The diagnosis of Bipolar Disorder (BD) is still controversial in the early stages of life, not only because of its difficulty, but also because of the precaution of professionals with this diagnosis, since it is a chronic illness.

To review and synthesize available information about paediatric BD.

The authors consulted, selected and reviewed information concerning the theme, mainly searched on-line articles.

It is difficult to diagnose BD in youths, considering the fewer specific symptoms and the high co-morbidity.

Despite some disagreement on this diagnosis, BD is a valid clinical entity in children and adolescents.

The study attempts to delineate the clinical correlates (suicidal risk, manic, depressive and psychotic symptom severity) and course characteristics (age of onset and details of past affective episodes) of bipolar mixed state and compare with bipolar manic and bipolar depressed state diagnosed according to ICD-10 Diagnostic Criteria for Research(ICD-10 DCR).

The study was carried out in inpatient psychiatry setting of Kasturba Hospital, Manipal, India over a period of 10 months. It was an Open, Non-randomised, Naturalistic study with sequential sampling. The rating scales used were Hamilton Depression Rating Scale (HDRS), Young Mania Rating Scale (YMRS), Positive and Negative Symptom Scale for Schizophrenia (PANSS) and Beck Scale for suicidal ideation.

A total of 70 subjects were included in the study meeting the criteria of bipolar disorder currently manic, depressed and mixed state according to ICD-10 DCR.

Manic group constituted the majority (n1 = 47) followed by depressed (n2 = 17) and mixed groups (n3 = 6). Mixed group was characterized by preponderance of females, high suicidal intent, high frequency of mood-incongruent psychotic symptoms, illness severity and significant family history.

The study was able to establish some core features that were specific to mixed states. A larger sample size and a prospective follow up study would throw light on the existence of this group as an independent entity.

Serum concentration of lithium may change according to mood states in bipolar patients, leading to reduced serum levels of lithium during manic periods.

Documentation of mood states and serum lithium levels in a rapid cycling patient

We report about a 58 year old female patient with rapid cycling disorder whose mood altered every 20 to 30 days. No treatment has been effective until now. The patient is treated with a stable combination of clozapine 200mg, valproate 1500mg and lithium carbonate 450mg. Noncompliance can be ruled out since intake of medication is supervised. For 13 months a mood diary was performed by a relative using a simple scale for mood which rated neutral mood with 0, mania with +1, +2 and +3 (highest mania) and depression from -1 to -3 (deepest depression). Lithium levels were obtained first on a monthly, later on a weekly to two-weekly basis.

Over a period of 13 months 7 depressive and 6 manic phases could be observed. The patient spent 230 (48%) days in depression (8 lithium samples obtained), 137 (29%) in mania (11 samples) and was euthymic on 68 (16%) days (2 samples). Mean lithium serum levels were 0.68mmol/l in depressive states, 0.37 mmol/l in manic states (p = .001, t-test). The lowest value was 0.13 mmol/l (in mania) and the highest 0.93 mmol/l (in depression).

In this patient mood-dependent changes of serum lithium levels during constant medication could be demonstrated. The reasons for this phenomenon are yet to be elucidated.

Bipolar disorder (BPD) is a common, severe, and persistent psychiatric illness affecting 1.3% to 1.7% of the population. Substance use disorders (SUDs) are also common. A community-based study found a lifetime prevalence of 17% for alcohol abuse or dependence and 6% for other substances. BPD and SUDs occur together more frequently than would be expected by chance alone.

This study was conducted to determine the pattern of substance abuse among Iranian bipolar disorder inpatients.

We reviewed the history of patients who admitted with bipolar diagnosis in any phase to determine types of substance usage.

This descriptive-analytical cross-sectional study on existing data, conducted among 322 patients with bipolar disorder attending to Imam-Hossein Hospital. The clinical records of each patient was assessed for any type of substance or alcohol related disorders.

84 patients (26.1%) had substance use disorders. 40.5% were using opioids, 6% mood-elevators, 7.1% alcohol, and 46.4% were using multiple substances. The mean duration of substance abuse was 104 months plus 23 days.

Totally, it may be concluded that substance abuse frequency among patients with bipolar disorder is high and may lead to deteriorated prognosis. Substances can also distort the clinical feature and course of the disorder and may create difficulties in correct diagnosis

Attention to caregiving consequences has been mainly restricted to bipolar disorder, although studies suggest that relatives of bipolar patients also experience considerable distress.

