A 26 year old-male,from Cabo Verde,is interviewed in the Emergency Department in June 2011 presenting disturbance of general behaviour.He is being aggressive and presents flight of ideas.The diagnosis: “Hypomanic state” treated with lorazepam 6 mg/day and Olanzapine 5 mg/day. August 2011, the patient is reevaluated because of his behaviour:soliloquies,laughs,expansive mood, abnormal irritability, easily excited to enthusiasm and irritable humor. He also presents psychomotor agitation associated to delusion of persecution.He has not been taking his medication. No other neurological symptoms are detected.

In Hospital he receives Risperidone 6 mg/day, Clorazepate Dipotassium45mg/day and Lormetazepam 2 mg /day disappearing most of the symptoms.

A MRI was done, presenting triventricular hydrocephalus with absence of intraparenchymal damage.After monitoring the intracranial pressure, Neurosurgery decides not to perform surgery.

In the case of not responding to Risperidone, studies have been published that Aripiprazole (atypical antipsychotic with a unique partial agonistic effect at D2receptors)is effective and safe in the treatment of manic episode. Some publications about the reduction of D2receptors demonstrated that the binding of striatal was reduced in NPH.

Sometimes imaging tests are needed in patients with behavioural disturbance as manic symptoms in order to avoid misdiagnosis and it is crucial for the correct medical and chirurgical treatment.

Our preceding studies showed that adding an antidepressant(AD) to quetiapine (acute-phase-mixed-episodes) would improve dysphoric-manic-symptoms and outcome.

To evaluate the maintenance of improvement (dysphoric-manic-symptoms)-(mixed-episodes).

Participants were 44-subjects diagnosed (type-I mixed-Bipolar-Disorder)-(DSM-IV-TR). After receiving open-label quetiapine (2-weeks), patients were subsequently randomised to receive either treatment with quetiapine(alone)(n = 22) or quetiapine+AD(n = 22). We followed-up these patients for a whole period of 54-weeks; subjects were evaluated every 4-weeks using Young-Mania-Rating-Scale(YMRS), Hamilton-Depression-Rating-Scale(HAMD-21).

Therefore of baseline 44-subjects 41(22 females) were evaluated up to week54, mean-age 42.0 ± 5.4; 21 were treated with AD; dosage of quetiapine was not different in the two-groups. The efficacy over depressive-symptoms progressed over time but parallel in both groups. Relatively to YMRS-scores, on the contrary, a similar continued improvement until study-end was observed but with differences in two groups, week18 scores dropped from 16.5 ± 4.7(vs)9.6 ± 3.8 to week54 score 10.2 ± 3.1(vs)6.1 ± 2.3: repeated-measures-ANOVA revealed significant time-effect=p < .001, treatment=p < .005; interaction=p = .001. Three YMRS-item-scores improved significantly: irritability, disruptive-aggressive-behaviour and insomnia. No suicide attempters were revealed (HAMD-item-4).

We cautiously suggest that adding an AD in order to treat every main features of mixed-episode further improved the dysphoric-manic-symptoms. Moreover, in the long-term, continuing AD-treatment further improve symptomatology, as indicated by a significant reduction of both HAMD-21 YMRS-scores; unexpectedly, the aspects better controlled seemed to be the manic ones, particularly disruptive-aggressive-behaviour irritability and insomnia. So, speculatively, even though for a long-period we have considered dysphoric-symptoms like manic-symptoms; on the contrary, only when we added AD, i.e. we treated as depressive-symptoms, we noticed that patients with bipolar-I-mixed improve dramatically in dysphoric-manic-symptoms.

The concept of catatonia has undergone a major evolution from the first descriptions by Kahlbaum catatonic syndrome. Although Kraepelin and Bleuler as mostly related to the dementia praecox and schizophrenia, respectively, it was later shown that its incidence is higher in affective disorders and especially mania. In 2003 Taylor and Fink reviews the diagnostic criteria and warn of its underdiagnosis

From the presentation of a case, we conducted a systematic review in various databases (PubMed, Medline…)

A case report. We present the case of a 46 year old woman diagnosed with bipolar disorder type I. First depressive episode at age 16. In the past 3 years has presented two hypomanic, a mixed episode and a depressive episode. The days before admission, presented disorganized behavior, confusion, bewilderment, motor retardation, respond poorly to stimuli, partially mute. Coincides with the abandonment of regular medication. Psychomotor agitation presented at admission. Lorazepam treatment was started 15 mg, Olanzapine 5 mg, venlafaxine 150 mg and 200 mg lamotrigine. After two weeks of income stabilization was achieved psychopathology.

