Mixed Episodes Research Articles

Validity of the Shahin Mixed Depression Scale: A Self-Rated Instrument Designed to Measure the Non-DSM Mixed Features in Depression.

BackgroundThe DSM5-defined mixed features in depression do not include psychomotor agitation, irritability or distractibility because they are considered overlapping symptoms. A growing number of modern psychiatrists have expressed dissatisfaction with this and proposed alternative sets of mixed symptoms that are much more common and clinically relevant. Among such alternative criteria were those proposed by Koukopoulos. He utilized the research diagnostic criteria of agitated depression (RDC-A) as a mixed depression subtype, and validated another form of mixed depression, the Koukopoulos criteria for mixed depression (K-DMX).PurposeThis study provides psychometric validation for the first self-rated scale designed to measure the most common mixed symptoms in depression as proposed by Koukopoulos.Patients and MethodsWe conducted a multicenter cross-sectional study of 170 patients with unipolar depression. They completed the Shahin Mixed Depression Scale (SMDS) and underwent expert interviews as a gold standard reference. SMDS’ psychometric properties were assessed, including Cronbach’s alpha, factor analysis, sensitivity, specificity, predictive value and accuracy.ResultsWe found significant association and agreement between mixity according to SMDS and the gold standard (K-DMX and RDC-A according to expert interview) with good internal consistency (Cronbach’s alpha=0.87), high sensitivity (=91.4%), specificity (=98.0%), positive predictive value (=96.9%), negative predictive value (= 94.2%) and accuracy (=95.2%). Factor analysis identified one factor for psychomotor agitation and another for mixity without psychomotor agitation.ConclusionSMDS was a reliable and valid instrument for assessing the frequently encountered and clinically relevant mixed features in depression.

Effects of mood episodes and comorbid anxiety on neuropsychological impairment in patients with bipolar spectrum disorder.

ObjectivesCases of patients with bipolar disorder (BD) having neuropsychological impairment have been reported, although inconsistently. The possibility of comorbidity with anxiety disorder (AD) has been suggested. The association between mood episodes and AD comorbidity on neuropsychological performance is unclear and thus was investigated in the current study.MethodsAll participants were informed about and agreed to participate in this study. Patients with BD were recruited from outpatient and inpatient settings, and healthy controls (HCs) were recruited as a comparison group. Six hundred and twenty‐eight participants (175 HCs and 453 BD—56 BDI and 397 BDII) were studied based on their current mood episode, namely, depressive (BDd), manic/hypomanic (BDm), mixed (BDmix), and euthymic (BDeu), compared with/without AD comorbidity (164 with AD).ResultsCompared to HCs, all BD groups had significantly more impaired neuropsychological profiles, but the BDeu group was found to have less impairment in memory and executive function than the episodic BD groups. The percentage of AD comorbidity in BDd, BDm, BDmix, and BDeu was 33.9%, 40.3%, 33.0%, and 35.6%, respectively (χ 2 = 1.61, p > .05). The results show that AD plays a different role in neuropsychological impairment across various mood episodes in BD.ConclusionMemory impairment and executive dysfunction may be state‐like cognitive phenotypes and are affected by AD comorbidity during mixed and depressive episodes in BD, while sustained attention deficiencies are more like trait markers, regardless of mood episodes, and persist beyond the course of the illness. The AD comorbidity effect on attentional deficit is greater when suffering from a manic episode.

Suicide Risk and Mood Disorders in Women in the Postpartum Period: a Longitudinal Study.

