The long-term impact of treatment with electroconvulsive therapy on discrete memory systems in patients with bipolar disorder.

OBJECTIVE: Electroconvulsive therapy (ECT) has been controversially associated with long-lasting memory problems. Verbal learning and memory deficits are commonly reported in studies of people with bipolar disorder (BD). Whether memory deficits can be exacerbated in patients with BD who receive ECT has, to our knowledge, not been systematically examined. We aimed to examine whether long-term effects of ECT on discrete memory systems could be detected in patients with BD. METHODS: We studied several domains of memory in 3 groups of subjects who were matched for age and sex: a group of healthy comparison subjects, a group of people with BD who had received ECT at least 6 months before memory assessment and another group with BD that had an equal past illness burden but had never received ECT. Memory was assessed with the California Verbal Learning Test, the Continuous Visual Memory Test and a computerized process dissociation task that examines recollection and habit memory in a single paradigm. RESULTS: Compared with healthy subjects, patients had verbal learning and memory deficits. Subjects who had received remote ECT had further impairment on a variety of learning and memory tests when compared with patients with no past ECT. This degree of impairment could not be accounted for by illness state at the time of assessment or by differential past illness burden between patient groups. CONCLUSIONS: From a clinical perspective, it is unlikely that such findings, even if confirmed, would significantly change the risk-benefit ratio of this notably effective treatment. Nonetheless, they may highlight the importance of attending to cognitive factors in patients with BD who are about to receive ECT; further, they raise the question of whether certain strategies that minimize cognitive dysfunction with ECT should be routinely employed in this patient group.

Impact of comorbid anxiety disorders on outcome in a cohort of patients with bipolar disorder.

BACKGROUND: High rates of comorbid anxiety disorders have been described in individuals with bipolar disorder. Although it is well recognized that anxiety disorders often co-occur with bipolar disorder, few studies have examined the impact of more than 1 anxiety disorder on long-term outcome in patients with bipolar disorder. METHOD: The rates of DSM-IV generalized anxiety disorder, panic disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder were determined using structured clinical interviews in 138 patients with bipolar disorder who presented consecutively between 1994 and 1999. Patients were then followed for up to 3 years with longitudinal clinical surveillance. The impact of 1 or more comorbid anxiety disorders on mood symptoms and general function was evaluated. RESULTS: In our sample, 55.8% of the patients had at least 1 comorbid anxiety disorder, and 31.8% had 2 or more anxiety disorder diagnoses. The most common anxiety disorder was generalized anxiety disorder, followed by panic disorder. The presence of an anxiety disorder led to significantly (p <.05) worse outcome on global as well as specific illness measures, including illness severity, proportion of patients characterized as euthymic, and proportion of the year spent ill. Number of anxiety disorders was less important than type, with generalized anxiety disorder and social phobia having the most negative impact on outcome. CONCLUSION: Our data suggested that multiple anxiety disorder comorbidities were not infrequent in bipolar disorder and that generalized anxiety disorder and social phobia were more likely to be associated with poor outcome. We discuss some potential mechanisms and implications in our findings.

Subsyndromal symptoms assessed in longitudinal, prospective follow-up of a cohort of patients with bipolar disorder.

BACKGROUND: Many patients with bipolar disorder (BD) do not regain full function following an acute illness episode, but the extent to which this impairment is the result of persistent symptoms has not been well established. This study examined factors associated with persistent subsyndromal symptoms in a well characterized group of BD patients who were prospectively followed for an average of 3 years. METHODS: Detailed life charting data from 138 patients with BD were reviewed. Patients were categorized into euthymic, subsyndromal or syndromal groups according to the clinical state during their most recent year of follow-up. The three groups were then examined with respect to comorbidity, function and treatment received. RESULTS: Patients with subsyndromal symptoms had high rates of comorbid anxiety disorders, and were more likely to have increased rates of eating disorders as well. Patients with subsyndromal symptoms had lower global assessment of function (GAF) scores than euthymic patients, and had as many clinic contacts and medication trials as patients with full episodes of illness. CONCLUSIONS: Persistent subsyndromal symptoms in BD patients are associated with high rates of comorbidity that is important to recognize and treat in order to optimize mood and functioning.

Longitudinal outcome in patients with bipolar disorder assessed by life-charting is influenced by DSM-IV personality disorder symptoms.

OBJECTIVES: Few studies have examined the question of how personality features impact outcome in bipolar disorder (BD), though results from extant work and studies in major depressive disorder suggest that personality features are important in predicting outcome. The primary purpose of this paper was to examine the impact of DSM-IV personality disorder symptoms on long-term clinical outcome in BD. METHODS: The study used a 'life-charting' approach in which 87 BD patients were followed regularly and treated according to published guidelines. Outcome was determined by examining symptoms over the most recent year of follow-up and personality symptoms were assessed with the Structured Clinical Interview for DSM-IV (SCID-II) instrument at entry into the life-charting study. RESULTS: Patients with better outcomes had fewer personality disorder symptoms in seven out of 10 disorder categories and Cluster A personality disorder symptoms best distinguished euthymic and symptomatic patients. CONCLUSIONS: These results raise important questions about the mechanisms linking personality pathology and outcome in BD, and argue that conceptual models concerning personality pathology and BD need to be further developed. Treatment implications of our results, such as need for psychosocial interventions and treatment algorithms, are also described.

Previous mood state predicts response and switch rates in patients with bipolar depression.

OBJECTIVE: The treatment of bipolar depression is a significant clinical problem that remains understudied. The role for antidepressant (AD) agents vs. mood stabilizers has been particularly problematic to ascertain. METHOD: Detailed life charting data from 42 patients with 67 depressive episodes were reviewed. Response rates and rates of switch into mania were compared based on the preceding mood state and on whether an AD or mood stabilizing (MS) agent was added following onset of depression. RESULTS: Patients who became depressed following a period of euthymia were more likely to respond to treatment (62.5%) than patients who became depressed following a period of mania or hypomania (27.9%). The ratio of response to switch for previously euthymic patients was particularly favorable. CONCLUSION: Mood state prior to onset of depression in bipolar disorder appears to be an important clinical variable that may guide both choice of treatment administered and expectation of outcome to treatment.