Predominant Polarity and Polarity Index of Maintenance Treatments for Bipolar Disorder: A Validation Study in a Large Naturalistic Sample in Italy
Abstract
:1. Introduction
Aims
2. Materials and Methods
2.1. Clinical Sample
2.2. Assessment of Polarity Index and Predominant Polarity
2.3. Statistical Analysis
3. Results
3.1. Clinical Sample
3.2. Clinical Characteristics of Bipolar Disorder Patients According to PP2/3 or PP50%
3.3. Comparison of Polarity Index among PP2/3 or PP50% Bipolar Disorders Subgroups
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Buoli, M.; Cesana, B.M.; Fagiolini, A.; Albert, U.; Maina, G.; de Bartolomeis, A. Which factors delay treatment in bipolar disor-der? A nationwide study focussed on duration of untreated illness. Early Interv. Psychiatry 2020, 1–10. [Google Scholar] [CrossRef]
- Wium-Andersen, I.K.; Vinberg, M.; Kessing, L.; McIntyre, R.S. Personalized medicine in psychiatry. Nord. J. Psychiatry 2016, 71, 12–19. [Google Scholar] [CrossRef]
- Maj, M. Beyond diagnosis in psychiatric practice. Ann. Gen. Psychiatry 2020, 19, 1–6. [Google Scholar] [CrossRef] [Green Version]
- Maj, M.; Van Os, J.; De Hert, M.; Gaebel, W.; Galderisi, S.; Green, M.F.; Guloksuz, S.; Harvey, P.D.; Jones, P.B.; Malaspina, D.; et al. The clinical characterization of the patient with primary psychosis aimed at personalization of management. World Psychiatry 2021, 20, 4–33. [Google Scholar] [CrossRef]
- Alda, M.; Manchia, M. Personalized management of bipolar disorder. Neurosci. Lett. 2018, 669, 3–9. [Google Scholar] [CrossRef]
- Salagre, E.; Dodd, S.; Aedo, A.; Rosa, A.; Amoretti, S.; Pinzon, J.; Reinares, M.; Berk, M.; Kapczinski, F.P.; Vieta, E.; et al. Toward Precision Psychiatry in Bipolar Disorder: Staging 2.0. Front. Psychiatry 2018, 9, 641. [Google Scholar] [CrossRef] [Green Version]
- Perugi, G.; De Rossi, P.; Fagiolini, A.; Girardi, P.; Maina, G.; Sani, G. Personalized and precision medicine as informants for treatment management of bipolar disorder. Int. Clin. Psychopharmacol. 2019, 34, 189–205. [Google Scholar] [CrossRef]
- Salagre, E.; Vieta, E.; Grande, I. Personalized treatment in bipolar disorder. In Personalized Psychiatry; Elsevier BV: Amsterdam, The Netherlands, 2020; pp. 423–436. [Google Scholar]
- Manchia, M.; Maina, G.; Carpiniello, B.; Pinna, F.; Steardo, L.; D’Ambrosio, V. Clinical correlates of age at onset distribution in bipolar disorder: A comparison between diagnostic subgroups. Int. J. Bipolar Disord. 2017, 5, 28. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Altamura, A.C.; Buoli, M.; Cesana, B.; Dell’Osso, B.; Tacchini, G.; Albert, U.; Fagiolini, A.; De Bartolomeis, A.; Maina, G.; Sacchetti, E. Socio-demographic and clinical characterization of patients with Bipolar Disorder I vs II: A Nationwide Italian Study. Eur. Arch. Psychiatry Clin. Neurosci. 2017, 268, 169–177. [Google Scholar] [CrossRef] [Green Version]