Suicide associated with severe psychiatric illnesses is considered the leading cause of maternal deaths. We aimed to assess the suicide risk in women who experienced depressive or mixed episodes of mood change during the postpartum period and to determine which disorder is more related to suicide risk in the same period. We conducted a longitudinal study with 706 women whose children were born from April 2007 to May 2008 in a southern city in Brazil, and received prenatal care by the Brazilian National System of Public Health. The first assessment occurred during the prenatal period and the second within 30 to 60days postpartum. The incidence of suicide risk was 10.9%. The odds of postpartum suicide risk were 6.50 (95% CI: 2.73; 15.48) higher in mothers with postpartum depression and 41.50 (95% CI: 12.11; 142.16) higher in those with mixed episodes than those who did not suffer from any mood disorder. Women with chronic episodes (who had depressive or mixed episodes during pregnancy and postpartum) were at increased odds of 4.94 (95% CI: 1.46; 16.69) of a postpartum suicide risk. The postpartum seems to be a critical period in the women's mental health. The impact of mental disorders in this period, especially mixed episodes, can increase the odds of a suicide risk onset. A good psychiatric evaluation and support during the prenatal and postpartum care may prevent the subsequent risk of suicide.

Antipsychotics Increasingly Prescribed for Bipolar Disorder

Antipsychotics Increasingly Prescribed for Bipolar Disorder

TO006NON-INVASIVE DIAGNOSIS OF BK VIRUS-ASSOCIATED NEPHROPATHY USING URINARY PROTEOMICS IN KIDNEY ALLOGRAFT PATIENTS

Abstract Background and Aims BK virus-associated nephropathy (BKvN) is an important complication occurring after kidney transplantation. Its treatment mainly relies on lowering immune suppression. BKvN’s histological aspect can mimic T cell-mediated rejection (TCMR) and other inflammatory conditions featuring tubulitis and interstitial infiltrate. At present, the screening strategy consists of measuring urinary and blood viral loads of BKv. Upon rising BK viremia, BKvN diagnosis is established by a graft biopsy. Biopsies are invasive and are not suitable for repeated screening. Therefore, the aim of this case-control study was to establish a urinary proteome-based test for BKvN diagnosis. Method Urine was obtained from 700 allograft recipients prior to either protocol or „for cause“ biopsies during the first year of post-transplantation surveillance. Aside from normal biopsy findings (N=294), the histological diagnoses included BKvN (N=50), IFTA II-III (N=145), glomerulonephritis (N=17) and T cell-mediated, antibody-mediated, mixed or borderline rejection episodes (N=194). From all patients, relevant clinical and demographic data including Banff classification scores, HLA mismatches and the presence of donor-specific antibodies was collected at the date of sample collection and in further clinical follow-up. BKvN cases were defined as having SV40-positive immunostaining on allograft biopsy. BKvN patients were considered as cases and all other recipients were considered as controls. Patient’s urinary peptide profiles were generated using capillary electrophoresis coupled to mass spectrometry consisting of 9430 different peptides in the mass range of 0.8 to 20 kDa. Results The CE-MS peptide profiles of randomly selected 30 BKvN cases and 307 kidney allograft controls (one sample per patient) were statistically analyzed to identify the most discriminative peptide markers for BKvN. In total, there were 117 peptides detected to have significantly different urinary excretion rates between both patient groups after false discovery rate adjustment for multiple testing. Thirty-two of these peptides were selected by cross-validated variable selection to establish a Support Vector Machine-based multi-marker model. Applying the 32-peptide marker model to an independent validation cohort consisting of 20 BKvN cases and 343 controls resulted in an area under the receiver operating characteristic curve of 0.86 and a 95% confidence interval from 0.82 to 0.89 with the p-value below 0.0001 and sensitivities and specificities for BKvN diagnosis of 85 and 76 %, respectively. Most notably, distribution of the classification values (figure 1) in the different patient groups of the validation set indicated specificities of the peptide marker model for TCMR/borderline of 85% (17 of 20 true negative classifications) and for viruria/viremia of 73% (8 of 11 true negative classifications) Conclusion In conclusion, the established urinary peptide marker model might serve as a non-invasive diagnostic test for BKvN and its differentiation from TCMR and states of isolated viruria or viremia.

