Affective

Background: Bipolar disorders (BP) are frequently diagnosed and treated as pure depression initially; accurate diagnosis often being delayed by 8 to 10 years. In prospective studies, the presence of hypomanic symptoms in adolescence is strongly predictive of later bipolar disorders. As such, an instrument for self-assessment of hypomanic symptoms might increase the detection of suspected and of manifest, but under-treated, cases of bipolar disorders. Methods: The multi-lingual hypomania checklist (HCL-32) has been developed and is being tested internationally. This preliminary paper reports the performance of the scale in distinguishing individuals with BP (N = 266) from those with major depressive disorder (MDD; N = 160). The samples were adult psychiatry patients recruited in Italy (N = 186) and Sweden (N = 240). Results: The samples reported similar clinical profiles and the structure for the HCL-32 demonstrated two main factors identified as bactive/elatedQ hypomania and brisk-taking/irritableQ hypomania. The HCL-32 distinguished between BP and MDD with a sensitivity of 80% and a specificity of 51%. Limitations: Although the HCL-32 is a sensitive instrument for hypomanic symptoms, it does not distinguish between BP-I and BP-II disorders. 0165-0327/$ -see front matter D Conclusions: Future studies should test if different combinations of items, possibly recording the consequences of hypomania, can distinguish between these BP subtypes. D

Background: This analysis was designed to assess the efficacy and safety of aripiprazole compared with placebo in subpopulations of patients with acute manic or mixed episodes of bipolar I disorder. Methods: Acutely manic patients experiencing DSM-IV manic/mixed episodes of bipolar I disorder were pooled from two randomized, three-week, flexible-dose, double-blind, placebo-controlled trials (N = 516) and stratified by disease severity (Young Mania Rating Scale, YMRS), episode type, presence or absence of psychotic features, episode frequency, age, gender, and baseline severity of depressive symptoms. Safety and treatment-emergent adverse-event analyses were also performed. Results: Aripiprazole significantly reduced mean YMRS total scores at end point compared with placebo in patients with more severe or less severe illness, with mixed or manic episodes, with or without psychotic features, or with a history of rapid or nonrapid cycling (p b 0.01 for each subpopulation); in men and women (p = 0.001 for both); in patients in the 18-40 and 41-55 year age groups (p ≤ 0.001 for both); and in three subgroups stratified by baseline severity of depressive symptoms using the Montgomery-Åsberg Depression Rating Scale (p b 0.05). The treatment-emergent adverse events reported in ≥ 5% of patients aged 18-40 years receiving aripiprazole were similar to those reported for the overall population. Limitations: This post hoc analysis utilized pooled data from two short-term studies. Conclusion: Efficacy of the second-generation antipsychotic aripiprazole was noted across a broad range of subpopulations often associated with treatment resistance in patients experiencing manic or mixed episodes of bipolar I disorder.

Background Few studies have examined the psychopathological profiles of child offspring of bipolar parents. Such investigations are useful as a first step to identifying potential prodromal manifestations of bipolar disorder. Methods The presence of psychopathology ...

Some patients with obsessive-compulsive disorder (OCD) exhibit an unsatisfactory reduction in symptom severity despite being treated with all the available therapeutic alternatives. The clinical variables associated with treatment-refractoriness in OCD are inconsistently described in the literature. Methods: To investigate factors associated with treatment-refractoriness of patients with OCD, we conducted a case-control study, comparing 23 patients with treatment-refractory OCD to 26 patients with treatment-responding OCD. Results: The factors associated with refractoriness of OCD were higher severity of symptoms since the onset of OCD (p < 0.001), chronic course (p = 0.003), lack of a partner (p = 0.037), unemployment (p = 0.025), low economic status (p = 0.015), presence of obsessive-compulsive symptoms of sexual/religious content (p = 0.043), and higher scores on family accommodation (p < 0.001). Only the three latter variables remained significantly associated with treatment-refractoriness after regression analyses. Limitations: small sample size, the biases and drawbacks inherent to a case-control study, and the inclusion criteria used to define the study groups may have limited the generalisation of the results. Conclusion: A major strength of this study is the systematic and structured evaluation of a vast array of variables related to the clinical expression of OCD, including epigenetic factors and ratings derived from instruments evaluating family accommodation. The presence of sexual/religious symptoms, low economic status and high modification on family function due to OCD were independently associated with treatment-refractoriness. Future longitudinal studies are warranted to verify if these variables represent predictive factors of treatment non-response.

Background: Stressful life events increase the probability of depressive problems in early adolescence. Several genetic and environmental risk factors may change individual sensitivity to the depressogenic effect of these events. We examined modification by parental depression and gender, and mediation of the former by temperament and family environment. Methods: Data were collected as part of a longitudinal cohort study of (pre)adolescents (n = 2127). During the first assessment wave at approximately age 11, we assessed parental depression, family functioning, perceived parenting behaviours, and temperamental frustration and fearfulness. At the second wave, about two and a half years later, stressful life events between the first and second assessment were assessed. Depressive problems were measured at both waves. Results: Adolescents with parents who had a (lifetime) depressive episode were more sensitive to the depressogenic effect of stressful events than adolescents without depressed parents. Furthermore, girls are more sensitive to these effects than boys. The modifying effect of parental depression was not mediated by temperament, family functioning and perceived parenting. Limitations: Life events were assessed without consideration of contextual information. Depressive problems were measured by questionnaires that did not directly represent DSM-IV criteria. The measure of parental depression was unspecific regarding severity and timing of depressive episodes. Conclusion: The results suggest that gender and parental depression are associated with increased sensitivity to depression after experiencing stressful life events during adolescence.

