated using the general health scale from the Medical Outcomes Study 36-item Short-Form Health Survey. Caregivers’ depression was evaluated using the Center for Epidemiological Studies of Depression Scale.

Results

Caregivers of patients who had increasing suicidal ideation over time reported worsening health over time compared to caregivers of patients whose suicidal ideation decreased or stayed the same. Caregivers of patients who had more suicidal ideation and depressive symptoms reported more depressed mood over a one-year reporting period than caregivers of patients with less suicidal ideation or depression. The pattern of findings was consistent across parent caregivers and spousal caregivers.

Conclusions

Caregivers, rightly concerned about patients becoming suicidal or depressed, may try to care for the patient at the expense of their own health and well-being. Treatments that focus on the health of caregivers must be developed and tested.

Background and objective

Asperger's Syndrome (AS) is a pervasive developmental disorder that is sometimes unrecognized, especially in the adult psychiatric setting. On the other hand, in patients with an AS diagnosis, comorbid psychiatric disorders may be unrecognized in the juvenile setting. The aim of the paper is to show and discuss some troublesome and complex problems of the management of patients with AS and comorbid Bipolar Disorder (BD).

Methods

The paper describes three patients affected by AS and bipolar spectrum disorders.

Results and conclusion

Mood stabilizers and 2nd generation antipsychotics were effective in the treatment of these AS patients with comorbid BD, while the use of antidepressants was associated with worsening of the mood disorder.

It is of importance to recognize both the psychiatric diagnoses in order to arrange an exhaustive therapeutic program and to define specific and realistic goals of treatment.

Background

Depressive disorders are commonly managed in primary care and family physicians are ideally placed to serve as central providers to these patients. Around the world, the prevalence of depressive disorders in patients presenting to primary care is between 10-20%, of which around 50% remain undiagnosed. In Hong Kong, many barriers exist preventing the optimal treatment and management of patients with depressive disorders. The pathways of care, the long term outcomes and the factors affecting prognosis of these patients requires closer examination.

Methods/Design

The aim of this study is to examine the prevalence, incidence and natural history of depressive disorders in primary care and the factors influencing diagnosis, management and outcomes using a cross-sectional study followed by a longitudinal cohort study.

Doctors working in primary care settings across Hong Kong have been invited to participate in this study. On one day each month over twelve months, patients in the doctor's waiting room are invited to complete a questionnaire containing items on socio-demography, co-morbidity, family history, previous doctor-diagnosed mental illness, recent mental and other health care utilization, symptoms of depression and health-related quality of life. Following the consultation, the doctors provide information regarding presenting problem, whether they think the patient has depression, and if so, whether the diagnosis is new or old, and the duration of the depressive illness if not a new diagnosis. If the doctor detects a depressive disorder, they are asked to provide information regarding patient management. Patients who consent are followed up by telephone at 2, 12, 26 and 52 weeks.

Discussion

The study will provide information regarding cross-sectional prevalence, 12 month incidence, remission rate, outcomes and factors affecting outcomes of patients with depressive disorders in primary care. The epidemiology, outcomes, pathways of care, predictors for prognosis and service needs for primary care patients with depressive disorders will be described and recommendations made for policy and service planning.

Objectives

To determine the association of early and long-term reductions in worry symptoms after cognitive behavioral therapy for generalized anxiety disorder (GAD) in older adults.

Design

Substudy of larger randomized controlled trial

Setting

Family medicine clinic and large multi-specialty health organization in Houston, TX, between March 2004 and August 2006

Participants

Patients (N=76) 60 years or older with a principal or coprincipal diagnosis of GAD, excluding those with significant cognitive impairment, bipolar disorder, psychosis or active substance abuse.

