An ISBD perspective on the sociocultural challenges of managing bipolar disorder: A content analysis.

OBJECTIVE: Clinical management of bipolar disorder patients might be affected by culture and is further dependent on the context of healthcare delivery. There is a need to understand how healthcare best can be delivered in various systems and cultures. The objective of this qualitative study was to gain knowledge about culture-specific values, beliefs and practices in the medical care provided to patients with bipolar disorders from a provider perspective in various areas of the world. SAMPLING AND METHODS: The International Society for Bipolar Disorders (ISBD) network provided the framework for this qualitative study. An electronic interview with open-ended questions was administered to 19 international experts on bipolar spectrum disorder representing the International Society for Bipolar Disorders chapter network in 16 countries and six continents. In addition, there were two in-depth interviews with bipolar spectrum disorder experts done prior to the survey. The data were analysed using content analysis, and the information was structured using the software NVivo by QSR International Pty Ltd. FINDINGS: All participants described sociocultural factors as important in healthcare delivery to bipolar patients in their part of the world, both in accessing healthcare and in providing culturally appropriate care. Factors that affected the provider's ability to supply good clinical management of patients were access to treatment options and long-term follow-up, as well as general strategies to combat stigma. In some societies, the patients' use of alternative treatments, gender issues and religion were also important factors. Understanding the impact of such culturally specific factors was overall regarded as essential for proper treatment interventions. CONCLUSION: Sociocultural factors clearly affect the nature and quality of medical services delivered to bipolar patients. Financial, social and cultural factors affect patients' health-seeking behaviour, and this highlights the need for knowledge about such factors in order to adequately identify and treat bipolar patients globally. Culturally adapted training and psychoeducation programmes are particularly warranted.

Comorbidity of migraine with ADHD.

OBJECTIVE: The purpose of this study was to investigate how often drugs used to treat migraine and ADHD are prescribed to the same patients to assess, indirectly, the comorbidity of these disorders. METHOD: We used data from the Norwegian prescription database for 2006, including the total Norwegian population (N = 4,640,219). RESULTS: Antimigraine drugs were prescribed to 81,225 persons (1.75% of the total population), anti-ADHD drugs to 18,481 persons (0.40%), and 284 persons were prescribed both types of drugs. There was a positive and significant association between prescription of antimigraine and anti-ADHD drugs for all age groups between 20 and 50 for both genders, with odds ratios ranging from 1.76 to 2.81. CONCLUSION: The prescription patterns for these drugs in adult patients indicate a comorbidity between migraine and ADHD.

Are migraine and bipolar disorders comorbid phenomena?: findings from a pharmacoepidemiological study using the Norwegian Prescription Database.

OBJECTIVES: Clinical, epidemiological, and, recently, genome-wide linkage and genome-wide association studies suggest migraine and bipolar disorder are comorbid phenomena. The objective of this study was to determine whether there is also evidence that this comorbidity exists by virtue of there being a positive relationship between the prescription of medications used to treat migraine and mood-stabilizing agents using the National Norwegian Prescription Database. METHODS: Data allowing ascertainment of the concurrence of prescriptions for migraine and mood-stabilizing agents were gleaned from the Norwegian Prescription Database for calendar year 2006, covering the total population (N = 4,640,219). Results were obtained using logistic regression analyses and were expressed by odds ratios (ORs). RESULTS: A total of 81,225 persons (1.8% of the population) received medications for migraine and 19,517 (0.45%) received a mood-stabilizing agent for a bipolar disorder; 843 persons received both types of medications. The OR expressing the relationship between the concurrent use of both categories of medications was 2.55 (95% confidence interval [CI], 2.38-2.73, P < 0.001, z score = 26.44), significant for all mood stabilizers (lithium: OR = 1.82 [95% CI, 1.58-2.10], P < 0.001, z score = 8.31; carbamazepine: OR = 2.48 [95% CI, 2.01-3.06], P < 0.001, z score = 8.42; valproic acid: OR = 2.26 [95% CI, 1.89-2.70], P < 0.001, z score = 8.96; and lamotrigine: OR = 3.50 [95% CI, 3.14-3.90], P < 0.001, z score = 22.68). The association was significantly higher for men (OR = 3.16 [95% CI, 2.74-3.66], P < 0.001, z score = 15.53) than for women (OR = 2.21 [95% CI, 2.04-2.39], P < 0.001, z score = 19.61) and was most pronounced in younger age groups and for lamotrigine. CONCLUSIONS: There was a strong positive association between the prescription of medications used to treat migraine and mood-stabilizing agents. This is compatible with the hypothesis that migraine and bipolar disorders are associated with one another.