Objective: Previous work has shown that manic-depressive illness and alcohol abuse are linked. This study further explores the relationship of alcohol and drug abuse in bipolar I patients and unipolar depressives and a comparison group obtained through the acquaintance method. Method: Diagnosis was accomplished according to Research Diagnostic Criteria (RDC): controls 5 469; bipolars 5 277; unipolar depressives 5 678. Systematic data were gathered using the SADS on lifetime and current drug abuse and alcoholism. Both patients and comparison subjects were then followed prospectively for 10 years. First degree family members were interviewed using the RDC family history method. Results: The group of bipolar patients and the group of unipolar patients had higher rates of drug and alcohol abuse than the comparison group when primary and secondary affective disorder patients were combined. However, primary unipolar patients did not have higher rates of alcohol or drug abuse than the comparison group. In contrast, primary bipolar patients had higher rates of alcoholism, stimulant abuse, and ever having abused a drug than the primary unipolar group and the control group. In an evaluation of the bipolar patients, drug abusers were significantly younger at intake and had a significantly younger age of onset of bipolar disorder. There was a significant increase in family history of mania or schizoaffective mania in the drug-abusing bipolar patients as compared to the non-abusing bipolar patients. Limitation: As in all adult samples of patients ẁith affective illness, the chronology of alcohol and substance problems vis-a-vis the onset of illness was determined retrospectively. Conclusions: (1) Alcoholism and drug abuse are more frequent in bipolar than unipolar patients. (2) The drug abuse of bipolar patients tends toward the abuse of stimulant drugs. (3) In a bipolar patient, familial diathesis for mania is significantly associated with the abuse of alcohol and drugs. (4) More provocatively, these findings suggest the hypothesis of a common familial-genetic diathesis for a subtype of bipolar I, alcohol and stimulant abuse. Clinical implications: The present analyses, coupled with two previous ones from the CDS, suggest that drug abuse may precipitate an earlier onset of bipolar I disorder in those who already have a familial predisposition for mania. Furthermore, in dually diagnosed patients with manic-depressive and alcohol / stimulant abuse history, mood stabilization of the bipolar disorder represents a rational approach to control concurrent alcohol and drug problems, and should be studied in systematic controlled trials.

Background: To determine whether significant symptoms of inattention were present among the offspring of wellcharacterized bipolar parents. Methods: We included 53 offspring of 30 parents meeting DSM-IV criteria for bipolar disorder diagnosed by consensus on the basis of a SADS-L interview and a wealth of longitudinal clinical data. The unaffected parent had no lifetime history of a major psychiatric illness. Offspring, prospectively followed for up to 5 years, completed psychometric measures of attention and mood when judged to be at a good level of functioning (well, remitted or treated). Results: Those offspring with any lifetime psychiatric diagnosis endorsed more subjective problems with attention. However, there was no measurable difference on tasks of sustained attention between those with and those without a lifetime psychiatric illness including affective disorder. There was a significant association between self-reported symptoms of depression and inattention, but no association between either self-report measure and an objective measure of sustained attention. Limitations: This study was not intended to be a comprehensive neuropsychological investigation of at risk offspring. Conclusions: In this high-risk population, subjective difficulty with attention appeared to be state-dependent, associated with the degree of subjective distress related to an underlying psychiatric illness.

Background: Deficits in social cognition, e.g. theory of mind (ToM) represent core characteristics involved in the etiology of psychopathological symptoms and an important predictor of social competence. In bipolar affective disorder, evidence for ToM deficits is scant, although brain imaging studies and impairments in non-social neurocognitive domains indicate deficits of prefrontal functions.

ObjectiveDepression often goes undetected and untreated in patients with chronic heart failure (CHF). To investigate whether patients with CHF show a specific profile of depression symptoms, we compared depression symptoms in depressed patients with and without CHF.

Since its first definition in the literature, schizoaffective disorder (SAD) has raised a considerable controversy regarding its clinical distinction from schizophrenia (SCH) and mood disorders (MD) as well as its validity as an independent nosological category.

Brand has been proven to match with human characteristics, lifestyles and preferences. However the relationship between brand and psychological element received little attention. This paper suggests three elements that form the customer-based psychological branding namely sensory, cognitive, and affective. These predictor variables are tested against brand loyalty. The setting for this study was the five-star hotel segment and for that reason guests who had experience staying in the selected five-star hotel segment were chosen. It is concluded that five senses, cognitive and affective are able to influence the evaluation towards hotel brand.

