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Franco Benazzi - One of the best experts on this subject based on the ideXlab platform.

  • the modified scid Hypomania module scid hba a detailed systematic phenomenologic probing
    Journal of Affective Disorders, 2009
    Co-Authors: Franco Benazzi, Hagop S Akiskal
    Abstract:

    Abstract Diagnosing past Hypomania is a difficult task. Current structured interviews (e.g. CIDI, SCID) limit the ability to probe for Hypomania. A modified SCID Hypomania Module was published by us (Benazzi and Akiskal, J Affect Disord 2003; Akiskal and Benazzi, J Clin Psychiatry 2005) in order to overcome the limitations of structured interviewing. Our papers outlined the framework of the modified SCID. In response to requests from many readers of this journal and other clinicians and investigators, we are hereby providing a more explicit step-by-step phenomenologic probing interview. DSM-IV criteria have to be met, but the probing for Hypomania is very different from that of the SCID. All past hypomanic symptoms are assessed. No negative meaning is given to symptoms, as Hypomania often improves functioning and it is seen by patients as a state of well being. The first step is probing for overactivity (increase in goal-directed activity), because observable behaviors are easier to remember by patients and key informants. There is no gold-standard for overactivity: each person becomes his/her own standard to ‘measure’ a clear-cut departure form the usual behavior. Questions, correspondingly, can change from patient to patient. The emotions associated with behavioral change are easier to be remembered than asking them first, as in the structured interviews. Structured interviews have mood change (elation, irritability) as stem question (corresponding to the criterion A of DSM-IV, which postulates that it must always be present). However, apart from a likely recall bias of past emotions, the description of mood change appears more or less negative in structured interviews (to increase specificity but by much reducing sensitivity, i.e. the false-negatives). Presenting mood change as simply having been more elated/irritable than usual can easily be interpreted as normal mood fluctuations, while presenting mood change as much more than usual could be understood as a severe mental disorder. Both ways are likely to lead to a negative response, moving the interviewers to unipolar disorders (the skip-out instruction). Our modified SCID is a fully semi-structured interview: many questions are asked about each symptom to make the question understandable according to each patient, and, very importantly, examples of the ‘events’ are systematically asked to check understanding and clinical relevance. Our interview follows DSM-IV criteria (apart from the minimum duration, 2 days versus DSM-IV 4 days), i.e. mood change must always been present, but our probing detects more hypomanic episodes than the SCID.

  • how best to identify a bipolar related subtype among major depressive patients without spontaneous Hypomania superiority of age at onset criterion over recurrence and polarity
    Journal of Affective Disorders, 2008
    Co-Authors: Franco Benazzi, Hagop S Akiskal
    Abstract:

    Abstract Background History of high depressive recurrence (without history of mania/Hypomania) has been proposed as a mood subtype close to bipolar disorders. Herein we test whether this is the best approach to this question. Methods We systematically evaluated consecutive 224 Major Depressive (MDD) and 336 Bipolar II Disorders (BP-II) outpatients in a private practice, by the SCID for DSM-IV (modified for better probing Hypomania by Akiskal and Benazzi [Akiskal, H.S., Benazzi, F., 2005. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J. Clin. Psychiatry 66, 914–921]). We conducted univariate and multivariate analyses on such putative bipolar validators as early age at onset of first major depressive episode (before 21 years), high recurrence, family history for bipolar disorders, and depressive mixed states (mixed depression, i.e. depression plus concurrent hypomanic symptoms), in order to identify an MDD subgroup close to BP-II. Results All bipolar validators were independent predictors of BP-II. Early onset was the only variable which identified an MDD subgroup significantly associated with all bipolar validators. This MDD subgroup was similar to BP-II on age at onset and bipolar family history, and had a high frequency of mixed depression. A dose–response relationship was found between number of bipolar validators present in MDD, and bipolar family history loading among MDD relatives. Limitations Study limited to outpatients. Conclusions From among the bipolar validators, early age at onset of first major depression (  4 depressive episodes) in identifying an MDD subgroup close to BP-II, which might be subsumed under the broad bipolar spectrum. Implications of unipolar–bipolar boundaries and genetic investigations are discussed.

  • bipolar disorder focus on bipolar ii disorder and mixed depression
    The Lancet, 2007
    Co-Authors: Franco Benazzi
    Abstract:

    Bipolar II disorder (recurrent depressive and hypomanic episodes) and related disorders (united in the bipolar spectrum) are understudied, despite a prevalence of about 5% in the community and about 50% in depressed outpatients. The apparent increase in prevalence of the bipolar spectrum is related to several changes in diagnostic criteria, including improved probing for history of Hypomania (focused more on overactivity than on mood change), lower minimum duration of Hypomania, and inclusion of unipolar depressions with bipolar signs (eg, family history of bipolar disorder, mixed depression). Prevalence of mixed depression, a combination of depression and manic or hypomanic symptoms, is high in patients with bipolar disorders. Controlled studies are needed to investigate treatment of mixed depression; antidepressants can worsen manic and hypomanic symptoms, and mood stabilising agents might be necessary.