- Di Salvo, G.; Pessina, E.; Aragno, E.; Martini, A.; Albert, U.; Maina, G.; Rosso, G. Impact of comorbid obsessive-compulsive disorder on suicidality in patients with bipolar disorder. Psychiatry Res. 2020, 290, 113088. [Google Scholar] [CrossRef] [PubMed]
- Scott, J.; Bellivier, F.; Manchia, M.; Schulze, T.; Alda, M.; Etain, B.; Cervantes, P.; Garnham, J.; Nunes, A.; O’Donovan, C.; et al. Can network analysis shed light on predictors of lithium response in bipolar I disorder? Acta Psychiatr. Scand. 2020, 141, 522–533. [Google Scholar] [CrossRef] [PubMed]
- Kukopulos, A.; Reginaldi, D.; Laddomada, P.; Floris, G.; Serra, G.; Tondo, L. Course of the Manic-Depressive Cycle and Changes Caused by Treatments. Pharmacopsychiatry 1980, 13, 156–167. [Google Scholar] [CrossRef] [PubMed]
- Koukopoulos, A.; Reginaldi, D.; Tondo, L.; Visioli, C.; Baldessarini, R. Course sequences in bipolar disorder: Depressions preceding or following manias or hypomanias. J. Affect. Disord. 2013, 151, 105–110. [Google Scholar] [CrossRef] [PubMed]
- Buoli, M.; Cesana, B.M.; Maina, G.; Conca, A.; Fagiolini, A.; Steardo, L. Correlates of current rapid-cycling bipolar disorder: Results from the Italian multicentric RENDiBi study. Eur. Psychiatry 2019, 62, 82–89. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Hui, T.P.; Kandola, A.; Shen, L.; Lewis, G.; Osborn, D.P.J.; Geddes, J.R.; Hayes, J.F. A systematic review and meta-analysis of clinical predictors of lithium response in bipolar disorder. Acta Psychiatr. Scand. 2019, 140, 94–115. [Google Scholar] [CrossRef] [Green Version]
- Teobaldi, E.; Albert, U.; Di Salvo, G.; Mencacci, C.; Rosso, G.; Salvi, V.; Maina, G. Manic-Depressive Cycles in Bipolar Disorder: Clinical and Treatment Implications. Psychopathology 2021, 54, 98–105. [Google Scholar] [CrossRef]
- Angst, J. The course of affective disorders. II. Typology of bipolar manic-depressive illness. Arch. Psychiatr. Nervenkr. 1978, 226, 65–73. [Google Scholar] [CrossRef]
- Colom, F.; Vieta, E.; Daban, C.; Pacchiarotti, I.; Sánchez-Moreno, J. Clinical and therapeutic implications of predominant polarity in bipolar disorder. J. Affect. Disord. 2006, 93, 13–17. [Google Scholar] [CrossRef]
- Tohen, M.; Frank, E.; Bowden, C.L.; Colom, F.; Ghaemi, S.N.; Yatham, L.N.; Malhi, G.S.; Calabrese, J.R.; Nolen, W.A.; Vieta, E.; et al. The International Society for Bipolar Disorders (ISBD) Task Force report on the nomenclature of course and outcome in bipolar disorders. Bipolar Disord. 2009, 11, 453–473. [Google Scholar] [CrossRef]
- Osher, Y.; Yaroslavsky, Y.; El-Rom, R.; Belmaker, R.H. Predominant polarity of bipolar patients in Israel. World J. Biol. Psychiatry 2000, 1, 187–189. [Google Scholar] [CrossRef]
- Forty, L.; Jones, L.; Jones, I.; Smith, D.J.; Caesar, S.; Fraser, C.; Gordon-Smith, K.; Hyde, S.; Craddock, N. Polarity at illness onset in bipolar I disorder and clinical course of illness. Bipolar Disord. 2009, 11, 82–88. [Google Scholar] [CrossRef]