An estimate of the minimum economic burden of bipolar I and II disorders in the United States: 2009.

OBJECTIVE: To conduct an analysis yielding estimates of the direct and indirect costs accruing from bipolar I and II disorders in 2009. The last analysis of these costs pertained to 1991. METHODS: The analysis presented is based on recent epidemiological data, a measure of the increase in the cost of health care services and commodities between 1991 and December 31, 2009, a measure of the increase in the cost of living after partialing out of the costs of health care between 1991 and December 31, 2009 and adjustment for growth in the population of the United States between 1991 and 2009 to calculate the direct and indirect costs of bipolar I and II disorders. RESULTS: The estimated direct and indirect costs of bipolar I and II disorders in 2009 were 30.7 and 120.3 billion dollars, respectively. The estimated total economic burden imposed by these disorders was 151.0 billion dollars. The increase in costs between 1991 and 2009 was not entirely due to inflation. Bipolar I and II disorders are now estimated to have a combined prevalence exceeding that used in the calculation of costs for 1991 by 1.6154-fold. Direct costs escalated out of proportion (2.2393-fold) to indirect costs (1.6148-fold). LIMITATIONS: The analysis required the acceptance assumptions that likely resulted in a net-underestimation of costs and did not take the entirety of the bipolar spectrum into account. CONCLUSIONS: The findings have implications for the formulation of public policy. The lifetime prevalences of not only bipolar I and II disorders but also the high prevalence of the entire body of bipolar spectrum disorders, the suffering that they create and the economic burden imposed by them render them worthy of having a high priority in the formulation of plans for the delivery of health care services, planning educational programs for the public and informing policymakers.

A pharmaco-epidemiological study of migraine and antidepressant medications: complete one year data from the Norwegian population.

BACKGROUND: Migraine, depression and anxiety disorders have been associated with one another in several epidemiological studies. However, it is not known if or how these associations are reflected in the concurrent use of medications for migraine and depressive/anxiety disorders in the general population. The purpose of the present study was to identify groups of patients particularly likely to receive clinical treatment for both conditions. METHODS: Data from the Norwegian Prescription Database for 2006 were analysed for the purpose of ascertaining concurrence of prescriptions for migraine and depression/anxiety disorders. Data were subjected to analysis testing deviation from unity for the OR performed by a chi-square test. RESULTS: In the total Norwegian population (N=4,640,219) migraine drugs were prescribed to 81,225 persons (1.8% of the population), antidepressant drugs to 257,700 persons (5.6% of the population), and 11,269 persons were prescribed both types of drugs. The prescription of antidepressants was significantly increased in patients receiving a prescription for a medication used to treat migraine (OR=2.82 (95% CI=2.76-2.88); chi-square p<0.001), and this association was stronger for men than for women. Teenage women carried the highest risk for this co-morbid constellation (OR=3.89 CI=3.17-4.77); chi-square p<0.001). CONCLUSION: This study revealed a strong positive association between the prescription of migraine and antidepressant medications, and this association was generally most pronounced in men. However, teenage girls carried the highest risk of receiving both kinds of prescriptions, suggesting particular attentiveness is required in the clinical management of these patients.

Comorbidity of asthma with ADHD.