  • bipolar ii disorder epidemiology diagnosis and management
    CNS Drugs, 2007
    Co-Authors: Franco Benazzi
    Abstract:

    Bipolar II disorder (BP-II) is defined, by DSM-IV, as recurrent episodes of depression and Hypomania. Hypomania, according to DSM-IV, requires elevated (euphoric) and/or irritable mood, plus at least three of the following symptoms (four if mood is only irritable): grandiosity, decreased need for sleep, increased talking, racing thoughts, distractibility, overactivity (an increase in goal-directed activity), psychomotor agitation and excessive involvement in risky activities. This observable change in functioning should not be severe enough to cause marked impairment of social or occupational functioning, or to require hospitalisation. The distinction between BP-II and bipolar I disorder (BP-I) is not clearcut. The symptoms of mania (defining BP-I) and Hypomania (defining BP-II) are the same, apart from the presence of psychosis in mania, and the distinction is based on the presence of marked impairment associated with mania, i.e. mania is more severe and may require hospitalisation. This is an unclear boundary that can lead to misclassification; however, the fact that Hypomania often increases functioning makes the distinction between mania and Hypomania clearer. BP-II depression can be syndromal and subsyndromal, and it is the prominent feature of BP-II. It is often a mixed depression, i.e. it has concurrent, usually subsyndromal, hypomanic symptoms. It is the depression that usually leads the patient to seek treatment.DSM-IV bipolar disorders (BP-I, BP-II, cyclothymic disorder and bipolar disorder not otherwise classified, which includes very rapid cycling and recurrent Hypomania) are now considered to be part of the 'bipolar spectrum'. This is not included in DSM-IV, but is thought to also include antidepressant/substance-associated Hypomania, cyclothymic temperament (a trait of highly unstable mood, thinking and behaviour), unipolar mixed depression and highly recurrent unipolar depression.BP-II is underdiagnosed in clinical practice, and its pharmacological treatment is understudied. Underdiagnosis is demonstrated by recent epidemiological studies. While, in DSM-IV, BP-II is reported to have a lifetime community prevalence of 0.5%, epidemiological studies have instead found that it has a lifetime community prevalence (including the bipolar spectrum) of around 5%. In depressed outpatients, one in two may have BP-II. The recent increased diagnosing of BP-II in research settings is related to several factors, including the introduction of the use of semi-structured interviews by trained research clinicians, a relaxation of diagnostic criteria such that the minimum duration of Hypomania is now less than the 4 days stipulated by DSM-IV, and a probing for a history of Hypomania focused more on overactivity (increased goal-directed activity) than on mood change (although this is still required for a diagnosis of Hypomania). Guidelines on the treatment of BP-II are mainly consensus based and tend to follow those for the treatment of BP-I, because there have been few controlled studies of the treatment of BP-II. The current, limited evidence supports the following lines of treatment for BP-II. Hypomania is likely to respond to the same agents useful for mania, i.e. mood-stabilising agents such as lithium and valproate, and the second-generation antipsychotics (i.e. olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole). Hypomania should be treated even if associated with overfunctioning, because a depression often soon follows Hypomania (the Hypomania-depression cycle). For the treatment of acute BP-II depression, two controlled studies of quetiapine have not found clearcut positive effects. Naturalistic studies, although open to several biases, have found antidepressants in acute BP-II depression to be as effective as in unipolar depression; however, one recent large controlled study (mainly in patients with BP-I) has found antidepressants to be no more effective than placebo. Results from naturalistic studies and clinical observations on mixed depression, while in need of replication in controlled studies, indicate that antidepressants may worsen the concurrent intradepression hypomanic symptoms. The only preventive treatment for both depression and Hypomania that is supported by several, albeit older, controlled studies is lithium. Lamotrigine has shown some efficacy in delaying depression recurrences, but there have also been several negative unpublished studies of the drug in this indication.

  • is overactivity the core feature of Hypomania in bipolar ii disorder
    Psychopathology, 2007
    Co-Authors: Franco Benazzi
    Abstract:

    Background: Recent studies found that overactivity (increased goal-directed activities) may be as important as mood change (elevated and/or irritable mood) for the diagnosis of mania/Hypomania (on family history and psychometric grounds), questioning DSM-IV-TR criteria always requiring mood change and listing overactivity among the other symptoms. The aim of the study was to find out if overactivity was at least as important as mood change for the diagnosis of Hypomania. Sampling and Methods: A consecutive sample of 137 bipolar II disorder (BP-II) and 76 major depressive disorder remitted outpatients were interviewed with the Structured Clinical Interview for DSM-IV by a senior clinical and research psychiatrist in a private practice. Patients were asked if they had had hypomanic symptoms and episodes, and which were the most common hypomanic symptoms during the various episodes. The study aim had not been planned when variables were collected for different study goals. Results: Overactivity was the most common hypomanic symptom in BP-II, more common than elevated mood, and had the strongest association with BP-II among all the hypomanic symptoms (overactivity odds ratio = 15.4, elevated mood odds ratio = 12.6). Three factors were found: an ‘elevated mood’ factor including elevated mood and increased self-esteem; a ‘mental activation’ factor including racing/crowded thoughts, and a ‘behavioral activation’ factor including overactivity. There was no relationship between overactivity and mood change. Irritable mood was not associated with overactivity and elevated mood. BP-II was present in 21.6%of patients without a history of overactivity, and in 81.0% of patients with a history of overactivity. BP-II was present in 25.0% of patients without elevated mood, and in 63.3% of patients with elevated mood. As a predictor of BP-II, overactivity had a sensitivity of 90.5%, a specificity of 61.8%, and a positive predictive value of 81.0% (elevated mood: 72.2, 82.8, and 88.3%, respectively). Five or more hypomanic symptoms had the most balanced combination of sensitivity (82.4%) and specificity (85.5%) for BP-II, and a positive predictive value of 91.1%. Overactivity was present in 89.5% of patients with a history of ≧5 hypomanic symptoms, while elevated mood was present in 76.6%. Conclusions: Theresults seem to support the view that overactivity may be a core feature of Hypomania, suggesting the upgrading of overactivity to a stem criterion for Hypomania.

