Predominant polarity in bipolar disorder patients: The COPE bipolar sample.

BACKGROUND: The concept of predominant polarity (PP) is defined as presenting more symptoms of one polarity. Previous studies have defined PP as one polarity (either a depression or mania episode) occurring during at least two-thirds of the lifetime. METHODS: We conducted an observational study with the COPE-BD (Clinical Outcome and Psycho-Education for Bipolar Disorder, Clinical Outcome Measures Section) dataset to identify the diagnostic and treatment differences between bipolar disorder (BD) patients with and without PP. RESULTS: The final sample included 210 BD-I (59.0%) and 146 BD-II (41.0%) patients. Of these, 28.9% patients presented predominant polarity (PP): 62 (17.4%) of those patients were depressed polarity predominant (DPP), 41 (11.5%) were manic polarity predominant (MPP), and 253 (71.1%) met criteria for bipolar disorders but did not present with PP. In comparison to this group of BD patients with undetermined polarity, the group of BD patients with PP presented more rapid cycling. Furthermore, in the undetermined polarity group, the onset of illness occurred earlier, and the duration of the illness was longer, with more hypomanic/manic and depressive episodes than patients who met the PP criteria. LIMITATIONS: This study has a naturalistic and retrospective design and does not allow a specific follow-up of polarity over time. CONCLUSIONS: These different clinical characteristics underline the importance of considering PP in patients with BD, and justify the need for differential treatment approach which could have an impact on patients' prognosis. Yet, more independent and prospective research is needed to confirm these findings, especially with the new classification of DSM-5 concerning mixed states.

Repetitive Transcranial Magnetic Stimulation (5 and 10 Hz) With Modified Parameters in the Treatment of Resistant Unipolar and Bipolar Depression in a Private Practice Setting.

BACKGROUND: A limited number of studies have investigated the safety and efficacy of repetitive transcranial magnetic stimulation (rTMS) in the treatment of resistant depression in an outpatient private practice setting. We hypothesized that rTMS would be safe and effective in the treatment of resistant depression in a nonresearch population. METHODS: We treated 22 outpatients with unipolar or bipolar depression who were experiencing a moderate to severe treatment-resistant major depressive episode (MDE). Treatment was based on a flexible dose schedule of either 5 Hz or 10 Hz rTMS applied over the left dorsolateral prefrontal cortex with modified parameters. Assessments were performed at baseline, then on a weekly basis. The patients had received at least 2 trials of antidepressant medication of an adequate dose and duration without satisfactory improvement in the index MDE. RESULTS: There was a significant change in Montgomery-Asberg Depression Rating Scale scores from baseline (29.14±5.85) to the end of week 4 (16.27±11.20); 50.00% (11/22) were responders and 40.9% (9/22) achieved remission. No major side effects were observed aside from mild headache in some patients. CONCLUSIONS: rTMS applied to the left dorsolateral prefrontal cortex was safe and effective in an important subset of outpatients with a moderate to severe MDE in a naturalistic setting. Outcomes demonstrated response rates similar to research populations. Further larger studies are needed to confirm the safety and effectiveness of rTMS in naturalistic conditions.

Psychosis Risk Syndrome: What Now?

BACKGROUND: Schizophrenia is a chronic psychiatric disorder that generally begins in late adolescence or early adulthood. This early onset is often linked with a devastating lifelong impact on both the social network and work capacities of the affected subjects. Beginning in the mid-1990s, several sets of diagnostic criteria aiming to identify "high-risk" patients were developed and applied in clinical studies. Short-term rates of onset of psychosis in this subgroup of subjects ranged from 20% to 40%. However, 20 years later, the proposal to introduce "psychosis risk syndrome" as a coded diagnostic category in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders remained controversial and was finally rejected. Instead, "attenuated psychosis syndrome" was included in section III of the newly published manual as a condition for further studies. OBJECTIVE: The goal of this article is to review the extant literature concerning the advantages and risks of early assessment of psychotic symptoms ("prodrome" and "psychosis-risk syndrome") and concerning available therapeutic options, both psychosocial and pharmacological. CONCLUSIONS: "Attenuated psychosis syndrome" is a clinically useful concept. It identifies help-seeking individuals with mental health problems who need an intervention and who, if no treatment strategy is proposed, present a higher likelihood of developing a psychosis spectrum disorder in the years following their first contact with a mental health facility. In parallel with the clinical utility of this concept, additional research focused on this group of patients is warranted to further understand the emerging phase of psychotic disorders and to develop effective and efficient evidence-based prevention strategies.

Determinants of dropout in a community-based mental health crisis centre.

BACKGROUND: Dropping out during the course of medical follow up is defined as an early therapy withdrawal without the agreement of the therapist. In a psychiatric crisis unit in Geneva, we empirically observed that almost 50% of the patients were not showing up to their first appointments, which were scheduled for 3 to 7 days post discharge. METHODS: The aim of this naturalistic descriptive cohort study is to identify the demographic, patient and care-related predictive factors of dropout in a community-based psychiatric crisis centre. We included 245 consecutive outpatients followed-up for 4 to 6 weeks of intensive outpatient psychiatric treatment. Logistic regression models were built to examine the association between dropout and demographic, care and patient-related variables. RESULTS: Among the 245 outpatients, dropout occurred in 37.5% of cases, and it most frequently occurred (81.8%) in the first 2 days of follow-up. Among care-related variables, referral by hospital units or private psychiatrists led to significantly lower levels of dropout compared to patients referred by the psychiatric emergency unit (respectively: OR = .32; p = .04; 95% CI [.10, .93]; OR = .36; p = .04; 95% CI [.13, .96]; OR = .22; p = .002; 95% CI [.08, .58]). Among patient-related variables, younger age increased the risk of dropout (OR = .96; 95%; p = .002; 95% CI [.94, .99]). Anxiety and personality but not mood disorders were also related to higher rates of dropout (respectively: OR = 2.40; p = .02; 95% CI [1.14, 4.99]; and OR = 1.98; p = .02; 95% CI [1.09, 3.59]). Unipolar depression (72.2%; OR = 1.47; p = .48; 95% CI [.34, 1.21]) was the most frequent primary diagnosis in this sample. CONCLUSIONS: This study makes clear the need for increased efforts to improve care adherence in young patients with anxious or personality disorders seen in emergency rooms because they are prone to early discontinuation of treatments. Future studies in this field are warranted to gain a better understanding into the complex reasons that surround discontinuation of care in outpatient settings.