#Bipolar Disorders

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By William Coryell, MD, George Winokur Professor of Psychiatry, Carver College of Medicine at University of Iowa


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Bipolar disorders are characterized by episodes of mania and depression, which may alternate, although many patients have a predominance of one or the other. Exact cause is unknown, but heredity, changes in the level of brain neurotransmitters, and psychosocial factors may be involved. Diagnosis is based on history. Treatment consists of mood-stabilizing drugs, sometimes with psychotherapy.

Bipolar disorders usually begin in the teens, 20s, or 30s . Lifetime prevalence is about 4%. Rates of bipolar I disorder are about equal for men and women.

Bipolar disorders are classified as

  • Bipolar I disorder: Defined by the presence of at least one full-fledged (ie, disrupting normal social and occupational function) manic episode and usually depressive episodes

  • Bipolar II disorder: Defined by the presence of major depressive episodes with at least one hypomanic episode but no full-fledged manic episodes

  • Unspecified bipolar disorder: Disorders with clear bipolar features that do not meet the specific criteria for other bipolar disorders

In cyclothymic disorder, patients have prolonged (> 2-yr) periods that include both hypomanic and depressive episodes; however, these episodes do not meet the specific criteria for a bipolar disorder.


Exact cause of bipolar disorder is unknown. Heredity plays a significant role. There is also evidence of dysregulation of serotonin and norepinephrine.

Psychosocial factors may be involved. Stressful life events are often associated with initial development of symptoms and later exacerbations, although cause and effect have not been established.

Certain drugs can trigger exacerbations in some patients with bipolar disorder; these drugs include

  • Sympathomimetics (eg, cocaine, amphetamines)

  • Alcohol

  • Certain antidepressants (eg, tricyclics, MAOIs)

Symptoms and Signs

Bipolar disorder begins with an acute phase of symptoms, followed by a repeating course of remission and relapse. Remissions are often complete, but many patients have residual symptoms, and for some, the ability to function at work is severely impaired. Relapses are discrete episodes of more intense symptoms that are manic, depressive, hypomanic, or a mixture of depressive and manic features.

Episodes last anywhere from a few weeks to 3 to 6 mo.

Cycles—time from onset of one episode to that of the next—vary in length among patients. Some patients have infrequent episodes, perhaps only a few over a lifetime, whereas others have rapid-cycling forms (usually defined as 4 episodes/yr). Only a minority alternate back and forth between mania and depression with each cycle; in most, one or the other predominates to some extent.

Patients may attempt or commit suicide. Lifetime incidence of suicide in patients with bipolar disorder is estimated to be at least 15 times that of the general population.


A manic episode is defined as 1 wk of a persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or energy plus 3 additional symptoms:

  • Inflated self-esteem or grandiosity

  • Decreased need for sleep

  • Greater talkativeness than usual

  • Flight of ideas or racing of thoughts

  • Distractibility

  • Increased goal-directed activity

  • Excessive involvement in activities with high potential for painful consequences (eg, buying sprees, foolish business investments)

Manic patients may be inexhaustibly, excessively, and impulsively involved in various pleasurable, high-risk activities (eg, gambling, dangerous sports, promiscuous sexual activity) without insight into possible harm. Symptoms are so severe that they cannot function in their primary role (occupation, school, housekeeping). Unwise investments, spending sprees, and other personal choices may have irreparable consequences.

Patients in a manic episode may be exuberant and flamboyantly or colorfully dressed and often have an authoritative manner with a rapid, unstoppable flow of speech. Patients may make clang associations (new thoughts that are triggered by word sounds rather than meaning). Easily distracted, patients may constantly shift from one theme or endeavor to another. However, they tend to believe they are in their best mental state.

Lack of insight and an increased capacity for activity often lead to intrusive behavior and can be a dangerous combination. Interpersonal friction results and may cause patients to feel that they are being unjustly treated or persecuted. As a result, patients may become a danger to themselves or to other people. Accelerated mental activity is experienced as racing thoughts by patients and is observed as flights of ideas by the physician.

Manic psychosis is a more extreme manifestation, with psychotic symptoms that may be difficult to distinguish from schizophrenia. Patients may have extreme grandiose or persecutory delusions (eg, of being Jesus or being pursued by the FBI), occasionally with hallucinations. Activity level increases markedly; patients may race about and scream, swear, or sing. Mood lability increases, often with increasing irritability. Full-blown delirium (delirious mania) may appear, with complete loss of coherent thinking and behavior.


A hypomanic episode is a less extreme variant of mania involving a distinct episode that lasts 4 days with behavior that is distinctly different from the patient’s usual nondepressed self and that includes 3 of the additional symptoms listed above under mania.

During the hypomanic period, mood brightens, the need for sleep decreases, and psychomotor activity accelerates. For some patients, hypomanic periods are adaptive because they produce high energy, creativity, confidence, and supernormal social functioning. Many do not wish to leave the pleasurable, euphoric state. Some function quite well, and in most, functioning is not markedly impaired. However, in some patients, hypomania manifests as distractibility, irritability, and labile mood, which the patient and others find less attractive.