The purpose of this study was to explore the lived experiences from family member caregiver with bipolar disorder patient.

In a qualitative research of phenomenological methodology, the family member's caregivers of bipolar disorder in farshian psychiatric hospital in Hamedan (Iran) were selected by purposive sampling in the year 2010. By reaching data saturation the number of participant was 12. Data were gathered through in-depth interviews and analyzed by “Van manen” method.

Analysis of the interviews revealed six major themes: emotional impact, physical impact, social impact, Financial Impact, Disruption of family functioning and social support needs.

Highlight the need for family-oriented mental health services to be developed and for further research to identify the specific nursing interventions that are effective in helping to sustain family caregiving.

Several studies revealed that cognitive functioning in BPD are impaired not only in the acute phase but over time (Mur et al., 2008). On Theory of Mind (ToM) recent studies found a impairment of this ability in remitted patients, supporting the theory that ToM deficits are trait-dependent (Bora et al., 2009) in contrast with another study that suggest a partially dependence(Wolf et al. 2010).

We explored: a) ToM in BPD investigating two cognitive processes: emotional recognition, second order beliefs attribution; b) Moral judgments in BPD; c) possible effects of neuropsychological functioning on ToM task and moral dilemmas.

The principal aim is to investigate the domain specificity of ToM and Moral sense, studying selective impairments.

A total of 20 patients with bipolar I disorder were tested and 20 healthy controls. We use a complete neuropsychological assessment, two ToM tasks (Eyes test, Sullivan's stories) and we added two moral dilemmas to asses moral judgment Results: We found ToM deficits in BDP, with a multiple correlation between ToM and neuropsychological functioning. Also we found for the first time a impairment on personal moral dilemma, with a correlation between emotional recognition and moral judgments.

Patients with BPD are impaired in ToM partially independent of other cognitive dysfunctions and in moral reasoning.

Superiority of asenapine vs placebo, as monotherapy or adjunctive therapy to lithium or valproate, for acute bipolar mania has previously been reported.

Present meta-analyses of asenapine compared with atypical antipsychotics based on placebo-controlled trials.

Further demonstrate the efficacy of asenapine for acute bipolar mania.

The primary endpoint was change from baseline vs placebo on Young Mania Rating Scale (YMRS) total score at treatment week 3. Data for asenapine (5 or 10 mg BID) and comparators were obtained from all monotherapy (n = 20) or adjunctive treatment trials in patients showing incomplete response to lithium or valproate monotherapy (n = 10) published at the time of the analysis. Meta-analyses used a random-effects model described by DerSimonian and Laird (Control Clin Trials 1986;7:177–188).

Treatment effects varied substantially across agents and for individual agents across trials. For monotherapy, the change from baseline in YMRS total score with asenapine exceeded placebo by 4.5 points (95% CI, 2.5–6.4; p < 0.0001); this was comparable to the treatment effect of all comparators vs placebo (4.9 points; 95% CI, 3.8–6.0). The treatment effect for adjunctive asenapine exceeded placebo by 2.4 points (95% CI, 0.5–4.3); this was also comparable to the overall treatment effect for the combined comparators (2.7 points; 95% CI, 2.0–3.3).

These meta-analyses demonstrate statistical superiority of asenapine over placebo, as monotherapy or adjunctive therapy, for acute bipolar mania. Further, they reveal that the efficacy of asenapine is similar to that of other atypical antipsychotics used as monotherapy or adjunctive therapy.

An observational study of the diagnosis of 300 consecutive new patients in a period of four years led to the main observation of a high percentage of bipolar spectrum diagnosis (4), followed to a new classification of “the bipolar spectrum” (ten sub-types of bipolar spectrum mood).

Inside these sub-types also the temperaments have been inserted, even if they are only sub-clinical aspects of the bipolar spectrum (sub-threshold forms).

With the same method (the diagnostic method was based on an analysis of clinical interviews and personal history of the illness) and with the same aims, others 123 consecutive new patients have been valued for the other subsequential two years; then, all the 423 patients of the six years evaluation have been revalued to put in evidence the presence of their temperaments, emerging from their personal anamnesis.