OBJECTIVE: To assess how frequently drugs used to treat asthma and ADHD are prescribed to the same patients. METHOD: The authors used data from the Norwegian Prescription Database for 2006, including the total Norwegian population (n = 4,640,219). RESULTS: Anti-asthma drugs were prescribed to 350,894 persons (7.56 % of the population), anti-ADHD drugs to 18,481 persons (0.40 %), and both to 1,730 persons. There was a 65% increased overall risk (OR = 1.65) of being prescribed one of the drugs given a prescription of the other. Women had a markedly higher risk than men. When data for each age group (10 years interval) and each gender were analyzed separately, the strongest associations were found for women between 20 and 49 years of age and men between 30 and 49 years of age. CONCLUSION: These prescription patterns suggested a marked comorbidity between asthma and ADHD.

Is a family history of bipolar disorder a risk factor for migraine among affectively ill patients?

AIMS: The aim was to determine whether having a family history of bipolar disorder (BPD) or unipolar major depressive disorder (MDD) is associated with an increased likelihood of having migraine headaches. METHODS: Latino adults received structured diagnostic interviews. Family history was determined by live interview of first-degree relatives or interview by proxy. All patients met the criteria for major depressive episode (MDE) at the time of assessment. The method of diagnosing migraine had sensitivity and specificity of 87 and 50%, respectively. Logistic regression was used to test for associations and control for confounding. RESULTS: In total, 153 patients met the criteria for MDD and 87 for BPD. Patients with MDD who had a family history of BPD were 4.3 times more likely to have migraine headaches than those who did not (OR=4.34, z=3.02, p=0.003, 95% CI=1.67-11.27). Patients with BPD who had a family history of BPD were 3 times more likely to have migraine than those who did not (OR=2.99, z=2.45, p=0.014, 95% CI=1.25-7.19). Within the entire group of patients, those with a family history of BPD were 4.4 times more likely to have migraine headaches than those who did not (OR = 4.38, p<0.0001, z=4.72, 95% CI=2.37-8.09). A family history of MDD was not associated with an increased risk of having migraine. CONCLUSION: Regardless of a patient's polarity, having a family history of BPD is associated with an increased risk of having migraine headache.

Migraine headache in affectively ill latino adults of mexican american origin is associated with bipolarity.

BACKGROUND: The objective of this cross-sectional study was to determine the prevalence of migraine headache among depressed Latino adults of Mexican American origin meeting the criteria for bipolar disorder (BPD) or major depressive disorder (MDD) relative to patients in a psychiatric comparison group. METHOD: In a mental health clinic for the indigent, consecutively and systematically evaluated acutely depressed Latino adults received structured diagnostic psychiatric interviews based on modules extracted from the Structured Clinical Interview for DSM-IV. All were asked as part of routine assessment whether they had headaches "in the last week." Patients with unilateral, pounding, pulsating headache were classified as having migraine headache. The prevalence of migraine headache among the patients with BPD and MDD was contrasted with that of patients in a psychiatric comparison group composed of patients with disorders other than schizophrenia or schizoaffective disorder. Logistic regression was used to test for associations and control for confounding effects. The data were collected between August 2001 and November 2004. RESULTS: Eighty-seven patients had BPD and 123 had MDD. Bipolar patients were 2.9 times more likely to have migraine headaches than patients with MDD (P < .0001). There was a trend for patients with MDD to have a higher prevalence of migraine than patients in the psychiatric comparison group. CONCLUSIONS: Bipolar patients had a high prevalence of migraine headache relative to patients with MDD. This study suggests that migraine is linked to bipolarity.

"Mixed hypomania" in children and adolescents: is it a pediatric bipolar phenotype with extreme diurnal variation between depression and hypomania?