T92. POSSIBLE COMBINATIONS OF DSM-IV AND DSM-5 CRITERIA IN SCHIZOPHRENIA AND SCHIZOAFFECTIVE DISORDER VERSUS MAJOR DEPRESSIVE AND MANIC EPISODES

BackgroundPsychiatric disorders diagnoses are based on the satisfaction of specific symptoms criteria. Although this categorical method of classification, which is based on the identification of clinical syndromes, has proven useful in terms of treatment, its validity has been criticized. The possible symptoms combinations for major psychotic and mood disorder diagnoses could be calculated using combinatorial mathematics and the results could provide indices of diagnostic heterogeneity.MethodsOur calculations were conducted using the binomial coefficient. In mathematics, this coefficient calculates the number of an unordered and unrepetitive selection of k items from a set S (a subset of k items from S) with the following formula: n!/k!(n-k)!. We calculated the possible number of combinations of symptoms required for diagnosing a) two major psychotic disorders (a1. Schizophrenia-SCZ and a2. schizoaffective disorder-SAD), and b) two major mood disorders-episodes (b1. Major Depressive Episode-MDE and b2. Manic Episode- ME), implementing the DSM-5 and DSM-IV diagnostic criteria. For each diagnosis, k corresponds to the number of the necessary symptoms, where S to the total number of symptoms described in the relevant criteria. The following calculations were conservative, since they did not take into account all the possible combinations within each criterion, the effect of specifiers or the effect of SCZ, or SAD subtypes.ResultsWe found the following combinations: DSM-5: SCZ=25, SAD=12,225, MDE=163, ME=326. DSM-IV: SCZ=74, SAD=2,762,198, MDE=163, ME=163. According to DSM-IV (but not to DSM-5), Criterion A for Schizophrenia could coexist with a mixed mood episode in SAD. Interestingly, the possible symptoms combinations for a mixed episode was 37,001. The possible symptoms combinations for the diagnosis of schizophrenia has been slightly reduced in DSM-5 as compared with DSM-IV, but the reduction in the number of relevant combinations for the diagnosis of SAD has been impressive. This reduction was driven by the removal of mixed mood episodes in DSM-5. The possible combinations in SCZ, albeit not in SAD, were fewer than those required for the diagnosis of a MDE and a ME.DiscussionThe above results indicated that the diagnostic heterogeneity of psychotic disorders differed from that of mood disorders. SAD appeared to be the most heterogeneous disorder. DSM-5 criteria have limited the possible combinations of symptoms and have therefore improved the heterogeneity of SCZ and SAD, but not that of major mood disorders. The extent and the clinical implications of diagnostic heterogeneity in different psychotic and mood disorders remain to be elucidated by future research.

Clinical and neuroendocrine correlates of childhood maltreatment history in adults with bipolar disorder.

Childhood maltreatment has been associated to an increased risk of developing bipolar disorder (BD). A role of the hypothalamus-pituitary-adrenal (HPA) axis in mediating trauma-related risk for adult psychopathology has been suggested but scarcely investigated in BD. Therefore, we explored the impact of childhood maltreatment on clinical features of BD and on the activity of the HPA axis. One hundred and six patients participated in the study. On the basis of their history of childhood trauma, as assessed by the Childhood Trauma Questionnaire (CTQ), they were divided into a group with a history of childhood maltreatment (CM+) and a group without (CM-). Twenty-nine participants (16 with a history of childhood trauma and 13 without) underwent the cortisol awakening response (CAR) test. Sixty-two patients had a history of childhood maltreatment and 44 had not. Maltreatment was significantly more frequent in females than males. CM+ patients showed a significant higher body mass index, a significant higher number of suicide attempts, and more severe mania symptoms than CM- ones. Logistic regression indicated a significant association between lifetime suicide attempts and any type of childhood maltreatment and between emotional abuse and the presence of psychotic symptoms or mixed mood episodes. CM+ individuals with BD exhibited a significantly reduced CAR with respect to CM- ones. Our results add to literature findings showing a worse clinical course in BD patients with a history of childhood maltreatments and show for the first time that childhood trauma exposure is associated to an impaired CAR in adults with BD.

