Clinical correlates of difficult-to-treat depression: Exploring an integrated day-care model of treatment.

BACKGROUND AND AIMS: This study aimed to test the effectiveness of an individualized, integrated, day-care treatment programme for the acute phase of "difficult-to-treat depression" (DTD) in a sample of bipolar and unipolar subjects with a complex co-morbidity pattern. METHODS: A total of 291 patients meeting criteria for DTD were consecutively recruited. All participants underwent a 12-week day-care intervention including individual psychological support and group psycho-education. Subjects were assessed for depressive symptom severity by the 21-item Hamilton Depression Rating Scale (HDRS) at the baseline (T0) and after 4 (T1) and 12 (T2) weeks of treatment. A repeated measures general linear model was performed to test for interactive effects among variables. RESULTS: An overall significant improvement was detected in the majority of cases (F = 138.6, p < 0.0001). Responders reported lower rates of personality disorders and higher baseline depressive severity. An interaction between bipolarity and co-morbidity was associated with a poorer outcome (F = 5.9, p = 0.0034). Family involvement was the only significant predictor for symptom improvement (F = 7.9, adjusted p = 0.0025). CONCLUSIONS: Our intervention proved to be effective in the treatment of complex and severe forms of depression. Our results on the role of family support require further investigation to better define suitable targets for tailored therapeutic approaches.

Augmentation of light therapy in difficult-to-treat depressed patients: an open-label trial in both unipolar and bipolar patients.

OBJECTIVES: We investigated the clinical benefits of bright light therapy (BLT) as an adjunct treatment to ongoing psychopharmacotherapy, both in unipolar and bipolar difficult-to-treat depressed (DTD) outpatients. METHODS: In an open-label study, 31 depressed outpatients (16 unipolar and 15 bipolar) were included to undergo 3 weeks of BLT. Twenty-five completed the treatment and 5-week follow-up. MAIN OUTCOME MEASURES: Clinical outcomes were evaluated by the Hamilton Depression Rating Scale (HDRS). The Snaith-Hamilton Pleasure Scale and the Depression Retardation Rating Scale were used to assess changes in anhedonia and psychomotor retardation, respectively. RESULTS: The adjunctive BLT seemed to influence the course of the depressive episode, and a statistically significant reduction in HDRS scores was reported since the first week of therapy. The treatment was well-tolerated, and no patients presented clinical signs of (hypo)manic switch during the overall treatment period. At the end of the study (after 5 weeks from BLT discontinuation), nine patients (36%, eight unipolar and one bipolar) still showed a treatment response. BLT augmentation also led to a significant improvement of psychomotor retardation. CONCLUSION: BLT combined with the ongoing pharmacological treatment offers a simple approach, and it might be effective in rapidly ameliorating depressive core symptoms of vulnerable DTD outpatients. These preliminary results need to be confirmed in placebo-controlled, randomized, double-blind clinical trial on larger samples.

Cognitive markers of psychotic unipolar depression: a meta-analytic study.

BACKGROUND: The goal of the current meta-analysis was to review and examine in detail the features of cognitive performance in psychotic (MDDP) versus non-psychotic (MDD) major depressive disorder. METHODS: An electronic literature search was performed to find studies comparing cognitive performance in MDDP versus MDD. A meta-analysis of broad cognitive domains (processing speed, reasoning/problem solving, verbal learning, visual learning, attention/working memory) and individual cognitive tasks was conducted on all included studies (n=12). Demographic and clinical features were investigated via meta-regression analysis as moderators of cognitive performance. RESULTS: No difference in socio-demographic and clinical variables was detected between groups. In general, a poorer cognitive performance was detected in MDDP versus MDD subjects (ES=0.38), with a greater effect size in drug-free patients (ES=0.69). MDDP patients were more impaired in verbal learning (ES=0.67), visual learning (ES=0.62) and processing speed (ES=0.71) tasks. A significantly poorer performance was also detected in MDDP patients for individual tasks as Trail Making Test A, WAIS-R digit span backward and WAIS-R digit symbol. Age resulted to have a negative effect on tasks involved in working memory performance. CONCLUSION: In line with previous meta-analyses, our findings seem to support an association between psychosis and cognitive deficits in the context of affective disorders. Psychosis during the course of MDD is associated with poorer cognitive performance in some specific cognitive domains, such as visual and verbal learning and executive functions.