It appears clear that significantly more patients within the series appear to have a soft bipolar illness than a major unipolar depression; the depressive episodes are now considered as only one phase of bipolar spectrum. Besides, every patient with bipolar spectrum disorder already presented in their personal history of the illness a sub-clinical evidence of one temperament (hyperthymic temper.: 35%; cyclothymic temper.: 49%; depressive temper.: 16%).

The subthreshold presence of the temperaments in the history of the patients with bipolar spectrum disorders allow us to consider this crucial way for early diagnosis of bipolar spectrum mood disorders.

It's not always evident to diagnose a bipolar disorder.The difficulties of diagnosis have been demonstrated by several studies, some of which have shown that one out of two bipolars consulted at least three health professionals before receiving a proper diagnosis, with an average period of 10 years evolution prior to diagnosis. hypomania is often experienced by patients as a pleasant experience and not a pathological one, rarely have they reported this phenomenon spontaneously. Thus, the diagnosis of hypomania or BP-II disorder is not established in 50% of cases.

to find the prevalence of bipolar disorder type II in a population of depressed people in order to highlight the role of scales in the early identification of this disease often under-diagnosed.

a prospective study of screening for a history of hypomania in a population of patients hospitalized for consultants or major depressive episode or recurrent depressive disorder; over a period of three months

The diagnoses of MDE and RDD were prepared according to the DSM-IV.TR.

The screening tool is the Hypomania Checklist (HCL French version) which was completed by patients or by the psychiatrist of illiterate patients after its translation into Arabic dialect

Sample of 35 patients: 20 women and 15 men, average age: 34 years; Composed of 25 RDD and 10 MED

15 patients answered “yes” to 10 or more items of the HCL-20, hypomanic history was confirmed by a clinical interview in 13 of them

Psychosocial representations about the manic episode may constitute personal difficulty factors in dealing with the disorder, to relate socially and compromise satisfactory adherence to clinical treatments. It was elected to recall the experiences of manic episode due to its social and individual stigma.

To discuss the meanings of life experiences regarding manic episodes as reported by outpatients with bipolar affective disorder in remission.

Research methodology from the Humanities employed to health settings, using clinical-qualitative method, with the technique of semi-directed interview with open-ended questions. The sample was closed by the criterion of theoretical saturation of information. Eight interviews were conducted in a university psychiatric clinic. Data were treated through the qualitative content analysis, with free-floating readings of the corpus - the set of the transcribed interviews - in order to categorization in core's discussion.

Patients whom experienced manic episodes use unique adaptive mechanisms to deal with their psychosocial experiences and emotions. The highlights were the recognized strategies of bargaining, denial, rationalization and escaping when facing the experienced problems.

The recognition of the management of patients’ experiences of mental disorder by the healthcare team can better harmonize the professional-patient relationship and develop strategies for greater adherence to the therapeutic and preventive measures for recurrence of the episodes.

Early onset forms of bipolar disorder may be difficult to distinguish from schizophrenia. Although operational criteria have become more precise, and there are more diagnostic systems to catalogue a psychotic adolescent, the clinicians continue having difficulties.

To know the stability of the diagnosis of definitively bipolar patients with psychotic symptoms during the episodes, and factors that can influence other psychotic diagnoses in the first episode of the illness.

140 bipolar patients of Araba, (Basque country) were included during 2 years. Patients were divided into two groups: unstable diagnoses (UD)(bipolar patients with an initial diagnosis of other psychosis) and stable diagnoses (SD) of bipolar disorder. Clinical and sociodemographic data were obtained.

The mean age at onset was significantly lower in the UD group (p = 0.004). It was rare to have an unstable diagnosis when the first psychotic episode occurred after age 38 (p = 0.008). There were more singles in the UD group (p = 0.010).

The presence of mood incongruent psychotic symptoms was more frequent in the UD group (p < 0.001).

Mood incongruent psychotic symptoms variable was the only independent factor significantly associated with an unstable diagnosis in the multivariate analysis (p = 0.036).

One third of the patients have been previously diagnosed with other psychotic illness.

This study suggests that the most important factor is the clinical picture, especially the presence of mood-incongruent psychotic symptoms. A correct diagnosis is important because patients who are prescribed mood stabilizers have lower rates of rehospitalisation than those who are not treated with mood stabilizers.