The presentations of this syndrome are varied, being able to alternate states of inhibition and agitation. Catatonia inhibited or benign catatonia, is the most common presentation. Malignant catatonia is characterized by acute onset, high-impact organic. The etiology can be multiple: psychiatric illness, medical conditions, pharmacological and toxic. Treatment should be hospitable. Initially with benzodiazepines (lorazepam, diazepam). If no response or the organic state is committed we recommend the use of electroconvulsive therapy.

International guidelines regarding the treatment of bipolar disorder differ noticeably from everyday practice, they stress the importance of the use of mood stabilizers as monotherapy. However, in practice polytherapy is widely used, including antipsychotic drugs, and for periods that far exceed the duration of acute episode.

Determine the frequency of long-term use of antipsychotic drugs in the treatment of bipolar disorder and identify situations that may justify this attitude.

Retrospective study of all first-admitted patients with bipolar disorder in two psychiatric wards of Razi Hospital between 2006 and 2008 and over a three-year follow-up.

Our sample consisted of 72 patients. Antipsychotic agents have been used in association with mood stabilizers for a period exceeding 6 months in over 80% of patients with an average duration of 26.56 months ± 12.21 months. Long-term antipsychotic use was significantly correlated with the following factors: male gender, bad family support, poor medication adherence, presence of mixed episodes, psychotic characteristics associated, high frequency of manic recurrences, absence of symptom-free interval, delayed diagnosis as well as a doubtful diagnosis with an acute psychotic disorder or schizophreniform disorder.

This study highlights the fact that international guidelines should be better applied in naturalistic conditions, and that clinicians have to be better informed about these recommendations.

The use of monotherapy with mood stabilisers during bipolar disorder concerns only few patients. Neuroleptics, benzodiazepines and recently the new-generation antipsychotic molecules are widely used as adjuvant therapy to mood stabilizers, indeed beyond the indications held by the guidelines.

Modalities of prescription of psychotropic medication during the first admission and over a three-year follow-up in subjects with bipolar disorder.

Evaluate the adequacy of prescribing practices in naturalistic conditions and international guidelines.

Retrospective study of all first-admitted patients with bipolar disorder in two psychiatric wards of Razi Hospital between 2006 and 2008 and over a three-year follow-up.

Our sample consisted of 72 patients. Over 80% of patients had initially received an incisive antipsychotic drug in combination with mood stabilizer; it was a conventional antipsychotic in 65.3%. Sedative neuroleptics were prescribed in 40.3% of cases with a duration average of 19.21 ± 11.97 months. The combination of two antipsychotic drugs was found in 33.3% of patients. The most frequent association was “haloperidol-chlorpromazine” (79%). Benzodiazepines were prescribed in acute phase in the majority of the sample (94%) with a duration average of 27 mo is ±8.4 months; it was the lorazepam in 70.6%.

Theoretical recommendations do not always reflect the practical situations. Evaluating indications and conditions of polytherapy are critical issues in future studies on the biological treatment of bipolar disorder.

The aim of the study was to investigate the relationship between the individual pattern of affective temperaments, non-typical symptoms of depression as measured with the Gotland Scale for Male Depression (GSMD), hopelessness and suicidal behavior in major mood disorder patients.

Participants were 346 adult inpatients (151 men and 195 women) with major mood disorders consecutively admitted to the Department of Psychiatry of the Sant'Andrea University Hospital in Rome, Italy. All the patients were administered the TEMPS-A, the GSMD, and the Beck Hopelessness Scale (BHS) and the Mini International Neuropsychiatric Interview (MINI).

A Two Step Cluster Analysis procedure, performed to reveal natural groupings within patients' response set, indicated that there were 2-groups: a cyclothymic-depressive-anxious group and a hyperthymic group. More than 81% of the patients with prevailing cyclothymic-depressive-anxious temperament had mild to severe suicidal risk on the MINI vs. only around 42% of the patients with prevailing hyperthymic temperament., Sixty-four percent of patients with prevailing cyclothymic-depressive-anxious temperament had BHS scores of 9 or higher versus only 13% of patients with prevailing hyperthymic temperament. Also, patients with prevailing cyclothymic-depressive-anxious temperament more likely had higher GSMD than patients with prevailing hyperthymic temperament.

Our results indicate that affective temperament measure along with Gotland Scale for Male Depression could be useful tools in screening and identifying those affective disorder patients who are at higher risk of suicidal behavior.

Bipolar patients have a high risk for somatic comorbidities that need to be treated by non-psychiatrist medics. Factors related to unhealthy lifestyle, disease and treatment may confer some additional risk of morbidity in people with bipolar disorder.