Health care for immigrant women in Italy: are we really ready? A survey on knowledge about female genital mutilation.

BACKGROUND: Because of immigration, female genital mutilation (FGM) is an issue of increasing concern in western countries. Nevertheless operators without a specific training may ignore the health condition of women subjected to this practice and fail to provide them adequate assistance. The purpose of the study was to estimate the current knowledge about FGM among social and health care assistants working with asylum seeker. MATERIAL AND METHODS: From October to December 2012, a questionnaire was used to interview 41 operators working in CARA (Shelter for Refugees and Asylum Seekers) in central and southern Italy. RESULTS: Only 7.3% of respondents states to know well FGM, while 4.9% do not know it at all. 70.7% declare to have never met or assisted a woman with FGM, nevertheless all respondents work with asylum seeker from countries where FGM are performed. CONCLUSIONS: Migration fluxes to Italy over the past decade created a healthcare challenge: women with FGM have specific medical and psychological problems that doctors, nurses and social assistants without specific training are not usually able to manage.

Polysomnographic findings in a cohort of chronic insomnia patients with benzodiazepine abuse.

STUDY OBJECTIVES: To evaluate sleep modifications induced by chronic benzodiazepine (BDZ) abuse. METHODS: Cohort study, comparison of sleep measures between BDZs abusers and controls. Drug Addiction Unit (Institute of Psychiatry) and Unit of Sleep Disorders (Institute of Neurology) of the Catholic University in Rome. Six outpatients affected by chronic BDZ abuse were enrolled, (4 men, 2 women, mean age 53.3 ± 14.8, range: 34-70 years); 55 healthy controls were also enrolled (23 men, 32 women, mean age 54.2 ± 13.0, range: 27-76 years). All patients underwent clinical evaluation, psychometric measures, ambulatory polysomnography, scoring of sleep macrostructure and microstructure (power spectral fast-frequency EEG arousal, cyclic alternating pattern [CAP]), and heart rate variability. RESULTS: BDZ abusers had relevant modification of sleep macrostructure and a marked reduction of fast-frequency EEG arousal in NREM (patients: 6.6 ± 3.7 events/h, controls 13.7 ± 4.9 events/h, U-test: 294, p = 0.002) and REM (patients: 8.4 ± 2.4 events/h, controls 13.3 ± 5.1 events/h, U-test: 264, p = 0.016), and of CAP rate (patients: 15.0 ± 8.6%, controls: 51.2% ± 12.1%, U-test: 325, p < 0.001). DISCUSSION: BDZ abusers have reduction of arousals associated with increased number of nocturnal awakenings and severe impairment of sleep architecture. The effect of chronic BDZ abuse on sleep may be described as a severe impairment of arousal dynamics; the result is the inability to modulate levels of vigilance.

Affective temperament and attachment in adulthood in patients with Bipolar Disorder and Cyclothymia.

OBJECTIVE: To examine attachment and affective temperament in patients who have been diagnosed with Bipolar Disorder and to investigate possible differences in both variables among Bipolar I Disorder (BD-I), Bipolar II Disorder (BD-II), and cyclothymic patients. METHODS: Ninety (45 male and 45 female) outpatients with bipolar or cyclothymic disorder between the ages of 18 and 65years were recruited consecutively between September 2010 and December 2011 at the Bipolar Disorder Unit of the Psychiatry Day Hospital affiliated with the University General Hospital "A. Gemelli" in Rome, Italy. Patients were assessed using the Structured Clinical Interview for DSM-IV, the Hamilton Depression Rating Scale, the Young Mania Rating Scale, the Temperament Evaluation of Memphis, Pisa, and San Diego-auto-questionnaire version, and the Experiences in Close Relationships (ECR) questionnaire applied by trained interviewers. RESULTS: The 3 groups of patients differed only on the ECR Anxiety scores with BD-I patients having the highest anxiety levels, followed by the BD-II patients, and the patients with cyclothymic disorder reporting the lowest level of anxiety. CONCLUSIONS: This finding suggests that bipolar disorder (type I, type II) and cyclothymic/dysthymic temperament are more strongly associated with insecure attachment style as compared to the general population.

Changes of dopamine transporter availability in depressed patients with and without anhedonia: a 123I-N-ω-fluoropropyl-carbomethoxy-3ß- (4-Iodophenyl)tropane SPECT study.

