Progress in Mind
Choose a channel
Check out the different Progress in Mind content channels.
Putting mania with depressive symptoms front and centre
How the updated DSM-5 criteria, plus anxiety, irritability and agitation (AIA), are helping highlight (and treat) an at-risk patient population
The first day of ECNP hit the ground running, with a trio of talks discussing mania with depressive symptoms in bipolar I disorder. First up to the rostrum was Professor David Kupfer: a key figure behind the latest update of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5) and one of its biggest champions.
He presented eloquent and compelling explanation of the usefulness that the updated DSM-5 offered for the diagnosis of mental disorders, using bipolar I disorder as an example.
A different class
DSM-5 classes bipolar I disorder on a spectrum (using ‘dimensional factors’), replacing the ‘categorical’ approach of DSM-IV that put patients into three distinct diagnostics silos. The new ‘manic with mixed features’ part of this spectrum, Prof Kupfer believes, represents an important update: allowing identification of a patient population with depressive symptoms who would have previously failed to make the stricter criteria of previous ‘mixed’ diagnosis.
He cited this as an important category of patients to recognise and that “we really do an injustice to ourselves and our patients if we don’t pay more attention to mixed features”. Not only because they represent a large section of the bipolar I population (up to 40% of the patient population, depending on the diagnostic criteria used)1– 5 but because of the greater burden of disease and higher incidence of suicide (plus greater clinicians dissatisfaction with treatment) than patients with a purely manic episode.6
A bestseller too
He also added that, with more than 725,000 copies sold to date (in English alone), he was impressed by how popular DSM-5 has already become in the short time since its release – both with clinicians and, he teased, maybe even a few patients too
Suicide: a timely intervention
Prof Michael Berk followed with a robust and data-rich discussion on the epidemiology of suicide in bipolar disorder. His reasons were clear: “in order to better detect and understand and manage suicidal risk, it’s really important to understand the epidemiology and clinical picture of suicide.”
A preventable event
He views suicide as a not only preventable but a big societal problem: for every person in the USA who commits suicide, four more attempt suicide. He showed that, when ranking mortality in mental disorders, patients with bipolar disorder unenviably sat in the number one spot. They were over 20 times more likely to commit suicide than the general population.7,8
Bipolar I – get them early
He went on to focus in on bipolar disorder, showing not only that there was a relationship between the risk of suicide and duration of illness, but that this risk was greater in the first year of onset before patients had the chance to properly come to terms with their illness.9 He stressed the need to be vigilant for suicide early on in the course of bipolar I disorder, especially in patients with mania with depressive symptoms (57.9% in one study demonstrated suicidality vs. 1.3% of those with pure mania).10
MINI, but mighty
Like all three speakers, the Professor highlighted symptoms of anxiety, irritability and agitation (AIA), which he considered as ‘gateway symptoms’ to suicide. He cited several ways to assess depressive symptoms (including suicidal ideation) in hypomanic and manic episodes, chief among them the Mini International Neuropsychiatric Interview (MINI) module self-rating scale.11
Referring back to the earlier talk by Professor Kupfer, Professor Berk saw the updated DSM-5 as “a welcome advance” because it “more clearly describes the clinical spectrum of patients that we see.”
Last, but definitely not least
The final talk was presented by the session chair – an impassioned and animated talk from Professor Andrea Faglioni for using AIA during bipolar diagnosis as a potential signal for the presence of depressive symptoms in a manic episode.
Data and experienced combined
Along with his personal perspective, from years of clinical experience to bear from years of first-hand clinical experience he presented both an individual case study alongside larger-scale clinical data. One such study of over 1000 patients with bipolar I disorder showed, during a manic episode, 69% of patients presented with one or more depressive symptoms (34% having sufficient depressive symptoms to qualify for a ‘mixed features’ diagnosis by DSM-5 criteria).12 The Professor used the fact that nearly three-quarters of patients who experienced mania with depressive symptoms also had symptoms of AIA to support his case.
Roll on tomorrow! Until next time, your correspondent
Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.
References
1. McElroy et al. Am J Psychiatry 1992; 149:1633–1644.
2. Azorin et al. BMC Psychiatry 2009; 9:33.
3. Hantouche et al. J Affect Disord 2006; 96:225–232.
4. Akiskal et al. J Affect Disord 1998; 50:175–186.
5. Vieta et al. J Affect Disord 2014; 156:206–213.
6. Young & Eberhard. Neuropsychiatr Dis Treat. 2015 [In press].
7. Adapted from: Harris & Barraclough. Br J Psychiatry 1997; 170:205–208.
8. Tondo et al. CNS Drugs 2003; 17:491–511.
9. Tondo et al. Psychiatr Scan 2007; 116:419–428.
10. Goldberg et al. Am J Psychiatry 1998; 155:1753–1755.
11. Hergueta & Weiller. Int J Bipolar Disord 2013;1:21.
12. Young & Eberhard. Neuropsychiatr Dis Treat 2015; 11:1137–1143.
13. Vieta et al. J Affect Disord 2014; 156: 206–213.