Background: It is alleged that depression distorts the assessment of general personality traits. To test that hypothesis, we examined scores on the Revised NEO Personality Inventory (NEO-PI-R) administered to acutely depressed patients at baseline and 14 to 26 weeks after treatment with antidepressant medication. Method: Two hundred and fifty patients completed the NEO-PI-R at baseline, 109 patients after 14 to 26 weeks of antidepressant pharmacotherapy. 48 patients (49.5%) were identified as responders while 49 (50.5%) were identified as nonresponders. The remaining 12 patients were excluded because they met HRSD response criteria but not the SCID-I MDD criteria at treatment completion. Results: At baseline, NEO-PI-R scales showed high internal consistency and replicated the normative factor structure, suggesting that psychometric properties were preserved. Among non-responders, retest correlations were uniformly high (rs = .50 to .88) and mean levels showed little change, providing evidence for the consistency of personality self-reports during an acute depressive episode. NEO-PI-R scales showed construct validity in the concurrent prediction of a number of clinical criteria. Effective treatment had significant effects on the mean levels of neuroticism, which decreased, and extraversion, openness, and conscientiousness, which increased. Limitations: The participants were from a clinical database and were not randomly assigned for the treatment. Conclusions: The results suggest that the effect of acute depression is to amplify somewhat the personality profile of people prone to depression. Rather than regard these depression-caused changes in assessed personality trait levels as a distortion, we interpret them as accurate reflections of the current condition of the individual. Personality traits have biological bases, and when they are changed (by disease or therapeutic interventions) trait levels change. D

Background: The purpose of this study was to estimate the contribution of genetic, commonand unique environmental factors in the aetiology of unipolar major depression (MD), and to investigate whether the unipolar depressive disorders; MD, atypical depression/depression NOS, dysthymia and depressive adjustment disorder can be viewed as various expressions of an underlying genetic commonality.

This paper briefly reviews and comments on the development of lamotrigine as a treatment for bipolar disorder. The events described include astute clinical observations by epileptologists, serendipitous coupling of the drug's clinical profile to unmet need of two refractory bipolar patients by a practicing psychiatrist, risk taking on the part of an industry sponsor, and persistence on the part of a few key internal and external advocates to see development through to its conclusion, taking place against a backdrop of a disease area which, at the time of the earliest events described here, had not seen the development of any new pharmacologic treatments for decades. Fortunately for patients, since that time there has been a veritable explosion of research into treatments for bipolar disorder, both old and new, so that now patients and physicians have multiple evidence-based options for the treatment of this devastating illness. The development of lamotrigine provides one example of the importance of prescience, patience and persistence in bringing a novel idea to clinical fruition.

Objective: Bipolar Disorder is associated with a higher frequency of attempted suicide than most other psychiatric disorders. The reasons are unknown. This study compared bipolar subjects with a history of a suicide attempt to those without such a history, assessing suicidal behavior qualitatively and quantitatively, and examining possible demographic, psychopathologic and familial risk factors. Methods: Patients (ages 18 to 75) with a DSM III-R Bipolar Disorder (n 5 44) diagnosis determined by a structured interview for Axis I disorders were enrolled. Acute psychopathology, hopelessness, protective factors, and traits of aggression and impulsivity were measured. The number, method and degree of medical damage was assessed for suicide attempts, life-time. Results: Bipolar suicide attempters had more life-time episodes of major depression, and twice as many were in a current depressive or mixed episode, compared to bipolar nonattempters. Attempters reported more suicidal ideation immediately prior to admission, and fewer reasons for living even when the most recent suicide attempt preceded the index hospitalization by more than six months. Attempters had more lifetime aggression and were more likely to be male. However, attempters did not differ from nonattempters on lifetime impulsivity. Limitations: The generalizability of the results is limited because this is a study of inpatients with a history of suicide attempts. Patients with Bipolar I and NOS Disorders were pooled and a larger sample is needed to look at differences. We could not assess psychopathology immediately prior to the suicide attempt because, only half of the suicide attempters had made attempts in the six months prior to admission. Patients with current comorbid substance abuse were excluded. No suicide completers were studied. Conclusions: Bipolar subjects with a history of suicide attempt experience more episodes of depression, and react to them by having severe suicidal ideation. Their diathesis for acting on feelings of anger or suicidal ideation is suggested by a higher level of lifetime aggression and a pattern of repeated suicide attempts.

Background: Suicide is a leading cause of death among individuals with anorexia nervosa (AN). In this paper, we examined competing explanations of the high rate of death by suicide among individuals with anorexia nervosa (AN). Methods: Nine case reports of individuals with AN who died by suicide were evaluated to determine whether death by suicide occurred a) because physical health was so compromised that what would be a non-lethal suicide attempt in a healthy adult became a fatal suicide attempt, or b) because highly lethal suicide attempts that would have killed any adult, healthy or medically compromised, were made. Results: The findings converged with the latter hypothesis, as predicted by Joiner's [Joiner, T., 2006. Why People Die By Suicide. Harvard University Press, Cambridge, MA] theory of suicide, which suggests individuals with AN may habituate to the experience of pain during the course of their illness and accordingly die by suicide using methods that are highly lethal. Limitations: This study utilized case reports instead of an experimental design, which impedes its ability to comment on whether there is a causal relationship between Joiner's theory and death by suicide among individuals with AN. Conclusions: Clinicians are encouraged to carefully assess suicidality in AN patients, paying particular attention to issues related to lethality.

