Course, outcomes, and psychosocial interventions for first-episode mania.

OBJECTIVES: The course of bipolar disorder tends to worsen over time, highlighting the importance of early intervention. Despite the recognized need for adjunctive psychosocial treatments in first-episode mania, very few studies have evaluated psychological interventions for this period of significant risk. In this empirical review, we evaluate existing research on first-episode bipolar disorder, compare this body of research to parallel studies of first-episode schizophrenia, and identify strategies for future research. METHODS: A comprehensive literature search of the MEDLINE and PsychINFO databases was conducted to identify studies of first-episode mania, as well as first-episode schizophrenia. Recovery and relapse rates were compared across studies. RESULTS: In contrast to a number of studies of first-episode schizophrenia, the authors identified only seven independent programs assessing first-episode mania. Findings from these studies suggest that, while pharmacological treatment helps patients achieve recovery from acute episodes, it fails to bring patients to sustained remission. Early psychosocial intervention may be imperative in reducing residual symptoms, preventing recurrence of mood episodes, and improving psychosocial functioning. However, very few studies of psychosocial interventions for first-episode mania have been systematically studied. CONCLUSIONS: Studies of first-episode mania indicate a gap between syndromal/symptomatic and functional recovery. Novel psychosocial interventions for first-episode mania may help bridge this gap, but require controlled study.

The role of depression, shame-proneness, and guilt-proneness in predicting criticism of relatives towards people with bipolar disorder.

Expressed emotion (EE) has been associated with poor patient outcomes in many different psychiatric disorders. Given its robust association with relapse, EE has become a major target of family psychoeducational interventions. Most psychoeducational interventions to date have failed to change EE levels among families of those with bipolar disorder. Better intervention strategies, then, may depend on an increased understanding of the predictors of EE. Although EE has traditionally included many facets, criticism appears to be the most robust predictor of outcome within bipolar disorder. The present study tested three primary predictors of criticism among family members of people with bipolar disorder: shame-proneness, guilt-proneness, and depression. Depressive symptoms were significantly associated with EE. Discussion focuses on limitations and implications of the study and suggestions for future research.

Ruminative Responses to Negative and Positive Affect Among Students Diagnosed with Bipolar Disorder and Major Depressive Disorder.

Rumination in response to negative affect has been found to predict the onset, severity, and duration of depressive symptoms. Few researchers, however, have considered rumination within bipolar disorder, nor have studies considered parallel responses that might intensify positive affect. The current study examined self-reported rumination in response to both negative and positive affect among people diagnosed via the SCID with BPD (n = 28), major depressive disorder (MDD; n = 35), or no mood disorder (n = 44). Participants completed the Ruminative Response Scale and the Responses to Positive Affect Questionnaire about their dispositional tendencies. Results indicated that compared to control participants, people with BPD and MDD endorsed heightened rumination in response to negative affect, but only those with BPD endorsed elevated rumination in response to positive affect. Within BPD, ruminative responses to negative affect were explained by depressive symptoms. Goals for understanding responses to negative and positive affect in BPD are suggested.

Dispositional Rumination in Individuals with a Depression History.

Many studies show that rumination is related to current depressive episodes but very few studies have examined whether rumination is elevated among those with a history of diagnosed depression. The goal of the current study was to examine whether a history of diagnosable major depressive disorder (MDD) is related to rumination among undergraduates. In addition, individual difference variables (i.e. problem-solving abilities, neuroticism and self-esteem) that might help explain rumination were examined. Participants were interviewed with the SCID to diagnose MDD. Fifty-one had no history of MDD and 41 had a MDD history. Depression history was significantly related to rumination, even after controlling for subsyndromal symptoms. Rumination was related to negative problem-solving orientation. Major limitations of this study are the cross-sectional design, undergraduate sample and the relatively small sample size, particularly for multidimensional analyses.

Life events and juvenile bipolar disorder: conceptual issues and early findings.

There is increasing interest in the psychosocial variables that might predict the course of child and adolescent bipolar disorder. In the literature on adult bipolar disorder, life events have been shown to be a major predictor of symptoms. In this review, we focus on studies of how life events influence the course of child and adolescent bipolar disorder. To begin, we review methodological considerations in life events research, and briefly summarize the findings regarding life events in adult bipolar disorder. Then, we discuss available studies on life events as a predictor of the course of juvenile bipolar disorder. We conclude with suggested directions for future research.

Impaired recruitment of the dorsolateral prefrontal cortex and hippocampus during encoding in bipolar disorder.

