Differentiating borderline personality disorder (BPD) from bipolar disorder: diagnostic efficiency of DSM BPD criteria.

OBJECTIVE: We sought to determine the differential diagnostic efficiency of all DSM-IV borderline personality disorder (BPD) criteria by studying a sample of those with BPD and a contrast group with a bipolar disorder (BP). METHOD: Participants were clinically assessed and assigned diagnoses based on DSM criteria - with prevalence rates and diagnostic efficiency values calculated. RESULTS: Fifty-three participants were assigned a BPD diagnosis, 83 a BP diagnosis, with comorbid participants excluded. The mean number of DSM BPD criteria assigned was 6.6 (SD = 1.0) in the BPD group and 1.9 (SD = 1.3) in the BP group. The most prevalent criterion in the BPD group was 'affective instability' (AI) (92.5%), with 'inappropriate anger' least endorsed (49%). The highest specificity criterion was 'abandonment fears', which displayed the greatest positive predictive value (PPV) = 0.9, and with AI offering the lowest specificity. 'Unstable relationships' had the highest overall negative predictive value (NPV) = 0.91. The highest percentage accuracy of classification was provided by 'identity disturbance' and 'abandonment fears' criteria, both 85%. CONCLUSION: The transdiagnostic nature of 'affective instability' means it is less useful for diagnostic decisions, whereas 'abandonment fears' and 'identity disturbance' offer superior diagnostic efficiency in distinguishing BPD from BP.

Comparison of guidelines for the treatment of unipolar depression: a focus on pharmacotherapy and neurostimulation.

OBJECTIVE: To determine the level of agreement across a set of evidence-based guidelines for management of the unipolar depressive disorders and with a focus on physical treatments. METHOD: A literature search was undertaken using the terms 'depression', 'depressive' and 'guidelines', using PubMed, Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse. Twelve national psychiatric or professional guideline-producing organizations were identified from the period 2007-2017, with guidelines qualitatively reviewed by two assessors. RESULTS: For major depressive disorder (MDD), there was general consensus to use an antidepressant (AD) in cases of greater severity, although disagreement on AD use in mild to moderate depression. There was some agreement on choice of AD class in first-line treatment recommendations, though great variability in second- and third-line management particularly in recommended augmentation and combined AD strategies. Electroconvulsive therapy was considered in all but one guideline, with other neurostimulation treatments being less consistently covered and with variable recommendations. Finally, there was low consistency in the management of dysthymia, persistent depressive disorder and treatment resistant depression. CONCLUSION: Our review identifies varying levels of consistency in guideline recommendations. Strategies to improve reliability in guideline formulation should also improve their validity.

Is there consensus across international evidence-based guidelines for the management of bipolar disorder?

OBJECTIVE: To examine the level of agreement across professionally auspiced evidence-based guidelines for managing the bipolar disorders. METHODS: A literature search in PubMed, the National Guideline Clearinghouse, the Cochrane Database of Systematic Reviews and PsycInfo was undertaken using the search terms 'bipolar disorder' and 'guidelines', generating 11 evidence-based guidelines published by professional organisations over the 2002-2015 period. Each guideline was reviewed by two independent reviewers and key themes extracted via qualitative analyses. RESULTS: There was agreement on issues such as the first-line treatment of mania where mood-stabilising and/or an antipsychotic medication together with tapering or ceasing antidepressant medications was most commonly recommended. Differences included the extent to which (i) the different bipolar disorders were defined or not, (ii) there were separate recommendations for bipolar I and bipolar II disorders vs. non-differentiating general bipolar management strategies, (iii) 'general' vs. severity-based recommendations were made, and (iv) narrow vs. broad sets of candidate medications were nominated, while there was variable consideration of treatments such as electroconvulsive therapy (ECT). CONCLUSIONS: While there was some consistency across guidelines on key recommendations, there was also substantial inconsistencies, limiting the generation of any 'meta-consensus' model for managing the bipolar disorders.

Comparing non-safety with safety device sharps injury incidence data from two different occupational surveillance systems.

The United States Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard as amended by the Needlestick Safety and Prevention Act requiring the use of safety-engineered medical devices to prevent needlesticks and sharps injuries has been in place since 2001. Injury changes over time include differences between those from non-safety compared with safety-engineered medical devices. This research compares two US occupational incident surveillance systems to determine whether these data can be generalized to other facilities and other countries either with legislation in place or considering developing national policies for the prevention of sharps injuries among healthcare personnel.