Little is known about the early phases of bipolar disorders (BPAD) and most of current knowledge derives from putative "high-risk" studies conducted in populations of bipolar off-spring; such information may therefore be relevant only to a sub-group of at-risk subjects. Methods: Retrospective assessment of the phase preceding the emergence of mania and of premorbid characteristics of patients treated for a first episode of psychotic mania. The collected data was used mainly to generate hypotheses. Results: Before onset of a first episode of psychotic mania, patients go through a phase of change from previous mental state where they present mood symptoms, sleep disruption and general functional decline. These clinical manifestations are however likely to have low specificity. However, their occurrence in patients presenting certain risk factors or markers of vulnerability that were identified at a relatively high prevalence in our sample, may be an indicator of impending first episode mania. Limitations: This is a retrospective study, in a small sample of patients presenting with psychotic mania. Criteria identified need therefore to be validated in larger prospective studies. Conclusions: Early identification of patients at risk to develop a first episode of psychotic mania is unlikely to be possible on the basis of symptoms alone. However, the occurrence of certain clinical characteristics in patients who have risk factors or markers of vulnerability to BPAD could be a sign of impending first episode mania.

BackgroundThe relationship between PTSD and complex PTSD remains unclear. As well as further addressing this issue, the current study aimed to assess the degree to which DESNOS (complex PTSD) was related to interpersonal trauma and had relational consequences.

Background: Stigma has been shown to have a significant influence on help-seeking, adherence to treatment and social opportunities for those experiencing depression. There is a need for studies which examine how the stigma of depression intersects with responses to depression.

Methods: 161 telephone interviews with people experiencing depressive symptoms, derived from a longitudinal cohort study, were sampled on the basis of their perceptions of stigma around depression. Interview transcripts were searched for references to stigma and analysed thematically. The frequency of the themes was calculated and cross-referenced, producing a meta-theme matrix.

Results: Stigma was closely linked to ideas about responsibility for causation and/or
continuation of depressive symptoms. Stigmatised individuals felt compelled to take steps to develop their resilience including drawing on existing support networks and expanding on positive emotions and personal strengths in order to counteract this stigma. However, such strategies were burdensome for some. These participants gained relief from relinquishing their personal responsibility.

Limitations: The data were briefer than many interview studies. This narrowed its
interpretation, but allowed a large sample of participants.

Conclusions: When considering how to tailor therapies for those experiencing depressive symptoms, health professionals should consider the interaction of stigma with coping strategies. Many individuals can build on existing relationships and personal strengths to develop resilience, some however need to first relinquish the expectation of having sufficient pre-existing resilience within themselves.

The survey investigated the perceptions and attitudes of Senior High School (SHS) students to polytechnic education. This is to serve as the basis for understanding their mind-set, needs and wants better to enable the polytechnics in Ghana mount programmes that better position them as tertiary institutions of choice rather than of last resort. The main objective of the study was to attempt to understand the perception, beliefs, and attitudes of the average Senior High School students to Higher National Diploma (HND) concept. Literature on related works was reviewed to define the conceptual framework for the study. 27-item questions, including Close-ended, open-ended, Likert 5-points attitude measurement scale, and multiple choice questionnaires were purposively administered to a total of 1693, involving 818 female and 875 male 3 rd and final year students from 20 selected schools in the Eastern Region of Ghana. SPSS was used to analyze and present data. The study revealed that SHS s...

Background: Efficient screening is important in two-phase surveys. We examined whether the Center for Epidemiologic Studies Depression Scale (CES-D) is an appropriate instrument for screening depressive disorders among adolescents in Taipei, an ethnic group whose depression is little known of. Methods: Among the 2440 students of a school in Taipei, aged 12 to 16 years who completed the CES-D and eating attitude test (EAT; response rate = 98.5%), 178 were randomly selected from four subgroups defined by the 90th percentile of the two screening tools for face-to-face interview, using the Schedule for Affective Disorders and Schizophrenia for Children (K-SADS). Discriminatory validities of instruments for depressive disorders were estimated, and then a stratum-specific likelihood ratio (SSLR) analysis was conducted for instruments with sufficient validity. Results: The prevalence estimates of depressive disorders varied with different levels of impairment, with a value of 2.4% for major depressive disorder and 0.3% for dysthymic disorder if at least two impairment items were endorsed. The areas under the receiver operative characteristic (ROC) curves were consistently high (0.88 -0.90) for major depressive disorder with or without impairment requirement, but low (0.49) for dysthymic disorder without impairment requirement. Three strata of CES-D scores (0 -28, 29 -48, and z 49) were derived for major depressive disorder with (SSLR = 0.63, 3.00, and 11.75) and without (SSLR = 0.61, 5.09, and 10.42) impairment requirement. Conclusions: The CES-D is useful in screening for major depressive disorder among nonreferred adolescents. Three strata are recommended for its practical application. D

Introduction: Despite antidepressants are widely used in treating bipolar depression, there is much debate about their utility and their potential dangers, involving mood switches and suicidality. Our hypothesis was that the pattern of initial antidepressant prescription, i.e., alone (AM) or in combination with stabilizers (AC) might impact the long-term outcome of patients with bipolar disorder (BP). We aimed to test this hypothesis and to identify outcome measures that could be predicted by initial AM or AC treatment in patients with BP. Methods: We included 95 patients with DSM-IV BP from a pool of 138 patients following a BP program. Patients were rated for initial AM vs. AC treatment when they were first seen in primary care and subdivided into two groups accordingly. Differences in their clinical course were sought investigating course both retrospectively and prospectively (mean follow-up 10 years). Primary outcome measures comprised suicidality and switch rate. Results: There were significantly more patients who switched in the AM group than in the AC group. The number of suicide attempts was higher in the AM group. Significance was retained after performing logistic regression. Limitations: Sample size was small and severe BP patients might be overrepresented in this sample. Discussion: Initial AM treatment of patients subsequently diagnosed as BP may entrain a course characterized by higher proneness to switch and suicidal behaviour. Accurate initial diagnosis of bipolar depression should prompt combined treatment with antimanic drugs.

