Letters to the editor cally as showing specificity to melancholia. We calculate a ratio of 2.7 – one that does differ clearly from the 1.9 ratio quantified by Wakefield for all 46 symptoms. Specificity and differentiation are now observed, seemingly annulling Wakefield’s ‘disconfirmation’ charge. While we interpret our LCA as differentiating depressive disease (i.e. bipolar and unipolar melancholia) from residual non-melancholic and normative mood states, Wakefield seeks to interpret our data according to an alternative binary model (i.e. complicated patho-suggestive vs. general-distress symptom types) and claims that his analyses of our data more confirm his hypothesis. We suggest that readers might make their own judgments about how best to interpret the issues and domains under examination. In conclusion, we thank Wakefield for his spirited interest and in adding another challenge to DSM-5’s criteria for melancholia.
G. Parker1,2 and D. Hadzi-Pavlovic1,2 School of Psychiatry, University of NSW, Sydney, NSW and 2 Black Dog Institute, Sydney, NSW, Australia
1
E-mail: [email protected]
References 1. Parker G, Paterson A, Hadzi-Pavlovic D. Cleaving depressive diseases from depressive disorders and non-clinical states. Acta Psychiatr Scand 2015;131:426–433. 2. Parker G, Hadzi-Pavlovic D. Development and structure of the CORE system. In: Parker G, Hadzi-Pavlovic D, eds. Melancholia. A disorder of movement and mood. Cambridge: Cambridge University Press, 1996:82–129. 3. Parker G, Paterson A. Melancholia: definition and management. Curr Opin Psychiatry 2014;27:1–6.
Rapid cycling bipolar disorder is associated with a higher lifetime prevalence of migraine DOI: 10.1111/acps.12450 Bipolar disorder (BD) is associated with high rates of migraine headache (1). Some authors have sustained that this comorbidity might comprise a subphenotype of patients with BD which is associated with an earlier age of onset, higher risk of suicide, poorer outcome, more lifetime mood episodes (particularly depressive ones), and a higher chance to have an additional psychiatry and clinical comorbidity (2). Rapid cycling (RC) could be an unrecognized clinical characteristic associated with this potential subphenotype of patients with BD, as it has been also associated with all the above clinical features (3). Nonetheless, a specific association between the presence of migraine and RC has not been previously described. To address this question, we investigated whether RC had more lifetime migraine than non-rapid cycling (NRC) in a multicenter sample of patients with BD (types I and II) from the Brazilian Bipolar Disorder Research Network. From 600 patients (69.5% female and 90.2% BD type I), we found that 17.3% were characterized as presenting RC in the previous year and 30.5% had a lifetime history of migraine. Comparing RC and NRC groups, there were no differences about age and gender. The RC group exhibited more lifetime history of migraine than NRC group (RC = 45.3%; NRC = 31.4%; P = 0.010). Other medical illness was investigated, but we did not observe a significant difference for hypothyroidism (RC = 21.1%; NRC = 16.9%; P = 0.345), hyperthyroidism (RC = 2.1%; NRC = 1.7%; P = 0.782), seizures (RC = 13.3%; NRC = 9.1%; P = 0.210), asthma (RC = 21.4%; NRC = 14.6%; P = 0.162), and diabetes mellitus (RC = 11.4%; NRC = 8.6%; P = 0.674). To our knowledge, this is the first study reporting an increased rate of migraine in a RC compared with a NRC group of patients with BD. The neurobiology of the association between migraine and BD has been investigated, and
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some evidence has shown that both disorders share hereditary vulnerabilities and specific genetic polymorphisms (4). Additionally, BD and migraine have been associated with abnormalities in the serotonergic, dopaminergic and glutamatergic systems (4). Furthermore, some drugs are successful in the prevention of both disorders, most notably valproate but also lamotrigine, quetiapine and lithium, which effectiveness in mood regulation has already been established (5). However, those alterations have not been investigated in the subgroup of RC patients and more studies are necessary to elucidate the mechanisms of the association between migraine and RC. Thus far, this new finding is clinically relevant and corroborates the evidence that the comorbidity migraine BD is associated with a more severe clinical picture and outcome. In conclusion, the association of RC with migraine is an interesting new data which requires confirmation by other groups and further investigation of shared vulnerabilities and pathophysiological mechanisms. A. D. Gigante1, I. Y. Barenboim1, R. da S. Dias1, ^ Miranda-Scippa2, F. P. Kapczinski3 and R. A. Toniolo1, A. B. Lafer1 1 Bipolar Disorder Program (PROMAN), Department of Psychiatry, University of S~ ao Paulo Medical School, S~ ao Paulo, 2 Program of Mood and Anxiety Disorders (CETHA), Department of Psychiatry, Federal University of Bahia, Salvador and 3Bipolar Disorder Program (PROTAHBI), Department of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil E-mail: [email protected]
References 1. Kemp DE, Sylvia LG, Calabrese JR et al. General medical burden in bipolar disorder: findings from the LiTMUS
Letters to the editor comparative effectiveness trial. Acta Psychiatr Scand 2014;129:24–34. 2. Brietzke E, Moreira CLRL, Duarte SVB et al. Impact of comorbid migraine on the clinical course of bipolar disorder. Compr Psychiatry 2012;53:809–812. 3. Carvalho AF, Dimellis D, Gonda X et al. Rapid cycling in bipolar disorder: a systematic review. J Clin Psychiatry 2014;75:578–586.
