A downscaled practical measure of mood lability as a screening tool for bipolar II
Outpatient Psychiatry Center (Ravenna and Forli, Italy) and the Department of Psychiatry, National Health Service, Forli, Italy. Journal of Affective Disorders
(Impact Factor: 3.38).
03/2005; 84(2-3):225-32. DOI: 10.1016/j.jad.2003.09.010
Current data indicate a strong association between Cyclothymic temperament (and its more ultradian counterpart of mood lability) and Bipolar II (BPII). Administration of elaborate measures of temperament are cumbersome in routine practice. Accordingly, the aim of the present analyses was to test if a practical measure of mood lability was unique to BPII, in comparison with major depressive disorder (MDD).
Using the Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version as modified by us [J. Affect. Disord. 73 (2003) 33; Curr. Opin. Psychiatry 16 (2003) S71], we interviewed 62 consecutive BPII outpatients, as well as their 59 MDD counterparts during a major depressive episode (MDE). Hypomanic symptoms during MDE were systematically assessed: three or more such symptoms defined depressive mixed state (DMX3) on the basis of previous work by us [J. Affect. Disord. 73 (2003) 113]. A downscaled definition of trait mood lability was adapted from Akiskal et al. [Arch. Gen. Psychiatry 52 (1995) 114] and Angst et al. [J. Affect. Disord. 73 (2003) 133], requiring a positive response to one of two queries on whether one is a person with frequent "ups and downs" in mood, and whether such mood swings occur for no reason. The patients selected for inclusion had not received neuroleptics and antidepressants for at least 2 weeks prior to the index episode, they were free of substance and alcohol abuse, and did not meet the DSM-IV criteria for borderline personality disorder (BPD). Associations between mood swings and clinical variables were tested by logistic regression (STATA 7).
Mood swings were endorsed by 50.4% of the entire sample: 62.9% of BPII and 37.2% of MDD (p = 0.0047). This practical measure of mood lability was significantly associated with BPII, lower age at onset, high depressive recurrences, atypical features, and DMX3. When controlled for number of major affective episodes, mood swings were still significantly associated with BP-II. Sensitivity and specificity of mood swings for predicting BPII were 62.9% and 62.7%, respectively.
The low specificity of trait mood lability for BPII diagnosis is probably due to the fact that we used a downscaled simplified measure of this trait.
On the other hand, the relatively high sensitivity of our downscaled measure of mood lability for predicting BPII supports its usefulness as a screening tool for this diagnosis. The lack of association between self-reported mood lability and number of major mood episodes indicates that such lability does not reflect the perception of history of frequent episodes, and that it has some validity as a trait indicator. Given that our sample excluded patients meeting the DSM-IV criteria for BPD, contradicts the opinion of the latter manual that such mood lability represents its pathognomonic characteristic that distinguishes it from BPII. The bipolar nature of mood lability is further supported by significant associations with external validating criteria for bipolarity. Overall, these data indicate that in the differential diagnosis between MDD and BPII, trait mood lability favors the latter at a significant statistical level.
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- "Furthermore, there are reports (Angst et al., 2003; Judd et al., 2003) that BP-II patients with 2-day hypomania and with 4-day hypomania had similar levels of cognitive dysfunction. Therefore, we preferred the 2-day duration of hypomania as a criterion for diagnosing BP-II, which is considered a more appropriate criterion in several studies with large study populations (Angst et al., 2003; Benazzi and Akiskal, 2005; Judd et al., 2003). Our study has three major limitations. "
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ABSTRACT: Bipolar disorder (BP) is often comorbid with anxiety disorder (ANX), especially in bipolar II disorder (BP-II). BP patients with comorbid ANX often manifest intensified symptoms and harmful dysfunctions. However, most studies have focused on bipolar I disorder (BP-I); few have investigated the effect of comorbid ANX on the neuropsychological function of BP-II patients. We examined neuropsychological functions in BP-II patients with and without comorbid ANX.
Fifty-nine participants were recruited: 20 patients with interepisode (symptom-free) BP-II without comorbid ANX, 20 with interepisode BP-II with comorbid ANX, and 19 healthy controls. All participants were screened using the Chinese version of the Modified Schedule of Affective Disorder and Schizophrenia-Lifetime (SADS-L). Individuals comorbid with major or minor mental illness other than BP-II were excluded. Comparisons were made between the three groups using neuropsychological tests to assess memory, attention, psychomotor speed, and frontal executive function.
