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