- González-Pinto, A.; Alberich, S.; Barbeito, S.; Alonso, M.; Vieta, E.; Martinez-Aran, A.; Saenz, M.; López, P. Different profile of substance abuse in relation to predominant polarity in bipolar disorder: The Vitoria long-term follow-up study. J. Affect. Disord. 2010, 124, 250–255. [Google Scholar] [CrossRef] [PubMed]
- Col, S.E.; Caykoylu, A.; Ugurlu, G.K.; Ugurlu, M. Factors affecting treatment compliance in patients with bipolar I disorder during prophylaxis: A study from Turkey. Gen. Hosp. Psychiatry 2014, 36, 208–213. [Google Scholar] [CrossRef] [PubMed]
- Baldessarini, R.J.; Undurraga, J.; Vázquez, G.H.; Tondo, L.; Salvatore, P.; Ha, K.; Khalsa, H.-M.K.; Lepri, B.; Ha, T.H.; Chang, J.S.; et al. Predominant recurrence polarity among 928 adult international bipolar I disorder patients. Acta Psychiatr. Scand. 2011, 125, 293–302. [Google Scholar] [CrossRef] [PubMed]
- Azorín, J.; Adida, M.; Belzeaux, R. Predominant polarity in bipolar disorders: Further evidence for the role of affective temperaments. J. Affect. Disord. 2015, 182, 57–63. [Google Scholar] [CrossRef] [PubMed]
- Sentissi, O.; Popovic, D.; Moeglin, C.; Stukalin, Y.B.; Mosheva, M.; Vieta, E.; Serretti, A.; Souery, D. Predominant polarity in bipolar disorder patients: The COPE bipolar sample. J. Affect. Disord. 2019, 250, 43–50. [Google Scholar] [CrossRef] [PubMed]
- Rosa, A.; Andreazza, A.; Kunz, M.; Gomes, F.; Santin, A.; Sanchez-Moreno, J.; Reinares, M.; Colom, F.; Vieta, E.; Kapczinski, F. Predominant polarity in bipolar disorder: Diagnostic implications. J. Affect. Disord. 2008, 107, 45–51. [Google Scholar] [CrossRef] [PubMed]
- Vieta, E.; Berk, M.; Wang, W.; Colom, F.; Tohen, M.; Baldessarini, R. Predominant previous polarity as an outcome predictor in a controlled treatment trial for depression in bipolar I disorder patients. J. Affect. Disord. 2009, 119, 22–27. [Google Scholar] [CrossRef] [PubMed]
- Mazzarini, L.; Pacchiarotti, I.; Colom, F.; Sani, G.; Kotzalidis, G.D.; Rosa, A.R.; Sanna, L.; De Rossi, P.; Girardi, N.; Bonnin, C.M.; et al. Predominant polarity and temperament in bipolar and unipolar affective disorders. J. Affect. Disord. 2009, 119, 28–33. [Google Scholar] [CrossRef] [PubMed]
- Nivoli, A.M.; Pacchiarotti, I.; Rosa, A.R.; Popovic, D.; Murru, A.; Valenti, M.; Bonnin, C.M.; Grande, I.; Sanchez-Moreno, J.; Vieta, E.; et al. Gender differences in a cohort study of 604 bipolar patients: The role of predominant polarity. J. Affect. Disord. 2011, 133, 443–449. [Google Scholar] [CrossRef]
- Pacchiarotti, I.; Mazzarini, L.; Kotzalidis, G.D.; Valentí, M.; Nivoli, A.M.; Sani, G.; Torrent, C.; Murru, A.; Sanchez-Moreno, J.; Patrizi, B.; et al. Mania and depression. Mixed, not stirred. J. Affect. Disord. 2011, 133, 105–113. [Google Scholar] [CrossRef] [PubMed]
- Nivoli, A.M.; Colom, F.; Pacchiarotti, I.; Murru, A.; Scott, J.; Valentí, M.; Mazzarini, L.; Bonnin, C.D.M.; Sánchez-Moreno, J.; Serretti, A.; et al. Treatment strategies according to clinical features in a naturalistic cohort study of bipolar patients: A principal component analysis of lifetime pharmacological and biophysic treatment options. Eur. Neuropsychopharmacol. 2013, 23, 263–275. [Google Scholar] [CrossRef] [PubMed]
