Unspecified Bipolar Disorder Research Articles

Predictors of Transition from Child and Adolescent Bipolar Not Otherwise Specified to Bipolar I Disorder, a Longitudinal 3.9-Year Study.

Background: Children and adolescents with subthreshold manic symptoms not meeting full DSM criteria for bipolar I or II disorder (BP-I or BP-II) are classified as unspecified bipolar disorder (formerly bipolar not otherwise specified: BP-NOS). Factors associated with transition from BP-II or NOS to BP-I may predict the progression of the disorder. Our objective is to analyze factors associated with transition to BP-I in a Spanish sample of youth with BP-NOS or BP-II. Methods: We included all youth diagnosed with BP before 18 years of age presenting to our clinic (October 1999-December 2014). We assessed clinical factors that may predict transition to BP I with a logistic regression and a multivariable model for data analysis. Results: A total of 72 patients with BP, mean (SD) age 14.5 (10.5-16.0) years, were followed for a median period of 3.9 years. In total, 95.8% of patients retained the BP diagnosis, but they changed type. Baseline BP-I % was 37.5%, and 62.5% at endpoint. BP-NOS decreased from baseline 54.2% to 25% at endpoint. The % of BP-II was 8.3% in both time points, but they were not the same individual patients, as some transitioned from BP-II to BP-I and some BP-NOS changed to BP-II. BP-NOS was stable in 46.1% of patients, but 38.5% transitioned to BP-I over time. Psychotic symptoms during prior depressive episodes (MDD) increased the risk of transition to BP-I by 11-fold. Each individual symptom of mania increased the risk of transition to BP-I by 1.41. Conclusions: BP-NOS was stable in 46.1% of patients, but 38.5% transitioned to BP-I over time. Psychotic symptoms during prior MDD episodes increased the risk of transition from BP-NOS to BP-I.

Bipolar Disorder in a female with CDKL5 Deficiency Disorder: A Case Report.

CDKL5 deficiency disorder (CDD) is an early-onset developmental and epileptic encephalopathy. While a subset of individuals is believed to experience comorbid behavioral disorders, none have reported well-defined affective disorders. Though there is a documented association between epilepsy and mood disorders, they may go undetected in the CDD population due to difficulty assessing mood in the presence of severe/profound intellectual disability and disease-related sleep dysregulation. We aimed to identify the clinical characteristics of an individual with CDD who presented with a mood disorder falling outside this expected behavioral phenotype. We identified one 22-year-old female with CDD diagnosed with unspecified bipolar disorder at 18 years of age. Family history was noncontributory. At diagnosis, she had fluctuations in mood, characterized by periods of elated affect, increased energy and vocalizations, hypertonia, and insomnia lasting 3-4 days alternating with periods of depressed affect, irritability, hypotonia, and excessive sleep lasting for up to one month. She had experienced frequent mood swings and sleep dysregulation from early childhood, and by early adulthood the duration of "up" and "down" periods fell in the range specified in the DSM-5 bipolar disorder criteria. Trazodone and suvorexant did not alleviate sleep related symptoms. Her epilepsy was well controlled on lamotrigine monotherapy since early childhood. Though lamotrigine treatment has had no psychiatric benefit despite its known mood stabilizing properties, aripiprazole has been effective in reducing severity and frequency of fluctuations between hypomania and depression. While sleep and behavioral disorders fall within the expected phenotype for CDD, this is the first report of bipolar disorder. Careful attention to patterns of sleep and behavior that may indicate mood cycling in this population is required, particularly in the setting of limited communication and functional abilities.

Bupropion Treatment for Stimulant Withdrawal in a Patient With Substance Use Disorder and Unspecified Bipolar Disorder

Patients presenting with comorbid stimulant use disorder is a common occurrence in nearly all medical specialties. New clinical strategies to care for patients experiencing stimulant withdrawal should be considered as an effort to improve clinical outcomes. Our patient, a woman in her early 20s with a history of substance use disorder and unspecified bipolar and related disorder, presented with acute psychosis with symptoms including agitation, auditory hallucinations, and delusions in the context of chronic mental illness and cocaine abuse. She was subsequently admitted to the inpatient psychiatry unit. Notable symptoms included mood swings, erratic behavior, anger, and agitation. Mood and psychotic symptoms were treated with olanzapine. She also received medications, including haloperidol, lorazepam, and diphenhydramine, as needed for agitation, which were given as an emergency treat option (ETO) injection. The patient continuously exhibited irritability and endorsed that she was undergoing cocaine withdrawal symptoms, for which she was started on bupropion. Within days of taking this medication, she reported significant improvement in her psychotic and mood symptoms. The patient continued this treatment during the remainder of her stay until the resolution of her symptoms and was discharged with both bupropion and olanzapine to continue while awaiting an outpatient psychiatry appointment in one week.

