Binge eating disorder, impulsivity and bipolar spectrum features in a sample of obese candidates for bariatric surgery.

AIMS: Candidates for bariatric surgery are routinely screened for psychiatric disorders because abnormal eating behaviors are considered common among these patients. This study aimed to evaluate the frequency and persistence, in terms of one month-to-lifetime prevalence ratio, of binge eating disorder (BED) and the potential association with impulsivity features and bipolar spectrum comorbidity in a sample of obese patients undergoing a psychiatric evaluation for bariatric intervention. METHODS: Overall, 80 candidates to bariatric surgery were assessed consecutively over 12 months within the framework of a collaboration between the University of Pisa Psychiatry and Internal Medicine Departments. Patients were evaluated through structured clinical interviews and self-report questionnaires. RESULTS: The lifetime and last-month frequencies of BED according to DSM-5 criteria were 46.3% and 17.5%, respectively, with a prevalence ratio of 37.8%. Rates of formal bipolar disorder diagnoses were extremely low in patients with or without BED. However, patients with BED showed more severe dyscontrol, attentional impulsivity and bipolar spectrum features than patients with no BED. CONCLUSIONS: The relationship of BED, impulsivity, and mood disorders in bariatric patients is more complex than usually reported in the literature. In particular, the presence of bipolar spectrum features should be systematically investigated in these patients because of their essential clinical and therapeutical implications.

Mood spectrum comorbidity in patients with anorexia and bulimia nervosa.

PURPOSE: To investigate the presence of mood spectrum signs and symptoms in patients with anorexia nervosa, restricting subtype (AN-R) or bulimia nervosa (BN). METHOD: 55 consecutive female patients meeting DSM-IV criteria for eating disorders (EDs) not satisfying DSM-IV criteria for Axis I mood disorders were evaluated with the Lifetime Mood Spectrum Self-Report (MOODS-SR) and the Mini-International Neuropsychiatric Interview (MINI). The MOODS-SR explored the subthreshold comorbidity for mood spectrum symptoms in patients not reaching the threshold for a mood disorder Axis I diagnosis. MOODS-SR included 161 items. Separate factor analyses of MOODS-SR identified 6 'depressive factors' and 9 'manic-hypomanic factors'. RESULTS: The mean total score of MOODS-SR was significantly higher in BN than in AN-R patients (97.5 ± 25.4 vs 61.1 ± 38.5, respectively; p = 0.0001). 63.6 % of the sample (n = 35) endorsed the threshold of ≥61 items, with a statistically significant difference between AN-R and BN (39.3 % vs 88.9 %; χ 2 = 14.6; df = 1; p = 0.0001). Patients with BN scored significantly higher than AN-R patients on several MOODS-SR factors: (a) MOODS-SR depressive component: 'depressive mood' (11.2 ± 7.4 vs 16.0 ± 5.8; p < 0.05), 'psychomotor retardation' (5.4 ± 5.6 vs 8.9 ± 3.8; p = 0.003), 'psychotic features' (2.0 ± 1.8 vs 4.1 ± 1.6; p = 0.001), 'neurovegetative symptoms' (5.0 ± 2.6 vs 7.7 ± 1.7; p = 0.001); (b) MOODS-SR manic/hypomanic component: 'psychomotor activation' (4.3 ± 3.6 vs 7.4 ± 3.1; p = 0.002), 'mixed instability' (1.0 ± 1.5 vs 2.0 ± 1.6; p < 0.05), 'mixed irritability' (2.5 ± 1.8 vs 3.7 ± 1.6; p < 0.05), 'inflated self-esteem' (1.1 ± 1.4 vs 2.1 ± 1.6; p < 0.05), and 'wastefulness/recklessness' (1.0 ± 1.4 vs 2.0 ± 1.2; p = 0.009). CONCLUSIONS: MOODS-SR identifies subthreshold mood signs/symptoms among patients with AN-R, and BN and with no Axis I comorbidity for mood disorders, and provides a better definition of clinical phenotypes.