A depressive episode has features typical of major depression; the episode must include ≥ 5 of the following during the same 2-wk period, and one of them must be depressed mood or loss of interest or pleasure:

  • Depressed mood most of the day

  • Markedly diminished interest or pleasure in all or almost all activities for most of the day

  • Significant (> 5%) weight gain or loss or decreased or increased appetite

  • Insomnia (often sleep-maintenance insomnia) or hypersomnia

  • Psychomotor agitation or retardation observed by others (not self-reported)

  • Fatigue or loss of energy

  • Feelings of worthlessness or excessive or inappropriate guilt

  • Diminished ability to think or concentrate or indecisiveness

  • Recurrent thoughts of death or suicide, a suicide attempt, or specific plan for suicide

Psychotic features are more common in bipolar depression than in unipolar depression.

Mixed features

An episode of mania or hypomania is designated as having mixed features if ≥ 3 depressive symptoms are present for most days of the episode. This condition is often difficult to diagnose and may shade into a continuously cycling state; the prognosis is worse than that in a pure manic or hypomanic state.

Risk of suicide during mixed episodes is particularly high.


  • Clinical criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition)

  • Thyroxine (T4) and TSH levels to exclude hyperthyroidism

  • Exclusion of stimulant drug abuse clinically or by blood or urine testing

Diagnosis of bipolar disorder is based on identification of symptoms of mania or hypomania as described above, plus a history of remission and relapse. Symptoms must be severe enough to markedly impair social or occupational functioning or to require hospitalization to prevent harm to self or others.

Some patients who present with depressive symptoms may have previously experienced hypomania or mania but do not report it unless they are specifically questioned. Skillful questioning may reveal morbid signs (eg, excesses in spending, impulsive sexual escapades, stimulant drug abuse), although such information is more likely to be provided by relatives. A structured inventory such as the Mood Disorder Questionnaire may be useful. All patients must be asked gently but directly about suicidal ideation, plans, or activity.

Similar acute manic or hypomanic symptoms may result from stimulant abuse or physical disorders such as hyperthyroidism or pheochromocytoma. Patients with hyperthyroidism typically have other physical symptoms and signs, but thyroid function testing (T4 and TSH levels) is a reasonable screen for new patients. Patients with pheochromocytoma are markedly hypertensive; if they are not, testing is not indicated. Other disorders less commonly cause symptoms of mania, but depressive symptoms may occur in a number of disorders .

A review of substance use (especially of amphetamines and cocaine) and blood or urine drug screening can help identify drug causes. However, because drug use may simply have triggered an episode in a patient with bipolar disorder, seeking evidence of symptoms (manic or depressive) not related to drug use is important.

Some patients with schizoaffective disorder have manic symptoms, but such patients may not return to normal between episodes..

Patients with bipolar disorder may also have anxiety disorders (eg, social phobia, panic attacks, obsessive-compulsive disorders), possibly confusing the diagnosis.



  • Mood stabilizers (eg, lithium, certain anticonvulsants), a 2nd-generation antipsychotic, or both

  • Support and psychotherapy

Treatment of bipolar disorder usually has 3 phases:

  • Acute: To stabilize and control the initial, sometimes severe manifestations

  • Continuation: To attain full remission

  • Maintenance or prevention: To keep patients in remission

Although most patients with hypomania can be treated as outpatients, severe mania or depression often requires inpatient management.

Drug therapy for bipolar disorder

Drugs for bipolar disorder include

  • Mood stabilizers: Lithium and certain anticonvulsants, especially valproate, carbamazepine, and lamotrigine

  • 2nd-generation antipsychotics: Aripiprazole, lurasidone, olanzapine, quetiapine, risperidone, and ziprasidone

These drugs are used alone or in combination for all phases of treatment, although at different dosages.

Choice of drug treatment for bipolar disorder can be difficult because all drugs have significant adverse effects, drug interactions are common, and no drug is universally effective. Selection should be based on what has previously been effective and well-tolerated in a given patient. If the patient has not previously been given drugs to treat bipolar disorder (or drug history is unknown), choice is based on the patient’s medical history (vis-à-vis the adverse effects of the specific mood stabilizer) and the severity of symptoms.

Specific antidepressants (eg, SSRIs) are sometimes added for severe depression, but their effectiveness is controversial; they are not recommended as sole therapy for depressive episodes.

Other treatments

Electroconvulsive therapy (ECT) is sometimes used for depression refractory to treatment and is also effective for mania.

Phototherapy can be useful in treating seasonal bipolar I or bipolar II disorder (with autumn-winter depression and spring-summer hypomania). It is probably most useful as augmentative therapy.

Education and psychotherapy

Enlisting the support of loved ones is crucial to preventing major episodes.

Group therapy is often recommended for patients and their partner; there, they learn about bipolar disorder, its social sequelae, and the central role of mood stabilizers in treatment.

Individual psychotherapy may help patients better cope with problems of daily living and adjust to a new way of identifying themselves.

Patients, particularly those with bipolar II disorder, may not adhere to mood-stabilizer regimens because they believe that these drugs make them less alert and creative. The physician can explain that decreased creativity is relatively uncommon because mood stabilizers usually provide opportunity for a more even performance in interpersonal, scholastic, professional, and artistic pursuits.

Patients should be counseled to avoid stimulant drugs and alcohol, to minimize sleep deprivation, and to recognize early signs of relapse.

If patients tend to be financially extravagant, finances should be turned over to a trusted family member. Patients with a tendency to sexual excesses should be given information about conjugal consequences (eg, divorce) and infectious risks of promiscuity, particularly AIDS.