Efficacy, Safety, and Tolerability of Theta-Burst Stimulation in Mixed Depression: Design, Rationale, and Objectives of a Randomized, Double-Blinded, Sham-Controlled Trial.

IntroductionMixed-specifier mood disorders are probably a different subgroup in terms of response to treatment, socio-demographic parameters, course, and family history. Here we describe the rationale and design of a clinical trial aimed to test the efficacy, safety, and tolerability of a non-pharmacological treatment known as theta-burst stimulation (TBS) for treating the mixed depressive episodes of both bipolar (I or II), and unipolar depression.MethodsThe study is designed as a randomized, sham-controlled, double-blinded clinical trial evaluating TBS for the treatment of moderate or severe major depressive episodes with mixed features of patients receiving at least one first or second-line pharmacological treatment for depressive episodes without adequate response. Ninety adult (18 to 65 years old) patients will be enrolled and submitted to 6-week (comprising 5 consecutive days a week sessions for the first 3 weeks and then 2 days a week for a further 3 week) of inhibitory followed by excitatory TBS in dorsolateral prefrontal cortex. Participants will be assessed using clinical and neuropsychological tests before and after the intervention. The primary outcome is change in Montgomery–Åsberg Depression Scale (MADRS) score over time and across groups. Cognitive parameters will also be assessed with neuropsychological tests.ResultsThe clinical results will provide evidence about TBS as an adjunctive treatment for mixed depression treatment and neuropsychological parameters will contribute toward an improved understanding the effects of TBS in cognition.ConclusionOur results could introduce a novel therapeutic technique for mixed depressive episodes of both bipolar and unipolar disorders.Clinical Trial Registrationwww.ClinicalTrials.gov, identifier NCT04123301; date of registration: 10/10/2019; URL: https://clinicaltrials.gov/ct2/show/NCT04123301?term=NCT04123301&rank=1.

One-pot reaction for determination of Asenapine maleate through facile complex formation with xanthine based dye: Application to content uniformity test.

Asenapine maleate was approved by the FDA for the treatment of schizophrenia and mania or mixed episodes with bipolar I disorder. In the present article, two spectroscopic methods were developed and validated for the determination of asenapine. Both methods depend on association complex formation between xanthine based dye (eosin Y) and the cited drug in acetate buffer pH=3.8. In the spectrophotometric method (method I), the absorbance of the formed complex was estimated at maximum wavelength of 545nm and Beer's law was obeyed in the range of 1-12μgmL-1. The spectrofluorimetric method (method II) depends on measuring the quenching effect of the drug on the native fluorescence of eosin Y at 545nm after excitation at 303nm. The linearity range of method II was 0.4-3.2μgmL-1. The limits of detection were 0.24 and 0.08μgmL-1 for method I and II, respectively. The instructions of ICH were followed to fully validate the developed analytical procedures. The formation constant of the reaction was 3.93×104 while its Gibb's free energy was -2.6×104Jmol-1. Finally, the methods were applied for the analysis of pharmaceutical tablets and for evaluation of their content uniformity.

Naturalistic follow-up in bipolar patients after successful electroconvulsive therapy