Psychotic spectrum symptoms across the lifespan are related to lifetime suicidality among 147 patients with bipolar I or major depressive disorder.

BACKGROUND: Conflicting evidence exists about the relationship between psychotic symptoms and suicidality in mood disorders. We aimed to investigate the lifetime suicidality and its relationship with dimensions of the psychotic spectrum over the lifespan among subjects with bipolar I (BD I) or major depressive disorder (MDD). METHODS: 147 Consecutive out- and inpatients with BD I or MDD presenting for treatment at 11 Italian Departments of Psychiatry were administered the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for the Psychotic Spectrum (SCI-PSY, lifetime version) and the Mood Spectrum Self-Report (MOODS-SR, lifetime version). RESULTS: Subjects with psychotic features did not differ from those without for MOODS-SR suicidality score. Controlling for age, gender and diagnosis (MDD/BD I), the SCI-PSY total score (p = .007) and Paranoid (p = .042), Schizoid (p = .007) and Interpersonal Sensitivity (p < .001) domain scores independently predicted lifetime MOODS-SR suicidality score in the overall sample. CONCLUSIONS: Psychotic features, as evaluated upon the presence of delusions or hallucinations, are not associated with suicidality among subjects with BD I or MDD. However, more subtle dimensions of the psychotic spectrum, such as Interpersonal Sensitivity, Paranoid and Schizoid symptoms, show a significant relationship with lifetime suicidality. Our findings highlight the potential usefulness of a spectrum approach in the assessment of psychotic symptoms and suicide risk among subjects with BD I or MDD.

Swedish Version of Mood Spectrum Self-Report Questionnaire: Psychometric Properties of Lifetime and Last-week Version.

BACKGROUND: Mood Spectrum Self Report (MOODS-SR) is an instrument that assesses mood spectrum symptomatology including subthreshold manifestations and temperamental features. There are different versions of the MOODS-SR for different time frames of symptom assessment: lifetime (MOODS-LT), last-month and last-week (MOODS-LW) versions. OBJECTIVE: To evaluate the psychometric properties of the MOODS-LT the MOODS-LW. METHODS: The reliability of the MOODS-LT and MOODS-LW was evaluated in terms of internal consistency and partial correlations among domains and subdomains. The known-group validity was tested by comparing out-patients with bipolar disorder (n=27), unipolar depression (n=8) healthy controls (n=68). The convergent and divergent validity of MOODS-LW were evaluated using the Montgomery Åsberg Depression Rating Scale (MADRS), the Young-Ziegler Mania Rating Scale (YMRS) in outpatients as well the General Health Questionnaire (GHQ-12) in healthy controls. RESULTS: Both MOODS-LT and MOOODS-LW showed high internal consistency with the Kuder-Richardson coefficient ranging from 0.823 to 0.985 as well as consistent correlations for all domains and subdomains. The last-week version correlated significantly with MADRS (r= 0.79) and YMRS (r=0.46) in outpatients and with GHQ-12 (r= 0.50 for depression domain, r= 0.29 for rhythmicity) in healthy controls. CONCLUSION: The Swedish version of the MOODS-LT showed similar psychometric properties to other translated versions. Regarding MOODS-LW, this first published psychometric evaluation of the scale showed promising psychometric properties including good correlation to established symptom assessment scales. In healthy controls, the depression and rhythmicity domain scores of the last-week version correlated significantly with the occurrence of mild psychological distress.

Mood Spectrum Model: Evidence reconsidered in the light of DSM-5.