BACKGROUND: Although DSM-IV and the literature on pediatric bipolarity recognize mania and mixed phases neither recognizes states of "mixed hypomania." There has been preliminary presentation of the latter phenomenon in the adult bipolar literature. The authors herein describe this phenomenon in a consecutive clinical series of bipolar children and adolescents. METHODS: This exploratory study involved 47 consecutive bipolar patients between the ages of 7 and 17 years presenting to an outpatient clinic. They were evaluated using a structured instrument designed to ascertain the presence of major depressive episodes (MDE), hypomania, mania, psychotic disorders, behavioral disorders such as oppositional defiant disorder and conduct disorder and substance use disorders. We defined mixed hypomania as MDE and hypomania coexisting over at least 2 weeks. RESULTS: Of 47 patients, 9 girls (42.9%) and 9 boys (34.6%) were bipolar II mixed. This paper focuses on them. The mean ages of the bipolar II girls and boys were 14.3 (1.9) years and 12.0 (3.4) years, respectively (p<0.05, t=2.45, df=17). This mixed subgroup tended to experience rising mood in the evening, often with spikes of euphoria; a history of late afternoon to evening increased talkativeness or pressured speech was common. Some patients exhibited flight of ideas. Psychomotor acceleration, heightened level of energy, and increased goal directed activity between 1900 and 0300 were frequently reported. Retrospectively obtained circadian information revealed, in most cases an age inappropriate phase delay of sleep onset: After falling asleep in the early hours of the morning the patients awoke feeling depressed, lethargic and as if they could sleep throughout much of the day. LIMITATION: Cross-sectional, exploratory study based on a relatively small sample size and in need of replication in other clinical settings. CONCLUSION: Mixed hypomania was a common phenomenon in pediatric bipolar II patients. It is apt to go unrecognized in cross-sectional assessments done in the morning or in the early or mid-afternoon. Those with this proposed phenotype would appear "depressed" at these times. Alternatively, what we have proposed can also be described as severe diurnal variation between depression and hypomania in the evening. Further study is required combining 24-hour clinical observation and state of the art technologically derived data.

Migraine in affectively ill Mexican adolescents.

The objective of this cross-sectional study was to determine the prevalence of migraine headache among depressed Latino adolescents of Mexican American origin. This is, to the best of our knowledge, the first study of the prevalence of migraine among depressed adolescents of any ethnic/racial background. In a mental health clinic for the indigent, 132 consecutive Latino adolescents fulfilling the DSM-IV criteria for major depressive episode were compared with a sample of adolescents with other mental disorders. Logistic regression was used to test for associations and control for confounding effects. The prevalence of migraine headache among depressed adolescents was 6 times greater than that of the comparison patients (OR = 5.98, z = 2.35, p = 0.019). This finding is consistent with previously published reports involving adult samples, in which the prevalence of migraine was found to exceed that in the general population. However, contrary to what we previously found in Latino adults, the prevalence of migraine was not higher in bipolar than in unipolar adolescents.

Treating depressive mixed States in bipolar disorders.

Although not recognized as a diagnostic entity in the DSM-IV-TR, mixed depression is a common clinical presentation. To treat depressive mixed states, clinicians in both Europe and the United States have developed valuable, yet different, therapeutic strategies. For example, the European model focuses on resolving patients' hypomanic symptoms, while the American model treats patients in depressive mixed episodes similarly to those who have bipolar II disorder. Common treatment practices between the 2 paradigms include the art of adopting pharmacotherapeutic regimens that are tailored to the needs of each patient and frequent evaluation of the patient's progress.

Diagnosing depressive mixed states in bipolar disorders.

The presence of depressive mixed states among patients originally diagnosed with unipolar depression suggests that these patients may actually fall along the bipolar spectrum, which has significant treatment implications. To accurately detect mixed depression, physicians should systematically inquire about the presence of manic and hypomanic symptoms in a formal, structured manner when evaluating a depressed patient. This includes specifically asking patients about symptoms of irritability, racing or crowded thoughts, talkativeness, and psychomotor agitation. Swift and accurate diagnosis of depressive mixed states is essential to alleviating symptoms and improving outcomes for patients with bipolar disorders.