BackgroundElectroconvulsive therapy (ECT) is an effective treatment for acute depression, mania and mixed states. We evaluated the long-term outcome of patients with bipolar depression or mixed state, responsive to ECT. Methodsthis observational follow-up study was conducted in 70 patients with Bipolar Disorder: 36 patients met DSM-IV-TR criteria for a major depressive episode (MDE) and 34 for a mixed episode (MXE). During the follow-up after ECT, the relapse rates and the duration of response and remission periods were recorded. Resultsthe mean duration of the follow-up was 57 weeks. 93% of the patients maintained at least a partial therapeutic response for more than 90% of the follow-up period. 73% of patients fulfilled the criteria for a full remission, 33% showed a depressive relapse and 10% a mixed relapse. No manic relapses occurred but almost 1/3 of the sample presented hypomanic episodes. MDE patients presented higher rates of remission compared to MXE ones. Patients with anxiety disorders reported earlier relapses than those without this comorbidity. Relapsed-patients showed higher functional impairment at baseline evaluation, compared to non-relapsed ones. Limitationsnonrandom allocation, limited sample size, possible influence of psychopharmacological treatment. ConclusionsGiven several methodological limitations, this study cannot draw definite conclusions but could suggest that in treatment-resistant bipolar patients with severe depression or mixed state, ECT may represent a useful treatment option. Patients with mixed features, comorbid anxiety disorders and higher functional impairment present less favorable outcome. Future research on long-term efficacy of ECT and on clinical predictors of relapse is needed.

Brain atrophy on a young male with bipolar disease

Bipolar disorder, sometimes referred to as manic depressive disorder is characterized by dramatic shifts in mood, energy, and activity levels that affects a person's ability to carry out day-to-day tasks. More than two-thirds of people with bipolar disorder have at least one close relative with the illness or with unipolar major depression, indicating that the disease has a heritable component (1). There have been numerous studies that have revealed the presence of cerebral atrophy especially in the prefrontal cortex in elderly patients with bipolar affective disorder, associated with loss of grey matter(2), but we will present the case of a 28 year-old male, known with bipolar disease, admitted for a mixed episode, with the predominance of depressive episodes, exacerbated in a work-related stress, on which we discovered a cerebral atrophy on CT examination. By introducing the neuroleptics and mood stabilizer, we were able to notice improvement on symptoms, as well as a regain on his social and professional functioning.

WE'RE SO ANXIOUS! CHALLENGES FACED AND LESSONS LEARNED IN THE MANAGEMENT OF ANXIETY IN OLDER ADULTS

This session will highlight several challenging and complicated cases of anxiety treated in an interdisciplinary geriatric outpatient clinic and nursing home settings. We will share our lessons learned from these clinical encounters with the assistance of Dr. Tawny Smith, a clinical psychiatric pharmacist. Dr. Lara will discuss a case of a patient with major depressive disorder with psychosis which mimicked new onset anxiety disorder. She will review the diagnostic challenges associated with anxiety disorders masking and exacerbating major depressive disorder and the treatment approach for this patient. In addition, Dr. Scott will discuss a case of a patient distressed by anxiety who was found to be most appropriately diagnosed with mixed features of a bipolar II disorder. She will review the overlap between uncomplicated anxiety and mixed features, and clinical pearls for distinguishing between the two. She will also discuss medication choices for treatment of a mixed episode. Dr. Nettles will discuss a case of a patient with Generalized Anxiety Disorder and Panic Disorder who had been managed long term with increasingly high dose benzodiazepines. She will review clinical pearls and challenges of managing this complicated patient and safely tapering high dose benzodiazepines while still managing anxiety. Lastly, Dr. Gonzalez will discuss the pharmacologic management of anxiety in a patient in a nursing home with co-morbid major neurocognitive disorder. Specifically, he will highlight the challenges of utilizing medications that address anxiety and underlying PTSD symptoms, while being mindful of medication side effects that can worsen neurocognitive symptoms. Dr. Smith will review clinical pearls related to the cases presented. In addition, we will share knowledge regarding literature updates, as well as guidelines for treatment of the aging patient with anxiety.