BACKGROUND/AIMS: Dopamine is an important neurotransmitter involved in the pathophysiology of depression and anhedonia. Dopamine transporters (DAT) may play a crucial role in the pathophysiology of dopaminergic transmission. We investigated the relationship between striatal DAT availability and depression, pointing out possible correlations with anhedonia and treatment outcomes. METHODS: Ten depressed patients with anhedonia, 10 depressed patients without anhedonia and 20 healthy controls underwent single photon emission computed tomography using (123)I-FP-CIT [(123)I-N-ω-fluoropropyl-carbomethoxy-3ß-(4-iodophenyl)tropane]. Psychometric measures included the Snaith-Hamilton Pleasure Scale and the Hamilton Depression Rating Scale. A further assessment of DAT availability was performed in the 10 patients with marked anhedonia after a 3-month pharmacological treatment. RESULTS: Depressed patients with and without anhedonia showed significantly lower (123)I-FP-CIT binding ratios in the bilateral striatum, caudate and putamen. No significant changes were detected after treatment in the 10 patients with marked anhedonia. When considering clinical outcomes, subjects with remission of depression showed a significant reduction of (123)I-FP-CIT binding ratios in all regions at baseline, but after treatment no differences were found any longer. CONCLUSIONS: We suppose that a hypofunction of the striatal dopaminergic system may be a 'state' feature of a depressive condition as a whole rather than anhedonia itself. On the other hand, some anhedonic features mainly represent an enduring trait that persists independently of mood state.

To be or not to be a bipolar disorder patient: problems with diagnosis.

The diagnosis of bipolar disorder (BD) is predominantly clinical. Some authors have suggested that BD is underdiagnosed and that many patients, particularly those with major depressive disorder, actually have BD. Some studies have suggested that BD is wrongly diagnosed, probably because of the idea of a "bipolar spectrum." To address this potential overdiagnosis, clinicians should carefully and systematically assess whether symptoms are included in diagnostic criteria and include the individual context of the patient.

Affective temperaments and psychopathological dimensions of personality in bipolar and cyclothymic patients.

The aims of the study were: (1) to study possible associations between temperament, personality dimensions, and psychopathological variables in a clinical sample of euthymic patients with bipolar disorder (BD) and cyclothymia; and (2) to assess how Cloninger's temperament and personality dimensions were associated with affective temperaments. Participants, consisting of 60 patients with BD (type I or II) and cyclothymia in the euthymic phase, completed Akiskal's Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A), and Cloninger's Temperament and Character Inventory-revised version (TCI-R). The diagnostic groups differed in past hospitalization, for age at onset of the disorder, and on two affective temperaments: the TEMPS-A Hyperthymia, and the TEMPS-A Irritability. There were six significant associations between affective temperaments and Cloninger's personality dimensions, ranging from 0.26 to 0.54. The measures of Akiskal and of Cloninger tap common behavioral features in patients with bipolar disorder and cyclothymia, yet the differences indicate that the two measures are not redundant. BD and cyclothymic patients differed significantly in temperament and personality, differences that may have important implications for treatment.

Enhanced BDNF serum levels in patients with severe pathological gambling.

Although the pathophysiology of gambling is unknown, an involvement of midbrain dopaminergic pathway has been hypothesized. In this study, the association between brain-derived neurotrophic factor (BDNF) and pathological gambling was investigated. We measured BDNF serum levels in (1) video players (n=10); (2) card players (n=9); (3) mixed players (n=21; both video and card players) and (4) age-matched controls (n=18). Mixed players had increased BDNF serum levels as compared to controls and higher South Oaks Gambling Screen score as compared to card or video players. Thus, the data demonstrate that patients affected by severe pathological gambling show enhanced BDNF serum levels.

Plasma levels of n-3 fatty acids in bipolar patients: deficit restricted to DHA.

Epidemiological studies suggest that n-3 polyunsaturated fatty acid (n-3 FA) deficiency is a risk factor for bipolar disorders (BDs). The aim of this study was to determine whether such a deficit does exist in patients with BD and to characterize the overall plasma fatty acid (FA) profile in these patients. Using gas chromatography/mass spectrometry, we measured fasting plasma levels of 15 FAs in 42 patients diagnosed with BD according to DSM-IV criteria and in 57 age- and gender-matched healthy controls. Plasma docosahexaenoic acid (DHA) levels were significantly decreased in bipolar patients (p < 0.001 versus healthy controls). Compared with controls, patients had higher plasma levels of all other FAs, including arachidonic acid (AA, p < 0.001), alpha-linolenic acid (ALA, p < 0.001), and eicosapentaenoic acid (EPA) (p < 0.001). Although in the present study we observed significant DHA deficits in the plasma of bipolar patients our findings do not support the therapeutic use of ALA and/or EPA supplementation. DHA may provide a basis for possible pharmacological intervention in psychiatric disorders at the level of second messengers linked to the phosphatidylinositol cycle. Finally, measurement of FA levels in plasma seems to be more reliable and reproducible than assays of erythrocyte FA content.