Pain complaints in latino adults of mexican origin with and without major depressive episode: a cross-sectional study.

BACKGROUND: The aim of this retrospective, cross-sectional study was to determine the prevalence of 5 pain complaints among Latino adults of Mexican origin meeting the criteria for major depressive episode (MDE). METHOD: In a mental health clinic for the indigent, consecutively evaluated Latino adults of Mexican origin received structured diagnostic psychiatric interviews based on modules extracted from the Structured Clinical Interview for DSM-IV Axis I Disorders-Clinical Version. All were specifically asked whether they had experienced headache, backache, abdominal pain, myalgia, or arthralgia "in the last week." Patients meeting the criteria for MDE were compared to patients without MDE from the same clinic. Associations and statistical significance of the differences between groups were determined using logistic regression models. The data were collected between August 2003 and November 2004. RESULTS: Two hundred ten patients had an MDE, and 35 individuals without an MDE comprised the comparison group. Eighty-eight percent of the patients with MDE versus 53% of the controls had at least 1 pain complaint (p < .0001). Patients with MDE were 8.3 times more likely to have 1 or more pain complaints than the comparison patients (p < .0001). The significant relationship between depression and pain applied when we examined those with ≥ 2, ≥ 3, and ≥ 4 pain complaints. Twenty-eight percent of the MDE subjects had all 5 pain complaints compared to 3% of subjects without MDE (p = .013). CONCLUSIONS: The method of assessment of the presence of pain led to the detection of a remarkably high prevalence of pain complaints. The findings presented have important implications not only for the practice of those who are widely recognized as being primary care physicians but also for practitioners of all clinical disciplines.

Differential patterns of lifetime multiple anxiety disorder comorbidity between Latino adults with bipolar I and major depressive disorders.

BACKGROUND: To determine the lifetime rates of panic disorder, obsessive-compulsive disorder (OCD), social phobia, and posttraumatic stress disorder (PTSD) among adult Latino patients with major depressive disorder (MDD) and bipolar disorder (BPD), and whether there are dose-response relationships between loading for comorbid anxiety disorders, the probability of having BPD, and attributes of severity of illness. METHODS: In a public sector clinic for the indigent located in a semiclosed rural community, 187 consecutively presenting affectively ill Latino patients were evaluated by use of the Structured Clinical Interview for DSM-IV. Polarity and the lifetime prevalence of panic disorder, OCD, social phobia, and PTSD were determined. Logistic regression was used to test associations. Trends in positive predictive values (PPVs) and likelihood ratios were assessed to determine whether dose-response relationships existed between loading for comorbid anxiety disorders and the likelihood of having BPD as opposed to MDD, psychosis, suicidal ideation, and suicide attempts. RESULTS: Of 187 subjects, 118 (63.1%) had MDD and 69 (36.9%) had BPD. The odds ratio of a patient with BPD, relative to MDD, of having panic disorder was 4.6 (p< .0001), OCD 7.6 (p< .0001), social phobia 6.0 (p< .0001) and PTSD 5.3 (p< .0001). The PPV of having BPD was 91.3% and of having psychotic features 83.0% if one had all four anxiety disorders. There was a dose-response relationship between loading for comorbid anxiety disorders and the likelihood of having had a suicide attempt (but not suicidal ideation). CONCLUSIONS: As previously reported by us for juvenile patients, Latino adults with BPD had a remarkably high risk of having each anxiety disorder relative to patients with MDD. The results indicate that the risk of having BPD, having a psychosis, and making a suicide attempt becomes increasingly great as the number of comorbid anxiety disorders increases. These data, which are consistent with the notion of anxious bipolarity, provide further support for a possible anxious diathesis in bipolar disorder.

Post-traumatic stress disorder among adolescents with bipolar disorder and its relationship to suicidality.