The primary endpoint of the study was to detect risk factors for the development of somatic comorbidities in patients with bipolar disorder.

To identify somatic comorbidities in patients with bipolar disorder and to allow appropriate treatment to improve their quality of life.

The study was conducted by interviewing and physical examination of a group of 21 consecutive patients who were hospitalized between 1 to 28 February 2011 in the Clinical Hospital of Psychiatry “Socola” Iasi and were diagnosed with bipolar disorder according to DSM-IV-TR criteria.

Patients age range was 24 to 58 years. Of the subjects 57.1% were female and 42.9% men. The study shows that 38.1% of patients with bipolar disorder smoked regularly, and 47.6% consumed alcohol abusively. The most common somatic diseases associated were dyslipidemia 57.1%, obesity 52.4%, hypertension 38.1%, type 2 diabetes mellitus 33.3%, pulmonary disease 19.0%, hypertensive heart disease 28.6%, peripheral sensory polyneuropathy 23.8%, liver disease 15.3%, and angina pectoris 14.3%. Metabolic syndrome criteria were met in 33.3% of the patients.

The patients with bipolar disorders showed a high proportion of alcohol abuse and smoking. Most somatic diseases recorded were related to metabolic syndrome and other disturbances typically caused by unhealthy diet and lifestyle.

Bipolar disorder (BD),attention deficit hyperactivity disorder (ADHD), the presence of clinical symptoms is quite often difficult treatment, symptomatology that makes the complex, the sharpness of diagnostic overshadowing, adversely affecting the course of the disease, is an important condition disrupts the quality of life and functionality. In this study, bipolar disorder, attention deficit and hyperactivity disorder by examining the sub-dimensions,to reach conclusions about the relationship has these symptoms,course of illness İUB,socio-demographic characteristics of this situation, to evaluate the relationship between disability and quality of life.

In our study,20% of patients favor BD period, were the symptoms of attention deficit and hyperactivity. Hyperactivity is not component where only the size of the group of patients is the lack of attention,21.3% of patients BD comprised of. DHB mean age between the groups, except that a smaller group, gender, marital status, education level, and there was not a statistical difference at the level of significance for comparison of properties. Clinical presentation in the same way as the age of disease onset and exacerbations in patients with DHB group averages low,the average hospitalization than the other two patients were BD.In our study,no significant differences between the groups at the level of deterioration İGDÖ scores were found to be only BD group. Comparisons of quality of life variables,especially the pure DB group more than those in the DHB group was more impaired.

Bipolar disorder, attention deficit and hyperactivity are the dimensions of the disease with increasing disability and impair quality of life.

The normothymic phase in bipolar disorders is generally considered to be symptom-free, which is controversial. Many authors emphasize that residual symptoms, such as emotional reactivity disturbance, are under-evaluated.

The aim of this study was to compare emotional reactivity between normothymic bipolar patients and healthy controls.

We evaluated emotional reactivity in 26 normothymic bipolar patients and 30 controls, using an emotional induction method based on the viewing of a set of 36 pictures (12 negative, 12 neutral, 12 positive) extracted from the International Affective Picture System. We evaluated subjective emotional reactivity (valence and arousal) with the Self-Assessment of Manikin and physiological reactivity measuring the pupil response with an eye-tracking material.

No difference was found between normothymic bipolar patients and controls regarding the subjective emotional reactivity. However, the dilatation of the pupil was significantly lower in normothymic bipolar patients during the viewing of positive pictures (p < 0.05).

Compared to controls, normothymic bipolar patients had less emotional reactivity to positive valence. This result is in coherence with the more frequent negative emotional bias (sadness, anxiety and anger) observed usually in bipolar patients. These preliminary results need to be replicated.

Major depressive episodes are characteristic of both Unipolar Depression (UPD) and Bipolar Disorder (BD). Cognitive impairment is a well documented finding in such episodes. Wide-ranging cognitive deficits have been reported in UPD patients, including psychomotor, attention, memory and executive functions. BD patients were found impaired in attention capacity, memory and learning deficits. Distinguishing BD from UPD patients on the basis of cognitive impairment requires additional research.

Our objective was to clarify differences in cognitive functioning between UPD and BD patients during an acute depressive episode.

A better understanding of the cognitive impairments in each disorder, may significantly improve early diagnosis in acute depressed patients, in cases where it is unclear whether the patient presents UPD or BD.