Plasma magnesium levels and treatment outcome in depressed patients.

OBJECTIVES: High, normal, or low plasma magnesium (Mg) levels have been observed in depressed patients. The aim of our study was to investigate the relationship of Mg levels with depression severity, specific psychopathological dimensions, and treatment outcome. METHODS: A total of 123 outpatients during a major depressive episode were recruited. All patients showed at least two major depressive episodes and did not achieve remission in the former treatment trial. A blood sample was collected to determine total plasma Mg levels. The psychopathological status was assessed using Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Depression Retardation Rating Scale for psychomotor retardation, and Snaith-Hamilton Pleasure Scale for anhedonia. Hamilton Depression Rating Scale was repeated at 3 months after treatment. RESULTS: All patients showed Mg levels mostly within the normal range. No association between Mg levels and psychopathological severity was reported. Patients who responded to antidepressant treatment showed higher Mg levels and higher retardation scores at basal evaluation in comparison with non-responders. DISCUSSION: Although further studies investigating the relationship between hypomagnesaemia, depression, and treatment outcome are certainly necessary, we have hypothesized that hypomagnesaemia could be an epiphenomenic biochemical trait in less drug-responsive depressed patients. It is also plausible that lower Mg levels and hyperactive traits identify a biological subtype of patients with increased catecholaminergic functioning and a poorer response to aminergic drugs. Moreover, Mg depletion could partly account for the correlation between low Mg levels and poor outcome and this raises the question of Mg's possible therapeutic role in depression.

Role of substance abuse comorbidity and personality on the outcome of depression in bipolar disorder: harm avoidance influences medium-term treatment outcome.

Comorbid conditions are frequent in bipolar disorder (BD) and may complicate the treatment and course of illness. We investigated the role of substance use disorder (SUD), axis II personality disorders (PD) and continuous personality traits on the medium-term outcome (6 months) of treatment for bipolar depression. One hundred and thirty-nine BD patients meeting criteria for a depressive episode were included in the study. SUD and PD were diagnosed according to structured interviews. Personality dimensions were evaluated by the Temperament and Character Inventory. Depressive severity over time was evaluated by the Hamilton Rating Scale for Depression. Neither PD nor SUD influenced the outcome of depression. Variables independently associated with a poor outcome were a high baseline severity and high scores for the temperamental trait of Harm Avoidance. Though several limitations characterize the present study, neurotic personality traits seem to be associated with a slower recovery from depressive symptoms in BD, independently from their initial severity.

Bipolar disorder: "pure" versus mixed depression over a 1-year follow-up.

OBJECTIVES: To compare two samples of Bipolar (BD) patients presenting "pure" (D) and mixed (Mx) depression to assess any difference in terms of clinical outcome, social functioning and quality of life during a 1-year follow-up. METHODS: A total of 114 depressed outpatients (HDRS > 13) were included. "Pure" depressed (D, n = 76) were divided from "mixed" depressed (Mx, n = 38) by the number of concomitant manic symptoms. All patients were evaluated by the Hamilton Depression Rating Scale (HDRS), the Hamilton Anxiety Rating Scale (HARS), the Young Mania Rating Scale (YMRS), the Global Assessment of Functioning (GAF), the Social Adjustment Self-reported Scale (SASS) and the Quality of Life Scale (QoL), at baseline and after 1, 3, 6 and 12 months of treatment. RESULTS: Mx patients were significantly younger at the onset of BD. Manic features persisted significantly higher in Mx than in D patients all over the follow-up period. Axis I comorbidities had a negative impact on the course of social functioning over the medium term period, while Mx patients showed a faster improvement in social adjustment than "pure" depressed patients. CONCLUSIONS: Mixed features may persist relatively stable throughout a depressive episode, having a negative impact over clinical and functional outcome, but not on social adjustment.

Internet addiction: hours spent online, behaviors and psychological symptoms.

