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This review explores the epidemiological evidence for the relationship between depression and cardiovascular disease from a mechanistic standpoint. It is important to examine the biological, behavioral and social mechanisms to improve outcomes for depressed cardiac patients. A number of plausible biobehavioral mechanisms linking depression and cardiovascular disease have been identified. Tricyclic antidepressants have various effects on the cardiovascular system, while selective serotonin reuptake inhibitors are not associated with adverse cardiac effects and should, therefore, be the preferred choice for the treatment of most patients with comorbid depression and cardiovascular disease.

Premenstrual dysphoric disorder (PMDD) is a complex clinical syndrome that is notoriously difficult to treat. The purpose of the present study was to provide preliminary data on the effectiveness of duloxetine in PMDD.Fifty-five women with PMDD were treated with a 60 mg/day dosage of duloxetine for two menstrual cycles. Responses were assessed at first and second treatment cycle.Outcome measures included a visual analogue scale, the Zung Self-rating Scale for Depression, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale and the Clinical Global Impressions Scale.Fifty patients completed the trial. All had significant improvement of depression and anxiety and response, defined as a 50% decrease in daily symptom scores, occurred in 39 (78%) patients. The effects of active treatment were marked by the first active cycle of menstruation.Duloxetine 60 mg/day was effective in reducing PMDD symptoms and generally well tolerated. Limitations of the study were open-label design and lack of placebo control. However, the results appeared to be strong and consistent across measures. Adverse events (nausea, insomnia, poor appetite) were low. Further studies are needed to confirm these results.

Objective To examine attachment and affective temperament in patients who have been diagnosed with Bipolar Disorder and to investigate possible differences in both variables among Bipolar I Disorder (BD-I), Bipolar II Disorder (BD-II), and cyclothymic patients. Methods Ninety (45 male and 45 female) outpatients with bipolar or cyclothymic disorder between the ages of 18 and 65 years were recruited consecutively between September 2010 and December 2011 at the Bipolar Disorder Unit of the Psychiatry Day Hospital affiliated with the University General Hospital “A. Gemelli” in Rome, Italy. Patients were assessed using the Structured Clinical Interview for DSM-IV, the Hamilton Depression Rating Scale, the Young Mania Rating Scale, the Temperament Evaluation of Memphis, Pisa, and San Diego—auto-questionnaire version, and the Experiences in Close Relationships (ECR) questionnaire applied by trained interviewers. Results The 3 groups of patients differed only on the ECR Anxiety scores with BD-I patients having the highest anxiety levels, followed by the BD-II patients, and the patients with cyclothymic disorder reporting the lowest level of anxiety. Conclusions This finding suggests that bipolar disorder (type I, type II) and cyclothymic/dysthymic temperament are more strongly associated with insecure attachment style as compared to the general population.

The aim of the present review was to examine objective and subjective burdens in primary caregivers (usually family members) of patients with bipolar disorder (BD) and to list which symptoms of the patients are considered more burdensome by the caregivers. In order to provide a critical review about caregiver’s burden in patients with bipolar disorder, we performed a detailed PubMed, BioMedCentral, ISI Web of Science, PsycINFO, Elsevier Science Direct and Cochrane Library search to identify all papers and book chapters in English published during the period between 1963 and November 2011. The highest levels of distress were caused by the patient’s behavior and the patient’s role dysfunction (work, education and social relationships). Furthermore, the caregiving role compromises other social roles occupied by the caregiver, becoming part of the heavy social cost of bipolar affective disorder. There is a need to better understand caregivers’ views and personal perceptions of the stresses and demands arising from caring for someone with BD in order to develop practical appropriate interventions and to improve the training of caregivers.