Participants were 128 acute depressive outpatients, 87 had UPD and 41 had BD. Patients were assessed using Hamilton depression rating scale; Clinical Global Impression severity scale; Hamilton Anxiety Depression Survey; Beck Depression Inventory and Cambridge Neuropsychological Test Automated Battery (CANTAB). We used statistical modeling via logistic regression, to differentiate between UPD vs. BD, by means of their cognitive functions.

Significant differences between the two groups were found in several domains: visual memory, working memory and sustained attention. The predictive model that was constructed has a discriminatory power as measured by the area under the ROC curve of 0.76.

UPD and BD patients present different cognitive impairments during acute depression. Our model may help to predict the underlying mental disorder, and thus facilitate earlier initiation of proper treatment.

Wide variations in guideline concordance rates for bipolar disorder have been reported. To the authors' knowledge, no studies have been carried out in Spain.

To evaluate whether maintenance treatment patterns for outpatients with bipolar disorders in usual practice are concordant with evidence-based prescription guidelines.

Cross-sectional data are being collected, starting June 2011, from outpatients diagnosed of bipolar I or II disorders attended at a Mental Health Center in Bilbao (Spain). Information about their maintenance treatment is reviewed, and labelled as “concordant” or “non-concordant”. Medication considered concordant with current guidelines1,3 are lithium (serum levels 0,6–1,2 mEq/L obtained within the previous 6 months), valproate (serum levels 50–100 μg/mL within the previous 6 months), carbamazepine (serum levels 4–12 μg/mL within the previous 6 months), quetiapine (≥300 mg/d), olanzapine (≥10 mg/d), aripiprazole (≥15 mg/d) and, in bipolar II, lamotrigine ≥100 mg/d. Adjunctive use of other medications is also recorded. To assess concordance when various drugs are combined, at least one of them needs to be within therapeutic dose.

Hitherto, data from 50 patients have been analyzed (66% females; mean age 52,82 ± 13,35; 68% bipolar I). 60% of them present a concordant treatment; 67,64% in the bipolar I subgroup and 43,75% in the bipolar II. Half of the patients are on antidepressants.

Despite the still small sample size and need of a multicenter assessment, adherence to guidelines seems suboptimal, mainly respecting bipolar II. Implementing interventions that have proven effective for enhancing evidence-based care and therefore improving outcomes should be considered.

The aim of the present study was to assess sociodemographic and clinical differences between BD patients, pure MDD patients, and MDD patients with cyclothymic temperament (MDD-CYC).

Participants were 281 adult inpatients (134 men and 147 women) consecutively admitted to the Department of Psychiatry of the Sant'Andrea University Hospital in Rome, Italy, between January 2008 and June 2010. The patients completed the Hamilton Scale for Depression (HAMD17), the Young Mania Rating Scale, the TEMPS-A (Temperament Evaluation of the Memphis, Pisa, Paris and San Diego - Autoquestionnaire) and the Beck Hopelessness Scale.

38.7% of the MDD patients met criteria to be included in the MDD-CYC group. Above 93% of the MDD-CYC reported suicidal ideation (27.6% suicide attempts) at the item 3 of the HAMD17.Furthermore, MDD-CYC patients reported higher hopelessness compered to other patients.

Our results are potentially limited by the small number of MDD-CYC patients included in the sample.

Our results support the clinical usefulness of the concept of soft bipolar spectrum. Patients with unipolar depression and cyclothymic temperament differ from pure MDD patients and BD patients in terms of temperamental profile and clinical variables.

Corticosteroids have been widely prescribed in routine clinical practice and physicians have long known their many side effects. These include metabolic syndrome, osteoporosis, glaucoma, cataracts, peptic ulcers and psychiatric symptoms. Psychiatric side effects from corticosteroids include mania, depression and mood disturbances.

Description of a 75 year old female patient's case study, without previous psychiatric history, diagnosed with bronchopneumonia and requiring treatment with prednisone 40 mg daily. Since the first week of treatment she reported behaviour changes such as episodes of elevated and irritable mood, pressured speech, insomnia, jealousy and megalomania delusions. These symptoms worsened, leading to admission in a psychiatric hospital.

Revision of the scientific literature through Pubmed, using search terms including corticosteroids, mania, depression, psychosis and mood. The research was complemented with information from Uptodate.

Prednisone was suspended and the patient began treatment with Olanzapine, starting with a dosage of 5 mg daily at night, reaching a maximum of 10 mg. The patient recovered complete euthymic mood and reverted to normal functioning. These results support the theory that this psychopathologic state was induced by the corticotherapy administered previously.

