Rakesh Reviews: Predictors of Diagnostic Transition From Major Depressive Disorder to Bipolar Disorder: A Retrospective Observational Network Study

Introducing the new "7 in 7: Clinical Journals on the Cutting-Edge" journal club hosted by Rakesh Jain, MD, MPH, clinical professor in the department of psychiatry at Texas Tech University School of Medicine, Permian Basin, Texas. In his first article review, Dr Jain walks us through the research study entitled, "Predictors of Diagnostic Transition From Major Depressive Disorder to Bipolar Disorder: A Retrospective Observational Network Study," published in Translational Psychiatry.

Read the transcript:

Dr. Rakesh Jain:  Hello, friends, and welcome to the Journal Article Review, where I, on a regular basis, review seven journals in seven minutes. This is Rakesh Jain.

My favorite seven journals, which I consider essential in my own development as a mental health clinician, are the following: "American Journal of Psychiatry," "Molecular Psychiatry," "Translational Psychiatry." The others are "The Lancet Psychiatry," "The Journal of Positive Psychology," "The Journal of American Academy of Child and Adolescent Psychiatry," and "The Journal of Wellness."

Of course, I read many other journals, just like you, but I consider these seven the very essentials.

My name is Rakesh Jain, and I'm a clinical professor in the Department of Psychiatry at Texas Tech University School of Medicine, Permian Basin in Midland, Texas. I'm also in private practice in Austin, Texas. I am the creator of this website, jainuplift.com, which I invite you to come visit at your leisure, and I am a member of the Steering Committee of Psych Congress 2022.

Today's featured article that we will conduct a journal review is this beautiful article from Translational Psychiatry. It is open access, by the way, so you can, and you should, absolutely read it for yourself. I'll give you a link shortly.

The title of this is so very important to health professionals, no matter whether we are in psychiatry or any other branch of medicine, "Predictors of Diagnostic Transition From Major Depressive Disorder to Bipolar Disorder - A Retrospective Observational Network Study." This is a major article, definitely worthy of journal club review today.

Details on this particular article are right here. As I said, this is an open-access journal in Translational Psychiatry and comes to us from researchers from a variety of institutions. The first author is from University of New Mexico School of Medicine. Why don't we cover some of the relevant background?

It's a very ambitious project to build a predictive model of major depression-to-bipolar disorder conversion, which I think is one of the most important topics in contemporary medicine, and to validate it across a multi-national network of patient databases.

This is not a small study, by the way. It's well over two and a half million patients that are included in all five training databases who met the study eligibility criteria. The time-to-conversion Kaplan-Meier analysis was performed up to a decade after diagnosis of MDD to see what percentage of patients actually convert and what are some of the risk factors.

The risk assessment algorithm that they used, which I think you will find as intriguing as I did, is right here. The presence of severe MDD gets the patient a +5. If it's mild MDD, it's -5. If psychosis is present, then it's +10; any other mental disorders, +2; presence of anxiety, +1; pregnancy is protective, -3; substance misuse, +5; self-harm and thoughts, +9.

If you can look at the various age groups, in many ways, the younger the individual, particularly when they are 34 years of age or younger, the risk added is substantial. The risk decreases, as you can see, from age 35 onwards till actually at age 70, there is a -3 risk, and at 75+, it's -5.

You add up the total score from this particular risk assessment algorithm, and now, we will see, for individual patients, what might be the risk stratification. The results are the following. Nine variables were identified, and they were thought to be predictive of a 1-year major depression-to-bipolar disorder transition. Why don't we take a quick look at these nine variables?

The first one, younger age, you already had a chance to look at it. Number 2, severity of the depression, severe depression really did act as a significant predictor, and so did the presence of psychosis. The other three are the presence of anxiety, the presence of substance misuse, and thoughts of self-harm or actual actions.

The other three are the presence of any other mental disorders besides substance misuse and anxiety that added to the risk. Pregnancy actually was protective, ever slightly so. An increasing age was also protective, more so in our geriatric population.

You might be wondering, based on this, what are the results? How do I calculate the one-year risk of converting from major depression to BD using this very innovative tool?

Here are the results. These are hazard ratios of MDD-to-BD conversion. On the y-axis, you're seeing the hazard ratios, 0, 10, 20, 30, 40. At the bottom, what you're seeing are the risk scores that we just obtained from the scale I presented to you.

As you can see, at zero risk score, the conversion hazard ratio is quite modest. It doesn't go up very much at, say, 5, but at 10, it's now starting to show an inflection point. By 15, there is a very dramatic lift-up, and that lift-up of the hazard ratio elevation simply does not stop. It, in fact, keeps going up and up and up and up.

For those of us who are practicing clinicians, knowing which are the risk factors, what combination of risk factors could be predictive of conversion from MDD to BD, would be profoundly important. Why don't we continue this conversation by looking at the risk assessment algorithm for 1-year diagnostic transition, by looking at the totality of it?

On the left-hand side, we are looking at the actual risk scale. Remember, we just discussed that a few minutes ago. Then, if you look at all five of these databases, in all five of them, increase in scores on this particular risk algorithm definitely correlates to 1-year transition risk from MDD to BD.

In my personal opinion, the risk after a score of 10 is elevated enough that we clinicians should be watching such patients very closely, and higher the score, quite dramatically elevated is the hazard ratio risk of conversion.

What did this very important article in Translation Psychiatry from University of New Mexico teach us?

Point number 1, risk of MDD-to-BD conversion can be accurately quantified by using just a few easily obtainable markers. Number 2, as a result, all of us, all clinicians, should be aware of these risk factors and utilize these findings from this article to enhance patient outcomes. Very important 2 points.

You want to read this article in its entirety? Good for you, and here is the link to it. By the way, because it is open access, the entire PDF is available for your review. In my opinion, this is one of the most important articles of the year, and therefore, it deserves close scrutiny by all of us, no matter what our backgrounds may be, psychiatry, primary care, or otherwise.

In case you have run into an article that you think I should include in my next week's Journal Club issue, please drop me a note. I'm giving you my email address. Let me know about the article, and I promise you I will cover it in a forthcoming issue of the Journal Club Review.

Thank you again. This is Rakesh Jain. I so appreciate you joining me for this issue of "7 Journals in 7 Minutes." I hope you found it useful, and I'll see you at the next issue. Goodbye for now.