Utility of Weekly Laboratory Monitoring in the Expectant Management of Hypertensive Disorders of Pregnancy.

Our retrospective cohort study evaluates the diagnostic yield of weekly laboratory surveillance in outpatient management of hypertensive disorders of pregnancy (HDP) based on patient clinical status at the time of laboratory testing. The study included 459 patients and 1,082 laboratory episodes: 356 (32.9%) episodes were performed in the setting of concerning clinical findings and 726 (67.1%) when the patient was asymptomatic. Overall, the diagnostic yield for abnormal laboratory values (n=11) was 1.0% (95% CI 0.4-1.6%) of all assessments performed and 2.4% (95% CI 1.0-3.8%) among all patients in the cohort. The prevalence of abnormal test results was higher in patients with clinical findings (2.8%, 95% CI 1.1-4.5%) compared with those who were asymptomatic (0.1%, 95% CI 0-0.2%) ( P <.01). Clinical findings suggestive of worsening disease had a 91% sensitivity (95% CI 59-100%) and a 99% (95% CI 99-100%) negative predictive value for abnormal laboratory values. Directed screening based on signs and symptoms, rather than universal weekly screening, may be a potential strategy to lower costs and reduce multiple blood draws for patients with HDP, because there is a low diagnostic yield for this practice.

The developmental trajectory of bipolar disorder.

BACKGROUND: Bipolar disorder is highly heritable and therefore longitudinal observation of children of affected parents is important to mapping the early natural history. AIMS: To model the developmental trajectory of bipolar disorder based on the latest findings from an ongoing prospective study of the offspring of parents with well-characterised bipolar disorder. METHOD: A total of 229 offspring from families in which 1 parent had confirmed bipolar disorder and 86 control offspring were prospectively studied for up to 16 years. High-risk offspring were divided into subgroups based on the parental long-term response to lithium. Offspring were clinically assessed and DSM-IV diagnoses determined on masked consensus review using best estimate procedure. Adjusted survival analysis and generalised estimating equations were used to calculate differences in lifetime psychopathology. Multistate models were used to examine the progression through proposed clinical stages. RESULTS: High-risk offspring had an increased lifetime risk of a broad spectrum of disorders including bipolar disorder (hazard ratio (HR) = 20.89; P = 0.04), major depressive disorder (HR = 17.16; P = 0.004), anxiety (HR = 2.20; P = 0.03), sleep (HR = 28.21; P = 0.02) and substance use disorders (HR = 2.60; P = 0.05) compared with controls. However, only offspring from lithium non-responsive parents developed psychotic disorders. Childhood anxiety disorder predicted an increased risk of major mood disorder and evidence supported a progressive transition through clinical stages, from non-specific psychopathology to depressive and then manic or psychotic episodes. CONCLUSIONS: Findings underscore the importance of a developmental approach in conjunction with an appreciation of familial risk to facilitate earlier accurate diagnosis in symptomatic youth.

Childhood anxiety: an early predictor of mood disorders in offspring of bipolar parents.

BACKGROUND: Anxiety disorders are common among the offspring of parents with bipolar disorder (BD). This study investigated the nature of the association between anxiety disorders and mood disorders in a prospectively studied high-risk cohort. METHODS: High-risk offspring were identified from families in which one parent had confirmed BD based on SADS-L interviews and best estimate diagnostic procedures. All agreeable offspring aged 8-25 years were enrolled in a longitudinal study involving repeated KSADS-PL format clinical assessments. Control (C) offspring from families in which neither parent met lifetime criteria for a psychiatric disorder were similarly assessed. All DSM-IV diagnoses in the offspring were confirmed on blind consensus review. Cumulative incidence and adjusted Cox Proportional Hazards models were used to calculate the risk of anxiety disorders and the predictive association with mood disorders. RESULTS: The cumulative incidence of anxiety disorders was higher (23.40% vs. 10.42%; HR=2.136; p=.0382) and occurred earlier (9.79 vs. 14.84 years; p=.0125) in high-risk compared to C offspring. In high-risk offspring generalized anxiety disorders (GAD) followed by social phobia were the most incident anxiety subtypes; while high emotionality (HR 1.111; p=.0096) and shyness (HR 1.144; p=.0053) increased the risk of anxiety disorders. Anxiety disorders increased the adjusted risk of mood disorders (HR 2.166; p=.0004), on average 8.49 years later (SD 5.97). LIMITATIONS: The cumulative incidence of BD is relatively low, as the cohort is still in the period of risk. CONCLUSIONS: Findings highlight the need for longitudinal surveillance of symptomatic high-risk children and suggest anxiety disorders are an important early intervention target.

Bipolar disorder and socioeconomic status: what is the nature of this relationship?

BACKGROUND: In psychiatric literature stretching over a century, there have been glaring discrepancies in the findings describing the relationship between bipolar disorder (BD) and socioeconomic status (SES). Early studies indicated an overall association between manic-depressive illness and higher social class. However, recent epidemiologic studies have failed to find an association between BD and SES. Instead, they report a similar distribution of BD among social classes and educational levels, and in one particular study, a lower family income was reported. The determinants of SES are complex, and the early findings are now interpreted as having been incorrect and stemming from past methodological weaknesses. METHODS: For this analysis we explored the relationship between SES and BD in a sample of patients who had participated in prior clinical and therapeutic studies. These patients met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BD, required long-term stabilizing treatment, and were assessed in terms of their response to lithium stabilization and a number of other clinical characteristics in accordance with research protocol. Good response to lithium stabilization (LiR) served as a proxy for identifying a subtype of manic-depressive illness, the classical form of BD. Non-responders to stabilizing lithium (LiNR) were considered belonging to other subtypes of bipolar spectrum disorder. The SES of the parents was measured upon entry into treatment using the Hollingshead SES scale, which despite its limitations has been used in psychiatry most widely to determine SES. The groups of LiR and LiNR were compared statistically in terms of SES. The influence of bipolar subtype and gender on SES was investigated. RESULTS AND DISCUSSION: A significantly higher SES was associated with the lithium-responsive form (LiR) of BD when compared with patients continuing to relapse despite adequate lithium treatment (representing other types of bipolar spectrum). Our observation suggests that the discrepant literature findings about SES and BD may be better explained by the change in diagnostic practices: early studies describing a positive relationship included mostly classical manic-depressive disorder, while the patients in recent studies have been diagnosed according to much broader criteria, reflecting the era of bipolar spectrum disorder.