4. Jacobsen KK, Nievergelt CM, Zayats T et al. Genome wide association study identifies variants in NBEA associated with migraine in bipolar disorder. J Affect Disord 2014;172C:453–461. 5. Finocchi C, Villani V, Casucci G. Therapeutic strategies in migraine patients with mood and anxiety disorders: clinical evidence. Neurol Sci 2010;31(Suppl 1):S95–S98.
DOI: 10.1111/acps.12452
chiatric and psychological variables are needed to determine whether RCBD–migraine represents a subtype of bipolar disorders.
Reply In their Letter ‘Rapid cycling bipolar disorder is associated with a higher lifetime prevalence of migraines’, Gigante and colleagues used a pre-existing data set to study the prevalence of migraine in patients with or without rapid cycling bipolar disorder (RCBD) and found that patients with RCBD had a significantly higher rate of migraine than those without RCBD, 45.3% versus 31.4% (1). This finding is consistent with a recent study of 1488 patients with bipolar I or II disorder with or without migraine (2), in which female gender, panic attacks and rapid cycling were significantly associated with an increased risk for migraine. Retrospective analysis of a longitudinal study of patients with bipolar disorder also found that patients with migraine had a higher rate of RCBD than those without it, 41% versus 31% with an OR of 1.5 (95% CI: 0.99– 2.4) (3). Moreover, bipolar men with migraine had a significantly higher rate of RCBD than those without it with an OR of 3.5 (95% CI 1.4–8.8). These data suggest that there is an association between migraine and RCBD, but it is difficult to determine whether RCBD–migraine represents a subtype of bipolar disorders. Some previous studies found that rapid cycling course was a transient phenomenon for some patients. Cross-sectional data of aforementioned studies might misclassify some of their patients. More importantly, patients with RCBD had higher rates of comorbid psychiatric conditions including anxiety and substance disorders (4,5). These conditions may increase the risk for migraine. Unless controlling all potential factors, the relationship between bipolar disorder, rapid cycling and migraine will never be established. Longitudinal studies from birth or younger age with clear documentation of the onset of bipolar disorder, rapid cycling course, migraine, and other psy-
K. Gao and J. R. Calabrese Mood and Anxiety Clinic in the Mood Disorders Program, Case Western Reserve University/University Hospitals Case Medical Centre, Cleveland, OH, USA E-mail: [email protected]
References 1. Gigante AD, Barenboim IY, Dias RS et al. Rapid cycling bipolar disorder is associated with a higher lifetime prevalence of migraines. Acta Psychiatr Scand 2015;132:308–309. 2. Gordon-Smith K, Forty L, Chan C et al. Rapid cycling as a feature of bipolar disorder and comorbid migraine. J Affect Disord 2015;175:320–324. 3. Saunders EF, Nazir R, Kamali M et al. Gender differences, clinical correlates, and longitudinal outcome of bipolar disorder with comorbid migraine. J Clin Psychiatry 2014;75: 512–519. 4. Gao K, Tolliver BK, Kemp DE et al. Differential interactions between comorbid anxiety disorders and substance use disorder in rapid cycling bipolar I or II disorder. J Affect Disord 2008;110:167–173. 5. Gao K, Verduin ML, Kemp DE et al. Clinical correlates of patients with rapid-cycling bipolar disorder and a recent history of substance use disorder: a subtype comparison from baseline data of 2 randomized, placebo-controlled trials. J Clin Psychiatry 2008;69:1057–1063.
Why clinicians still use community treatment orders DOI: 10.1111/acps.12463 Community treatment orders (CTOs) failed to achieve a reduction in hospital admissions (1) or improve any other clinical or social outcomes (2) in the OCTET sample. However, one could rightly argue that patients referred to the OCTET were likely to have differed significantly from ‘real-world’ patients, due to the exclusion of those who were viewed by their clinicians as clear candidates for a CTO (3). Further, the OCTET reports (1, 2) do not show the proportion of patients in the study
sample who received care from forensic and assertive outreach teams – a rough proxy for the levels of risk, and social and functional impairment. Thus, it would be hard to justify extrapolating the OCTET results to the larger CTO population. Nonetheless, it has recently been shown using a robust statistical analysis that the marked protocol violation the OCTET suffered was detrimental to its internal validity, which left the OCTET with an only 35.2% chance of proving the effectiveness of CTOs (4).