AIM: to investigate studies conducted with the Mood Spectrum Structured Interviews and Self-Report versions (SCI-MOODS and MOODS-SR). METHODS: We conducted a review of studies published between 1997 and August 2014. The search was performed using Pubmed and PsycINFO databases. Analysis of the papers followed the inclusion and exclusion criteria recommended by the PRISMA Guidelines, namely: (1) articles that presented a combination of at least two terms, "SCI-MOODS" [all fields] or "MOODS-SR" [all fields] or "mood spectrum" [all fields]; (2) manuscript in English; (3) original articles; and (4) prospective or retrospective original studies (analytical or descriptive), experimental or quasi-experimental studies. Exclusion criteria were: (1) other study designs (case reports, case series, and reviews); (2) non-original studies including editorials, book reviews and letters to the editor; and (3) studies not specifically designed and focused on SCI-MOODS or MOODS-SR. RESULTS: The search retrieved 43 papers, including 5 reviews of literature or methodological papers, and 1 case report. After analyzing their titles and abstracts, according to the eligibility criteria, 6 were excluded and 37 were chosen and included. The SCI-MOODS and the MOODS-SR have been tested in published studies involving 52 different samples across 4 countries (Italy, United States, Spain and Japan). The proposed mood spectrum approach has demonstrated its usefulness mainly in 3 different areas: (1) Patients with the so-called "pure" unipolar depression that might manifest hypomanic atypical and/or sub-threshold aspects systematically detectable with the mood questionnaire; (2) Spectrum features not detected by other instruments are clinically relevant, because they might manifest in waves during the lifespan, sometimes together, sometimes alone, sometimes reaching the severity for a full-blown disorder, sometimes interfering with other mental disorders or complicating the course of somatic diseases; and (3) Higher scores on the MOODS-SR factors assessing "psychomotor disturbances", "mixed instability" and "suicidality" delineate subtypes of patients characterized by the more severe forms of mood disorders, the higher risk for psychotic symptoms, and the lower quality of life after the remission of the full-blown-episode. CONCLUSION: The mood spectrum model help researchers and clinicians in the systematic assessment of those areas of psychopathology that are still neglected by the Diagnostic and Statistical Manual of Mental Disorders 5 classification.

Ziprasidone as adjunctive therapy in severe bipolar patients treated with clozapine.

Aim. To confirm the efficacy and tolerability of ziprasidone as adjunctive therapy in bipolar patients partially responding to clozapine or with persisting negative symptoms, overweight, or with metabolic syndrome. Methods. Eight patients with psychotic bipolar disorder were tested with the BPRS, the HAM-D, and the CGI at T0 and retested after 2 weeks (T1). Plasma clozapine and norclozapine levels and BMI were tested at T0 and T1. Results. Ziprasidone was well tolerated by all the patients. BPRS and HAM-D scores were reduced in all patients. BMI was reduced in patients with a BMI at T0 higher than 25. Plasma levels of clozapine and norclozapine showed an irregular course.

Manic episode after ventricular-peritoneal shunt replacement in a patient with radiation-induced hydrocephalus: the role of lifetime subthreshold bipolar features.

We present a case report of a woman hospitalized for a ventricular-peritoneal shunting replacement, who developed a manic episode with psychotic symptoms after hydrocephalus resolution. We have no knowledge of cases of manic episodes due to hydrocephalus resolution by ventricular-peritoneal shunt replacement, although previous case reports have suggested that hydrocephalus might induce rapid-onset affective episodes or mood cycles. The patient's history revealed the lifetime presence of signs and features belonging to the subthreshold bipolar spectrum, in absence of previous full-blown episodes of a bipolar disorder. Our hypothesis is that such lifetime sub-threshold bipolar features represented precursors of the subsequent full-blown manic episode, triggered by an upregulated binding of striatum D2 receptors after the ventricular-peritoneal shunt replacement.

The role of psychomotor activation in discriminating unipolar from bipolar disorders: a classification-tree analysis.