Clinical vs. DSM diagnosis of bipolar disorder, borderline personality disorder and their co-occurrence.

OBJECTIVE: To investigate the extent and reasons contributing to discrepancies between those receiving a DSM as against a clinical diagnosis of a bipolar disorder (BP) and/or a borderline personality disorder (BPD). METHOD: We interviewed participants previously receiving a BP or BPD diagnosis, studying those who met DSM or clinical criteria for one or both conditions. We compared the numbers of participants allocated to the three diagnostic categories according to rater strategy to calculate concordance rates and determine reasons for discordance. RESULTS: Rates of assignment to BP, BPD and comorbid BP/BPD varied according to the diagnostic strategy. Concordance rates were reduced as BP disorder duration criteria were relaxed, with discordance mainly arising from clinical allocation of a BP disorder for those DSM assigned as unipolar depression. Rates of BPD allocation varied marginally, with discordance mostly arising from so clinically diagnosed receiving a comorbid BP/BPD DSM diagnosis. Finally, DSM overestimated comorbidity compared with clinician diagnoses. Of central importance, not imposing the DSM duration criteria for BP did not increase the prevalence of misdiagnosing BPD, a finding at variance with the literature. CONCLUSION: Rates and reasons for discordance between clinical and DSM diagnosis are detailed, which should assist clinical decision-making.

Are the bipolar disorders best modelled categorically or dimensionally?

OBJECTIVE: Considerable debate exists as to whether the bipolar disorders are best classified according to a categorical or dimensional model. This study explored whether there is evidence for a single or multiple subpopulations and the degree to which differing diagnostic criteria correspond to bipolar subpopulations. METHOD: A mixture analysis was performed on 1081 clinically diagnosed (and a reduced sample of 497 DSM-IV diagnosed) bipolar I and II disorder patients, using scores on hypomanic severity (as measured by the Mood Swings Questionnaire). Mixture analyses were conducted using two differing diagnostic criteria and two DSM markers to ascertain the most differentiating and their associated clinical features. RESULTS: The two subpopulation solution was most supported although the entropy statistic indicated limited separation and there was no distinctive point of rarity. Quantification by the odds ratio statistic indicated that the clinical diagnosis (respecting DSM-IV criteria, but ignoring 'high' duration) was somewhat superior to DSM-IV diagnosis in allocating patients to the putative mixture analysis groups. The most differentiating correlate was the presence or absence of psychotic features. CONCLUSION: Findings favour the categorical distinction of bipolar I and II disorders and argue for the centrality of the presence or absence of psychotic features to subgroup differentiation.

Distinct neurobiological signatures of brain connectivity in depression subtypes during natural viewing of emotionally salient films.

BACKGROUND: Establishing an evidence-based diagnostic system informed by the biological (dys)function of the nervous system is a major priority in psychiatry. This objective, however, is often challenged by difficulties in identifying homogeneous clinical populations. Melancholia, a biological and endogenous subtype for major depressive disorder, presents a canonical test case in the search of biological nosology. METHOD: We employed a unique combination of naturalistic functional magnetic resonance imaging (fMRI) paradigms - resting state and free viewing of emotionally salient films - to search for neurobiological signatures of depression subtypes. fMRI data were acquired from 57 participants; 17 patients with melancholia, 17 patients with (non-melancholic) major depression and 23 matched healthy controls. RESULTS: Patients with melancholia showed a prominent loss of functional connectivity in hub regions [including ventral medial prefrontal cortex, anterior cingulate cortex (ACC) and superior temporal gyrus] during natural viewing, and in the posterior cingulate cortex while at rest. Of note, the default mode network showed diminished reactivity to external stimuli in melancholia, which correlated with the severity of anhedonia. Intriguingly, the subgenual ACC, a potential target for treating depression with deep brain stimulation (DBS), showed divergent changes between the two depression subtypes, with increased connectivity in the non-melancholic and decreased connectivity in the melancholic subsets. CONCLUSION: These findings reveal neurobiological changes specific to depression subtypes during ecologically valid behavioural conditions, underscoring the critical need to respect differing neurobiological processes underpinning depressive subtypes.

Differentiating the bipolar disorders from borderline personality disorder.