Support groups (eg, the Depression and Bipolar Support Alliance [DBSA]) can help patients by providing a forum to share their common experiences and feelings.

Key Points

  • Bipolar disorder is a cyclic condition that involves episodes of mania with or without depression (bipolar 1) or hypomania plus depression (bipolar 2).

  • Bipolar disorder markedly impairs the ability to function at work and to interact socially, and risk of suicide is significant; however, mild manic states (hypomania) are sometimes adaptive because they can produce high energy, creativity, confidence, and supernormal social functioning.

  • Length and frequency of cycles vary among patients; some patients have only a few over a lifetime, whereas others have 4 episodes/yr (rapid-cycling forms).

  • Only a few patients alternate back and forth between mania and depression during each cycle; in most cycles, one or the other predominates.

  • Diagnosis is based on clinical criteria, but stimulant abuse and physical disorders such as hyperthyroidism or pheochromocytoma must be ruled out by examination and testing.

  • Treatment depends on the manifestations and their severity but typically involves mood stabilizers (eg, lithium, valproate, carbamazepine, lamotrigine) and/or 2nd-generation antipsychotics (eg, aripiprazole, lurasidone, olanzapine, quetiapine, risperidone, ziprasidone).

#Functional MRI distinguishes #bipolar disorder from #depression

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  •  Noticias Médicas Univadis

Amygdala activation and connectivity during facial emotion processing can distinguish bipolar disorder (BP) from major depressive disorder (MDD), even among patients in remission, according to new research.

Although emotion-elicited amygdala reactivity has been found to distinguish BP from MDD in depressed states, this study examined the distinction is patients in remission.

Supra- and sub-liminal processing of threat, sad, happy and neutral faces during functional magnetic resonance imaging (fMRI) was completed for 23 BP patient and 25 MDD patients matched for age-gender, the number of depressive episodes and severity, along with 25 age-gender matched healthy controls.

The BP and MDD groups were distinct from controls across several measures for amygdala activation and connectivity.

Compared with the MDD group, BP patients showed lower left amygdala activation during supraliminal and subliminal threat, sad and neutral processing and for subliminal happy processing. BP was associated with lower connectivity to the insula and hippocampus for threat, and to the medial orbito-frontal cortex for supraliminal and subliminal happy processing. BP participants had greater amygdala-insula connectivity for supraliminal and subliminal sad face processing.

The authors say the findings “provide evidence that this neural substrate could be a potential trait-marker to differentiate these two disorders, largely independent of illness state”.

#Les suppléments de #vitamine D traitent la #dépression

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La dépression est une maladie mentale très courante. Au Québec, il est estimé que de 10 % à 15 % des gens en souffriront au cours de leur vie. La dépression peut être très handicapante pour les gens qui en souffrent. Parmi les symptômes couramment observés, on retrouve une grande tristesse, des problèmes d’appétit, des troubles du sommeil, une grande fatigue, une difficulté à se concentrer, des sentiments de culpabilité inappropriés et même des pensées récurrentes de mort ou des idées suicidaires. Cette maladie est présentement traitée à l’aide d’antidépresseurs et/ou de psychothérapie.


La vitamine D et le cerveau


La vitamine D est produite par la peau lorsqu’elle est exposée au soleil. On la retrouve également dans certains aliments. Ceci étant dit, plusieurs chercheurs estiment que la carence en vitamine D est plus répandue qu’on le croit, surtout dans les pays comme le nôtre où il est impossible d’en synthétiser durant l’hiver.


On connaît le rôle de la vitamine D sur la santé osseuse depuis longtemps. Cependant, plusieurs autres rôles ont été découverts dans les dernières années et il y a fort à parier que l’on continuera d’en découvrir pendant longtemps. Par exemple, on retrouve des récepteurs à la vitamine D dans plusieurs parties du cerveau, notamment certaines qui sont impliquées dans la dépression. Pour cette raison, des chercheurs croient que la vitamine D pourrait jouer un rôle dans la dépression et même la traiter.


Les études d’observation


En 2013, une méta-analyse a évalué les résultats de 13 études d’observation qui s’intéressaient au lien entre le taux de vitamine D dans le sang et les risques de souffrir de dépression. En analysant les données de 31 424 participants, les chercheurs ont observé un lien entre de faibles taux sanguins de vitamine D et des risques élevés de souffrir de dépression. Ceci étant dit, les études étaient très hétérogènes entre elles puisque la dépression n’était pas diagnostiquée de la même façon dans toutes les études répertoriées et les taux de vitamine D qui étaient considérés comme « faibles » étaient également différents.


Cette méta-analyse donne tout de même un indice que de faibles taux de vitamine D sont associés à la dépression, mais rien n’indique qu’il s’agit d’un lien de cause à effet. Par exemple, les gens souffrant de dépression pourraient moins sortir à l’extérieur, être moins exposés au soleil et, par le fait même, synthétiser moins de vitamine D.


Pour éclaircir ce lien, il faut donc se tourner vers des études cliniques.


Les études cliniques


Quelques études cliniques de bonne qualité ont tenté d’élucider le rôle possible de la vitamine D contre la dépression. Pour ce faire, les protocoles se ressemblaient tous sensiblement. On administrait aux patients un supplément de vitamine D ou un placebo, puis on mesurait les symptômes dépressifs à l’aide de questionnaires.