Jules Angst - One of the best experts on this subject based on the ideXlab platform.

  • Bipolar disorders in ICD-11: current status and strengths
    International Journal of Bipolar Disorders, 2020
    Co-Authors: Jules Angst, Vladeta Ajdacic-gross, Wulf Rossler
    Abstract:

    Background The Clinical descriptions and diagnostic guidelines for the ICD-11 Classification of mental and behavioural disorders should soon be finalized. To measure their potential impact, the new proposed definitions of bipolar disorders in ICD-11 were applied to data from the Zurich cohort study and compared with the definitions of ICD-10 and DSM-5. Results We found little difference between ICD-11 and ICD-10 in the identification of subjects with bipolar disorders, but compared to DSM-5 a considerable increase in the diagnosis of hypomanic episodes and therefore of bipolar-II disorders. Conclusions Compared to ICD-10 and DSM-5 the definition of hypomanic episodes according to ICD-11 represents important progress. A higher prevalence of BP-II disorder makes sense from a clinical point of view. Further transcultural research is needed into whether out-patient treatment should be included as a criterion for Hypomania. Pure mania is unfortunately missing as an independent and codable disorder in the international diagnostic manuals, whether ICD-11 or DSM-5.

  • exploration of the psychometric properties of the 33 item Hypomania checklist external assessment hcl 33 ea
    Journal of Affective Disorders, 2019
    Co-Authors: Meng Fang, Yuanyuan Wang, Yuan Feng, Gabor S Ungvari, Gang Wang, Yutao Xiang, Jules Angst
    Abstract:

    Abstract Background Misdiagnosis of bipolar disorder (BD) is common in clinical practice, leading to inappropriate treatment and detrimental consequences. The 33-item Hypomania Checklist (HCL-33) is a newly developed screening instrument for hypomanic symptoms in patients with BD. The 33-item Hypomania Checklist-external assessment (HCL-33-EA) is a version of the HCL-33 for carers of patients with mood disorders. In this study, the psychometric properties of the HCL-33-EA in a Chinese population were explored. Method A total of 182 inpatients and 240 carers were recruited in this study. Patients were diagnosed with bipolar depression or major depressive disorder (MDD) according to the International Classification of Diseases (ICD-10). The patients completed the HCL-33, while their carers filled out the HCL-33-EA. Results The HCL-33-EA showed high internal consistency (Cronbach's alpha = 0.876) with two-factorial dimensions. Paired samples t-test revealed that the mean score of the HCL-33-EA was significantly lower than that of the HCL-33 (t = 10.1, p  Conclusion The HCL-33-EA has acceptable psychometric properties and could be an effective screening tool for patients’ carers, enabling identification of the symptoms of Hypomania.

  • the 33 item Hypomania checklist hcl 33 a study of the consistency between self and external assessments in polish bipolar patients
    Psychiatria Polska, 2016
    Co-Authors: Dorota łojko, Jules Angst, Dominika Dudek, Marcin Siwek, Michal Michalak, Janusz K Rybakowski
    Abstract:

    OBJECTIVES The Hypomania Checklist (HCL) has become an important tool for the assessment of hypomanic symptoms in patients with mood disorders and in the general population. The HCL-33 scale, containing 33 symptom items, is a new instrument which, in addition to the self-administered questionnaire, has a version for external rating. The aim of this study is to evaluate the consistency between the self - and external assessments using the HCL-33 in Polish patients with bipolar disorder. METHODS The data from 81 euthymic bipolar patients recruited in Poznan and Krakow centers were analyzed. All the patients filled out the HCL-33 questionnaire, and, for each patient, the HCL-33 questionnaire-external assessment was completed by his/her significant other. RESULTS Of the 33 symptom items, sufficient agreement (significance of kappa factor < 0.05) was found for 13 out of the 19 questions of the "active/elated" (factor 1) and for all 14 items of the "irritable/risk-taking" (factor 2). Insignificant consistency was found for 6 items of factor 1 and the question regarding the longest period of Hypomania. The inter-rater agreement between patient and significant other was not affected by gender, living together or subtype of relationship with the patient. CONCLUSIONS The results show significant consistency between self - and external assessments for 27 symptom items (82%) of the HCL-33. The future status of the items showing insufficient consistency should be discussed. Limitation of the study is a small number of subjects recruited from only two centers which may not be representative for the Polish population.