OBJECTIVE: To identify features differentiating bipolar disorder (BP) from borderline personality disorder (BPD) and with each condition variably defined. METHOD: Participants were assigned a BP or BPD diagnosis on the basis of DSM criteria and, separately, by clinical judgment, and undertook a diagnostic interview and completed self-report measures. RESULTS: Predictors of BPD status varied according to diagnostic decisions, but with the most consistent items being childhood sexual abuse, childhood depersonalization, personality variables relating to relationship difficulties and sensitivity to criticism, and the absence of any BP family history. Across diagnostic groups, personality measure items alone predicted diagnostic allocation with an accuracy of 81-84%, the refined study variables other than hypo/manic features improved the classification rates to 88%, and when the presence or absence of hypo/manic features was added, classification rates increased to 92-95%. CONCLUSION: Study findings indicate that BPD can be differentiated from BP with a high degree of accuracy.

Marine omega-3 fatty acids and mood disorders--linking the sea and the soul. 'Food for Thought' I.

OBJECTIVE: While there has long been interest in any nutritional contribution to the onset and treatment of mood disorders, there has been increasing scientific evaluation of several candidate nutritional and dietary factors in recent years. In this inaugural study of our 'Food for Thought' series, we will overview the evidence for any role of omega-3 fatty acids (FA) in regulating mood. METHOD: Relevant literature was identified through online database searches and cross-referencing. RESULTS: Plausible mechanisms exist by which omega-3 FA may influence neuronal function and mood. Cross-sectional studies demonstrate an association between omega-3 fatty acid deficiency and both depressive and bipolar disorders. Studies investigating the efficacy of omega-3 fatty acid supplementation for mood disorders have however provided inconsistent results. The proportion of treatment studies showing a significant advantage of omega-3 supplementation has dropped over the last 5 years. However, the vast heterogeneity of the trials in terms of constituent omega-3 FAs, dose and length of treatment makes comparisons of these studies difficult. CONCLUSION: More research is required before omega-3 supplementation can be firmly recommended as an effective treatment for mood disorders. Whereas increased omega-3 FA intake may alleviate depressive symptoms, there is little evidence of any benefit for mania.

Survival following an acute coronary syndrome: a pet theory put to the test.

OBJECTIVE: The aim of this study was to revisit findings from previous studies reporting that pet ownership improves outcome following an admission for acute coronary syndrome (ACS). METHOD: Four hundred and twenty-four patients admitted to a cardiac unit with an ACS completed questions regarding pet ownership in hospital. Rates of cardiac death and readmission were assessed 1 year following hospitalization. RESULTS: Pet owners were more likely to experience a death or readmission following their hospitalization, after controlling for key psychosocial and medical covariates. When dog and cat owners were considered separately, cat ownership was significantly associated with increased risk of death or readmission. CONCLUSION: In this independent study, pet ownership at baseline, and cat ownership in particular, was associated with increased cardiac morbidity and mortality in the year following an admission for an acute coronary syndrome, a finding contrary to previous reports.

Is bipolar II depression phenotypically distinctive?

OBJECTIVE: We examine the depressive symptom profile of bipolar II disorder patients compared with a comparator (composite) group of those with unipolar depression, with stratification by melancholic and non-melancholic subtypes. METHOD: Out-patients (n = 394) attending a specialist depression clinic comprised the sample. Data on severity and prototypic status of depressive symptoms were analysed. RESULTS: Age-matched analyses revealed minimal differentiation between bipolar II and composite unipolar groups. Stratified analyses suggested that 'bipolar II depression' more closely approximated melancholic depression in terms of psychomotor and cognitive slowing. Severity-based analyses and prototypic symptom patterns yielded differing results, suggesting that definition of bipolar II depression is influenced by rating strategies, and age. CONCLUSION: We found limited differentiation of bipolar II depression from unipolar, melancholic and non-melancholic depression. Differences suggested previously may reflect age, gender and severity differences, highlighting the need for appropriately matched groups in defining bipolar II depression.

Quantified superiority of cognitive behaviour therapy to antidepressant drugs: a challenge to an earlier meta-analysis.

OBJECTIVE: The study aimed to review the conclusion of a previously published meta-analysis which quantified distinct superiority of cognitive therapy to antidepressant drug-therapy (P < 0.0001). METHOD: We sought to include all studies used in the original meta-analysis. Adopting both that study's inclusion criteria and additional criteria resulted in a reduced set of studies. We analysed both 'completer' and 'intention to treat' data, using effect size and odds ratio quantification. RESULTS: There was an overall trend for cognitive therapy to be superior to antidepressant drug-therapy, but this was significant for only one of the four meta-analyses (an intention to treat analysis). We demonstrated considerable heterogeneity between studies, and a significantly higher drop-out rate in the antidepressant groups. CONCLUSION: The previous interpretation--cognitive therapy being distinctly superior to antidepressant medication--cannot be sustained from the currently analysed data set.