Background: Women who have low socioeconomic status (SES) or live in disadvantaged circumstances are a vulnerable group at risk for depression. Little is known about the efficacy of preventive interventions to reduce depressive symptoms in low-SES women. The aim of this study is to provide an overview of controlled outcome studies and to investigate the overall efficacy and moderators of interventions targeted at reducing depressive symptoms in this population. Methods: A systematic review and meta-analysis were conducted for 14 studies (N = 1396). The effect size of the studies was computed for outcomes assessing changes in depressive symptom levels using the standardized mean difference effect size. Study, target population, and intervention descriptors expected to influence effect size were analyzed using univariate subgroup and metaregression techniques with mixed-effects statistical models. Results: The estimated overall effect size of 0.31 was significant; study sample characteristics, intervention characteristics and the research design of the studies did not moderate intervention effects.

Background: The majority of randomised controlled trials examining the effectiveness of antenatal group interventions at preventing postnatal depression in "at risk" women have used a "psychoeducational" intervention. The aim of the present study is to evaluate the effectiveness of an antenatal cognitive behavioural group intervention in a primary care setting for pregnant women identified with mild to moderate symptoms in pregnancy and/or at risk of developing depression or anxiety in the perinatal period. Method: Subjects were randomised to a CBT group intervention or control condition (information booklet) and administered the EPDS and STAI at pre (Time 1) and post intervention (Time 2), and at 2 months (Time 3) and 4 months postpartum (Time 4). MINIs were administered at Times 1, 3 and 4. Results: Of the 774 women approached, 277 accepted and were suitable; thus 191 were randomised to the CBT intervention and 86 to the control condition. The subsequent 52% drop-out left 89 women "completing" the CBT groups and 43 in the control group; these two groups were well matched on demographic variables. Intention to treat analyses revealed relatively low mean baseline EPDS scores (means 6.88 -8.16) with no reduction in EPDS scores in either group from Time 1 to Time 4. MINI depression criteria were fulfilled by 19% of all participants at Time 1 but there was no reduction in depression in either group; in contrast those with MINI anxiety diagnoses reduced from 28% in late pregnancy to 16% at four months postpartum in the CBT group with similar reductions in the control group. Analyses on the 132 "completers" showed significant symptomatic improvement over time for both the CBT group and control condition. Depression scores in the most symptomatic women (EPDS N 12; N = 19) decreased steadily by over 50% over the total time course but there were no differences in improvement between the CBT and control groups. Limitations: A number of methodological factors may have obscured our results including a tendency to natural remission in mildly symptomatic subjects and the possibility that our control condition was therapeutic in itself.

Background: There has been interest in the relationship between homosexuality, gender role and suicide risk. Though homosexuals are more likely to identify as cross-gender, research has not simultaneously examined sexual orientation and gender role in assessing suicide risk. In the current study, the unique and interactive effects of sexual orientation and gender role were assessed in regard to suicidal ideation, related psychopathology and measures of coping. Methods: 77 participants were recruited from an undergraduate psychology subject pool (n = 47) or from gay, lesbian and transgender student organizations (n = 30) and assessed on measures of gender role, homosexuality, and psychopathology. Results: Consistent with expectations, cross-gender role (i.e., personality traits associated with the opposite sex) is a unique predictor of suicidal symptoms. Moreover, gender role accounted for more of the overall variance in suicidal symptoms, positive problem orientation, peer acceptance and support, than sexual orientation. After accounting for gender role, sexual orientation contributed little to the variance in suicidal symptoms, associated pathology and problem-solving deficits. There was no support for gender role by sexual orientation interaction effects. Limitations: The cross-sectional nature of the data limits statements regarding causality. Conclusions: Cross-gendered individuals, regardless of sexual orientation, appear to have higher risk for suicidal symptoms. Researchers and clinicians should assess gender role in evaluations of youth samples. D

Background: We studied the characteristics of family functioning in bipolar children and healthy comparison children. We hypothesized that the family environment of bipolar children would show greater levels of dysfunction as measured by the Family Environment Scale (FES). Methods: We compared the family functioning of 36 families that included a child with DSM-IV bipolar disorder versus 29 comparison families that included only healthy children. All subjects and their parents were assessed with the K-SADS-PL interview. The parents completed the FES to assess their current family functioning. Multivariate analysis of variance was used to compare the family environment of families with and without offspring with bipolar disorder. Results: Parents of bipolar children reported lower levels of family cohesion ( p b 0.001), expressiveness ( p = 0.005), activerecreational orientation ( p b 0.001), intellectual-cultural orientation ( p = 0.04) and higher levels of conflict ( p b 0.001) compared to parents with no bipolar children. Secondary analyses within the bipolar group revealed lower levels of organization ( p = 0.031) and cohesion ( p = 0.014) in families where a parent had a history of mood disorders compared to families where parents had no history of mood disorders. Length of illness in the affected child was inversely associated with family cohesion (r = −0.47, p = 0.004). Limitations: Due to the case-control design of the study, we cannot comment on the development of these family problems or attribute their cause specifically to child bipolar disorder. Conclusion: Families with bipolar children show dysfunctional patterns related to interpersonal interactions and personal growth. A distressed family environment should be addressed when treating children with bipolar disorder.