Une méta-analyse d’essais cliniques randomisés contrôlés publiée en 2014 a ainsi mis en commun les résultats de sept études et est arrivée à la conclusion que la supplémentation en vitamine D ne semblait pas réduire les symptômes dépressifs.


Même son de cloche pour une seconde méta-analyse publiée en 2014 et rassemblant cette fois six essais cliniques randomisés contrôlés et pour une troisième publiée en 2015 ayant mis en commun les résultats de neuf essais cliniques randomisés contrôlés.


Il est important de noter que la plupart des études effectuées jusqu’à présent sont assez différentes les unes des autres, notamment pour la dose de vitamine D donnée et la durée des études. Il est donc difficile de tirer des conclusions claires.


Bref, même si on observe un lien entre un faible taux sanguin de vitamine D et les risques de dépression, il est pour l’instant impossible d’affirmer que la supplémentation en vitamine D permet de diminuer les symptômes de cette maladie.


Malgré tout, consommer une alimentation variée contenant des aliments riches en vitamine D reste une habitude à intégrer à votre quotidien qui ne peut que vous amener du bien.

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#Smart Phone Technologies and #Ecological Momentary Data: Is This the Way Forward on #Depression Management and Research?

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Abstract and Introduction


Purpose of review: Depression is a complex and burdensome condition; it often leads to personal, societal and economic costs. Despite advances in treatments, its management over time remains a challenge; many treated for depression do not achieve full recovery or remain well for long. Novel ways to monitor patients are warranted, as well as better understanding of contributors to relapse or sustained wellness. Mobile health technologies (m-Health) are emerging as useful tools for real-time assessments of moods, behaviours and activities in a more convenient and less burdensome manner. Yet, there are numerous questions around privacy, reliability and accuracy of data collected via mobile apps. This review provides a critical overview of advances in m-Health and evaluate the future potential of smartphone technology in the assessment and treatment of depression.

Recent findings: There is an abundance of apps in the market that claim to exert beneficial effects on the management of depression; to date, only a small fraction has been validated in clinical trials or has had the support of academic centers.

Summary: Although promising, the use of mobile health applications in depression warrants further investigation and incorporation into mainstream research to facilitate greater adoption and validation of its clinical utility.


Over the past two decades, the field of mobile technologies has witnessed a remarkable – and dramatically rapid – evolution in the nature of cellular phones, from what now seem like very primitive devices to incredibly sophisticated ones with the capacity to do infinitely more than make and receive phone calls. Paralleling that technological evolution has been an enormous expansion of the user base. More than half of the globe owns a smartphone. In 2016, there were reportedly 3.9 billion smartphone subscribers worldwide – a number that is expected to climb to 6.8 billion by 2022 – close to 70% of the predicted population.[1] Once limited to corporate executives, cellular technology now has users across all strata of society and age groups ranging from preteens to adults in their 80s and beyond. This, in turn, has led to a strong interest in mobile health technology or m-Health, across many areas of medicine as a potentially valuable clinical tool. It has not been lost on those in the field of mental health assessment that the smartphone has the capacity to capture, either through in-the-moment self-report or through continuous passive sensing, a wealth of data of a kind that has never before been available to clinical practitioners or researchers. Furthermore, the smartphone is beginning to show promise as an avenue for just-in-time intervention as well as ecologically valid assessment. Here we provide a critical overview of the most recent literature describing these advances and evaluate what these reports suggest about the future potential of smartphone technology in the assessment and treatment of depression.

Mobile Technology: Is This Just Hype?

Mobile health technologies were first coined in the early 2000s as internet-based telemedicine began to receive some attention.[2] Since then, the field has evolved and encompassed smart devices, wearables, and mobile apps (mApps) that are capable of addressing several healthcare challenges including coordination of resources, treatment adherence, real-time symptom monitoring, and detection of first signs of relapse.[3] Mobile devices as well as wearable biosensors or wearable user interfaces (WUI) have demonstrated the ability to assist the management of patients with multiple and complex medical conditions; m-Health technologies now facilitate care for people who would otherwise have limited access to providers because of geographic isolation or limited physical mobility; the adoption of these technologies is already enabling patients, in many cases, to be monitored remotely, thus avoiding long waiting lines, diminishing traveling costs and time, and reducing the burden incurred by multiple visits to healthcare services. Yet, the m-Health sector has developed at such a fast pace that policy-makers have not been able to address or regulate various issues regarding quality, data privacy, interoperability and usability in a timely manner.