OBJECTIVE: The aim of this study was to investigate psychopathological symptoms, behaviors and hours spent online in patients with internet addiction disorder (IAD) at a new psychiatric service for IAD inside a policlinic. METHOD: Eighty-six subjects participated in the study. Thirty-three patients asking for psychiatric consultation regarding their excessive use of the internet were assessed with IAD interview, internet addiction test (IAT), Symptom Checklist-90-Revised (SCL-90-R) and a brief sociodemographic survey. Moreover, patients had to respond to the following question: Over the last month, how much time have you spent online per week? At the end of psychiatric assessment, 21 of the 33 patients satisfied inclusion (IAD interview) and exclusion (psychotic disorders, neurocognitive deficits, dementia, serious mental delay, current alcohol or drug abuse) criteria. Twenty-one patients of the clinical group were compared with 65 subjects of a control group who were recruited online using IAT. RESULTS: IAD patients showed significantly higher scores on the IAT compared to subjects of the control group. Only item 7 (How often do you check your e-mail before something else that you need to do?) showed a significant inverse trend. SCL-90-R anxiety and depression subscale scores and item 19 (How often do you choose to spend more time online over going out with others?) of the IAT were positively correlated with number of weekly hours spent online in IAD patients. CONCLUSION: Findings suggest that a misuse of internet, characterized by many hours spent online avoiding interpersonal relationships with real and known people, could be an important criterion in the clinical interview in order to diagnose the IAD. The association between the lost interest in communicating with real people and psychological symptoms such as anxiety and depression could be relevant to detect IAD patients.

Factors associated with the course of symptoms in bipolar disorder during a 1-year follow-up: depression vs. sub-threshold mixed state.

BACKGROUND: Mixed mood states, even in their sub-threshold forms, may significantly affect the course and outcome of bipolar disorder (BD). AIM: To compare two samples of BD patients presenting a major depressive episode and a sub-threshold mixed state in terms of global functioning, clinical outcome, social adjustment and quality of life during a 1-year follow-up. METHODS: The sample was composed by 90 subjects (Group 1, D) clinically diagnosed with a major depressive episode and 41 patients (Group 2, Mx) for a sub-threshold mixed state. All patients were administered with a pharmacological treatment and evaluated for depressive, anxious and manic symptoms by common rating scales. Further evaluations included a global assessment of severity and functioning, social adjustment and quality of life. All evaluations were performed at baseline and after 1, 3, 6 and 12 months of treatment. RESULTS: The two groups were no different for baseline as well as improvement in global severity and functioning. Though clearly different for symptoms severity, the amount of change of depressive and anxiety symptoms was also no different. Manic symptoms showed instead a trend to persist over time in group 2, whereas a slight increase of manic symptoms was observed in group 1, especially after 6 months of treatment. Moreover, in group 1, some manic symptoms were also detected at the Young Mania Rating Scale (n = 24, 26.6%). Finally, improvement in quality of life and social adjustment was similar in the two groups, though a small trend toward a faster improvement in social adjustment in group 1. CONCLUSIONS: Sub-threshold mixed states have a substantial impact on global functioning, social adjustment and subjective well-being, similarly to that of acute phases, or at least major depression. In particular, mixed features, even in their sub-threshold forms, tend to be persistent over time. Finally, manic symptoms may be still often underestimated in depressive episodes, even in patients for BD.

Brain-derived neurotrophic factor and electroconvulsive therapy in a schizophrenic patient with treatment-resistant paranoid-hallucinatory symptoms.

It has been proposed that deficits in the production and the utilization of brain-derived neurotrophic factor (BDNF) may contribute to the pathogenesis of schizophrenia. At the same time, electroconvulsive shock, an experimental model of electroconvulsive therapy (ECT), has been shown to induce an increase of BDNF protein in brains of animal models. These findings suggest that one putative mechanism of action of ECT is the regulation of BDNF and/or related neurotrophins. In this case report, a 54-year-old man with severe treatment-resistant schizophrenic symptoms was treated with ECT. To evaluate the effect of ECT on BDNF serum levels, we collected a blood sample before each ECT session. During the course of ECT treatment, the paranoid and hallucinatory symptoms gradually improved, whereas BDNF levels increased over time. In addition, there was a general improvement of its positive and negative schizophrenic symptoms and depressive state. In conclusion, this case report further validates the therapeutic efficacy of ECT in schizophrenic patients with inadequate or poor response to traditional treatments. Moreover, ECT therapeutic effect is associated with an increase in BDNF serum levels. Further studies are needed to characterize the relationship between BDNF and ECT in schizophrenic patients.