  • transcultural validity of the Hypomania checklist 32 hcl 32 in patients with major depressive episodes
    Bipolar Disorders, 2013
    Co-Authors: Alex Gamma, Eduard Vieta, Charles L Bowden, Jules Angst, Jeanmichel Azorin, Giulio Perugi, Allan H Young
    Abstract:

    Gamma A, Angst J, Azorin J-M, Bowden CL, Perugi G, Vieta E, YoungAH. Transcultural validity of the Hypomania Checklist–32 (HCL-32) inpatients with major depressive episodes.Bipolar Disord 2013: 15: 701–712. © 2013 John Wiley & Sons A/S.Published by John Wiley & Sons Ltd.Objectives: There is mounting evidence that current diagnostic systemsinadequately recognize clinically relevant levels of Hypomania indepressed patients, thereby leading to an under-diagnosis of bipolardisorders and the associated risk of treatment that is inappropriate ormay actually worsen illness course. The Hypomania Checklist–32 revisedversion 2 (HCL-32-R2) is a self-rating scale for hypomanic symptomsspecifically developed to address this problem. The goal of this study wasto assess the transcultural validity of the HCL-32-R2.Methods: Measurement invariance of HCL-32-R2 responses from themultinational Bipolar Disorders: Improving Diagnosis, Guidance, andEducation (BRIDGE) Study of 5635 patients with major depressiveepisodes (MDEs) was assessed by exploratory and confirmatory factoranalysis across five cultural regions.Results: Two previously identified factors were reproduced andexplained 60% of the variance in test responses. Only three out of 32items had cross-culturally variable factor loadings. Some moderatemeasurement invariance was also found with regard to age and gender.In discriminating unipolar from bipolar disorder, the HCL-32-R2showed a sensitivity of 82% with a specificity of 57% when currentDMS-IV criteria for bipolar disorder were used, and substantially higherspecificity of 73% when evidence-based modified criteria were applied.Conclusions: The psychometric properties of the HCL-32-R2 werelargely culture-independent. This finding replicates that of our previousinternational study and is a step towards validating the HCL-32-R2 as abroadly applicable screening instrument for hypomanic features,facilitating the detection of hidden bipolarity in depressed patients.

  • validation of the Hypomania checklist hcl 32 in a nonclinical sample of german adolescents
    Journal of Adolescence, 2009
    Co-Authors: Martin Holtmann, Jules Angst, Franca Portner, Eftichia Duketis, Hanshenning Flechtner, Gerd Lehmkuhl
    Abstract:

    We tested the psychometric properties of the Hypomania Checklist (HCL-32) in a sample of nonclinical adolescents, examined the association with current psychopathology, and tested if "hypomanic" adolescents differ from other participants regarding HCL-scores and psychopathology. A total of 294 students completed the HCL-32 and the SDQ, a screening for psychopathology. In adolescence, the internal structure of Hypomania seems to be represented by a triple structure. The first factor "active-elated" is an indicator of symptoms related to energy and activity. The adult factor "irritable-risk taking" is better reflected by two separate factors ("disinhibited/stimulation-seeking" and "irritable-erratic"). These factors were associated with externalizing problems. "Hypomanic" adolescents showed higher HCL total and disinhibited/stimulation-seeking scores and reported more conduct problems than "non-hypomanic" youngsters. The internal structure of the HCL in adolescents mirrors the association of juvenile bipolarity with substance use and symptoms of ADHD and conduct disorder and presents preliminary evidence for its validity.

Hagop S Akiskal - One of the best experts on this subject based on the ideXlab platform.

  • the modified scid Hypomania module scid hba a detailed systematic phenomenologic probing
    Journal of Affective Disorders, 2009
    Co-Authors: Franco Benazzi, Hagop S Akiskal
    Abstract:

    Abstract Diagnosing past Hypomania is a difficult task. Current structured interviews (e.g. CIDI, SCID) limit the ability to probe for Hypomania. A modified SCID Hypomania Module was published by us (Benazzi and Akiskal, J Affect Disord 2003; Akiskal and Benazzi, J Clin Psychiatry 2005) in order to overcome the limitations of structured interviewing. Our papers outlined the framework of the modified SCID. In response to requests from many readers of this journal and other clinicians and investigators, we are hereby providing a more explicit step-by-step phenomenologic probing interview. DSM-IV criteria have to be met, but the probing for Hypomania is very different from that of the SCID. All past hypomanic symptoms are assessed. No negative meaning is given to symptoms, as Hypomania often improves functioning and it is seen by patients as a state of well being. The first step is probing for overactivity (increase in goal-directed activity), because observable behaviors are easier to remember by patients and key informants. There is no gold-standard for overactivity: each person becomes his/her own standard to ‘measure’ a clear-cut departure form the usual behavior. Questions, correspondingly, can change from patient to patient. The emotions associated with behavioral change are easier to be remembered than asking them first, as in the structured interviews. Structured interviews have mood change (elation, irritability) as stem question (corresponding to the criterion A of DSM-IV, which postulates that it must always be present). However, apart from a likely recall bias of past emotions, the description of mood change appears more or less negative in structured interviews (to increase specificity but by much reducing sensitivity, i.e. the false-negatives). Presenting mood change as simply having been more elated/irritable than usual can easily be interpreted as normal mood fluctuations, while presenting mood change as much more than usual could be understood as a severe mental disorder. Both ways are likely to lead to a negative response, moving the interviewers to unipolar disorders (the skip-out instruction). Our modified SCID is a fully semi-structured interview: many questions are asked about each symptom to make the question understandable according to each patient, and, very importantly, examples of the ‘events’ are systematically asked to check understanding and clinical relevance. Our interview follows DSM-IV criteria (apart from the minimum duration, 2 days versus DSM-IV 4 days), i.e. mood change must always been present, but our probing detects more hypomanic episodes than the SCID.