Smartphones for the Capture of Ecological Momentary Assessment Via Self-report

There are at least 1500 mobile phone apps currently available that claim to aid patients in tracking mood and mood-related activities. Of those, a small number has been minimally evaluated in the scientific literature, whereas the majority has yet to receive any scientific or academic evaluation.[4] Recent studies indicate that mobile phone-based self-monitoring of mood, stress, and daily activities can increase emotional self-awareness and decrease depressive symptoms in young adults.[5,6] A recent meta-analysis identified the use of 22 smartphone apps across 18 randomized controlled trials. The use of smartphone apps was associated with significant reduction in depressive symptoms, particularly whenever integrated with other human/computerized aspects of the treatment. The study suggests a promising role of m-Health technologies for self-management of depression.[7]

Although self-tracking alone may lead to greater self-awareness among individuals coping with mood and anxiety disorders, these mobile technologies also allow for the possibility of in-the-moment feedback and prompts. Such two-way interactions have been found to improve adherence to behavior modification interventions in chronic disease self-management.[8] For example, increased use of mobile alerts on the myCompass platform, including symptom-tracking reminders and short motivational messages, was associated with significant improvements in anxiety and functional impairment among psychiatric patients with depression, anxiety and stress or stress alone.[9] The combination of symptom tracking, motivational messages and diaries on the myCompass platform was associated with significantly greater improvement in symptoms of depression, anxiety and stress compared with that observed in control conditions.[10] In studies involving the same platform, Clarke et al.[11] observed significantly greater improvement in mental health self-efficacy (MHSE) compared with that observed among controls suggesting that the MHSE mediated the reduction of anxiety and stress symptoms in this population.

Smartphones as Tools for ‘Sensing’ Clinically Relevant Behaviors

The unobtrusive or ‘passive’ collection of information through mobile devices, sometimes referred to as context-sensing or ecological momentary assessment (EMA), is another area of growing interest. Although adherence to the kind of self-report required from most mood tracking apps is known to decline relatively quickly, especially in nonresearch clinical populations, the smartphone has become an intimate device that a majority of users keep with them nearly constantly. This creates an opportunity to monitor clinically relevant behaviors on a 24/7 basis without making any active demands on the user. This is especially relevant for depressed patients who may find it difficult to meet the demands of constant or even intermittent self-report.

The Mobilyze! platform is an example of using context sensing in combination with user inputs to predict mental-health states. This platform includes 38 smartphone sensor streams including global positioning system (GPS) for location, accelerometers, call logs, and ambient light sensors. Sensor inputs were combined with EMA through prompted self-report states in order to train the system to detect negative mental health states and subsequently elicit self-management strategies and the use of educational tools. A feasibility intervention trial with eight participants demonstrated significant improvement on self-reported and interview measures of depressive symptoms, and decrease in the likelihood of meeting criteria for MDD diagnosis.[12]

Mohr and colleagues found interesting associations between depression symptom severity and circadian rhythm regularity and location variance. The same group found that Purple Robot, using GPS location and phone usage data together with PHQ-9 prompts to infer behavior, could predict depression symptom severity in a prospective study with 40 adult participants, 11 with depressive disorder.[13]

Using a prototype of an app called Measure, Aung et al.,[14] replicated the relevance of circadian regularity and location entropy variables and demonstrated the importance of other passively acquired behavioral data streams for the prediction of depression severity in a general medical population. More recently, the same group has shown statistically significant associations between a series of unobtrusively acquired data streams from their Measure app and depression severity in a small population of carefully characterized patients with depression who were participants in the Canadian Biomarker Integration Network in Depression (CAN-BIND) study.[15]

Smartphones as Tools for Digital Phenotyping

Digital phenotyping (defined as a ‘real-time, moment-by-moment quantification of the individual-level human phenotype in situ using data from personal digital devices) may provide us with a footprint of one’s health status through use of various mobile technologies and social media. Ultimately, digital phenotyping and digital biomarkers may carve out an important role among the tools contributing to a better understanding and management of depression, its recovery (sustained wellness), relapse or resilience. As suggested by the aforementioned data, certain behavioral patterns that can be easily and continuously captured by smartphone data streams may, in fact, constitute digital phenotypes. In addition to constructs such as circadian movement and location entropy, smartphone sensor streams represent excellent ways of assessing chronotype; it is quite plausible that smartphone sensors ultimately offer more accurate measures of chronotype and might be more sensitive to treatment-induced changes in chronotype than self-report measures such as the Composite Scale of Morningness (CSM)[16**] that have traditionally been used to assess this variable. Although a single sensor stream may provide little information for segmenting clinical populations according to risk status or for identifying moderators of treatment outcomes in research trials, the combination of complex variables constructed from the multitude of smartphone sensor streams has the potential to generate relevant digital biomarkers.

Implications for Clinical Practice and Research: A Series of Challenges

Perhaps precisely because the need for resources is so great and access to quality healthcare can be incredibly limited in many countries, the m-Health sector has experienced an exponential growth that requires a closer look. Despite hundreds of apps claiming beneficial effects for depression, few are truly targeted to individuals with clinically significant depression and most were designed to provide some sort of intervention or adapted treatment including music therapy, positive affirmation, cognitive behavioral therapy (CBT), as well as psychoeducation or assessment and symptom management.[17*] Unfortunately, there is no easily accessible guide to the credibility of these apps. This is particularly concerning whenever one notes that fewer than 6% of the developers of these apps are associated with a medical center or academic institution and more than 50% of the app descriptions fail to provide sufficient information about the developer(s) to determine whether they have any such affiliation. The present lack of standards also leads to concerns about issues that are particularly critical in the area of mental health including data privacy, interoperability and usability for those who may have either acute or chronic cognitive limitations. Given this state of affairs, experts in the m-Health field have cautioned against premature adoption of technologies that have not been rigorously evaluated.[18] On the positive side, however, several national organizations and professional groups have begun to take up the challenge of evaluating the quality of these apps. The National Health Services (NHS) in the United Kingdom has created a medical app library that includes a mental health section in order to alleviate consumer confusion and provide navigable ways to find safe apps.[19] Similarly, Health Canada regulates medical devices – including apps – that require approval before entering the market – although the information provided is scant and the apps listed are only some higher risk ones with diagnostic or therapeutic capabilities. There are no requirements for low-risk medical apps including those that monitor or encourage well being. Although these apps may not claim to have a direct therapeutic impact on their users, one could argue that they should at least demonstrate no deleterious effects – including unnecessary delays or derailments from accessing adequate diagnosis and effective treatments or effective treatments alone.

