Elsevier

Journal of Affective Disorders

Volume 170, 1 January 2015, Pages 161-165
Journal of Affective Disorders

Research report
Cyclothymic temperament rather than polarity is associated with hopelessness and suicidality in hospitalized patients with mood disorders

https://doi.org/10.1016/j.jad.2014.08.042Get rights and content

Abstract

Background

The aim of the present study was to assess sociodemographic and clinical differences between inpatients with major mood disorders (bipolar disorder – BD – and major depression – MDD) and the cyclothymic phenotype (CYC), and pure BDs or MDDs.

Methods

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

Results

38.7% of the MDD patients and 48.3% of the BD patients satisfied criteria to be included in the cyclothymic groups. Above 92% of the patients with the cyclothymic phenotype reported suicidal ideation at the item #3 of the HAMD17. Furthermore, patients with the cyclothymic phenotype reported higher hopelessness than other patients.

Limitations

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

Conclusions

Our results support the clinical usefulness of the concept of soft bipolar spectrum. Patients with the cyclothymic phenotype differ from pure MDD patients and BD patients for temperamental profile and clinical variables.

Introduction

The concept of “soft bipolar spectrum” is now a well-known concept (Akiskal and Mallya, 1987), which includes patients with unipolar depression and cyclothymic temperament (bipolar II1/2) or hyperthymic temperament (bipolar IV) (Akiskal and Pinto, 1999). Recently, Maina et al. (2010) assessed whether cyclothymic temperament is associated with well-established validators of bipolar disorder diagnosis such as age at onset and family history of bipolar disorder in 104 Italian patients with major depressive disorder (MDD). Cyclothymic temperament was the most represented prevalent temperament in the sample of MDD patients (12.3%). The authors found that MDD patients with a cyclothymic temperament had an earlier age at onset and a higher family history for bipolar disorder than patients without any dominant affective temperament (see also Akiskal et al. (2006)). Also, patients with cyclothymic temperament had been reported to have more frequently an onset with mixed features, which is indicative of a more severe course of the illness (Azorin et al., 2011).

Cyclothymic temperament has been associated with suicidality in different subtypes of mood disorder. For example, compared to non-cyclothymic bipolar II patients (n=120) cyclothymic bipolar II subjects (n=74) reported significantly more frequent lifetime suicide attempts (38% vs. 49%) and experienced more current hospitalization for suicidal risk (50% vs. 61%) (Akiskal et al., 2003). The same trend has been reported in an Italian National Bipolar I sample, where dominant cyclothymic-sensitive patients reported higher number of lifetime suicide attempts when compared to the dominant hyperthymic patients (Perugi et al., 2010). Kochman et al. (2005), in a prospective study of 80 depressed children and adolescent inpatients with major depression, reported that those with a cyclothymic-hypersensitive temperament were 7.4 time more at risk to report suicidal ideation and 10.5 times more at risk to report a suicide attempt. More recently, higher scores on the cyclothymic dimension have been associated with more frequent suicide attempts and ideation, and were predictors of bipolarity in a sample of patients with recurrent depression (Mechri et al., 2011). However, in a study on 107 consecutive outpatients with DSM-IV atypical features, Perugi et al. (2003) found a non-significant difference in the reported rates of suicide attempt during the current depressive episode.

Cyclothymic temperament seems to be also a contributor of suicidality in patients with other than current major depressive episode and in patients recruited from Primary Care (Rihmer et al., 2013). Comparing obsessive–compulsive disorder patients with (n=302) and without (n=272) cyclothymic temperament, the rate of patients with prior suicide attempt was almost double in the cyclothymic (20%) than in the non-cyclothymic (12%) subgroup (Hantouche et al., 2003).

Taken together, these preliminary findings indicate the need for heightened clinical attention in the subgroup of patients with predominant cyclothymic temperament, although further studies are needed before we can consider cyclothymic temperament as a valid risk factor for suicide. In fact, most of the cited studies examined small samples, most of the times limiting their sample to patients with homogeneous characteristics (e.g., BD II patients or outpatients with DSM-IV atypical features). Furthermore, they did not examine other well-known predictors of suicide in mood disorders patients, such as hopelessness.

Thus, the aim of the present study was to assess hopelessness, suicidality and other related clinical features in a large sample of depressive inpatients with MDD, MDD with cyclothymic temperament (MDD-CYC) and BD. Furthermore, we aimed to assess whether bipolar disorder patients with the cyclothymic phenotype (BD-CYC) differ from other BDs without the cyclothymic phenotype. We hypothesized that BD-CYC phenotype is associated with more severe suicidality and hopelessness.

Section snippets

Subjects

Participants were 281 adult inpatients (134 men and 147 women) consecutively admitted to the Department of Psychiatry of the Sant׳Andrea University Hospital in Rome, Italy, between January 2008 and June 2010. The inclusion criterion was a diagnosis of a major mood disorder (MDD and BD type I and II). Exclusion criteria were any condition affecting the ability to take the .assessment, including delirium, dementia or denial of the informed consent.

All the patients accepted voluntarily to

Differences between MDD patients with the cyclothymic phenotype and other groups

Twenty-nine patients satisfied the criteria to be included in the MDD-CYC group (10.3% of the sample, and 38.7% of the MDD patients).

Differences between MDD and MDD-CYC and between BD and MDD-CYC are listed in Table 1. MDD and MDD-CYC differed for several temperamental dimensions and the BHS. MDD-CYC patients (compared to MDD) had higher scores on affective temperaments with a depressive component: TEMPS-A Depression (16.38±3.77 vs. 13.83±4.66; t73=2.48; p<0.05), Irritability (10.03±3.62 vs.

Discussion

This study sought to shed light on the role of cyclothymic temperament in characterizing mood disorder patients as for their level of hopelessness and suicide risk. Past research indicated that MDD patients with cyclothymic temperament could have an earlier age at onset and a higher family history for bipolar disorder than patients without any dominant affective temperament (Akiskal et al., 2006, Maina et al., 2010).

Our study indicates that prevalence of MDD patients with the cyclothymic

Role of funding source

There were no funding sources for this paper.

Conflict of interest

The authors have no conflicts of interest to report in relation to the research presented in this manuscript.

Acknowledgments

Maurizio Pompili and Marco Innamorati contributed equally to this paper. Xenia Gonda is a recipient of the Janos Bolyai fellowship of the Hungarian Academy of Science.

References (25)

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