The aims of the study were: (1) to study possible associations between temperament, personality dimensions, and psychopathological variables in a clinical sample of euthymic patients with bipolar disorder (BD) and cyclothymia; and (2) to assess how Cloninger's temperament and personality dimensions were associated with affective temperaments. Participants, consisting of 60 patients with BD (type I or II) and cyclothymia in the euthymic phase, completed Akiskal's Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A), and Cloninger's Temperament and Character Inventory-revised version (TCI-R). The diagnostic groups differed in past hospitalization, for age at onset of the disorder, and on two affective temperaments: the TEMPS-A Hyperthymia, and the TEMPS-A Irritability. There were six significant associations between affective temperaments and Cloninger's personality dimensions, ranging from 0.26 to 0.54. The measures of Akiskal and of Cloninger tap common behavioral features in patients with bipolar disorder and cyclothymia, yet the differences indicate that the two measures are not redundant. BD and cyclothymic patients differed significantly in temperament and personality, differences that may have important implications for treatment.

BACKGROUND: Mixed mood states, even in their sub-threshold forms, may significantly affect the course and outcome of bipolar disorder (BD). AIM: To compare two samples of BD patients presenting a major depressive episode and a sub-threshold mixed state in terms of global functioning, clinical outcome, social adjustment and quality of life during a 1-year follow-up. METHODS: The sample was composed by 90 subjects (Group 1, D) clinically diagnosed with a major depressive episode and 41 patients (Group 2, Mx) for a sub-threshold mixed state. All patients were administered with a pharmacological treatment and evaluated for depressive, anxious and manic symptoms by common rating scales. Further evaluations included a global assessment of severity and functioning, social adjustment and quality of life. All evaluations were performed at baseline and after 1, 3, 6 and 12 months of treatment. RESULTS: The two groups were no different for baseline as well as improvement in global severity and functioning. Though clearly different for symptoms severity, the amount of change of depressive and anxiety symptoms was also no different. Manic symptoms showed instead a trend to persist over time in group 2, whereas a slight increase of manic symptoms was observed in group 1, especially after 6 months of treatment. Moreover, in group 1, some manic symptoms were also detected at the Young Mania Rating Scale (n = 24, 26.6%). Finally, improvement in quality of life and social adjustment was similar in the two groups, though a small trend toward a faster improvement in social adjustment in group 1. CONCLUSIONS: Sub-threshold mixed states have a substantial impact on global functioning, social adjustment and subjective well-being, similarly to that of acute phases, or at least major depression. In particular, mixed features, even in their sub-threshold forms, tend to be persistent over time. Finally, manic symptoms may be still often underestimated in depressive episodes, even in patients for BD.

Objectives . To compare two samples of Bipolar (BD) patients presenting “ pure ” (D) and mixed (Mx) depression to assess any difference in terms of clinical outcome, social functioning and quality of life during a 1-year follow-up. Methods . A total of 114 depressed outpatients (HDRS 13) were included. “ Pure ” depressed (D, n 76) were divided from “ mixed ” depressed (Mx, n 38) by the number of concomitant manic symptoms. All patients were evaluated by the Hamilton Depression Rating Scale (HDRS), the Hamilton Anxiety Rating Scale (HARS), the Young Mania Rating Scale (YMRS), the Global Assessment of Functioning (GAF), the Social Adjustment Self-reported Scale (SASS) and the Quality of Life Scale (QoL), at baseline and after 1, 3, 6 and 12 months of treatment. Results . Mx patients were signifi cantly younger at the onset of BD. Manic features persisted signifi cantly higher in Mx than in D patients all over the follow-up period. Axis I comorbidities had a negative impact on the course of social functioning over the medium term period, while Mx patients showed a faster improvement in social adjustment than “ pure ” depressed patients. Conclusions . Mixed features may persist relatively stable throughout a depressive episode, having a negative impact over clinical and functional outcome, but not on social adjustment.