  • how best to identify a bipolar related subtype among major depressive patients without spontaneous Hypomania superiority of age at onset criterion over recurrence and polarity
    Journal of Affective Disorders, 2008
    Co-Authors: Franco Benazzi, Hagop S Akiskal
    Abstract:

    Abstract Background History of high depressive recurrence (without history of mania/Hypomania) has been proposed as a mood subtype close to bipolar disorders. Herein we test whether this is the best approach to this question. Methods We systematically evaluated consecutive 224 Major Depressive (MDD) and 336 Bipolar II Disorders (BP-II) outpatients in a private practice, by the SCID for DSM-IV (modified for better probing Hypomania by Akiskal and Benazzi [Akiskal, H.S., Benazzi, F., 2005. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J. Clin. Psychiatry 66, 914–921]). We conducted univariate and multivariate analyses on such putative bipolar validators as early age at onset of first major depressive episode (before 21 years), high recurrence, family history for bipolar disorders, and depressive mixed states (mixed depression, i.e. depression plus concurrent hypomanic symptoms), in order to identify an MDD subgroup close to BP-II. Results All bipolar validators were independent predictors of BP-II. Early onset was the only variable which identified an MDD subgroup significantly associated with all bipolar validators. This MDD subgroup was similar to BP-II on age at onset and bipolar family history, and had a high frequency of mixed depression. A dose–response relationship was found between number of bipolar validators present in MDD, and bipolar family history loading among MDD relatives. Limitations Study limited to outpatients. Conclusions From among the bipolar validators, early age at onset of first major depression (  4 depressive episodes) in identifying an MDD subgroup close to BP-II, which might be subsumed under the broad bipolar spectrum. Implications of unipolar–bipolar boundaries and genetic investigations are discussed.

  • the emergence of the bipolar spectrum validation along clinical epidemiologic and familial genetic lines
    Psychopharmacology Bulletin, 2007
    Co-Authors: Hagop S Akiskal
    Abstract:

    A new paradigm of the bipolar spectrum is shaping up in the research literature and in clinical practice. It represents a partial return to the Kraepelinian broad concept of manic depression which included many recurrent depressions. Although bipolar I and bipolar II are now part of the official nomenclature of Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), the breadth of bipolarity is not represented in this manual. Old and new evidence indicate that the most common form of bipolar II is characterized by Hypomanias of shorter duration than the arbitrary threshold of four days, and that cyclothymic depressions represent a prevalent variant of the bipolar II pattern. Furthermore, evidence is now compelling that Hypomania in association with antidepressant treatments requires familial bipolar diathesis for bipolar disorder (bipolar III). There also exist clinical depressions superimposed on hyperthymic temperament (bipolar IV), referring to individuals with subthreshold hypomanic traits rather than episodes. Given emerging data for a population prevalence of at least 5% for a broadly conceived bipolar spectrum-and 6% for the cyclothymic temperament-the author submits that one of ten individuals in the community either has bipolar disorder, or is at risk for it. These are probably conservative estimates, because the range of clinical phenotypes and that of temperaments at risk are expanding. A provocative development is the emergence of extensive clinical and research evidence for the comorbidity of panic, social phobia, and related anxiety states with bipolar, and especially bipolar II, disorder. In addition, prevalent mixed states beyond dysphoric mania have been described, consisting of hypomanic intrusions into major depressive states.The net effect of the broadened boundaries of bipolarity is encroachment into the terrain of so-called "unipolar" anxious-depressions and of axis II cluster B. This is an evolving reformulation of the subclassification of affective disorders reviewed in this article, validated on the basis of phenomenology, epidemiology, course, family history, twin studies, and molecular genetics. These considerations have major implications for clinical practice, methodology of genetic investigations, pharmaceutical trials of putative bipolar agents in affective disorders, and public health.

  • the duration of Hypomania in bipolar ii disorder in private practice methodology and validation
    Journal of Affective Disorders, 2006
    Co-Authors: Franco Benazzi, Hagop S Akiskal
    Abstract:

    Abstract Background DSM-IV 4-day minimum Hypomania duration is not evidence-based. Epidemiologic data suggest that briefer Hypomanias are prevalent in the community. We sought to find out the relative prevalence of short (2–3 days) versus long (≥ 4 days) Hypomanias in private practice. Methods 206 bipolar-II (BP-II) depressed outpatients (group B) and a group of 140 remitted BP-II (group R) were assessed with the DSM-IV Structured Clinical Interview, as modified by the authors. BP-II with short vs. longer Hypomania were compared on such bipolar validators as early age at onset, depressive recurrence, atypical feature specifier, depressive mixed state and bipolar family history. In addition, to ascertain the bipolar status of depressed patients with brief Hypomanias, we included a comparison group of 178 major depressive disorder (MDD) patients assessed when depressed. Results 27–30% of Hypomanias (depending on whether assessment occurred when patients were depressed or in remission) had 2–3-day duration; 72% lasted less than 4 weeks. Except for the atypical feature specifier, BP-II with short vs. BP-II with longer Hypomania were not significantly different on bipolar validators. Moreover, BP-II with short, like its longer hypomanic counterpart, was significantly different from the comparison MDD group on all bipolar indicators. Limitations Single interviewer and retrospective evaluation of duration of Hypomania. Conclusions As BP-II patients almost never present clinically in a hypomanic episode, the retrospective assessment of the duration of these episodes is clinically unavoidable. Most Hypomanias last from 2 days to a few weeks. BP-II with shorter vs. longer Hypomanias had significantly higher rates of females, comorbidity and atypical features, but were otherwise indistinguishable on crucial bipolar validators. Furthermore, such validators, including bipolar family history, robustly distinguished BP-II with short Hypomanias from the MDD group. The conservative 4-day threshold would misclassify one out of three BP-II as MDD. Such misclassification has relevant implications for treatment and outcome, as well as clinical research methodology for depressive and bipolar disorders.

  • toward a clinical delineation of dysphoric Hypomania operational and conceptual dilemmas
    Bipolar Disorders, 2005
    Co-Authors: Hagop S Akiskal, Franco Benazzi
    Abstract:

    Objective:  Unlike dysphoric mania, we are unaware of any formal studies of dysphoric Hypomania (DH). For this reason, DH is not formally recognized by DSM-IV and ICD-10. Analogous to the DSM-IV approach in the diagnosis of manic mixed state, in this exploratory study we operationalized DH as coexisting full syndromal hypomanic and major depressive states. Methods:  In an Italian outpatient private practice setting, 320 BP-II outpatients [meeting DSM-IV criteria except for shorter (≥2 days) floor duration for history of hypomanic episodes] were further interviewed with the modified SCID-CV for the simultaneous presence of hypomanic and depressive signs and symptoms during the index presenting affective episode or its exacerbation. Hypomania always included irritable mood plus at least four hypomanic signs and symptoms. Such non-euphoric Hypomania had to last at least 1 week. Results:  Only 45 (14.0%) met our proposed criteria for DH. Less stringently defined depressive mixed states (DMX) were excluded from further analyses. When compared with 120 of the 320 (37.5%) ‘pure’ BP-II (i.e., not meeting mixed state criteria), DH emerged as an irritable affective state, demonstrated a significantly higher rate of females, mood lability, racing/crowded thoughts, distractibility, increased talkativeness, psychomotor agitation, and increased goal-directed drives. Psychomotor agitation/activation had a specificity of 87% and sensitivity of 94%, correctly classifying 92% of cases of DH. Conclusions:  The DSM-IV concept of dysphoric manic mixed state can be extended to DH. In the latter, eutrophic exuberance is replaced by irritable-labile mood, and the hypomanic expansiveness finds expression in mental, psychomotor and behavioral activation that could involve increased drives (e.g., travel, substances, and sex) and social disinhibition. It is useful to contrast the foregoing picture of DH as hypomanic exuberance muted by leaden paralysis, with that of our previous work on DMX as a major depressive mixed state with more subtle excitatory hypomanic intrusions. We discuss methodologic, theoretical and practical implications of categorical (DH) and dimensional (DMX) conceptualizations of mixed states beyond mania.

Katherine Gordonsmith - One of the best experts on this subject based on the ideXlab platform.

  • reducing the Hypomania checklist hcl 32 to a 16 item version
    Journal of Affective Disorders, 2010
    Co-Authors: Liz Forty, Lisa Jones, Ian Jones, Sian Caesar, Christine Fraser, Katherine Gordonsmith, Mark James Kelly, Emma Barnes, Emily Griffiths
    Abstract:

    Background The under-recognition of hypomanic symptoms by both clinicians and patients is a major clinical problem which contributes to misdiagnosis and diagnostic delay in patients with bipolar disorder. The recent development of validated screening instruments for Hypomania, such as the Hypomania Checklist (HCL-32), may help to improve the detection of bipolar disorder. In this study, we assess whether it is possible to reduce the number of items on the HCL-32 without any loss in the screening tool's ability to reliably differentiate between bipolar disorder (BD) and major depressive disorder (MDD). Methods Using our large samples of patients with DSM-IV defined bipolar I disorder (BD-I) (n = 230) and recurrent MDD (n = 322), we performed item correlations in order to identify potentially redundant items in the HCL-32. We then tested the performance of a shortened 16-item HCL questionnaire within a separate sample of patients with BD (including BD-I, BD-II and BD-NOS) (n = 59) and MDD (n = 76). Results The structure of the 16-item HCL demonstrated two main factors similar to those identified for the HCL-32 (an ‘active-elated’ factor and a ‘risk-taking/irritable’ factor). A score of 8 or more on a shortened 16-item version of the HCL had excellent ability to distinguish between BD and MDD. The sensitivity (83%) and specificity (71%) of the 16-item version were very similar to those for the full 32-item HCL. Limitations The HCL-16 was derived after subjects had completed the full HCL-32. It will be important to test the validity of a ‘stand-alone’ 16-item HCL questionnaire. Conclusions A shortened 16-item HCL (the HCL-16) is potentially a useful screening tool for Hypomania within busy clinical settings.