OBJECTIVES: The aims of this cross-sectional pilot study were to ascertain the rates of post-traumatic stress disorder (PTSD) among adolescents with bipolar disorder (BPD) and major depressive disorder (MDD) relative to a comparison group comprised of non-affectively ill patients, and to determine whether PTSD is related to suicidal ideation and attempts. The impetus for the study was born of clinical impressions derived in the course of routine clinical practice. METHODS: Patients were screened by a single interviewer for BPD, MDD and PTSD, panic disorder, obsessive-compulsive disorder (OCD) and social phobia using the apposite modules from the Structured Clinical Interview for DSM-IV (SCID) and histories of suicidal ideation and attempts. The data were subjected to analysis using a logistic regression model. RESULTS: The database included 34 patients with BPD, 79 with MDD and 26 with a non-affective disorder. The risk for PTSD for a patient with BPD significantly exceeded that for a patient with MDD [odds ratio (OR) = 4.9, 95% confidence interval (CI) = 1.9-12.2, p = 0.001]. Patients with PTSD had an insignificantly increased risk for suicidal ideation (OR = 2.8, 95% CI = 0.9-8.9, p = 0.069), and a 4.5-fold significantly increased risk of having had a suicide attempt (OR = 4.5, 95% CI = 1.7-11.7, p = 0.002). The relationship between PTSD and suicide attempts remained significant even after controlling for the confounding effects of concurrent panic disorder, OCD and social phobia (OR = 3.4, 95% CI = 1.1-10.0, p = 0.023). CONCLUSIONS: Patients with BPD have a greater risk for PTSD than those with MDD. Post-traumatic stress disorder is significantly related to history of suicide attempts.

Dose-response relationship between number of comorbid anxiety disorders in adolescent bipolar/unipolar disorders, and psychosis, suicidality, substance abuse and familiality.

OBJECTIVES: To ascertain rates of panic, obsessive-compulsive (OCD) and social phobic disorders among adolescents with bipolar disorder (BP), unipolar major depressive disorder (MDD) and psychiatric comparison patients, to assess their relationships to suicidality, psychosis, comorbidity patterns and familiality. METHODS: The first author (SCD) interviewed 313 Latino adolescents using a structured interview based on the SCID. Family history was ascertained by live interview or interview by proxy. Patients were classified as BP, MDD, or non-affectively ill comparison controls (CC). Data regarding suicidality and psychosis were collected. Regression analysis was used to test associations and control for confounding effects. Positive likelihood ratios were used to measure the dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness. RESULTS: Of the total sample, 36.7% were BP, 44.7% MDD and 18.5% CC. In BP vs. MDD the odds of panic disorder were 4.4, of OCD 5.1, and of social phobia 3.3. MDD, in turn, were more likely to have these disorders than CC. BP (but not MDD) with panic disorder and social phobia, were more likely to have suicidal ideation; among the anxiety disorders, only social phobia was associated with having greater odds of suicide attempts. Among BP and MDD, patients with all three anxiety disorders were more likely to be psychotic. Presence of any mood disorder among first-degree relatives substantially increased the odds of having panic disorder and social phobia. The presence of one comorbid anxiety disorder increased the odds of having another. Finally, there were dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness. LIMITATIONS: Single interviewer using the SCID; cross sectional exploratory study. CONCLUSIONS: BP adolescents have a greater anxiety disorder burden than their MDD counterparts. The results are compatible with the hypothesis that heavy familial-genetic loading for affective illness in juveniles is associated with bipolarity, cumulative anxiety disorder comorbidity, suicidality and psychosis. These observations are in line with pioneering psychopathologic observation in the early 1900s by two French psychiatrists, Gilbert Ballet and Pierre Kahn, who saw common ground between what until then had been considered the distinct categories of the neuroses and cyclothymic (circular) psychoses. This perspective has much in common with current complex genetic models of anxious diatheses in bipolar disorder.

Mixed states: the most common outpatient presentation of bipolar depressed adolescents?