Objective: To assess the sensitivity and specificity of two self-report instruments for detection of bipolarity in a sample of Argentinean patients. Method: Spanish versions of the MDQ and the BSDS were administered over four months at 11 sites in Argentina. Diagnoses were made using DSM-IV criteria and the MINI. The study sample consisted of patients diagnosed with Bipolar Disorder (BD) Types I, II, or NOS. BDNOS diagnoses were made using extended guidelines for bipolar spectrum symptoms. Unipolar patients were used as a control group. Of 493 patients screened, 354 completed evaluation by MDQ and MINI, and 363 by BSDS and MINI. Results: Specificity of MDQ was 0.97 and BSDS was 0.81. MDQ sensitivity was 0.70 for bipolar type I (BD-I), 0.52 for bipolar II (BD-II) and 0.31 for bipolar not otherwise specified (BDNOS). BSDS sensitivities were 0.75, 0.70 and 0.51 respectively. Limitations: This study was performed in specialized outpatient settings and thus its results are not necessarily representative for other clinical settings. There was not a systematic evaluation of comorbid psychiatric disease or test-retest reliability. Conclusion: The local versions of the MDQ and the BSDS showed a sensitivity and specificity comparable to previous research. Our results indicate that in this sample, MDQ was more specific for BD and BSDS was more sensitive to detect BD-II and NOS. Since BD-I is more readily recognized than bipolar spectrum disorders, enhanced sensitivity of BSDS for soft bipolarity may be an advantage.

Background: There are high rates of co-occurring depression among young people with substance use disorders. While there is preliminary evidence for the effectiveness of integrated cognitive behaviour therapy (CBT) in combination with antidepressants among alcohol and substance dependent adolescents and adults with co-existing depression, no studies have examined the effectiveness of integrated CBT interventions in the absence of pharmacotherapy.

Background: Bright artificial light improves non-seasonal depression. Preliminary observations suggest that sunlight could share this effect. Methods: Length of hospitalization was recorded for a sample of 415 unipolar and 187 bipolar depressed inpatients, assigned to rooms with eastern (E) or western (W) windows. Results: Bipolar inpatients in E rooms (exposed to direct sunlight in the morning) had a mean 3.67-day shorter hospital stay than patients in W rooms. No effect was found in unipolar inpatients. Conclusions: Natural sunlight can be an underestimated and uncontrolled light therapy for bipolar depression. Limitations: This is a naturalistic retrospective observation, which needs to be confirmed by prospective studies.

Introduction: As several lines of evidence point to irregular biological rhythms in bipolar disorder, and its disruption may lead to new illness episodes, having an instrument that measures biological rhythms is critical. This report describes the validation of a new instrument, the Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN), designed to assess biological rhythms in the clinical setting.

Background: It has recently been hypothesized that bipolar disorders are associated with accelerated aging. Telomere dysfunction, a biomarker of aging, is determined by the load of short telomeres, rather than by the mean telomere length. To our knowledge, the load of short telomeres has not been reported in any psychiatric disorder. The aims of the study were to examine the load of short telomeres and the mean telomere length and their relationships with illness duration and lifetime number of depressive episodes in bipolar II disorder (BD-II). Methods: Twenty-eight patients (mean age = 34.8 ± 7.7) with a DSM-IV diagnosis of BD-II and 28 healthy control subjects (mean age = 34.8 ± 9.2) matched for age, sex, and education participated. The load of short telomeres (percentage of telomeres b 3 kilobases) and mean telomere length in peripheral blood mononuclear cells were measured using high-throughput quantitative fluorescence in situ hybridization. Results: The load of short telomeres was significantly increased in patients with BD-II relative to healthy controls and may represent 13 years of accelerated aging. The load of short telomeres and the mean telomere length were associated with lifetime number of depressive episodes, but not with illness duration. Limitations: Modest sample size and cross-sectional design. Conclusions: Our results suggest that BD-II is associated with an increased load of short telomeres. Depressive episode-related stress may accelerate telomere shortening and aging. However, longitudinal studies are needed to fully clarify telomere shortening and its relationship with clinical variables in BD-II.