Preliminary evaluation of the utility of parental ratings in a Child Network

Introduction: Children in the US have a high incidence of psychiatric disorders, but the symptoms of these illnesses are often poorly recognized and treated. We thus created a Child Network for parents of children aged 2-12 to rate their child on a weekly basis on a secure website so that longitudinal ratings could be easily visualized. Methods: After giving informed consent, parents filled out: a one-time questionnaire and a 97 item Child Checklist; and then rated the severity of depression, anxiety, ADHD, oppositional behavior, and mania each week. The new Checklist ratings were correlated with the 23 previous validated in adults (the M-3), and symptom burden was compared with diagnoses received in the community. Results: The 23 item M-3 ratings were highly correlated with the more extensive Child Checklist. Symptom severity also corresponded to diagnoses received in the community. An example of the longitudinal weekly ratings of a child with a dysphoric mania is also presented. Conclusions: The convergence of scores on the adult and child portions of the Child Checklist and the ease of visualization of symptoms and response to treatment suggest the utility of the ratings in the Child Network.

Inosine prevents hyperlocomotion in a ketamine-induced model of mania in rats

Bipolar Disorder is a disorder characterized by alternating episodes of depression, mania or hypomania, or even mixed episodes. The treatment consists on the use of mood stabilizers, which imply serious adverse effects. Therefore, it is necessary to identify new therapeutic targets to prevent or avoid new episodes. Evidence shows that individuals in manic episodes present a purinergic system dysfunction. In this scenario, inosine is a purine nucleoside known to act as an agonist of A1 and A2A adenosine receptors. Thus, we aimed to elucidate the preventive effect of inosine on locomotor activity, changes in purine levels, and adenosine receptors density in a ketamine-induced model of mania in rats. Inosine pretreatment (25 mg/kg, oral route) prevented the hyperlocomotion induced by ketamine (25 mg/kg, intraperitoneal route) in the open-field test; however, there was no difference in hippocampal density of A1 and A2A receptors, where ketamine, as well as inosine, were not able to promote changes in immunocontent of the adenosine receptors. Likewise, no effects of inosine pretreatments or ketamine treatment were observed for purine and metabolic residue levels evaluated. In this sense, we suggest further investigation of signaling pathways involving purinergic receptors, using pharmacological strategies to better elucidate the action mechanisms of inosine on bipolar disorder. Despite the limitations, inosine administration could be a promising candidate for bipolar disorder treatment, especially by attenuating maniac phase symptoms, once it was able to prevent the hyperlocomotion induced by ketamine in rats.

Treatment of Mixed Features in Bipolar Disorder: an Updated View.

Mixed presentations in bipolar disorder have long posed clinical and nosological challenges. The DSM-5 mixed features specifier was developed to provide a more flexible and clinically relevant definition of mixed presentations compared with narrowly defined DSM-IV mixed episodes. However, there is little guidance on treating such presentations. Here, we summarize the evidence for biological treatments of DSM-5 and similarly defined mixed features (MFs). The literature on treating MFs is almost exclusively based on post hoc analyses. Within this limited evidence base is preliminary positive data for aripiprazole, asenapine, cariprazine, olanzapine, risperidone, and ziprasidone in treating acute mania with MFs, and cariprazine, lurasidone, olanzapine, and ziprasidone for depressive symptoms in depression with MFs. Divalproex may also be efficacious for acute mania with MFs. The few extant maintenance studies suggest that divalproex and olanzapine may have long-term efficacy in those with index MFs or for the prevention of MFs, respectively. The existing evidence suggests that clinicians consider atypical antipsychotics and divalproex for treating acute mixed presentations. However, adequately powered treatment trials-and studies of maintenance and neurostimulation therapies-are needed. Additionally, data-driven techniques to identify relevant symptom clusters may help improve our conceptualization of mixed presentations.