Intervention

Cognitive behavioral therapy, up to 10 sessions over 12 weeks, or enhanced usual care (regular, brief telephone calls and referrals to primary care provider as needed)

Measurements

Penn State Worry Questionnaire (PSWQ) administered by telephone at baseline, 1 month (mid-treatment), 3 months (post-treatment), and at 3-month intervals through 15 months (1-year follow-up). We used binary logistic regression analysis to determine the association between early (1-month) response and treatment responder status (reduction of more than 8.5 points on the PSWQ) at 3 and 15 months. We also used hierarchical linear modeling to determine the relationship of early response to the trajectory of score change after post-treatment.

Results

Reduction in PSWQ scores after the first month predicted treatment response at post-treatment and follow-up, controlling for treatment arm and baseline PSWQ score. The magnitude of early reduction also predicted the slope of score change from post-treatment through the 15-month assessment.

Conclusions

Early symptom reduction is associated with long-term outcomes after psychotherapy in older adults with GAD.

The hypothesis for this paper is that adult patients who have higher screening scores for mental health co‐morbidities and depression have a greater likelihood of not responding to treatment with collaborative care management (CCM) for their depression within six months.

For the 334 patients in this study, the primary endpoints were if the patient was in remission at six months (PHQ‐9 score <5) or if they were non‐responsive (NR) (PHQ‐9 >50% of baseline score). Initial evaluation included screening for alcoholism (AUDIT), anxiety (GAD‐7) and bipolar disorders (MDQ).

The differences in marital status, percentage of minority patients, gender, initial PHQ‐9 and AUDIT scores were not statistically significant. Mood Disorders Questionnaire (MDQ) screening was more likely to be negative for the group in remission (96.2% vs 90.0%, P=0.049) and positive for the NR group (8.0% vs 2.1%, P=0.026). GAD‐7 screening was significantly lower in the remission group (9.85) than in the NR group (11.53, P=0.009).

Results of multiple logistic regression analysis demonstrated that age, gender, race, marital status, PHQ‐9 score and AUDIT score were not related to the odds of being NR. A one‐point higher GAD‐7 score was associated with approximately 6% higher adjusted odds of being NR. Patients with a positive MDQ were associated with elevated odds of non‐response (adjusted OR=3.4714, P=0.044) when controlling for all other variables.

A higher initial screening score for anxiety or bipolar disorder is associated with a statistically significant increase in the relative risk of patients in CCM not responding to current treatments for depression within six months.

Background

Previous research has documented that the symptoms of bipolar disorder are often mistaken for unipolar depression prior to a patient's first bipolar diagnosis. The assumption has been that once a patient receives a bipolar diagnosis they will no longer be given a misdiagnosis of depression. The objectives of this study were 1) to assess the rate of subsequent unipolar depression diagnosis in individuals with a history of bipolar disorder and 2) to assess the increased cost associated with this potential misdiagnosis.

Methods

This study utilized a retrospective cohort design using administrative claims data from 2002 and 2003. Patient inclusion criteria for the study were 1) at least 2 bipolar diagnoses in 2002, 2) continuous enrollment during 2002 and 2003, 3) a pharmacy benefit, and 4) age 18 to 64. Patients with at least 2 unipolar depression diagnoses in 2003 were categorized as having an incongruent diagnosis of unipolar depression. We used propensity scoring to control for selection bias. Utilization was evaluated using negative binomial models. We evaluated cost differences between patient cohorts using generalized linear models.

Results

Of the 7981 patients who met all inclusion criteria for the analysis, 17.5% (1400) had an incongruent depression diagnosis (IDD). After controlling for background differences, individuals who received an IDD had higher rates of inpatient and outpatient psychiatric utilization and cost, on average, an additional $1641 per year compared to individuals without an IDD.

Conclusions

A strikingly high proportion of bipolar patients are given the differential diagnosis of unipolar depression after being identified as having bipolar disorder. Individuals with an IDD had increased acute psychiatric care services, suggesting higher levels of relapses, and were at risk for inappropriate treatment, as antidepressant therapy without a concomitant mood-stabilizing medication is contraindicated in bipolar disorder. Further prospective research is needed to validate the findings from this retrospective administrative claims-based analysis.