- Carvalho, A.F.; McIntyre, R.S.; Dimelis, D.; Gonda, X.; Berk, M.; Nunes-Neto, P.R.; Cha, D.S.; Hyphantis, T.N.; Angst, J.; Fountoulakis, K.N. Predominant polarity as a course specifier for bipolar disorder: A systematic review. J. Affect. Disord. 2014, 163, 56–64. [Google Scholar] [CrossRef]
- Nivoli, A.M.A.; Murru, A.; Pacchiarotti, I.; Valenti, M.; Rosa, A.R.; Hidalgo, D.; Virdis, V.; Strejilevich, S.; Vieta, E.; Colom, F. Bipolar disorder in the elderly: A cohort study comparing older and younger patients. Acta Psychiatr. Scand. 2014, 130, 364–373. [Google Scholar] [CrossRef] [PubMed]
- Popovic, D.; Font, C.T.; Goikolea, J.M.; Cruz, N.; Sanchez-Moreno, J.; Gonzalez-Pinto, A.; Vieta, E. Clinical implications of predominant polarity and the polarity index in bipolar disorder: A naturalistic study. Acta Psychiatr. Scand. 2013, 129, 366–374. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Volkert, J.; Zierhut, K.C.; Schiele, M.; Wenzel, M.; Kopf, J.; Kittel-Schneider, S.; Reif, A. Predominant polarity in bipolar disorder and validation of the polarity index in a German sample. BMC Psychiatry 2014, 14, 322. [Google Scholar] [CrossRef] [Green Version]
- Martinez-Aran, A.; Vieta, E.; Colom, F.; Torrent, C.; Sanchez-Moreno, J.; Reinares, M. Cognitive impairment in euthymic bi-polar patients: Implications for clinical and functional outcome. Bipolar Disord. 2004, 6, 224–232. [Google Scholar] [CrossRef]
- Popovic, D.; Reinares, M.; Goikolea, J.M.; Bonnin, C.M.; Gonzalez-Pinto, A.; Vieta, E. Polarity index of pharmacological agents used for maintenance treatment of bipolar disorder. Eur. Neuropsychopharmacol. 2012, 22, 339–346. [Google Scholar] [CrossRef]
- Carvalho, A.F.; Quevedo, J.; McIntyre, R.S.; Soeiro-de-Souza, M.G.; Fountoulakis, K.N.; Berk, M. Treatment Implications of Pre-dominant Polarity and the Polarity Index: A Comprehensive Review. Int. J. Neuropsychopharmacol. 2015, 18, pyu079. [Google Scholar] [CrossRef] [Green Version]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Association: Arlington, VA, USA, 2013. [Google Scholar]
- Post, R.M.; Roy-Byrne, P.P.; Uhde, T.W. Graphic representation of the life course of illness in patients with affective disorder. Am. J. Psychiatry 1988, 145, 844–848. [Google Scholar] [CrossRef]
- Judd, L.L.; Akiskal, H.S. Depressive episodes and symptoms dominate the longitudinal course of bipolar disorder. Curr. Psychiatry Rep. 2003, 5, 417–418. [Google Scholar] [CrossRef]
- Etain, B.; Lajnef, M.; Bellivier, F.; Mathieu, F.; Raust, A.; Cochet, B.; Gard, S.; M’Bailara, K.; Kahn, J.P.; Elgrabli, O.; et al. Clinical expression of bipolar disorder type I as a function of age and polarity at onset: Convergent findings in samples from France and the United States. J. Clin. Psychiatry 2012, 73, 561–566. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Maron, M.; Vaiva, G. Polarité prédominante, mixité et suicide [Predominant polarity, mixed states and suicide]. L’Encéphale 2012, 38, 155–159. [Google Scholar] [CrossRef]