Research evidence on bipolar disorder supports the importance of patients’ active role to improve outcome and the efficacy of a number of psychosocial interventions. The lower cost and potential ease of dissemination of group psychoeducation suggest that this should be a first line approach, with more complex interventions, requiring highly specialized skills, reserved to selected patients. However, to what extent research models can be transferred to everyday practice remains to be seen.

To explore the delivery of psychosocial interventions to bipolar disorders patients in routine mental health care.

To estimate the treated prevalence of bipolar disorders in Milan and to collect data about the variety of psychosocial interventions patients received by mental health services.

A survey of psychosocial interventions received by bipolar patients in three mental health services of Milan (catchment area 867,000 inhabitants) was conducted in 2009. Data from the Regional Mental Health Information System were retrieved to calculate the number of patients involved in psychosocial interventions and the kind of intervention provided.

The treated prevalence rate was low, showing a probable treatment gap. Only 20% of 636 bipolar patients received at least one psychosocial intervention. The interventions provided were: family psychoeducation (3,8%), individual social skills training (11,5%), group social skills training (1,4%), and relatives group (3,0%).

Few bipolar patients receive psychosocial interventions in the MHS of Milan. Moreover, the interventions received were not specifically designed for bipolar disorder. Treatment gap could be reduced providing psychoeducation especially designed for bipolar patients.

Bipolar disorder (BD) is a major psychiatric disorder that has important consequences for those who live with it. Day by day new contributions for diagnosis and treatment appear thanks to a continuous research advance. However there are many challenges to defeat such as the pathways to care that bipolar patients choose, and the different factors that have an impact on seeking for treatment.

To describe the role that perception of disease has on the selection of pathways to care in patients with BD.

To generate information to augment the available data for specific interventions in bipolar patients.

We studied perception of disease in six patients with BD through focused interviews. The results were analyzed from a qualitative approach.

We found that even when the main type of health care practices reported by these patients had to do with the allopathic form, usually they combine and try different health care forms. This allows each patient to build their own pathway to care in order to meet their needs and their suffering from living with BD.

Pathways to care in BD are composed of a combination of health care practices, this situation happens because the patient needs to look for the possibility to get a stock of potential alternatives of treatment which allow to maximize his/her curative resources. Beside this, having a variety of treatment modalities helps bipolar people to deal with the different issues that are part of the experience of living with BD.

The Wide AmbispectiVE study of the clinical management and burden of bipolar disorder (BD) (WAVE-bd; NCT01062607) is ongoing to address limitations of longitudinal BD studies to-date focused on single disease phases or treatment.

To describe baseline bipolar mood state and severity in a cohort of patients with BD.

Multinational, multicentre, non-interventional, longitudinal study of patients diagnosed with BD-I or BD-II with ≥1 mood event in the preceding 12 months (retrospective data collection from index mood event to enrolment, followed by 9-14 months’ prospective follow-up). Site and patient selection provided a sample representative of bipolar populations. The study includes descriptive analyses of demographics, diagnosis and medical history.

2880 patients (mean age 46.5 years [SD: 13.3]; 62.0% female) were recruited March to September 2010: 1989 (69.1%) BD-I and 891 (30.9%) BD-II. Time (years) from first symptoms to diagnosis was 2.9 [SD: 6.6] (BD-I) and 4.4 [SD: 8.0] (BD-II). Of the total population, 20.8% lived alone (13.9% BD-I, 6.9% BD-II), 36.7% were employed (24.0% BD-I, 12.7% BD-II) and 13.3% unemployed (9.5% BD-I, 3.8% BD-II). Disease status at inclusion (BD-I, BD-II, respectively [mild, moderate, severe]) included hypomania (7.9% [67.7%, 31.0%, 1.3%], 6.5% [70.7%, 29.3%, 0%]), mania (7.1% [26.1%, 47.2%, 26.8%], 0%), euthymia (58.6%, 60.3%), depression (19.7% [38.8%, 47.7%, 13.5%], 31.1% [41.2%, 46.9%, 11.9%]) and mixed (5.7% [30.1%, 46.9%, 23.0%], 0%).

This ongoing study provides detailed insight into a large BD population, showing the majority with euthymia and an important proportion with depression both in BD-I and BD-II patients.