Introduction There is a lack of studies regarding sexuality and sexual behavior in women with bipolar disorder. The aim of this study is to investigate sexual behavior in women affected by bipolar disorder in order to stimulate interest and debate in this area of care. Methods Sixty women (30 BD I and 30 BD II) consent to participate in the study and were included in the sample. Moreover, sixty female healthy subjects without histories of psychiatric disorders were recruited as normal controls. Patients and healthy subjects were given the Sexual Interest and Sexual Performance Questionnaire, a questionnaire devised to explore various aspects of sexual behavior. Results The results of the present study suggest an increase of sexual interest in patients with BD I as compared both with BD II patients and healthy controls. In women with BD I such increase of interest was detected on some items of section I of the Sexual Interest and Sexual Performance Questionnaire, in particular “Actual Value of Sexuality” and “Implicit Sexual Interest”, which implicitly explore sexual interest without overtly focusing upon sexual problems. Moreover, we observed a higher desired frequency of intercourse in women with BD I than BD II and a higher occurrence of repeated sexual intercourse in women with BD I than BD II. Conclusions The main finding of the present study was an increase of sexual interest in BD I as compared with BD II female patients and normal controls. This result was detected when sexual interest was explored implicitly. Our study is limited by the small size of our subject groups. Further investigations on larger subject samples are needed to better clarify particular aspects of sexual behavior of BD patients.

Comorbid conditions are frequent in Bipolar disorder (BD) and may complicate the treatment and course of illness. We investigated the role of Substance use disorder (SUD), axis II Personality disorders (PD) and continuous personality traits on the medium-term outcome (6 months) of treatment for bipolar depression. One-hundred and thirty-nine BD patients meeting criteria for a depressive episode were included in the study. Fifty-six patients were diagnosed for antecedent SUD and 61 for PD. Personality dimensions were evaluated by the Temperament and Character Inventory (TCI-R). Depressive severity over time was evaluated by the Hamilton Rating Scales for Depression (HAMD). Neither PD nor SUD influenced the outcome of depression, though relapse in SUD was concurrent with a slight worsening of depressive symptoms. Variables independently associated with a poor outcome were a high baseline severity and high scores at the temperamental trait of Harm avoidance. Results did not confirm SUD and PD as complicating factors for the medium-term treatment of depression in BD patients. Though several limitations characterize the present study, neurotic personality traits are supposed to be associated with a slower recovery from depressive symptoms in BD, independently from their initial severity.

Behavioural addictions (BAs) can be understood as disorders characterized by repetitive occurrence of impulsive and uncontrolled behaviours. Very few studies have investigated their association with mood disorders. The present study was undertaken to determine the prevalence of the main behavioural addictions in a sample of bipolar outpatients in euthymic phase or stabilised by medications and to investigate the role of impulsivity and temperamental and character dimensions.One-hundred-fifty-eight Bipolar Disorder (BD) (DSM-IV) outpatients were assessed with tests designed to screen the main behavioural addictions: pathological gambling (SOGS), compulsive shopping (CBS), sexual (SAST), Internet (IAD), work (WART) and physical exercise (EAI) addictions. TCI-R and BIS-11 were administered to investigate impulsivity and personality dimensions mainly associated with BAs. The clinical sample has been compared with 200 matched healthy control subjects.In bipolar patients, 33% presented at least one BA respect to the 13% of controls. Significantly higher scores at the scales for pathological gambling (p.001), compulsive buying (p.05), sexual (p.001) and work addictions (p.05) have been found. Self-Directness (p=.007) and Cooperativeness (p=.014) scores were significantly lower while impulsivity level was significantly higher (p=.007) in bipolar patients with BA than those without BA.To our knowledge, this is the first study investigating the prevalence of behavioural addictions in BD showing a significant association of these disorders. BAs are more frequent in bipolar patients than in healthy controls and are related to higher impulsivity levels and character immaturity.