In the United States, the Food and Drug Administration (FDA) regulates mobile health apps on a risk-based approach; focusing on those that could cause harm or pose a risk to its consumers should the apps functionality demonstrate ill intent. Similar to the Canadian Medical Association, researchers associated with an American Psychiatric Association taskforce have attempted to guide clinicians whenever considering medical apps for mental health.[20*] But placing more stringent regulations through the gateway platforms may be more influential than providing guidelines. Recognizing the sensitivity of medical apps, Apple announced an updated screening tool for both functionality and consumer privacy that will have major implications for apps currently in the iOS store. For instance, personal health information would no longer be stored on the iCloud and increased scrutiny will be enforced over apps that are misleading or provide incorrect information. Different levels of regulatory assessment could cover a range of concerns that are inherent in the burgeoning mobile health landscape and should be considered by national regulatory agencies, professional associations and commercial entities making these products available.


#Mediterranean Diet Improves #Depression

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Diet matters when it comes to mental health. When people with severe depression followed the Mediterranean diet, they experienced a significant reduction in symptom severity that lasted up to 6 months.

In one of the first randomized controlled trials to examine the effect of the Mediterranean diet supplemented with fish oil in people with severe depression, researchers found the diet to be associated with a reduction in depression symptoms.

Dr Natalie Parletta

“While both the intervention and control groups experienced significant mental health improvements, participants eating the Mediterranean diet experienced a greater reduction (45%) in the severity of their depression compared with the control group (27%),” study investigator Natalie Parletta, PhD, told Medscape Medical News. Dr Parletta is a senior research fellow from the Center for Population Health Research, University South Australia, in Adelaide.

The study was published online December 18 in Nutritional Neuroscience.

No Impact of Supplemental Fish Oil

Population research has shown a link between diet and depression. The current study, the authors note, is only the second randomized controlled trial to use a Mediterranean dietary intervention in people with severe depression. The first trial, published earlier this year in BMC Medicine, was also conducted in patients with moderate to severe depression.

In that study, following the Mediterranean diet was found to be associated with significant improvements in depression scores. However, in contrast to the latest study, it ended at 3 months, used buddies for the social control group, and did not supplement the diet with fish oil.

To further investigate the impact of the Mediterranean diet on mental health and quality of life in people with severe depression, the researchers recruited 152 adults aged 18 to 65 years (105 women and 47 men). Thirty-eight percent of participants reported a diagnosis of depression, and 36% reported taking an antidepressant.

Participants were randomly assigned to receive a traditional Mediterranean diet (n = 75) or a traditional Mediterranean diet supplemented with fish oil or a control intervention (n = 77)

The Mediterranean diet intervention included an initial nutritional consultation, biweekly group cooking workshops, easy, inexpensive recipes, and take-home food hampers for making the recipes.

The control intervention involved biweekly meetings that included social activities such as board games, book clubs, and photo sharing. Participants were provided with light snacks, such as biscuits, dips, cheese, crackers, coffee, tea, juice, or water.

Participants were assessed at baseline, 3 months, and 6 months using validated, reliable instruments. Primary mental health outcomes were assessed with the Depression, Anxiety and Stress Scale and the Assessment of Quality of Life.

Secondary outcomes were assessed with the Positive and Negative Assessment Scale, the Mediterranean Diet questionnaire, and the Simple Dietary Questionnaire. To measure the impact of the fish oil supplements on mental health, erythrocyte blood samples were taken and analyzed for polyunsaturated fatty acids (omega 3 and 6).

The investigators found that the Mediterranean diet was significantly associated with lower anxiety, negative affect, and better coping and overall quality of life. Dr Parletta said she was “surprised” that the fish oil supplements did not have a significant effect on depression.

“We wanted to boost those levels because previous research showed that people with depression had very low levels of omega 3s compared with the national average,” she said.

Diet’s Role in Mental Health Underappreciated

The researchers also found associations between food groups and mental health outcomes. For example, eating more vegetables was associated with less stress and more positive emotions, and eating more fruit was associated with less anxiety and more positive emotions and relationships.

Eating a wide range of vegetables and fruits also improved mental health outcomes. Eating a traditional Mediterranean diet also decreased the amount of take-out food and unhealthy snacks the participants ate.

Social interaction also played an important role in improving participants’ mental health.

“The Mediterranean diet is more than just food, it’s a lifestyle. Participants cooked and ate meals together every 2 weeks. The cooking workshops were the most popular of all the workshops in our pilot studies,” said Dr Parletta. She noted that the control group also met every 2 weeks for social activities.

The main limitations of the study were that it used self-reported assessments, there was a high dropout rate, and that single-blinding was used. Participants were not blinded to their treatment allocation, which contributed to the dropout rate.