Treatment-resistant depression: resistant to definition?

OBJECTIVE: To better define treatment-resistant depression (TRD) so as to assist clinical management and refine treatment guidelines. METHOD: In this study, we examine a broad range of clinical variables in depressed patients (n=196) referred to a tertiary referral Mood Disorders Unit (MDU). Information was collected from patients, referrers and assessors over a period of 32 months and included evaluations of treatments, treatment resistance and related variables. Data were analysed across trichotomized 'high', 'low' and 'no' treatment resistance groupings of patients. RESULTS: A significantly greater proportion of patients with melancholia were amongst the high TRD group, and this was consistent across different strategies for evaluating melancholia. CONCLUSION: Melancholia perhaps provides a prototypic TRD subset that perhaps reflects some innate aspects of melancholic depression or factors such as the impact of ageing. Research into TRD is needed to both replicate this finding and perhaps explicate it further.

Identifying "paradigm failures" contributing to treatment-resistant depression.

BACKGROUND: "Treatment resistant depression" is likely to emerge from a number of factors, including application of the wrong diagnostic and treatment models. METHOD: Current paradigms for managing both depression and treatment resistant depression are considered. We then examine the prevalence of a set of paradigm failures that appeared to contribute to treatment resistant depression in outpatients of a tertiary referral Mood Disorders Unit. RESULTS: Six illustrative paradigm failures are described and their frequencies within the clinical sample reported. Identified paradigm failures were diagnosing and/or managing a non-melancholic condition as if it were melancholic depression, failure to diagnose and manage bipolar disorder, psychotic depression or melancholic depression, misdiagnosing secondary depression and failure to identify organic determinants. CONCLUSION: We suggest that the identification of such "paradigm failures"--and of others that can be assumed to operate--has the potential to enrich the assessment and management of depressed patients, and reduce the prevalence of treatment resistance.

Structural and functional models of depression: from sub-types to substrates.

OBJECTIVE: To present a functional model of depression facilitating research and clinical understanding. METHOD: The authors conducted a systematic literature search and reviewed articles pertaining to the neurochemistry and pathophysiology of depressive disorders, focusing on the contribution made by the principal monoamines to three differing depressive structural sub-types (i.e. psychotic, melancholic and non-melancholic). RESULTS: We suggest that the three structural depressive subtypes appear functionally underpinned by differential contributions of serotonergic, noradrenergic and dopaminergic neurotransmitters, so influencing phenotypic distinction (our structural model) and allowing an aetiological model to be derived with treatment specificity implications. CONCLUSION: The functional model logically iterates with the structural model of depression and provides a useful framework for conceptualizing the depressive disorders. This model provides a logic for distinguishing between principal depressive subtypes, pursuing their functional underpinnings and explaining treatment differential effects across the three sub-types.

Attitudes toward psychiatry among students entering medical school.

OBJECTIVE: To survey the attitudes of Australian medical students to determine their views about the relative attractiveness of psychiatry as a career compared with other specialties, and against findings from a North American study. METHOD: We surveyed 655 first-year medical students attending six Australian Universities. RESULTS: Responses indicated that Australian medical students view psychiatry as distinctly less 'attractive' than other career options, as reported in the North American sample. In comparison with other disciplines, psychiatry was regarded as more interesting and intellectually challenging, but also as lacking a scientific foundation, not being enjoyable and failing to draw on training experiences. CONCLUSION: Our findings suggest that psychiatry has an image problem that is widespread, reflecting community perceptions and the specialist interests of medical students on recruitment. If psychiatry is to improve its 'attractiveness' as a career option, identified image problems need to be corrected and medical student selection processes re-considered.

Rediscovering chronic mania.

OBJECTIVE: This paper presents a case of chronic mania and reviews the diagnosis with respect to its definition and utility. METHOD: A case of chronic mania is described. RESULTS: Unremitting mania poses a diagnostic and management challenge. CONCLUSION: Persistent mania of this duration is rare, but a diagnosis of chronic mania should not be rejected on the basis of chronicity.