BP-II patients with comorbid ANX showed poorer neuropsychological functions than those in the BP-II-only and control groups. Additionally, BP-II-only patients and controls showed equal cognitive performance.
Because BP-II patients with comorbid ANX had the lowest scores in the majority of neuropsychological functional tests, we conclude that they have greater cognitive impairments than do BP-II patients without comorbid ANX. Neuropsychological dysfunctions seemed more strongly associated with ANX than with BP-II in interepisode periods. Identifying and managing ANX comorbidity is critical when treating BP-II patients.
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ABSTRACT: Residual depressive symptoms are common in mood disorders. Inter-episode mood lability (IML; i.e. frequent ups and downs of mood) is understudied as a possible residual symptom. The study aim was to find the frequency of IML, and to find if it was more likely to be a residual symptom or if it was instead part of the natural course of mood disorders. Consecutive 89 bipolar-II (BP-II) and 89 major depressive disorder (MDD) outpatients who were not on psychoactive drugs, were interviewed by the Structured Clinical Interview for the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders as modified by Benazzi and Akiskal. Kraepelin's basic definition of IML (i.e. frequent up and down fluctuations of mood between episodes) was followed. IML was present in 48.3% of the patients, significantly more common in BP-II than in MDD (62.9% vs. 33.7%, P= 0.000). The sample of BP-II and MDD plus IML, versus the sample BP-II and MDD without IML, had significantly more BP-II, lower age at onset, longer illness duration, more depressive recurrences, more depressions with atypical features, more depressive mixed states, and more family history of mood disorders. Logistic regression of IML versus recurrences, controlled for duration of illness, found odds ratio = 1.8, z= 1.6, P= 0.103. Forward stepwise multiple logistic regression of IML versus the variables found significant in the univariate analysis, showed that only BP-II (P = 0.002) and duration of illness (P = 0.015) were significant predictors of IML. IML was common in mood disorder outpatients. Its association with BP-II (an unstable disorder by definition) and duration of illness (but not with recurrences when controlled for illness duration), suggest that IML may be more likely to be part of the natural course of illness than the result of kindling induced by recurrences. Its association with depressive mixed state (a depression reported to be more difficult to treat) and the possibility that it may induce/facilitate recurrences (to be shown by prospective studies), support the need to better study IML for its possible important impact on treatment.
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ABSTRACT: Recent transatlantic concern about suicidality in patients receiving antidepressants prompted us to examine the psychopathologic correlates of suicidal ideation occurring in clinically depressed patients.
The study sample, which consisted of 644 consecutive major depressive outpatients, of which 58.0% had bipolar II disorder (BP-II), was systematically interviewed with the SCID, in order to delineate the diagnostic and psychopathologic correlates of suicidal ideation.
Such ideation, which was present in 49.5% [and favoring BP-II vs. major depressive disorder (MDD)] at an odds ratio (OR) of 1.3 (95% confidence interval = 0.98-1.8), was clinically significantly associated with depressive mixed state (racing/crowded thoughts and psychomotor agitation/activation during index depression), mood lability, decreased self-esteem, anorexia, as well as melancholic and psychotic features. Multiple logistic regression of suicidal ideation versus depressive symptoms and intradepressive excitatory symptoms revealed that decreased self-esteem (OR = 3.3), racing/crowded thoughts (OR = 1.5), and psychomotor agitation/activation (OR = 1.4) were independent and clinically significant correlates of suicidal ideation, irrespective of depression severity.
From a psychopathologic standpoint, suicidality might be conferred by a combination of both the excited (mixed) depressive and agitated (melancholic) clusters. Trait mood lability appears to favor the genesis of these affective clusters. Within the framework of Kraepelinian psychiatry, both clusters represent depressive mixed states. Given that such states are more prevalent in BP-II, our data provide a possible explanation for the greater suicidality in BP-II patients reported in the literature. In light of the higher odds of suicidal ideation in BP-II versus MDD patients, we hypothesize that the higher prevalence of mental and psychomotor activation in BP-II might be one factor among others that favors the greater likelihood of the transition from suicidal ideation to suicidal action in BP-II. Our analyses delineate a mixed depressive substrate at risk for suicidality. To what extent, if any, antidepressant monotherapy might contribute to the genesis of such states and/or suicidality cannot be answered with the methodology of the present study.
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