OBJECTIVE: Multiple studies indicate that bipolar disorders are often underrecognized, misdiagnosed, and incorrectly treated. The aim of the present report is to determine which combination of clinical, demographic, and psychopathological factors and corresponding cutoff scores best discriminate patients with unipolar disorder from those with bipolar disorders. METHOD: The study sample includes outpatients and inpatients (N = 1,158) participating in 5 studies carried out in the United States and Italy between October 2001 and March 2008, one of which was a randomized clinical trial. Diagnostic assessment was carried out with the SCID, which allows diagnoses to be made according to DSM-IV-TR criteria. Using an exploratory statistical approach based on a classification tree, we employed 5 mania spectrum factors and 6 depression spectrum factors derived from the Mood Spectrum Self-Report Instrument (MOODS-SR) in combination with demographic and clinical characteristics to discriminate participants with unipolar versus bipolar disorders. RESULTS: The psychomotor activation factor, assessing the presence of thought acceleration, distractibility, hyperactivity, and restlessness for 1 or more periods of at least 3 to 5 days in the lifetime, identified subgroups with an increasing likelihood of bipolar disorder diagnosis. Mixed instability and suicidality contributed to further subtyping the sample into mutually exclusive groups, characterized by a different likelihood of receiving a diagnosis of bipolar disorder. Of the demographic and clinical characteristics included in the analysis, only sex proved to be useful to improve the discrimination. CONCLUSIONS: The psychomotor activation factor proved to be the most potent discriminator of those with unipolar versus bipolar diagnoses. The items that constitute this factor, together with those that constitute the mixed instability, suicidality, and euphoria factors, might be useful in making the differential diagnosis.

Incidence and predictors of relapse during continuation treatment of major depression with SSRI, interpersonal psychotherapy, or their combination.

BACKGROUND: Despite the availability of many effective treatments, patients with major depression remain at risk for relapse following remission of a depressive episode. The aims of this report are to estimate the relapse rates associated with the acute treatment strategies employed in this study and to investigate demographic and clinical predictors of relapse. METHODS: The study sample includes 225 patients who entered the 6-month continuation treatment phase after remitting from an acute depressive episode. Treatment during the acute phase was interpersonal psychotherapy, SSRI (escitalopram), or the combination of the two when monotherapy did not lead to response. Relapse was defined by a Hamilton Depression Rating Scale score ≥15, confirmed by the diagnosis of major depression. The probability of relapsing was modeled using logistic regression. Three separate models were fit with subgroups of covariates. RESULTS: Of the 225 patients, 29 (12.9%) relapsed and 28 (12.4%) discontinued the protocol prematurely. The proportion of patients who relapsed among the group requiring combination treatment to achieve remission was three times as high as among patients who had remitted with monotherapy. In the final logistic regression model, older age, higher baseline HDRS scores, last month (residual) depressive mood spectrum factor score, and requiring combination treatment to achieve remission were each associated with an increased likelihood of relapse. CONCLUSIONS: Our results suggest that greater initial depression severity, greater difficulty in stabilizing symptoms, and presence of residual mood spectrum symptoms once remission is achieved are predictive of relapse. Risk of relapse is more likely as age increases, partly because aging confers lower resilience.

Relationship of residual mood and panic-agoraphobic spectrum phenomenology to quality of life and functional impairment in patients with major depression.

The aim of this study was to analyze the relationship of residual mood and panic-agoraphobic spectrum phenomenology to functional impairment and quality of life in 226 adult outpatients who had remitted from a major depressive episode. Quality of life and functioning were assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire and the Work and Social Adjustment Scale. Residual symptoms were assessed using the Mood and Panic-Agoraphobic Spectrum Questionnaires. Linear and logistic regression models were used to analyze the relationship of mood and panic-agoraphobic spectrum factors with quality of life and functioning. Poor quality of life was associated with the Mood Spectrum Self-Report Questionnaire factors 'depressive mood' and 'psychotic features' and the Panic-Agoraphobic Spectrum Self-Report Questionnaire factors 'separation anxiety' and 'loss sensitivity'. Functional impairment was associated with the Mood Spectrum Self-Report Questionnaire factor 'psychomotor retardation' and the Panic-Agoraphobic Spectrum Self-Report Questionnaire factor 'fear of losing control'. These relationships were held after controlling for the severity of depression at the entry in the continuation treatment phase. In conclusion, the spectrum assessment is a useful tool for clinicians to identify areas of residual symptomatology that can be targeted with focused and effective long-term treatment strategies.

Treatment-emergent mania/hypomania in unipolar patients.