BACKGROUND: The aim of the present study was to examine the functional neuroanatomy of episodic memory impairment in euthymic subjects with bipolar I disorder. There is evidence that individuals with bipolar disorder have cognitive impairments not only during mood episodes but also when they are euthymic. The most consistently reported cognitive difficulty in euthymic subjects with bipolar disorder is impairment in verbal episodic memory (i.e., the ability to learn new verbal information). METHODS: The current study examined verbal learning in eight euthymic, remitted subjects with bipolar I disorder (BP-I; seven nonmedicated) and eight control subjects matched for age, gender, education, and intelligence. Subjects underwent (15)O-CO(2) positron emission tomography scanning while completing a verbal learning paradigm that consisted of encoding (learning) several lists of words. RESULTS: The BP-I subjects had more difficulties learning the lists of words compared with the control subjects. Compared with control subjects, BP-I subjects exhibited blunted regional cerebral blood flow (rCBF) increases in the left dorsolateral prefrontal cortex (Brodmann's area 9/46) during encoding. CONCLUSIONS: Consistent with previous studies, subjects with BP-I were impaired in learning new verbal information. This was associated with rCBF abnormalities in brain regions involved in learning and episodic memory.

Psychopathology in the offspring of parents with bipolar disorder: a controlled study.

BACKGROUND: To examine the risk for psychopathology in offspring at risk for bipolar disorder and the course of psychiatric disorders in these youth. METHODS: Using structured diagnostic interviews (Structured Clinical Interview for DSM-IV [SCID] and Kiddie Schedule for Affective Disorders and Schizophrenia [K-SADS]), psychiatric diagnoses of 117 nonreferred offspring of parents with diagnosed bipolar disorder were compared with those of 171 age- and gender-matched offspring of parents without bipolar disorder or major depression. RESULTS: Compared with offspring of parents without mood disorders, high-risk youth had elevated rates of major depression and bipolar disorder, anxiety, and disruptive behavior disorders. High-risk offspring also had significantly more impaired Global Assessment of Functioning (GAF) scores, higher rates of psychiatric treatment, and higher rates of placement in special education classes. Disruptive behavior disorders, separation anxiety disorder, generalized anxiety disorder (GAD), social phobia, and depression tended to have their onset in early or middle childhood, whereas bipolar disorder, obsessive-compulsive disorder (OCD), panic disorder, and substance use disorder had onset most frequently in adolescence. CONCLUSIONS: These findings support the hypothesis that offspring of parents with bipolar disorder are at significantly increased risk for developing a wide range of severe psychiatric disorders and accompanying dysfunction. Early disruptive behavior and anxiety disorders, as well as early-onset depression, may be useful markers of risk for subsequent bipolar disorder in high-risk samples.

Suicidality in bipolar I disorder.

People with bipolar disorder are at high suicide risk. The literature suggests that suicidality is predicted by higher symptom severity and less use of pharmacological agents, but few studies have examined the joint contributions of these variables. The present study examines the conjoint contribution of symptom severity and pharmacological treatment to suicidal ideation and behavior among participants with bipolar disorder. The model was able to account for 53% of the variance in suicidality scores. Depression, mixed state, and hopelessness were significantly associated with suicidality. All other variables were nonsignificant once symptom severity had been controlled. Implications for future research are described.

A clinical monitoring form for mood disorders.

OBJECTIVE: The Clinical Monitoring Form (CMF) for mood disorders was developed as a time efficient record keeping tool for routine clinical use. This report presents preliminary data evaluating the correlation between the CMF's dimensional subscales for depression and mood elevation and formal mood rating scales across a wide spectrum of mood states. METHODS: To harvest data for 500 follow-up visits required collection of data from consecutive records accumulated during the conduct of seven double blind clinical trials involving a total of 58 participants. These trials utilized the CMF as a source document in conjunction with formal study outcome scales, e.g. Hamilton Rating Scale for Depression (HRSD), the Montgomery-Asberg Depression Rating Scale (MADRS), the Young Mania Rating Scale (YMRS) and the Mania Rating Scale (MRS) from the Schedule of Affective Disorders-Current (SUM-C). Correlation coefficients were calculated to examine the relationship between the formal rating scales, Clinical Global Impression and the depression (SUM-D) and mood elevation (SUM-ME) subscales of the CMF. RESULTS: Robust correlations were observed between SUM-D and the formal depression scales, HRSD and MADRS, r = 0.79, r = 0.88. respectively. Similar robust correlations were also found between the SUM-ME and the formal mood elevation scales, YMRS and the MRS, r = 0.84, r = 0.86, respectively. CONCLUSION: The CMF appears to offer a reasonable alternative to the formal rating scales typically used in research studies.