The Wide AmbispectiVE study of clinical management and burden of bipolar disorder (BD) (WAVE-bd; NCT01062607) is ongoing to address limitations of longitudinal BD studies to-date focused on single disease phases or treatment.

To understand current treatment approaches for patients with BD in daily clinical practice.

Multinational, multicentre, non-interventional, longitudinal study of patients diagnosed with BD-I or BD-II with ≥1 mood event in the preceding 12 months, followed-up for 12-27 months (including retrospective and prospective phases). Site and patient selection provided a sample representative of bipolar populations. The study includes descriptive analyses of demographics, diagnosis, medical history and clinical management. Medication use during the retrospective phase will be presented.

Preliminary results (based on data availability at time of submission) are presented from 2829 patients recruited March-September 2010. During the retrospective period, 94.3% (94.2% BD-I, 94.6% BD-II) of patients received BD therapy. Among BD-I and BD-II patients, respectively, the most common number of prescribed drugs was two (29.5%, 31.5%); 17.6% and 18.1% were prescribed one drug, and 11.5% and 9.8% were prescribed five or more. Drug classes most commonly used (BD-I, BD-II, respectively) were atypical antipsychotics (64.5%, 48.9%) anticonvulsants (58.0%, 54.3%), antidepressants (39.6%, 66.7%) and lithium (31.2%, 17.3%). Electroconvulsive therapy was used in 12 (0.4%) patients (9 BD-I, 3 BD-II). Average treatment duration with atypical antipsychotics, anticonvulsants and antidepressants was 165.0, 199.7 and 169.7 days, respectively.

This ongoing study provides a multinational perspective on BD patient management practices in a large sample population. Financial support: AstraZeneca

To determine the characteristics and time course of diagnostic conversion from unipolar depression to bipolar depression in a retrospective cohort of psychiatric outpatients, and to compare the clinical and sociodemographic profiles of the bipolar switch group against a matched group without conversion.

This is a retrospective case-control study in which outpatients newly diagnosed of unipolar depression from 1st January 1994 to 31st December 1999 were reviewed. Those with conversion to bipolar depression were identified and controls were matched.

Multivariate conditional logistic regression was carried out to identify predictors of bipolar switch.

88 patients out of 823 were identified with bipolar switch. The mean age at switch was 37.58 years old. The mean time interval from presentation to conversion was 58.13 months. Sodium valproate was most commonly used after switch. Bipolar switch was associated with male sex (OR 2.601, 95% CI 1.279 – 5.291, p = 0.008), an earlier age at presentation of depression of < 37 years old (OR 2.238, 95% CI 1.136 – 4.409, p = 0.020), family history of bipolar affective disorder (OR 5.684, 95% CI 1.149 – 28.124, p = 0.033) and use of 3 or above different antidepressants in the first five years after presentation (OR 2.105, 95% CI 1.082 – 4.098, p = 0.028).

The incidence of bipolar switch found in this study was 10.7%. Family history of bipolar affective disorder and frequent switch of antidepressants in depressive patients presenting at a young age can be helpful guidance for identification of those at high risk for a bipolar course.

A notion exists of a special kind of relationship between poets and being “crazy”. A possible correlation between madness and genius is one of the oldest and most persistent and controvertialof cultural concepts. We decided to investigate the relationship between manic-depressive illness and the artistic temperament.

A review was conducted on Professor Kay Redfield Jamison's treatise Touched with Fire, Manic-depressive Illness and the Artistic Temperament.

Research strongly suggests that, compared with the general population, writers and artists show a vastly disproportionate rate of the affective disorders manic-depressive and depressive illness. Research employing systematic biographical methodology has also given strong support to a much higher rate of mood disorders in artistic populations than could be expected from chance alone. A British study revealed many overlapping mood, cognitive, and behavioral changes between hypomania and intense creative states. Many of the changes in mood, thinking, and perception that characterize the mildly manic states are highly characteristic of creative thought as well. Although it seems counterintuitive at first, melancholy has also been reported to be associated with artistic inspiration and productivity.

Not all (not even most) writers and artists suffer from major mood disorders. Likewise, most of those who have a major mood disorder are not writers or artists. However despite this, research does strongly suggest that there is a correlation between manic-depressive illness and the artistic temperament. The major resistance to an association between psychopathology, or mental illness, and creativity seems to revolve around a few central points.