Corticosteroids are usually associated with psychiatric disorders and cognitive symptoms. Mania symptoms are the most important manifestations of corticosteroids-induced psychiatric toxicity. It usually occurs within the first two weeks of therapy and it seems to be dose-related. Clinicians should be aware of these facts and carefully monitor patients for psychiatric and cognitive side effects of corticosteroid use.

Despite therapeutic advances, we still have difficulties in predicting response to treatment in bipolar disorder (BD). Brain-Derived Neurotrophic Factor (BDNF) has been put forward as a potential peripheral marker of treatment response.

To prospectively study the relation between clinical response to treatment and serum BDNF levels.

To investigate a) a possible association between serum BDNF levels and clinical response along 16 week follow-up and b) the role of val66met polymorphism in clinical response in a sample of drug-free patients with BD going through a mood episode.

This is a naturalistic, open-label prospective nested case control study matched for age, gender and ethnicity. Patients were 18 years or older, required BD diagnosis, undergoing a current manic, mixed or depressive episode and be off-medication for at least 2 weeks. Clinical assessment and blood withdrawn were conducted along follow-up. At the end of the study, patients were classified according to clinical response.

25 of 36 (69.4%) of the patients were female and the mean age was 37.8 (SD 11.8) years old. Baseline serum BDNF levels did not show any difference between patients and controls (p = 0.075).There was a significant negative correlation between differences in serum BDNF levels and in CGI score along follow-up (r = −.372, p = 0.028). Serum BDNF levels were significant higher in responders compared to non-responders at week 4, 8 and 16 (p = 0.026, p = 0.009, p = 0.001 respectively). Val66met polymorphism did not seem to interfere in clinical response.

Changes in serum BDNF levels may help in monitoring treatment response.

Offspring of parents with Bipolar Disorder are at increased risk for a range of psychopathology, including Bipolar Disorder, ADHD and disruptive behavior disorders and problems in their psychosocial and cognitive functioning. Familial aggregation of BD is associated with earlier age of onset, more frequent co-occurrence of other psychiatric disorders, more severe illness course.

To compare subsequent generations of BD patients in one family, taking account of a number of variables related to course of illness and patients’ functioning.

Twelve patients with

1. (1) Adolescent-diagnosed BD and

2. (2) BD in first-degree relatives in at least three generations, were analyzed. The first-degree relatives with Bipolar Disorder in each family were compared regarding: age of onset; cognitive functioning (WCST); social functioning; course of illness, medication response, co-occurrence of other psychiatric disorders.

In subsequent generations, familial aggregation of Bipolar Disorder was associated with: earlier age of onset; more severe episodes and co-occurrence of other psychiatric disorders; worse medication response (Lithium) for a part of families; lower cognitive and social functioning.

In order to reduce the risk for long-term functional impairment in offspring, interventions addressing parental functioning and early interventions targeting the child's psychopathology should be introduced.

Comparing Lamotrigine versus Lithium efficacy, tolerability, safety in treatment of BPD II.

30 female patients,19–60 years old, diagnosed with BPD II according to DSM IV-TR criteria, were enrolled in the study for 24 weeks. HAM-D ≥ 18 and Y-MRS ≤ 10 were used to diagnose depression and hypomania; CGI for severity and improvement. 28 patients analyzed for efficacy, 30 patients for safety. Response to treatment was defined the reduction 50% of values from starting point measured by HAM-D, Y-MRS, CGI-I for values < 2. Remission considered HAM-D ≥ 7, patients were evaluated on week 12 and 24. Paroxetine and lorazepam were used. Time,dose were compared between two parallel groups. Statistical analysis evaluated through Student test (X2) and Z test variable changes on week 0;12;24

After statistical analysis on validity of comparison considering numbers of past episodes,type of actual episode and age, the groups were comparable without significant statistical differences. Lamotrigine and Lithium showed significant efficacy on BP-II ((p = 0.001). They resulted equal efficacious in the treatment of depression and hypomania, for response and remission rate. Was not statistical significant difference between groups on week 8(p = 0,787), 12 (p = 0,124) and 24 (p = 0,348) for Y-MRS, reflecting comparable efficacy on hypomania symptoms. On week 12 six patients(21.2%) resulted in remission with lamotrigine and four (14.3%)with lithium. Statistical analysis showed no difference for dose and time for paroxetine (p = 0.953);(p = 0.701) and lorazepam (p = 0.937);(p = 0.411). Lamotrigine has higher tolerability rate. Side effects prevalence during study period was 12.5% for lamotrigine and 57.14% for lithium groups.

Lamotrigine and lithium resulted equally efficacious for both episodes of BP-II during acute and maintenance treatment. Lamotrigine manifested less side effects, better compliance.