“Some people joined the study for the nutrition education and cooking classes and were disappointed when they didn’t receive that,” said Dr Parletta. Of the 152 eligible participants, 95 completed 3-month assessments, and 85 completed 6-month assessments.

Dr Parletta said the medical community has been slow to recognize the role dietary interventions can play, especially in improving mental health. “I would like mental health professionals to take this seriously and start looking at people’s diets when they go for counseling.”

Dr Parletta and a colleague are writing a paper on the cost-effectiveness of the dietary interventions used in the study. The data look promising, she said.

Exciting Findings

Commenting on the findings for Medscape Medical News, Drew Ramsey, MD, assistant clinical professor of psychiatry from Columbia University in New York City and a practicing nutritional psychiatrist, said, “2017 has been an exciting year for nutritional psychiatry. We now have two randomized controlled trials showing significant efficacy for the treatment of clinical depression with dietary and nutritional interventions.”

This study builds on the “groundswell of science connecting nutritional intake and mood disorders, especially depression,” said Dr Ramsey. “We have known for decades that certain nutritional deficiencies, such as B12 and folate, can cause clinical depression. These exciting findings show that that diet can work as a clinical intervention with depression.”

“This is exciting news for mental health professionals. Medications take up to 6 weeks to work, and the benefits of psychotherapy can take months. Nutritional interventions give patients something they can work on today,” he added.

The two randomized controlled trials demonstrated that even people with severe depression can learn and benefit from dietary interventions, dispelling the notion that only people with mild depression can benefit, said Dr Ramsey.

“We also know that nutritional interventions work well with other treatments.”

Dr Ramsey said clinicians who want to be on the cutting edge of evidence-based medicine should include dietary interventions in the treatment of clinical depression.

“Great interventions don’t have to be complicated. It can be just getting people to eat more leafy greens, anchovies, or lentils or learning how to make delicious vegetables so they will eat them,” he said.

He challenged clinicians to offer nutrition services.

“There are many ways to do this, including learning basic nutrition, using simple food assessments, and prescribing healthy food. Another option is to partner with registered dieticians, nutritional health coaches, or local chefs. The challenge for medicine is to change how we think about nutritional interventions.”

The study was supported by the National Health and Medical Research Council. Dr Parletta has disclosed no relevant financial relationships. Dr Ramsey serves on the editorial board of Medscape Psychiatry.

Nutr Neurosci. Published online December 7, 2017. Full text

#ECG distinguishes #depression from #bipolar disorder

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A groundbreaking study suggests that a simple 15-minute electrocardiogram (ECG) could help to determine whether a patient has major depression or bipolar disorder. The research found that heart rate variability measured by electrocardiogram distinguished between the two conditions.

The findings of the study, presented in the World Journal of Biological Psychiatry, suggest ECG could limit the risk of misdiagnosis of bipolar disorder as major depression, and avoid inadvertently triggering a manic episode by prescribing an antidepressant without a safeguard mood stabilising drug.

A total of 64 adults with major depression and 37 adults with bipolar disorder were enrolled in the study. Subjects with major depression were found to have significantly higher respiratory sinus arrhythmia than those with bipolar disorder. In a secondary finding, patients with bipolar disorder demonstrated higher blood levels of inflammation biomarkers than patients with major depression.

Commenting on the results, senior study author, Angelos Halaris said: “Having a noninvasive, easy-to-use and affordable test to differentiate between major depression and bipolar disorder would be a major breakthrough in both psychiatric and primary care practices.” However, he added that further research is needed to confirm the study’s findings and determine their clinical significance.

Hage B, Britton B, Daniels D, Heilman K, PorgesSW, Halaris A. Low cardiac vagal tone index by heart rate variability differentiates bipolar from major depression. World J Biol Psychiatry. 2017 Oct 5:1-9. doi: 10.1080/15622975.2017.1376113. PMID: 28895492. [Epub ahead of print]

#Online Therapy Eases #Depression, #Anxiety in #Primary Care Setting

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Meg Barbor, MPH

Online computerized cognitive-behavioral therapy (CCBT), both alone and in combination with an Internet support group (ISG), is more effective than usual primary care for the treatment of depression and anxiety, new research shows.

Investigators at the University of Pittsburgh, in Pennsylvania, found that CCBT, when managed by a care manager and when utilized either alone or in combination with ISG, significantly improved depression and anxiety symptoms compared to usual care. However, the addition of an ISG provided no further benefit.

The study is the first randomized trial to evaluate the effectiveness of providing these technologies through a collaborative care program. The model is now up and running in 26 practices in the Pittsburgh area.

“We were able to show this model can be used where there aren’t enough mental health professionals, such as inner cities or rural areas,” lead investigator Bruce Rollman, MD, MPH, University of Pittsburgh School of Medicine, told Medscape Medical News. “I hope this will be practice changing in the US.

“But I want to stress that it’s not just about technology; it’s also about the people,” he said. “What our study showed is that these programs work, but it’s really important to have a human involved.”

The study was published online November 8 in JAMA Psychiatry.

Lack of Data

Numerous trials have proven the effectiveness of collaborative care strategies in the treatment of depression and anxiety, and this approach is known to be superior to usual care from primary care physicians for these conditions.

These programs usually involve nonphysician care managers who contact patients to promote evidence-based treatment protocols for chronic conditions and to monitor patients’ clinical response under the supervision of a primary care physician.