Dimensional treatment of aggression, impulsivity, and activation: a study on psychiatric inpatients

Most psychotropic drugs are effective for several mental disorders, rather than for specific diagnoses. The dimensional approach to psychiatric nosology can explain the non-specificity of drug action, and it could usefully integrate the traditional categorical approach and may help optimize personalised psychiatric treatment. This study aimed at examining the use of antiepileptic drugs, particularly valproate, for the treatment of prominent aggression, impulsivity, and activation, within the conceptual framework of a "dimensional pharmacotherapy" strategy. This observational, naturalistic study included 846 adult psychiatric inpatients. Within 48 hours from admission and then again at discharge, each patient was administered the Brief Psychiatric Rating Scale (BPRS) and the SVARAD scale for rapid dimensional assessment. We found a statistically significant association between the prescription of an antiepileptic drug (valproate in the vast majority of cases) and the presence of high levels of aggression, impulsivity, and activation. In patients with high levels of these psychopathological dimensions, the prescription of an antiepileptic drug was significantly associated with a greater decrease in BPRS total score from admission to discharge. This finding remained significant after the exclusion of patients experiencing a manic or mixed episode. Although methodological limitations dictate caution in interpreting our results, these preliminary findings suggest that a "dimensional pharmacotherapy" strategy (i.e., selecting drugs based on neurobiological action rather than categorical diagnosis) for the treatment of aggression, impulsivity and activation is commonly used in daily practice and may lead to greater clinical improvement, in the absence of severe adverse effects.

Coherence of jaw and neck muscle activity during sleep bruxism.

BackgroundStudies have shown co‐contraction of jaw and neck muscles in healthy subjects during (sub) maximum voluntary jaw clenching, indicating functional inter‐relation between these muscles during awake bruxism. So far, coherence of jaw and neck muscles has not been evaluated during either awake or sleep bruxism.ObjectiveThe objective of this study was to evaluate the coherence between jaw and neck muscle activity during sleep bruxism.MethodsIn a cross‐sectional observational design, the electromyographic activity of jaw (masseter, temporalis) and neck (sternocleidomastoid, trapezius) muscles in individuals with “definite” sleep bruxism was measured using ambulatory polysomnography (PSG). Coherence for masseter‐temporalis, masseter‐sternocleidomastoid and masseter‐trapezius was measured during phasic and mixed rhythmic masticatory muscle activity episodes using coherence‐analysing software. Outcome measures were as follows: presence or absence of significant coherence per episode (in percentages), frequency of peak coherence (FPC) per episode and sleep stage.Results A total of 632 episodes within 16 PSGs of eight individuals were analysed. Significant coherence was found between the jaw and neck muscles in 84.9% of the episodes. FPCs of masseter‐temporalis were significantly positively correlated with those of masseter‐sternocleidomastoid or masseter‐trapezius (P < .001). Sleep stages did not significantly influence coherence of these muscular couples.ConclusionDuring sleep bruxism, jaw and neck muscle activation is significantly coherent. Coherence occurs independently of sleep stage. These results support the hypothesis of bruxism being a centrally regulated phenomenon.

Mixed episodes and suicide risk: A community sample of young adults

BackgroundSuicide is the second leading cause of death among young adults worldwide, and few studies have assessed the factors associated with suicidality in this specific population. Thus, the aim of this study was to assess the association between mixed episodes and suicidality in a community sample of young adults. For this aim, we compared young adults in a mixed episode with individuals in a depressive or (hypo)manic episode, and community controls. MethodThis is a cross-sectional population-based study including young adults aged 18–24 years old. Information about participants’ age, sex, self-reported skin color and study status were obtained using a sociodemographic questionnaire. Mixed, (hypo)manic and depressive episodes, as well as suicide risk were assessed using the Mini International Neuropsychiatric Interview. ResultsThe sample included 1560 individuals. Young adults in a mixed episode showed a 13.50 times higher probability to have suicide risk, as compared to community controls (p < 0.001), 5.67 higher probability to have suicide risk as compared to individuals in a (hypo)manic episode (p < 0.001), and 2.18 times higher probability to have suicide risk as compared to young adults in a depressive episode (p < 0.001). LimitationThe assessment of suicide risk includes both suicide attempts and ideation. ConclusionYoung adults in a mixed episode showed a higher rate of suicide risk than individuals with depression or mania/hypomania. Considering the already increasing prevalence of suicide among young adults, there is an urgent need for the early diagnosis and treatment of mixed episodes in this specific population.