Background: The influence of psychosocial stress on the course of bipolar disorder has been increasingly recognized. The authors tested hypotheses about both stress and early adversity "sensitization" on the course of bipolar disorder over a one-year period. Methods: The participants were 58 adults (29 male and 29 female) with a diagnosis of bipolar I disorder. They were evaluated every three months for one year. Stressful life events and the presence of early adversity were assessed by structured interview. Results: There was no significant interaction between stress and episode number in the prediction of bipolar recurrence. The interaction of early adversity severity and stressful life events significantly predicted recurrence in a manner consistent with the sensitization hypothesis. Participants with early adversity reported lower levels of stress prior to recurrence than those without early adversity. Individuals with early adversity also had a significantly younger age of bipolar onset. Limitations: The sample size was small and the number of past episodes was determined retrospectively, mainly through self-report. Conclusions: Severe early adversity may result in a greater effect of stress on bipolar recurrence and earlier onset of bipolar disorder, suggesting the need for further studies of stress mechanisms in bipolar disorder and of treatments designed to intervene early among those at risk.

Background: Since treatment approaches thought to be useful for mania are presumably suitable for hypomania as well, little systematic research has been done on the treatment of hypomanic episodes and their long-term outcome. As systematic trials have shown that the atypical antipsychotic risperidone may be effective and safe in the treatment of acute mania, we decided to conduct an open-label study of its effectiveness and tolerability in hypomania associated with bipolar II. Methods: Forty-four DSM-IV bipolar II patients with Young Mania Rating Scale (YMRS) scores above 7 were included and followed-up for 6 months. Efficacy was measured by means of the YMRS and the Clinical Global Impression for Bipolar Disorder (CGI-BD). Treatment-emergent depression was measured by the Hamilton Depression Rating Scale (HDRS-17), and the Udvalg for Kliniske Undersøgelser (UKU) subscale was used for neurological/extrapyramidal side-effects. Results: Thirty-four patients completed the trial. The mean dose of risperidone at endpoint was 2.8 mg/day. Last observation-carried-forward analysis showed significant reduction of YMRS scores from the first week of treatment, which continued until the endpoint (P<0.0001). At 6-month follow-up, 60% of patients were assymptomatic according to the CGI. The 32% who received risperidone in monotherapy seemed to respond equally well. Risperidone, as used in this study, appeared to be most protective against hypomanic than depressive recurrences. Nine patients (12%) had a depressive relapse during 6-month follow-up, one patient (2%) had an hypomanic relapse and another (2%) had both. No patients developed tardive dyskinesia during the duration of the study. Although most patients received risperidone in combination with standard mood-stabilizers, only three patients discontinued risperidone because of other side-effects. Limitations: In the absence of a placebo arm, it is uncertain to what extent the foregoing results could be ascribed to spontaneous remission of bipolar II disorder. Conclusions: Risperidone, either in combination with mood-stabilizers or alone was well-tolerated in bipolar II patients, who presented in a hypomanic state, and appeared efficacious. Further controlled research on the role of atypical antipsychotics in the treatment of less-than-manic forms of bipolar illness is warranted.

Background: Several lines of evidence suggest hippocampal dysfunction in major depression, but the prevalence and nature of specific dysfunctions during the long-term course of major depression is yet to be assessed. A 3D virtual environment navigation task and measurements of hippocampal volume were assessed in remitted former inpatients with moderate to severe depression after an 8 year follow-up period to evaluate whether functional and structural differences existed in the hippocampus beyond depression. Methods: Performance on a right hippocampus-dependent 3D virtual reality navigation task, memory tests and right and left hippocampal volumes were assessed in 31 remitted depressed (unipolar) patients and 37 healthy subjects. Results: Remitted depressed patients did not differ significantly from healthy subjects in terms of either neuropsychological performance or hippocampal volume. Limitations: The sample consisted of remitted inpatients that had been treated with psychotropic drugs during the 8-year follow-up period. Moreover, 11 of the 42 patients included in the original study were excluded from the follow-up study due to persisting depressive illness and suicide. Conclusions: The study of visuospatial navigation ability and hippocampal volume in remitted depressed patients offers a specific way of assessing dysfunction in the hippocampus in major depression. Our findings do not support the notion that hippocampal impairment of visuospatial function exists beyond the depressive state, thus indicating that hippocampusrelated cognitive dysfunction and previously reported reduced hippocampal volume might represent a state and not a permanent trait of the illness. Moreover, our study suggests that intensive drug treatment of the depressive episodes might prevent the deterioration of the hippocampus.

Objective: We conducted a critical literature review of studies assessing the prevalence of mood disorders (MD) in subjects with eating disorders (ED; anorexia nervosa and bulimia nervosa). In the first part of this article, we discuss methodological issues relevant to comorbidity studies between ED and MD. In the second part, we summarize the findings of these studies in light of the methodological considerations raised. Method: A manual computerised search (Medline) was performed for all published studies on comorbidity between ED and MD. In order to have sufficiently homogeneous diagnostic criteria for both categories of disorders, this search was limited to articles published between 1985 and 2006.

Objective: To evaluate a brief training program on suicide prevention for front-line general hospital personnel in terms of its impact on their attitudes and beliefs towards suicidality. Method: Forty non-clinical (e.g., security staff), and 102 clinical (e.g., nursing attendants) professionals employed in a university hospital in Brazil were evaluated with the Suicide Behavior Attitude Questionnaire [SBAQ] before the start and immediately after a 3hour training on suicide prevention. Results: Surprisingly, there were no significant differences for the great majority of the SBAQ items (i.e., 20 of 21) between clinical and non-clinical staff both pre-and post-training. Furthermore, their attitudes and beliefs towards suicidality were significantly improved after training in the majority of SBAQ items, with p-values ranging from 0.01 to b0.0001.