BACKGROUND: The purpose of this study was to determine the rate of bipolar disorder in adolescent outpatients presenting with DSM-IV major depressive episode (MDE) and, among the bipolar group, to find out what proportion were in a mixed state. METHODS: 247 MDE Hispanic adolescents presenting to a community mental health clinic received structured screens for hypomania/mania by history. One hundred met the criteria for bipolar I or II disorder, depressed. Patients meeting the full DSM-IV criteria for both MDE andhypomania/mania simultaneously for at least 1 continuous week during the index episode were classified as being in a mixed state. RESULTS: One hundred of the 247 adolescents were bipolar (40.5%). Of these bipolars, 58 (58.0%) were boys. The mean age of the bipolar patients was 14.6 (+/-1.5) years. Eighty-two (82.0%) were in a mixed state. Of those in mixed states, 46 (56.1%) were boys, 45 (54.9%)had psychotic features, 40 (48.8%) had family histories of either major depressive disorder or of bipolar disorders, 26 (31.7%) had family histories of bipolar disorder, 55 (67.1%) had suicidal ideation and 42 (51.2%) had a history of a physically self-destructive act such as wrist cutting or overdoses. DISCUSSION: The mixed state was the most common presentation for bipolar adolescents who were in the midst of an MDE at the time of presentation to a mental health clinic. Such presentation dictates different treatments. Although this clinic caters to Hispanic youth with relatively severe affective illness, we submit that our data can be generalized to other settings in light of the fact that the unavailability of psychiatric beds for such destitute patients is driving them to ambulatory clinics. To the best of our knowledge, this is the first report of such a high prevalence of mixed states in adolescent bipolar patients evaluated in the course of routine clinical practice in an outpatient setting.

Pain complaints in adolescent patients with affective disorders versus adolescent psychiatric controls.

OBJECTIVE: To ascertain the frequencies of 4 prospectively determined pain complaints among adolescents meeting the criteria for major depressive episode (MDE) relative to non-affectively ill controls. METHOD: In a community mental health clinic for the indigent situated on the border of the United States and Mexico (Rio Grande City, Tex.), adolescents (age range, 12-17 years) who consecutively presented to the clinic from August 2001 to November 2003 received structured psychiatric diagnostic screens for depression and mania using the modules from the DSM-IV. Subsequently, all subjects were asked whether they had had significant (distressing or bothersome) backache, abdominal pain, headaches, or myalgia in the last 7 days. We compared patients meeting the criteria for MDE with individuals without affective symptomatology. Significance of the differences between groups was assessed using the Fisher exact test and multivariate logistic regression analysis. The odds ratios were adjusted for age and sex. RESULTS: One hundred thirty-two subjects met the criteria for MDE. Forty-eight had non-affective disorders. Seventy-six percent of the subjects meeting the criteria for MDE had at least 1 pain complaint compared to 33% of the control subjects (p < .0001). Fifty percent of the subjects in the midst of a MDE had at least 2 pain complaints compared to 6% of the control subjects (p < .0001). Twenty-nine percent of the subjects in the midst of a MDE had at least 3 pain complaints compared to 2% of the control subjects (p < .0001). Fourteen percent of the subjects in the midst of a MDE had all 4 pain complaints compared to none of the control subjects (p = .002). The odds ratio of subjects with a MDE having a pain complaint relative to control subjects was 5.8 (p < .0001). CONCLUSION: That in excess of three fourths of clinically depressed adolescents had 1 or more pain complaints has important implications for adolescent psychiatry and primary care, as well as somatic medicine.

Gender, suicidality and bipolar mixed states in adolescents.