Introduction Bipolar disorder patients (BP) with comorbid Substance Use Disorder (SUD) may present clinical features that could compromise adherence and response to pharmacological treatment. The purpose of this study was to examine clinical and psychopathological features of BP with and without comorbid SUD in a real-world setting. Methods The sample was composed by 131 affective patients. Sixty-five patients were affected by Bipolar Disorder I (BP-I, 49.2%), 29 by Bipolar Disorder II (BP-II, 22.3%) and 37 by Cyclothymic Disorder (CtD, 28.5%), according to DSM-IV. Sixty-six patients were diagnosed for a comorbid SUD. All patients have been submitted to psychometric assessment with Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Young Mania Rating Scale (YMRS), Global Assessment Scale (GAS), Social Adjustment Self-reported Scale (SASS), Quality of Life Scale (QoL), at baseline and repeated follow-up periods (1, 3, 6, 12 months). Results BP comorbid for SUD were more likely diagnosed as BP-II and CtD and were less likely to present a moderate–severe manic symptomatology. Furthermore, personality disorders were more frequent in SUD patients than in non-comorbid BP. BP with SUD were not different for primary outcome measure (HDRS, HARS, YMRS, GAS) from non-comorbid BP; however, BP with SUD were significantly more impaired in social functioning (SASS) at any stage of the follow-up and poor functioning increased the risk of relapse in substance use during treatment. Finally, SUD comorbidity did not represent a risk factor for treatment drop-out, while in our sample young age, low treatment dosage and BP-I diagnosis were significantly associated with drop-out. Discussion The primary finding of this work is that BP with comorbid SUD are significantly more compromised in social functioning. Second, these patients were less likely to be diagnosed for BP-I and to present a severe manic symptomatology. Finally, we found that the diagnosis of SUD, but young age, low treatment dosage and BP-I diagnosis to be risk factors for treatment drop-out. Physicians should be alert to these differences in their clinical practice.

ObjectivesThe aim of our study is the investigation of burn-out indexes in public mental health services employees (psychiatrists, psychologists, nursing staff, care providers) working with patients affected by Bipolar Disorder in order to correlate them with patients’ indexes of satisfaction about received treatment and care.MethodsA sample of 20 employees of mental health services (psychiatrists, psychologists, nurses) and one consisting of 22 patients with a diagnosis of Bipolar Disorder have been recruited at the Bipolar Disorders Unit of the Day Hospital of Psychiatry of the A. Gemelli Hospital in Rome. Operators have been submitted the Maslach Burnout Inventory (Emotional distress, Depersonalization, Personal satisfaction/achievement/fulfilment) while patients have been submitted the Questionnaire on Satisfaction of patient (QS)ResultsBy calculating the Spearman Correlation Coefficient the Depersonalization dimension proves highly correlated with the three subscales of QS: Doctor-Patient relationship quality (-.51); Information Quality and Doctor's therapeutic competence (-.48); Efficiency of service organization (-.58)ConclusionsIn our sample high levels of Depersonalization are correlated to a low satisfaction of patients. We therefore expect low levels of Depersonalization to be correlated with a higher satisfaction of the patient. Although it is not possible to generalize these results we can hypothesize that burn out negatively influences patients’ satisfaction.

ObjectivesThis study aims to evaluate different kinds of temperament and attachment in a sample of alcohol-dependent patients, divided in Cloninger typology 1 and 2, compared to an healthy group.Materials and procedureA group of 40 patients was recruited, in a 3 months period, from Alcohology Unit of “Villa Rosa” in Viterbo. This sample was selected by a clinical diagnosis of Alcohol Dependence and compared to a control group of 40 healthy subjects. Each participant was screened by: SCID-I for Axis I Diagnosis, SCID-II for Axis II Diagnosis, TEMPS-A for Temperament, ECR for Attachment Styles.ResultsStatistical analysis showed significative differences between the two groups (p< 0.05). The mean of the scores (t Student) and the Mann-Whitney U test results higher in the experimental group. Regarding the ECR, we found differences in the “avoidance” between Cloninger's typology 1 and 2. Control group: 92.5% of the subjects showed a “secure” attachment, 7.5% a “dismissing” attachment. Experimental group: 40% of the sample showed a “secure” attachment, 35% a “dismissing” attachment, 17.5% a “preoccupied” attachment and 7.5% a “fearful/avoidant” attachment.DiscussionOur sample showed that the “preoccupied” and the “dismissing” attachment styles were the most prevalent among alcoholists, while the “secure” style was typical of control subjects. Concerning the TEMPS-A we found high prevalence of the hyperthymic and cyclothymic temperaments.