Background: The temperament evaluation of the Memphis, Pisa, Paris and San Diego questionnaire (TEMPS), in its rater-wise and its self-evaluation forms, has been designed to evaluate temperamental characteristics in clinical and non-clinical populations. The validation process is currently in progress in various countries. In order to improve this validation process we have extended the area of correlations of its self-evaluation form (TEMPS-A[P]) to MMPI, and to a special RS that allows assessment of the emotional-affective state following a stressful situation. Methods: In 693 candidates applying to become cadets in the Italian Air Force we have assessed the correlation between the TEMPS-A[P] and the MMPI validity and clinical scales, and administered an emotional-affective state questionnaire (EAS-RS) after they had gone through the stressful challenge of taking an academy entrance examination. Results: As regards MMPI validity scales, TEMPS-A[P] depressive candidates tend to report their symptoms sincerely. Hyperthymic candidates tend to give false answers so that others will see them in a good light. Cyclothymic and irritable candidates tend to exaggerate symptoms. As regards the MMPI clinical scales, a low level of linkage between affective temperaments and abnormal personality traits was found. As regards EAS-RS: hyperthymic temperament on one hand, and cyclothymic and depressive temperaments on the other, are characterized by counterpolar emotional states following the test; these are desirable in the first case and undesirable in the other two. Conclusions: The convergent and discriminant validity of TEMPS-A[P] was confirmed. From a personalistic point of view, temperaments seem to belong to the realm of normality rather than to that of pathology, in line with their putative adaptive role.

Aims and objectives. To provide a meta-analysis of the effects of music interventions on patients with dementia, separating, for the first time, between different types of interventions and different outcome measures, namely affective, behavioural, cognitive and physiological. Background. Music therapy is an attractive form of intervention for the growing number of demented patients, for whom pharmacological interventions are not always effective and may lead to undesired side effects. While music is more frequently applied in clinical settings for each year, no meta-analysis has considered effects of music interventions on affective, behavioural, cognitive and physiological outcomes separately. Design. A standard meta-analysis approach was applied. Methods. We include all original studies found for the key words music and dementia. Mean effect sizes and confidence intervals are computed from study effect sizes according to standard methods, and these are considered for various common types of music interventions separately. Results. Nineteen studies with a total of 478 dementia patients exhibit effect sizes ranging from 0Á04-4Á56 (M = 1Á04). Many of these indicate large positive effects on behavioural, cognitive and physiological outcome measures, and medium effects on affective measures. Conclusions. Music interventions seem to be effective and have the potential of increasing the quality of life for patients with dementia. Many studies in this area suffer from poor methodological quality, which limits the reach of meta-analysis and the strength and generalisability of these conclusions. Relevance to clinical practice. Being inexpensive and largely without adverse side effects, current knowledge seems to indicate that music interventions can be recommended for patients in all stages of dementia.

ecent economic reports in the United States indicate that more than 550,000 families of young children are homeless (National Center on Family Homelessness, 2003) and 13 million children are living in poverty (Fass & Cauthen, 2007). Yet homelessness and the effects of poverty on families go beyond U.S. borders; they are global problems. More than 100 million families worldwide lack permanent housing or sufficient income to meet their basic needs (Capdevila, 2005). Impact of Homelessness on Children Multiple causes of homelessness include a lack of affordable housing, low wages, war, domestic violence, and natural disasters such as hurricanes, tornadoes, and floods. Some homeless children are able to succeed in school despite the many challenges they face, but others are at risk for emotional (

Background: The Young Mania Rating Scale (YMRS) has validity in the assessment of mania in adults. The purpose of this study was to examine how the YMRS might optimally be used in the assessment of youths. Methods: Children and adolescents between the ages of 5 and 17 years of age participated in this study. All youths were evaluated with the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). Based on the K-SADS results, subjects were then assigned to one of five groups: a bipolar I group, another bipolar spectrum group, a depressive disorders group, a disruptive behaviors disorders group, and a no diagnosis group. Guardians completed a version of the YMRS modified for parent reporting. Clinicians completed the YMRS on all participating youths. Results: Both parent and clinician ratings on the YMRS assigned patients (n = 117) to the appropriate diagnostic group with 71 -98% accuracy. Combining information from multiple informants did not significantly improve diagnostic group assignment. Limitations: The same raters completed the clinician YMRS and the K-SADS interview involving the parent. Findings need replication in an independent sample with lower base rates of bipolar disorder, less rigorously trained and supervised raters, and using a prospective design to provide maximum generalizability of results. Current results should be interpreted as a 'best case' scenario. Conclusions: These data suggest that the YMRS may be a useful adjunct in assessing the severity of mania in youths. Tentative cutting scores are proposed to maximize efficiency, sensitivity, and specificity. D

BackgroundDespite the fact that public speaking is a common academic activity and that social phobia has been associated with lower educational achievement and impaired academic performance, little research has examined the prevalence of social phobia in college students. The aim of this study was to evaluate the prevalence of social phobia in a large sample of Brazilian college students and