Behavioural addictions in adolescents and young adults: results from a prevalence study.

Our study aims to assess the prevalence of behavioural addictions in an adolescent population, evaluating the effects of gender and age, and to assess the correlations among different behavioural addictions. 2853 high school students were assessed in order to evaluate the prevalence of behavioural addictions such as Pathological Gambling (PG), Compulsive Buying (CB), Exercise Addiction (EA), Internet Addiction (IA), and Work Addiction (WA), in a population of Italian adolescents. The South Oaks Gambling Screen-Revised Adolescent (SOGS-RA), the Compulsive Buying Scale (CBS), the Exercise Addiction Inventory (EAI), the Internet Addiction Test (IAT), and the Work Addiction Risk Test (WART), were compiled anonymously by the students. Overall prevalence was 7.0% for PG, 11.3% for CB, 1.2% for IA, 7.6% for WA, 8.5% for EA. PG and EA were more common among boys, while gender had no effect on the other conditions. CB was more common among younger (<18 years old) students. The scores of all of these scales were significantly correlated. The strong correlation among different addictive behaviours is in line with the hypothesis of a common psychopathological dimension underlying these phenomena. Further studies are needed to assess personality traits and other clinical disorders associated with these problems behaviours.

Chronic ketamine use increases serum levels of brain-derived neurotrophic factor.

RATIONALE: Ketamine is a non-competitive N-methyl-D: -aspartate (NMDA) receptor antagonist which interferes with the action of excitatory amino acids (EAAs) including glutamate and aspartate. The use of ketamine at subanaesthetic doses has increased because of its psychotomimetic properties. However, long-term ketamine abuse may interfere with memory processes and inhibit the induction of long-term potentiation (LTP) in the hippocampus, an effect probably mediated by its NMDA antagonist action. Neurotrophins such as brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) serve as survival factors for selected populations of central nervous system neurons, including cholinergic and dopaminergic neurons. In addition, neurotrophins, particularly BDNF, may regulate LTP in the hippocampus and influence synaptic plasticity. OBJECTIVES: The purpose of this study was to test the hypothesis that ketamine use in humans is associated with altered serum levels of neurotrophins. METHODS: We measured by enzyme-linked immunosorbent assay the NGF and BDNF serum levels in two groups of subjects: frequent ketamine users and healthy subjects. RESULTS: Our data show that BDNF serum levels were increased in chronic ketamine users as compared to healthy subjects, while NGF levels were not affected by ketamine use. CONCLUSION: These findings suggest that chronic ketamine intake is associated with increases in BDNF serum levels in humans. Other studies are needed to explore the pharmacological and molecular mechanism by which ketamine, and/or other NMDA antagonists, may induce modification in the production and utilization of BDNF and alter normal brain function.

Sexual behavior in women with bipolar disorder.

INTRODUCTION: There is a lack of studies regarding sexuality and sexual behavior in women with bipolar disorder. The aim of this study is to investigate sexual behavior in women affected by bipolar disorder in order to stimulate interest and debate in this area of care. METHODS: Sixty women (30 BD I and 30 BD II) consent to participate in the study and were included in the sample. Moreover, sixty female healthy subjects without histories of psychiatric disorders were recruited as normal controls. Patients and healthy subjects were given the Sexual Interest and Sexual Performance Questionnaire, a questionnaire devised to explore various aspects of sexual behavior. RESULTS: The results of the present study suggest an increase of sexual interest in patients with BD I as compared both with BD II patients and healthy controls. In women with BD I such increase of interest was detected on some items of section I of the Sexual Interest and Sexual Performance Questionnaire, in particular "Actual Value of Sexuality" and "Implicit Sexual Interest", which implicitly explore sexual interest without overtly focusing upon sexual problems. Moreover, we observed a higher desired frequency of intercourse in women with BD I than BD II and a higher occurrence of repeated sexual intercourse in women with BD I than BD II. CONCLUSIONS: The main finding of the present study was an increase of sexual interest in BD I as compared with BD II female patients and normal controls. This result was detected when sexual interest was explored implicitly. Our study is limited by the small size of our subject groups. Further investigations on larger subject samples are needed to better clarify particular aspects of sexual behavior of BD patients.