BACKGROUND: The purpose of this study was to determine the relationship between mixed states and suicidality among adolescent outpatients presenting with a DSM-IV defined major depressive episode (MDE). METHODS: Two-hundred and forty-seven adolescents meeting the criteria for MDE were screened for the presence of concurrent, intra-MDE hypomania/mania (i.e., mixed states). All patients were asked whether they had current suicidal ideation or had recently attempted any self-destructive physical act associated with the thought of dying (i.e., a suicide attempt). The data were subjected to analysis using univariate logistic regression. RESULTS: One hundred of the 247 (40.5%) adolescents were bipolar type I or type II. Of these, 82% were in mixed states. Of the patients with suicidal ideation, 62.8% were girls, and of those with histories of a suicide attempt, 69.4% were girls. Girls had more than twice the risk of having suicidal ideation (OR=2.2, p=0.004) and nearly 3 times the risk of having histories of a suicide attempt than boys (OR=2.87, p<0.0001). Being in a mixed state per se did not predict either suicidal ideation or a suicide attempt among all of the 247 patients. However, mixed states apparently independently contributed to the risk of (non-fatal) suicidal behavior among girls only. Of the mixed states, girls had nearly 4 times the risk of having made a suicide attempt compared with those without mixed states (OR=3.9, p=0.003). Age, presence of psychotic features and family history of mood disorder had little or no bearing on suicidality. LIMITATIONS: Correlational chart review study, no data collection on Axis I and Axis II comorbidity and adverse life-events. CONCLUSIONS: This report of greater suicidality in adolescent girls in a mixed state parallels the well-known adult literature of high frequency of mixed states in women. The findings are of relevance to the controversy of antidepressants and suicidality in juvenile depressives in that they identify a vulnerable group. In line with earlier suggestions by the senior author [Akiskal, H.S., 1995. Developmental pathways to bipolarity: are juvenile-onset depressions pre-bipolar? J. Am. Acad. Child Adolesc. Psych. 34, 754-763], our data highlight the public health importance of the wider recognition of bipolar mixed states in juvenile patients masquerading as unipolar depression. Finally, it appears to us that it is the failure of our formal nosology on mixed states--rather than the antidepressants per se--which is the root problem in this controversy.

High rate of unrecognized bipolar mixed states among destitute Hispanic adolescents referred for "major depressive disorder".

OBJECTIVE: To ascertain the rate of bipolarity among adolescent Hispanic youths referred for the treatment of "major depressive disorder" (MDD) in a community mental health clinic (CMHC) in which the threshold for referral was moderate to severe impairment. METHODS: The patients were 49 consecutively presenting Hispanic adolescents (33 girls and 16 boys with a range of 12-17 years), many of whom had histories of unruly, hostile and/or assaultive behavior; indeed, 1 out of 3 had been referred to the CMHC from the "First-Time Offenders Program." Upon evaluation at the CMHC triage unit, all were diagnosed as MDD rendered by a licensed paramedical mental health professional managing this unit. They were subsequently evaluated by a psychiatrist using the Structured Clinical Interview for DSM-IV. RESULTS: Seventeen (51.5%) of the girls and 10 (62.5%) of the boys met the DSM-IV criteria for bipolar disorder. Among the bipolars, 44.4% were bipolar II and 55.6% bipolar I; 74.1%% had mixed states and 40.7% were psychotic (not mutually exclusive categories). Euphoric mania was virtually absent in this population. LIMITATION: Data on social deviance was based on chart review. Nonetheless, given that a third had already entered the juvenile justice system upon referral validates the accuracy of characterizing this population as at least moderately impaired from the social deviance standpoint. CONCLUSIONS: Hispanic adolescents referred with a presumptive diagnosis of MDD must be carefully assessed for the presence of occult bipolarity using a structured interview. Concurrent aggressiveness and depression should tip mental health clinicians towards bipolarity--especially mixed states. Such activated-hostile depressive (and/or manic) mixed states may in part underlie the social deviance in these patients. Given that these destitute youth are often simultaneously encountered in the juvenile justice system, undetected bipolarity among Hispanic adolescents initially regarded to have MDD represents a matter of grave public health importance. Appropriate training for mental health staff to recognize bipolar spectrum disorders in CMHCs should be mandated.