309
G. Parker1,2 and D. Hadzi-Pavlovic1,2 School of Psychiatry, University of NSW, Sydney, NSW and 2 Black Dog Institute, Sydney, NSW, Australia
1
E-mail: [email protected]
References 1. Parker G, Paterson A, Hadzi-Pavlovic D. Cleaving depressive diseases from depressive disorders and non-clinical states. Acta Psychiatr Scand 2015;131:426–433. 2. Parker G, Hadzi-Pavlovic D. Development and structure of the CORE system. In: Parker G, Hadzi-Pavlovic D, eds. Melancholia. A disorder of movement and mood. Cambridge: Cambridge University Press, 1996:82–129. 3. Parker G, Paterson A. Melancholia: definition and management. Curr Opin Psychiatry 2014;27:1–6.
Rapid cycling bipolar disorder is associated with a higher lifetime prevalence of migraine DOI: 10.1111/acps.12450 Bipolar disorder (BD) is associated with high rates of migraine headache (1). Some authors have sustained that this comorbidity might comprise a subphenotype of patients with BD which is associated with an earlier age of onset, higher risk of suicide, poorer outcome, more lifetime mood episodes (particularly depressive ones), and a higher chance to have an additional psychiatry and clinical comorbidity (2). Rapid cycling (RC) could be an unrecognized clinical characteristic associated with this potential subphenotype of patients with BD, as it has been also associated with all the above clinical features (3). Nonetheless, a specific association between the presence of migraine and RC has not been previously described. To address this question, we investigated whether RC had more lifetime migraine than non-rapid cycling (NRC) in a multicenter sample of patients with BD (types I and II) from the Brazilian Bipolar Disorder Research Network. From 600 patients (69.5% female and 90.2% BD type I), we found that 17.3% were characterized as presenting RC in the previous year and 30.5% had a lifetime history of migraine. Comparing RC and NRC groups, there were no differences about age and gender. The RC group exhibited more lifetime history of migraine than NRC group (RC = 45.3%; NRC = 31.4%; P = 0.010). Other medical illness was investigated, but we did not observe a significant difference for hypothyroidism (RC = 21.1%; NRC = 16.9%; P = 0.345), hyperthyroidism (RC = 2.1%; NRC = 1.7%; P = 0.782), seizures (RC = 13.3%; NRC = 9.1%; P = 0.210), asthma (RC = 21.4%; NRC = 14.6%; P = 0.162), and diabetes mellitus (RC = 11.4%; NRC = 8.6%; P = 0.674). To our knowledge, this is the first study reporting an increased rate of migraine in a RC compared with a NRC group of patients with BD. The neurobiology of the association between migraine and BD has been investigated, and
308
some evidence has shown that both disorders share hereditary vulnerabilities and specific genetic polymorphisms (4). Additionally, BD and migraine have been associated with abnormalities in the serotonergic, dopaminergic and glutamatergic systems (4). Furthermore, some drugs are successful in the prevention of both disorders, most notably valproate but also lamotrigine, quetiapine and lithium, which effectiveness in mood regulation has already been established (5). However, those alterations have not been investigated in the subgroup of RC patients and more studies are necessary to elucidate the mechanisms of the association between migraine and RC. Thus far, this new finding is clinically relevant and corroborates the evidence that the comorbidity migraine BD is associated with a more severe clinical picture and outcome. In conclusion, the association of RC with migraine is an interesting new data which requires confirmation by other groups and further investigation of shared vulnerabilities and pathophysiological mechanisms. A. D. Gigante1, I. Y. Barenboim1, R. da S. Dias1, ^ Miranda-Scippa2, F. P. Kapczinski3 and R. A. Toniolo1, A. B. Lafer1 1 Bipolar Disorder Program (PROMAN), Department of Psychiatry, University of S~ ao Paulo Medical School, S~ ao Paulo, 2 Program of Mood and Anxiety Disorders (CETHA), Department of Psychiatry, Federal University of Bahia, Salvador and 3Bipolar Disorder Program (PROTAHBI), Department of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil E-mail: [email protected]
References 1. Kemp DE, Sylvia LG, Calabrese JR et al. General medical burden in bipolar disorder: findings from the LiTMUS
Letters to the editor comparative effectiveness trial. Acta Psychiatr Scand 2014;129:24–34. 2. Brietzke E, Moreira CLRL, Duarte SVB et al. Impact of comorbid migraine on the clinical course of bipolar disorder. Compr Psychiatry 2012;53:809–812. 3. Carvalho AF, Dimellis D, Gonda X et al. Rapid cycling in bipolar disorder: a systematic review. J Clin Psychiatry 2014;75:578–586.