Bipolar Disorder

Bipolar disorder (BD), previously known as “manic depressive illness,” is a recurrent chronic disorder characterised by mood and energy-state fluctuations. People who have BD comprise more than 1% of the world’s population from all nationalities, ethnic origins, and socioeconomic statuses. There are four different types of bipolar-related disorders: bipolar disorder I, bipolar disorder II, cyclothymic disorder, and unspecified BD, which are classified by different patterns of manic, hypomanic, and depressive episodes. Where manic and hypomanic episodes are both states of increased activity, energy, or agitation, hypomanic episodes only last around four consecutive days and are less severe compared to manic episodes, which last around one week. Depressive episodes are characterised by feelings of despair and a loss of interest in previously enjoyed activities. Like many other psychological disorders, BD is often difficult to diagnose accurately in clinical practice due to large variations in individual symptoms, symptom overlap, or lack of approved biomarkers. Additionally, because many patients with BD only seek treatment for depressive episodes, many BD patients are initially misdiagnosed. Two studies conducted in 1999 and 2000 found that nearly 40% of patients with BD are initially diagnosed with unipolar depression. Previous diagnosis criteria for the types of BD were also overly restrictive. For example, according to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) criteria, bipolar disorder II requires an episode of mania or hypomania lasting four days, even though many experts believe that the average duration of the hypomanic state ranges between one to three days. Moreover, it is often difficult to elicit a past history of hypomanic episodes from patients because of its milder presentation. For many patients, the increased energy and activity experienced during hypomanic episodes may not even be considered negative, and thus will go unreported. Currently, the DSM-5 contains the most widely acknowledged diagnostic classifications for bipolar disorder.

Bipolar Disorder

Bipolar disorder (BD), previously known as “manic depressive illness,” is a recurrent chronic disorder characterised by mood and energy-state fluctuations. People who have BD comprise more than 1% of the world’s population from all nationalities, ethnic origins, and socioeconomic statuses. There are four different types of bipolar-related disorders: bipolar disorder I, bipolar disorder II, cyclothymic disorder, and unspecified BD, which are classified by different patterns of manic, hypomanic, and depressive episodes. Where manic and hypomanic episodes are both states of increased activity, energy, or agitation, hypomanic episodes only last around four consecutive days and are less severe compared to manic episodes, which last around one week. Depressive episodes are characterised by feelings of despair and a loss of interest in previously enjoyed activities. Like many other psychological disorders, BD is often difficult to diagnose accurately in clinical practice due to large variations in individual symptoms, symptom overlap, or lack of approved biomarkers. Additionally, because many patients with BD only seek treatment for depressive episodes, many BD patients are initially misdiagnosed. Two studies conducted in 1999 and 2000 found that nearly 40% of patients with BD are initially diagnosed with unipolar depression. Previous diagnosis criteria for the types of BD were also overly restrictive. For example, according to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) criteria, bipolar disorder II requires an episode of mania or hypomania lasting four days, even though many experts believe that the average duration of the hypomanic state ranges between one to three days. Moreover, it is often difficult to elicit a past history of hypomanic episodes from patients because of its milder presentation. For many patients, the increased energy and activity experienced during hypomanic episodes may not even be considered negative, and thus will go unreported. Currently, the DSM-5 contains the most widely acknowledged diagnostic classifications for bipolar disorder.

Predictors of excellent response to lithium

The aim of this study was to identify sociodemographic and clinical predictors of excellent response, that is, 'cure' of future affective episodes, to lithium in monotherapy. We used nationwide registers to identify all patients with a diagnosis of bipolar disorder in psychiatric hospital settings who were prescribed lithium from 1995 to 2006 in Denmark (N=3762). Excellent lithium responders were defined as patients who after a stabilization lithium start-up period of 6 months, continued lithium in monotherapy without getting hospitalized. The rate of excellent response to lithium in monotherapy was 8.9% [95% confidence interval (CI): 7.9-9.9] at 5-year follow-up and 5.4% (95% CI: 4.4-6.3) at 10-year follow-up. The rate of nonresponse to lithium monotherapy was significantly increased for female patients [hazards ratio (HR)=1.12, 95% CI: 1.04-1.21) and for patients with a depressive index episode compared with patients in remission or with a diagnosis of other or unspecified bipolar disorder before first lithium purchase (HR=1.13, 95% CI: 1.03-1.25). The rate of nonresponse increased by 3% (95% CI: 2-5%) for every psychiatric hospitalization before first purchase of lithium. Patients with somatic comorbidity had increased rates of non-response to lithium compared with patients without somatic comorbidity (HR=1.23, 95% CI: 1.00-1.52).It is concluded that the prevalence of excellent response to lithium monotherapy is low and such patients are characterized by few earlier psychiatric hospitalizations, a manic index episode before lithium and reduced somatic comorbidity.