ObjectivesBehavioural addictions (BAs) can be understood as disorders characterized by repetitive occurrence of impulsive and uncontrolled behaviours. Very few studies have investigated their association with mood disorders. The present study was undertaken to determine the prevalence of the main behavioural addictions in a sample of bipolar outpatients in euthymic phase or stabilised by medications and to investigate the role of impulsivity and temperamental and character dimensions.MethodsOne-hundred-fifty-eight Bipolar Disorder (BD) (DSM-IV) outpatients were assessed with tests designed to screen the main behavioural addictions: pathological gambling (SOGS), compulsive shopping (CBS), sexual (SAST), internet (IAD), work (WART) and physical exercise (EAI) addictions. TCI-R and BIS-11 were administered to investigate impulsivity and personality dimensions mainly associated with BAs. The clinical sample has been compared with 200 matched healthy control subjects.ResultsIn bipolar patients, 33% presented at least one BA respect to the 13% of controls. Significantly higher scores at the scales for pathological gambling (p< .001), compulsive buying (p< .05), sexual (p< .001) and work addictions (p< .05) have been found. Self-Directness (p=.007) and Cooperativeness (p=.014) scores were significantly lower while impulsivity level was significantly higher (p=.007) in bipolar patients with BA than those without BA.ConclusionsTo our knowledge, this is the first study investigating the prevalence of behavioural addictions in BD showing a significant association of these disorders. BAs are more frequent in bipolar patients than in healthy controls and are related to higher impulsivity levels and character immaturity.

ObjectivesThe aim of the present study was to thoroughly investigate the existing comorbidity between Axis II and Bipolar Disorder (BD) pointing out as well the meaningful existing comorbidity between Personality Disorders and Cyclothymia.Materials and methodsA study group composed of 70 patients affected by Bipolar Disorder (Type I, Type II, and Cyclothymia) was enrolled at the Bipolar Disorders Unit of the Catholic University of the Sacred Heart of Rome. Axis I diagnosis was made by SCID-I; Axis II diagnosis was made by SCID-II.ResultsIn a sample of 70 patients in euthymic phase, 39 patients (55.7%) showed comorbidity with Axis II Disorders. Clusters were represented as follows: 2 patients (5.1%) fell within cluster A; 24 patients (61.5%) within cluster B; 9 patients (23%) within cluster C; and 4 patients (10.4%) turned out to be affected by NAS Personality Disorders. On the whole 39 patients - 24 patients (61.5%) affected by BD I, 6 patients (15.3%) affected by BD II, and 9 patients (23.0%) affected by Cyclothymia were found to have comorbidity with Axis II Disorders. Besides, in our sample there was a significant comorbidity between Cyclothymia and Personality Disorders.DiscussionMore than half of patients (55.7%) showed comorbidity with Axis II Disorders. Moreover most of patients turned out to be affected by Personality Disorders falling within cluster B while 23% of Cyclothymic patients were found to have comorbidity with Axis II Disorders.

Introdution:Our study represents a pilot evaluation about how the MOOD-SR recognizes subthreshold manifestations that may be associated with clinical symptomatology in a group of bipolar patients.Methods:At Day Hospital of Psychiatry, Policlinico “A. Gemelli”, Bipolar Disorders Unit, it has been conducted an experimental study on a heterogeneous sample of 24 patients with a diagnosis of Bipolar Disorder type I. Patients have been assessed with the MOOD-SR, a clinical self-reported interview, that is specific for the spectrum of subthreshold pathology, and with the Quality of Life (QoL), that investigates the patient's quality of life.Results:We have found that 16 patients on 24 report a score higher than 60 (68,4%). Among these, 10 female patients on 15 have a total score higer than 61 (68.75%) while 6 male patients on 9 obtain a total score higher than 60 (62,5%). However, these results have only preliminary value, further studies are needed in order to obtain a deeper evaluation.Conclusion:Spectrum manifestations are both indicator of course and response to treatment and predictive for relapse. This finding may represent an important preventive instrument for maniacal relapse in patients with Bipolar Disorder, that is often underdiagnosed or confused for Unipolar Depression. By adequately recognizing the problem we will be able to refine diagnosis and individualize therapy.