Subthreshold Bipolar Disorder Research Articles

Subthreshold Bipolar Disorder Is Disabling, Costly

Subthreshold Bipolar Disorder Is Disabling, Costly

The lifetime prevalence, health services utilization and risk of suicide of bipolar spectrum subjects, including subthreshold categories in the São Paulo ECA study

Identifying the bipolar (BP) spectrum, including the classic Bipolar I subtype (BP-I), Bipolar II (BP-II) and subthreshold bipolar disorders not meeting DSM-IV diagnostic criteria has raised growing interest, as these softer expressions of bipolar spectrum have been underdiagnosed in spite of clinical consequences. Data are from the Sao Paulo Epidemiological Catchment Area Study (N=1464). Non-affective controls were compared to BP spectrum groups, based on DSM-IIIR and on the "clinical significance" criteria: Subsyndromal Hypomania (SSH) and Manic Symptoms (MS). The lifetime prevalence of BP subgroups was 8.3% (N=122). All BP-I and -II and around 75% of SSH and MS subjects had a lifetime depressive syndrome. Compared to controls and MS subjects, BP-I, BP-II and SSH groups searched more medical help and mental health services. SSH group displayed higher rates of clinical significance than BP-I subjects, and suicidality was higher in BP groups compared to controls. Even the softer MS group had higher rate of suicide attempts than SSH subjects. This is a cross-sectional study and interviews were conducted by lay personnel. Replication in bigger community samples using a mood spectrum approach is necessary to confirm these findings. However, our findings were very similar to those obtained by other authors. Softer expressions of BP disorders appear in 6.6% of this community sample and have serious clinical consequences, which supports the importance of including these categories in the BP spectrum.

Bipolar disorders during adolescence.

To examine the incidence, correlates, course and family history of bipolar disorder (BD) and subthreshold BD in adolescents. Structured diagnostic interviews were conducted with a large community sample of adolescents and their first-degree relatives, and the adolescents were re-evaluated as young adults. The first lifetime onset of BD and subthreshold BD almost always occurred in adolescence. Adolescent BD and subthreshold BD were associated with elevated impairment, comorbidity, and suicide attempts. Adolescents with BD were at increased risk for BD, and adolescents with subthreshold BD were at increased risk for major depressive disorder (MDD) in young adulthood. Relatives of BD adolescents had elevated rates of subthreshold BD and MDD, and relatives of subthreshold BD adolescents had elevated rates of BD and MDD. 'Classical' BD clearly exists in adolescence, but there is also a spectrum of milder bipolar conditions. Remediating and preventing BD in adolescents should be a high public health priority.

The bipolar spectrum: a clinical reality in search of diagnostic criteria and an assessment methodology

Failure to recognize subthreshold expressions of mania contributes to the frequent under-diagnosis of bipolar disorder. There are several reasons for the lower rate of recognition of subthreshold manic symptoms, when compared to the analogous pure depressive ones. These include the lack of subjective suffering, enhanced productivity, ego-syntonicity, and diurnal and seasonal rhythmicity associated with many of the manic and hypomanic symptoms, and the psychiatrists' tendency to subsume persistent or even alternating symptoms among personality disorders. Furthermore, the central diagnostic importance placed on alterations in mood distracts clinicians from paying attention to other more subtle but clinically meaningful symptoms, such as changes in energy, neurovegetative symptoms and distorted cognitions. Although officially accepted in both ICD-10 and DSM-IV, we believe bipolar II disorder is underdiagnosed because of inattention to symptoms of hypomania. Moreover, by requiring the presence of both full-blown hypomanic and major depressive episodes, current nosology fails to include symptoms or signs which are mild and do not meet threshold criteria. There is already agreement in the field that such symptoms are important for depression. We now propose that attention should also be devoted to mild symptomatic manifestations of a manic diathesis, even if such manifestations may sometimes enhance quality of life. The term `spectrum' is used to refer to the broad range of such manifestations of a disorder from core symptoms to temperamental traits. Spectrum manifestations may be present during, between, or even in the absence of, an episode of full-blown disorder. We have developed a structured clinical interview to assess the mood spectrum (SCI-MOODS) to evaluate the whole range of depressive and manic symptoms. This instrument is currently undergoing psychometric testing procedures. Similar to the SCID interview, the SCI-MOODS interview provides a separate rating for each of the major DSM-IV™ symptoms, but the latter also identifies and rates subthreshold and atypical manifestations. This paper presents the concept of a subthreshold bipolar disorder and discusses the potential epidemiological, diagnostic and therapeutic relevance of such a spectrum conditions. We also describe the SCI-MOODS interview used reliably to identify the occurrence of a bipolar spectrum condition. Obviously a great deal of systematic research needs to be conducted to ascertain the reliability and validity of subthreshold bipolarity as summarized in this paper and embodied in our instrument.