OBJECTIVE: The aim of this study was to estimate the incidence of treatment-emergent mania/hypomania (TEMH) and to describe the clinical characteristics of patients with major depression experiencing this event during treatment with a selective serotonin reuptake inhibitor (SSRI) and/or interpersonal psychotherapy (IPT). METHODS: Following an algorithm-based protocol, 344 patients with major depression confirmed with the Structured Clinical Interview for DSM-IV disorders were treated with an SSRI, interpersonal psychotherapy, or their combination for nine months. The emergence of mania/hypomania was carefully monitored throughout the study using the Young Mania Rating Scale and clinical assessment. RESULTS: Overall, eight patients experienced TEMH. The incidence of this event was 3.0% in patients treated with an SSRI and 0.9% in patients treated with IPT alone. Among patients treated with an SSRI, the difference between sites was higher than expected by chance alone (6.8% at Pisa and 0% at Pittsburgh, p = 0.002). Despite the adoption of an identical protocol at the two sites, some demographic and clinical characteristics of participants may account for this unexpected result. Alternatively, the greater number of episodes and earlier age of onset at the Pittsburgh site suggests that the unipolar course of illness was more clearly established prior to study entry. CONCLUSIONS: TEMH is an infrequent event, occurring in 2.3% of patients treated for major depression. Nevertheless, its consequences are clinically relevant and require prompt and appropriate therapeutic interventions. For this reason, recognising those patients at risk for such an event is of paramount clinical significance. The observed difference in the incidence of TEMH between the two sites requires further investigation.

Borderline personality disorder and mood spectrum.

Several lines of evidence have raised the question of whether Borderline Personality Disorder (BPD) is an independent disease entity or it might be better conceptualized as belonging to the spectrum of mood disorders. This study explores a wide array of lifetime mood features (mood, cognitions, energy, and rhythmicity and vegetative functions) in patients with BP and mood disorders. The sample consisted of 25 BPD patients who did not meet the criteria for bipolar disorders, 16 bipolar disorders patients who did not meet the criteria for BPD, 19 unipolar patients who did not meet the criteria for BPD, and 30 non-clinical subjects. Clinical diagnoses were determined by administering the structured clinical interviews for DSM-IV disorders. The Mood Spectrum Self-Report (MOODS-SR) was used for measuring lifetime mood phenomenology. Clinical subjects displayed higher mean scores than normal subjects in all domains of the MOODS-SR, and BPD patients displayed higher scores than unipolar patients in the Mood and Cognition depressive subdomains. Differences between patients with BP and bipolar disorders on MOODS psychopathology did not attain statistical significance for any (sub)domain considered. The results of this study are consistent with previous findings suggesting the importance of mood dysregulations in patients with BPD.

Lifetime rhythmicity and mania as correlates of suicidal ideation and attempts in mood disorders.

BACKGROUND: The aim of this study is to establish to what degree variation in lifetime experience of rhythmicity and manic-hypomanic features correlates with suicidality in individuals with mood disorders and other major psychiatric diagnoses and in a comparison group of controls. METHOD: Suicidal ideation and attempts were investigated in a clinical sample, including 77 patients with schizophrenia, 60 with borderline personality disorder, 61 with bipolar disorder, 88 with unipolar depression, and 57 with panic disorder, and in a comparison group of 102 controls. Using information derived from the diagnostic interview and a self-report assessment of mood spectrum symptoms, subjects were assigned to 3 categories according to the maximum level of suicidality achieved in the lifetime (none, ideation/plans, and suicide attempts). The association of categorical and continuous variables with suicidality levels was investigated using multinomial logistic regression models. RESULTS: Suicidal ideation and plans were more common in unipolar depression (50%) and bipolar disorder (42.4%) than in borderline personality disorder (30%), whereas the reverse was true for suicidal attempts. In each of the study groups, the number and the type of mood spectrum items endorsed, including depressive and manic-hypomanic items and rhythmicity and vegetative symptoms, were associated with increased levels of suicidality. CONCLUSIONS: Our results suggest that the assessment of lifetime rhythmicity and manic-hypomanic features may be clinically useful to identify potential suicide attempters in high-risk groups.