However, challenges have limited the provision of collaborative care in routine clinical practice, and until now, advances in technology that have the potential to overcome these barriers have not been tested. Use of ISGs have grown in popularity around the world, and though anecdotal evidence of their effectiveness has been widely circulated, their effectiveness has not been established in randomized trials.

Eligible patients were required to have Internet and email access. They were also required to have scored 10 or greater on either the seven-item Generalized Anxiety Disorder scale or the nine-item Patient Health Questionnaire and to be free of alcohol dependence, active suicidality, or other serious mental illness.

In response to an electronic medical record prompt, primary care physicians from 26 practices in Pittsburgh referred 2884 patients aged 18 to 75 years to the trial from August 2012 to September 2014.

The study utilized the Beating the Blues CCBT program, which consists of a 10-minute introductory video followed by eight 50-minute interactive sessions that care managers encourage patients to complete every 1 to 2 weeks.

The ISG was password protected, could be accessed by patients via computer or smartphone, and offered discussion boards and links to external resources. The duration of the program was 6 months, and care managers informed primary care physicians of their patients’ progress.

A total of 704 patients met eligibility criteria and were randomly assigned to CCBT alone (n = 301), CCBT+ISG (n = 302), or usual care (n = 101). The majority of patients were white; about 80% were women; and the mean age was 42.7 years.

At 6-month assessment, about 84% of patients who received CCBT alone had started the program, and 37% had completed all eight sessions. In the CCBT+ISG group, 75% had logged into the ISG at least once, of whom 62% provided one or more comments or posts.

At 6-month follow-up, mental health–related quality of life was measured with the 12-Item Short-Form Health Survey Mental Health Composite Scale. Depression and anxiety symptoms were measured with the Patient-Reported Outcomes Measurement Information System (PROMIS). Treatment durability was assessed 6 months later.

Improved Mood, Anxiety

The investigators observed similar 6-month improvements in mental health–related quality of life, mood, and anxiety symptoms in the CCBT+ISG and CCBT-alone cohorts.

However, when compared to patients who received usual care, patients in the CCBT-alone cohort were found to have significant 6-month effect size improvements in PROMIS mood symptoms (effect size, 0.31) and PROMIS anxiety symptoms (effect size, 0.26). The improvements persisted 6 months later.

The investigators also found a dose effect such that the more CCBT sessions a patient completed, the stronger the improvement in effect size (PROMIS mood symptoms in patients who completed ≥4 sessions: effect size, 0.41; patients who completed all eight sessions: effect size, 0.52).

This dose effect confirms the importance of patient engagement, said Dr Rollman. He cited a 2015 study by Prof Simon Gilbody and colleagues in which the investigators found no differences in mood symptoms among 691 primary care patients with depression. The patients were randomly assigned to receive either CCBT or usual care, and the study employed the same CCBT program that Dr Rollman’s team used.

In Dr Gilbody’s study, staff offered minimal support but did not monitor patients’ symptoms or send recommendations to primary care providers. As a result, patient adherence to CCBT was low (median sessions completed, <2).

“This was, predictably, a negative study,” said Dr Rollman. He noted the importance of utilizing a collaborative care model: “Gilbody had the program, but there wasn’t enough human support.”

Dr Rollman predicted that in the near future, CCBT programs will be used increasingly for other conditions, including heart disease, insomnia, tobacco addiction, and substance abuse. He said that an ideal time to use these programs is when patients are undergoing treatments such as dialysis. “These programs are scalable and allow us to mass-customize interventions to provide care to patients,” he said.

“Our report confirms the effectiveness of guided CCBT, highlights the critical importance of patient engagement with online interventions, and provides high-quality evidence about the limits and potential benefits of these emerging technologies,” the authors note.

Important Implications

Commenting on the findings for Medscape Medical News, Lori Raney, MD, who was not involved in the study, noted that there is a national shortage of individuals trained to deliver collaborative care, so technology that extends “the reach of our limited behavioral health workforce ― we call them practice extenders ― allows care managers to take on larger caseloads.

“This is exciting research, and we need more of it,” said Dr Raney, who is a leading authority on the collaborative care model and is chair of the American Psychiatric Association’s Workgroup on Integrated Care. “Now that integrated care is getting ready to take off, we don’t have a workforce to do it. Studies like this are extremely helpful in guiding us to where we need to go.”

However, adherence to online programs remains a barrier to care, she said. She noted that only 37% of patients in the study who received CCBT alone completed all eight sessions.

“That’s one of the drawbacks of the technology. For whatever reason, about half the patients don’t go all the way through the sessions,” she said. “So the question remains: What else is it going to take to get people to engage, or is the fact that they did half of the sessions sufficient?

“There are flaws in our thinking around this, because patients aren’t engaging like we want them to with the technology,” she added. “Maybe we need to have patients involved in the development of the technology. That’s one of the frontiers of research right now ― patients telling us what works for them.”

The study authors note that these findings “have important implications for transforming the way mental health care is delivered in primary care and focus further attention to the emerging field of e-mental health.”

This trial was funded by the National Institute of Mental Health. The computer program used in the study was donated by the University of Pittsburgh Medical Center. The authors, Dr Rollman, and Dr Raney have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online November 8, 2017. Full text