  • identifying hypomanic features in major depressive disorder using the Hypomania checklist hcl 32
    Journal of Affective Disorders, 2009
    Co-Authors: Liz Forty, Daniel J. Smith, Lisa Jones, Ian Jones, Sian Caesar, Christine Fraser, Katherine Gordonsmith, Nicholas John Craddock
    Abstract:

    Background Recent studies have challenged the traditional unipolar/bipolar divide with increasing support for a more dimensional view of affective disorders. We here examine the occurrence of hypomanic symptoms in individuals with a history of major depression selected to exclude indicators of underlying bipolarity. Methods The presence of hypomanic symptoms was assessed by the Hypomania Checklist (HCL-32) self-report questionnaire in a sample of almost 600 patients meeting DSM-IV criteria for Bipolar I disorder (BPI N = 260) or Major Recurrent Depressive disorder (MDDR N = 322). Subjects were recruited and assessed using consistent, robust methodology. Results We found that a score of 20 or more on the HCL-32 yielded the best combination of sensitivity (68%) and specificity (83%) to distinguish between BPI and MDDR. Within our highly selected and well defined MDDR sample (for which exclusion criteria included personal or family histories of bipolar or psychotic illness), 17% of MDDR subjects scored over the threshold of 20 on the HCL-32. Conclusions The HCL-32 identified a substantial number of patients meeting DSM-IV criteria for recurrent major depression (even when selected to exclude personal and family histories of bipolar illness) who reported bipolar symptoms at a level similar to that reported by patients meeting diagnostic criteria for bipolar disorder. This demonstrates the limitations of using DSM-IV criteria to distinguish those with and without bipolar features of illness.

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  • impact of modification to dsm 5 criterion a for Hypomania mania in newly diagnosed bipolar patients findings from the prospective bio study
    International Journal of Bipolar Disorders, 2021
    Co-Authors: Mette U Fredskild, Trisha Suppes, Sharleny Stanislaus, Klara Coello, Sigurd Melbye, Hanne Lie Kjaerstad, Kimie Stefanie Ormstrup Sletved, Maj Vinberg, Lars Vedel Kessing
    Abstract:

    DSM-IV states that criterion A for diagnosing Hypomania/mania is mood change. The revised DSM-5 now states that increased energy or activity must be present alongside mood changes to diagnose Hypomania/mania, thus raising energy/activity to criterion A. We set out to investigate how the change in criterion A affects the diagnosis of hypomanic/manic visits in patients with a newly diagnosed bipolar disorder. In this prospective cohort study, 373 patients were included (median age = 32; IQR, 27–40). Women constituted 66% (n = 245) of the cohort and 68% of the cohort (n = 253) met criteria for bipolar type II, the remaining patients were diagnosed bipolar type I. Median number of contributed visits was 2 per subject (IQR, 1–3) and median follow-up time was 3 years (IQR, 2–4). During follow-up, 127 patients had at least one visit with fulfilled DSM-IV criterion A. Applying DSM-5 criterion A reduced the number of patients experiencing a hypomanic/manic visit by 62% at baseline and by 50% during longitudinal follow-up, compared with DSM-IV criterion A. Fulfilling DSM-5 criterion A during follow-up was associated with higher modified young mania rating scale score (OR = 1.51, CL [1.34, 1.71], p < 0.0001) and increased number of visits contributed (OR = 1.86, CL [1.52, 2.29], p < 0.0001). Applying the stricter DSM-5 criterion A in a cohort of newly diagnosed bipolar patients reduced the number of patients experiencing a hypomanic/manic visit substantially, and was associated with higher overall young mania rating scale scores, compared with DSM-IV criterion A. Consequently, fewer hypomanic/manic visits may be detected in newly diagnosed bipolar patients with applied DSM-5 criterion A, and the upcoming ICD-11, which may possibly result in longer diagnostic delay of BD as compared with the DSM-IV.

  • first controlled treatment trial of bipolar ii Hypomania with mixed symptoms quetiapine versus placebo
    Journal of Affective Disorders, 2013
    Co-Authors: Trisha Suppes, Terence A Ketter, Iola S Gwizdowski, Ellen B Dennehy, Shelley J Hill, Grace E Fischer, Diane Snow, Robert Gonzalez, Suresh Sureddi
    Abstract:

    Abstract Objectives To compare the efficacy and safety of adjunctive quetiapine (QTP) versus placebo (PBO) for patients with bipolar II disorder (BDII) currently experiencing mixed hypomanic symptoms in a 2-site, randomized, placebo-controlled, double-blind, 8-week investigation. Methods Participants included 55 adults (age 18–65 years) who met criteria for BDII on the Structured Clinical Interview for DSM-IV-TR (SCID). Entrance criteria included a stable medication regimen for ≥2 weeks and Hypomania with mixed symptoms ( > 12 on the Young Mania Rating Scale [YMRS] and > 15 on the Montgomery Asberg Depression Rating Scale [MADRS] at two consecutive visits 1–3 days apart). Participants were randomly assigned to receive adjunctive quetiapine (n=30) or placebo (n=25). Results Adjunctive quetiapine demonstrated significantly greater improvement than placebo in Clinical Global Impression for Bipolar Disorder Overall Severity scores (F(1)=10.12, p=.002) and MADRS scores (F(1)=6.93, p=.0138), but no significant differences were observed for YMRS scores (F(1)=3.68, p=.069). Side effects of quetiapine were consistent with those observed in previous clinical trials, with sedation/somnolence being the most common, occurring in 53.3% with QTP and 20.0% with PBO. Conclusions While QTP was significantly more effective than PBO for overall and depressive symptoms of BDII, there was no significant difference between groups in reducing symptoms of Hypomania. Hypomania improved across both groups throughout the study.

  • bipolar ii disorder arguments for and against a distinct diagnostic entity
    Bipolar Disorders, 2008
    Co-Authors: Eduard Vieta, Trisha Suppes
    Abstract:

    Objective:  As a commitment to the International Society for Bipolar Disorders (ISBD), a Task Force was developed to investigate the diagnostic value of bipolar II disorder. Methods:  Task Force members worked jointly reviewing all relevant literature (original articles, reviews, letters, book chapters and congress presentations) that included ‘bipolar II disorder’ and/or ‘Hypomania’ as key words. Results:  Bipolar II disorder appears to be a reasonably valid and reliable diagnostic category yet often underdiagnosed or misdiagnosed as unipolar disorder or personality disorder. Moreover, it is officially recognized as a mental disorder in DSM-IV-TR but not in ICD-10, and many clinicians still regard it as a milder form of manic-depressive illness, despite data supporting high morbidity and mortality rates. In fact, bipolar II may be the most prevalent bipolar phenotype, although current diagnostic boundaries are seen as quite restrictive concerning the required duration for Hypomania (4 days), the exclusion of hypomanic episodes potentially triggered by antidepressants and other substances, and the negligence of hypomanic mixed states. The course of bipolar II disorder is characterized by depressive predominant polarity, and its treatment is still controversial and poorly evidence-based. Conclusions:  Bipolar II disorder is supported as a distinct category within mood disorders, but the definition and boundaries deserve a greater clarification in the DSM-V and ICD-11.

  • three times more days depressed than manic or hypomanic in both bipolar i and bipolar ii disorder
    Bipolar Disorders, 2007
    Co-Authors: Ralph W Kupka, Mark A Frye, Susan L Mcelroy, Willem A Nolen, Paul E Keck, Trisha Suppes, Lori L Altshuler, David A Luckenbaugh, Gabriele S Leverich, Heinz Grunze
    Abstract:

    Objectives: To assess the proportion of time spent in mania, depression and euthymia in a large cohort of bipolar subjects studied longitudinally, and to investigate depression/mania ratios in patients with bipolar I versus bipolar II disorder. Methods: Clinician-adjusted self-ratings of mood were completed daily for one year for naturalistically treated outpatients with bipolar I (n = 405) or bipolar II (n = 102) disorder. Ratings were analyzed for mean time spent euthymic, depressed, manic, hypomanic, and cycling, and the percentages of time spent ill were compared between the two groups. Results: Percentages of time spent ill for bipolar I versus II patients were: euthymia 47.7% versus 50.2%; depression 36.0% versus 37.0%; Hypomania 11.5% versus 9.8%; mania 1.0% versus 0.2%; and cycling 3.7% versus 2.8%. The depression/mania ratio was 2.9 in the bipolar I and 3.8 in bipolar II sub-groups. Conclusions: Depression represents the predominant abnormal mood state for treated outpatients with bipolar I and II disorder. In contrast to other studies, we found that depression/mania ratios were of a similar magnitude, suggesting the same tendency towards mood instability in both sub-groups.

  • risk of switch in mood polarity to Hypomania or mania in patients with bipolar depression during acute and continuation trials of venlafaxine sertraline and bupropion as adjuncts to mood stabilizers
    FOCUS, 2007
    Co-Authors: Gabriele S Leverich, Mark A Frye, Susan L Mcelroy, Willem A Nolen, Paul E Keck, Trisha Suppes, Lori L Altshuler, Ralph W Kupka, Kirk D Denicoff, Heinz Grunze
    Abstract:

    Objective: The authors examined the comparative risks of switches in mood polarity into Hypomania or mania during acute and continuation trials of adjunctive antidepressant treatment of bipolar depression. Method: One hundred fifty-nine patients with bipolar I disorder or bipolar II disorder participated in a total of 228 acute (10-week) randomized trials of bupropion, sertraline, or venlafaxine as an adjunct to a mood stabilizer. Patients in 87 of these trials entered continuation treatment for up to 1 year. Antidepressant response and the occurrence of subthreshold brief Hypomania (emergence of brief Hypomania [at least 1 but <7 days] or recurrent brief Hypomania) and threshold switches (emergence of full-duration Hypomania [≥7 days] or mania) were blindly assessed by using clinician-rated daily reports of mood-associated dysfunction on the National Institute of Mental Health Life Chart Method. Results: Threshold switches into full-duration Hypomania and mania occurred in 11.4% and 7.9%, respectively, o...