An evaluation of suicidal risk in bipolar patients with comorbid posttraumatic stress disorder

BackgroundWhile bipolar disorder (BD) and posttraumatic stress disorder (PTSD) frequently co-occur and individually have a higher risk of suicide compared to the general population, few studies have examined the impact of comorbid PTSD on suicidal ideation in patients with BD. MethodsWe analyzed baseline data from the Clinical and Health Outcomes Initiative in Comparative Effectiveness for bipolar disorder study (Bipolar CHOICE), a 6-month, pharmacological comparative effectiveness trial of individuals with BD. Bipolar CHOICE enrolled 482 individuals. A hierarchical multiple regression analysis assessed whether comorbid PTSD was associated with increased suicidal ideation as assessed by the Concise Health Risk Tracking Scale (CHRT) total and factor scores, while controlling for common correlates of suicidal ideation in this population such as a current major depressive episode, comorbid anxiety disorders, severity of illness and previous suicide attempts. ResultsConsistent with our hypothesis, diagnosis of comorbid PTSD was a significant predictor of the CHRT total score (β=2.59, p=.03). Comorbid PTSD was also a significant predictor of the CHRT propensity factor (β=2.32, adjusted p=.04), but was not a significant predictor of the active suicidal thoughts factor. Additionally, all participants with comorbid PTSD (N = 58) endorsed current suicidal ideation (p=.005) and were more likely to have had a previous suicide attempt (p<.001) compared to those without PTSD. LimitationsGeneralizability beyond outpatient settings is limited, mixed affective states were not assessed, and analyses were cross-sectional. ConclusionsPatients have an increased risk of suicidal ideation when PTSD is comorbid with BD.

Clinical correlates associated with the long-term response of bipolar disorder patients to lithium, valproate or lamotrigine: A retrospective study

BackgroundAlthough mood stabilizers such as lithium (LIT), valproate (VAL), and lamotrigine (LMT) appear to be efficacious treatments for bipolar disorder (BD) in research settings, the long-term response to these mood stabilizers in clinical practice is highly variable among individuals. Thus, the present study examined the characteristics associated with good or insufficient responses to long-term treatment with LIT, VAL, or LMT for BD.MethodsThis study retrospectively analyzed the medical records of patients who visited an outpatient clinic with a diagnosis of BD I or II. Data from patients who were treated with one of three mood stabilizing medications (LIT, VAL, or LMT) for more than 6 months were selected, and the long-term treatment responses were evaluated using the Alda scale. For the purposes of this study, two response categories were formed: insufficient response (ISR), including non-response or poor response (Alda total score ≤ 6), and good response (GR; Alda total score ≥ 7).ResultsOf the 645 patients included in the present study, 172 were prescribed LIT, 320 were prescribed VAL, and 153 were prescribed LMT for at least 6 months. A binary logistic regression analysis revealed that a diagnosis of BD II (odds ratio [OR], 8.868; 95% confidence interval [CI], 1.123–70.046; p = 0.038), comorbid alcohol/substance use disorder (OR, 4.238; 95% CI, 1.154–15.566; p = 0.030), and a history of mixed episodes (OR, 4.363; 95% CI, 1.191–15.985; p = 0.026) were significant predictors of LIT-ISR. Additionally, a depressive-predominant polarity significantly predicted LMT-GR (OR, 8.586; 95% CI, 2.767–26.644; p < 0.001).ConclusionThe present findings demonstrated that patients with a diagnosis of BD II, a comorbid alcohol/substance problem, or a history of mixed episodes were not likely to respond to LIT treatment. Additionally, LMT might be a better treatment choice for patients with a depressive-predominant polarity.