4. Jacobsen KK, Nievergelt CM, Zayats T et al. Genome wide association study identifies variants in NBEA associated with migraine in bipolar disorder. J Affect Disord 2014;172C:453–461. 5. Finocchi C, Villani V, Casucci G. Therapeutic strategies in migraine patients with mood and anxiety disorders: clinical evidence. Neurol Sci 2010;31(Suppl 1):S95–S98.
DOI: 10.1111/acps.12452
chiatric and psychological variables are needed to determine whether RCBD–migraine represents a subtype of bipolar disorders.
Reply In their Letter ‘Rapid cycling bipolar disorder is associated with a higher lifetime prevalence of migraines’, Gigante and colleagues used a pre-existing data set to study the prevalence of migraine in patients with or without rapid cycling bipolar disorder (RCBD) and found that patients with RCBD had a significantly higher rate of migraine than those without RCBD, 45.3% versus 31.4% (1). This finding is consistent with a recent study of 1488 patients with bipolar I or II disorder with or without migraine (2), in which female gender, panic attacks and rapid cycling were significantly associated with an increased risk for migraine. Retrospective analysis of a longitudinal study of patients with bipolar disorder also found that patients with migraine had a higher rate of RCBD than those without it, 41% versus 31% with an OR of 1.5 (95% CI: 0.99– 2.4) (3). Moreover, bipolar men with migraine had a significantly higher rate of RCBD than those without it with an OR of 3.5 (95% CI 1.4–8.8). These data suggest that there is an association between migraine and RCBD, but it is difficult to determine whether RCBD–migraine represents a subtype of bipolar disorders. Some previous studies found that rapid cycling course was a transient phenomenon for some patients. Cross-sectional data of aforementioned studies might misclassify some of their patients. More importantly, patients with RCBD had higher rates of comorbid psychiatric conditions including anxiety and substance disorders (4,5). These conditions may increase the risk for migraine. Unless controlling all potential factors, the relationship between bipolar disorder, rapid cycling and migraine will never be established. Longitudinal studies from birth or younger age with clear documentation of the onset of bipolar disorder, rapid cycling course, migraine, and other psy-
K. Gao and J. R. Calabrese Mood and Anxiety Clinic in the Mood Disorders Program, Case Western Reserve University/University Hospitals Case Medical Centre, Cleveland, OH, USA E-mail: [email protected]
References 1. Gigante AD, Barenboim IY, Dias RS et al. Rapid cycling bipolar disorder is associated with a higher lifetime prevalence of migraines. Acta Psychiatr Scand 2015;132:308–309. 2. Gordon-Smith K, Forty L, Chan C et al. Rapid cycling as a feature of bipolar disorder and comorbid migraine. J Affect Disord 2015;175:320–324. 3. Saunders EF, Nazir R, Kamali M et al. Gender differences, clinical correlates, and longitudinal outcome of bipolar disorder with comorbid migraine. J Clin Psychiatry 2014;75: 512–519. 4. Gao K, Tolliver BK, Kemp DE et al. Differential interactions between comorbid anxiety disorders and substance use disorder in rapid cycling bipolar I or II disorder. J Affect Disord 2008;110:167–173. 5. Gao K, Verduin ML, Kemp DE et al. Clinical correlates of patients with rapid-cycling bipolar disorder and a recent history of substance use disorder: a subtype comparison from baseline data of 2 randomized, placebo-controlled trials. J Clin Psychiatry 2008;69:1057–1063.
Why clinicians still use community treatment orders DOI: 10.1111/acps.12463 Community treatment orders (CTOs) failed to achieve a reduction in hospital admissions (1) or improve any other clinical or social outcomes (2) in the OCTET sample. However, one could rightly argue that patients referred to the OCTET were likely to have differed significantly from ‘real-world’ patients, due to the exclusion of those who were viewed by their clinicians as clear candidates for a CTO (3). Further, the OCTET reports (1, 2) do not show the proportion of patients in the study
sample who received care from forensic and assertive outreach teams – a rough proxy for the levels of risk, and social and functional impairment. Thus, it would be hard to justify extrapolating the OCTET results to the larger CTO population. Nonetheless, it has recently been shown using a robust statistical analysis that the marked protocol violation the OCTET suffered was detrimental to its internal validity, which left the OCTET with an only 35.2% chance of proving the effectiveness of CTOs (4).
309