Antipsychotic treatment adherence and associated mental health care use among individuals with bipolar disorder

Background: Up to 48% of patients with bipolar disorder are either nonadherent or partially adherent to antipsychotic drug treatment. Medication adherence may differ by bipolar disorder subtype. Objective: This study evaluated the association between antipsychotic treatment adherence and mental health care use among individuals with bipolar disorder with predominantly manic/mixed symptoms or predominantly depressive symptoms. Methods: Individuals with bipolar or manic disorder who had at least 1 medical claim with International Classification of Diseases, Ninth Revision, Clinical Modification codes 296.4-296.8 (bipolar disorder) or 296.0 or 296.1 (manic disorder) were identified from medical and pharmacy claims in the PharMetrics database for the period from January 1999 through December 2004. Adherence was measured by intensity (medication possession ratio [MPR]) and treatment duration. The association between adherence and health care use during and after antipsychotic treatment was evaluated using multiple regression analysis. The traditional P < 0.05 threshold was used for statistical significance; however, results that approached significance at P < 0.10 were also noted. Results: Claims data were examined for 13,941 antipsychotic treatment episodes occurring in 12,952 individuals with bipolar or manic disorder. Of these, 6153 treatment episodes occurred in 5711 individuals with predominantly manic/mixed symptoms, and 2617 occurred in 2381 individuals with predominantly depressive symptoms. The remaining 5171 treatment episodes occurred in 4860 individuals with unspecified bipolar disorder and were not included in the analysis. In individuals with manic/mixed symptoms, a higher MPR was associated with reduced total and outpatient mental health expenditures over subsequent stages of treatment (reduction in total expenditure per 1-point increment in MPR: $123-$439; P < 0.001). In individuals with predominantly depressive symptoms, the association between MPR and subsequent mental health expenditure reached statistical significance only in months 10-12, the 3rd of the 4 treatment segments examined (total mental health expenditure: -$714 [P < 0.001]; outpatient mental health expenditure: -$468 [P < 0.001]). A higher MPR was also associated with a lower likelihood of acute mental health care (inpatient hospitalization or an emergency department visit) in subsequent months in individuals with manic/mixed symptoms or depressive symptoms (odds ratio = 0.545 [95% CI, 0.30- 1.00] and 0.395 [95% CI, 0.14-1.12], respectively; both NS at the P < 0.05 threshold), and was not associated with mental health inpatient days. In both subgroups, a longer duration of treatment was associated with lower total and outpatient mental health expenditures during the 4 months after the termination of treatment (both, P < 0.01). Conclusions: In these individuals with bipolar or manic disorder, improved adherence to antipsychotic treatment was associated with lower subsequent total and outpatient mental health care expenditures. This association was less pronounced in individuals with predominantly depressive symptoms than in those with predominantly manic/mixed symptoms.

Prader-Willi syndrome: new insights in the behavioural and psychiatric spectrum.

Prader-Willi syndrome (PWS) is a genetic disorder caused by the loss of the paternal contribution of the proximal part (15q11-q13) of the long arm of chromosome 15 (i.e. deletion, disomy and imprinting mutation). The syndrome is associated with distinct physical dysmorphism, as well as with specific behavioural and psychopathological characteristics. Psychiatric symptoms in adolescence and adulthood have been described, including acute cycloid psychosis, and obsessive compulsive, bipolar and pervasive developmental disorders. At the Centre for Human Genetics in Leuven, Belgium, 53 individuals (31 children and adolescents, and 22 adults) have been followed up for 15 years by a special multidisciplinary team. Attention was given to their medical, cognitive, behavioural and emotional development, and the evolution of psychiatric disorders in adolescence and adulthood. This study describes the psychiatric problems in four patients diagnosed with acute cycloid psychosis and traces their development from infancy to adolescence. Four other individuals needed psychiatric evaluation and treatment, and could be diagnosed as having unspecified bipolar disorder, also termed unstable mood disorder. Both groups were compared, and significant differences in early development and later evolution into adulthood were noted. The individuals with PWS who later developed psychotic episodes were described as active and extrovert toddlers, and showed autistic behaviour during their primary school education. Their intellectual functioning was in the moderate to severely retarded range. The individuals with PWS who later developed an unstable mood disorder were described as rather passive and introvert toddlers, and they presented less disturbed behaviour during their primary school education. The intellectual functioning of these subjects was in the normal to borderline range.