- Pacchiarotti, I.; Bond, D.J.; Baldessarini, R.J.; Nolen, W.A.; Grunze, H.; Licht, R.W. The International Society for Bipolar Disor-ders (ISBD) Task Force Report on Antidepressant Use in Bipolar Disorders. Am. J. Psychiatry 2013, 170, 1249–1262. [Google Scholar] [CrossRef] [PubMed]
Variable | |
---|---|
Female, n (%) | 388 (59.4) |
Age at interview (years), mean (SD) | 50.6 (15.6) |
Age at onset (years), mean (SD) | 30.3 (12.9) |
Illness duration (years), mean (SD) | 20.2 (13.9) |
Employment ¥ | |
Employed, n (%) | 119 (18.3) |
Unemployed, n (%) | 368 (56.4) |
Retired, n (%) | 165 (25.3) |
Marital status, n (%) | |
Single | 186 (28.5) |
Married/Cohabiting | 341 (52.2) |
Divorced | 84 (12.9) |
Widowed | 42 (6.2) |
Diagnosis, n (%) | |
Bipolar disorder type I | 262 (40.1) |
Bipolar disorder type II | 371 (56.8) |
Unspecified bipolar disorder | 19 (2.9) |
Substance/medication induced bipolar disorder | 1 (0.2) |
Polarity of first episode, n (%) | |
Hypo/manic | 211 (32.3) |
Depressive | 418 (64.0) |
NA | 24 (3.7) |
Predominant polarity2/3, n (%) | |
Depressive | 236 (36.1) |
Hypo/manic | 70 (10.7) |
None | 347 (53.1) |
Predominant polarity50%, n (%) | |
Depressive | 361 (55.3) |
Hypo/manic | 118 (18.1) |
None | 174 (26.6) |
Prescribed mood stabilizers/antipsychotics, n (%) | |
Lithium | 407 (62.3) |
Valproate | 209 (32.0) |
Carbamazepine | 14 (2.1) |
Oxcarbazepine | 8 (1.2) |
Lamotrigine | 52 (7.9) |
Olanzapine | 81 (12.4) |
Quetiapine | 155 (23.7) |
Clozapine | 7 (1.1) |
Risperidone | 24 (3.7) |
Paliperidone | 3 (0.5) |
Ziprasidone | 4 (0.6) |
Asenapine | 28 (4.3) |
Amisulpride | 8 (1.2) |
Haloperidol | 27 (4.1) |
On antidepressants, n (%) | 272 (41.7) |
Clinical Variable | Manic Predominant Polarity2/3 (n = 70) | Depressive Predominant Polarity2/3 (n = 236) | χ2 or t/U | p |
Female, n (%) | 33 (47.1) | 144 (61.0) | 4.2 | 0.05 |
Age at interview (years), mean (SD) | 44.4 (15.4) | 52.8 (15.0) | −4.1 | <0.0001 |
Age at onset (years), mean (SD) | 29.5 (13.65) | 31.9 (13.6) | −1.3 | 0.2 |
Presence of family history of any psychiatric disorder, n (%) | 47 (67.1) | 144 (61.0) | 0.9 | 0.4 |
Presence of family history of mood disorder, n (%) | 41 (58.6) | 127 (53.8) | 0.5 | 0.5 |
Presence of family history of bipolar disorder, n (%) | 14 (20.0) | 43 (18.2) | 0.11 | 0.73 |
Number of first- and second-degree family members affected by psychiatric disorders, mean (SD) | 0.77 (0.8) | 0.76 (0.9) | 0.07 | 0.9 |
Number of manic episodes, mean (SD) | 2.9 (3.1) | 0.4 (0.9) | 3536.0 | <0.0001 |
Number of hypomanic episodes, mean (SD) | 2.6 (3.4) | 1.5 (1.5) | 8207.0 | 0.9 |
Number of depressive episodes, mean (SD) | 1.5 (1.5) | 6.0 (4.4) | 1413.0 | <0.0001 |
Total number of episodes, mean (SD) | 7.3 (5.3) | 8.3 (5.6) | −1.3 | 0.2 |
Illness duration (years), mean (SD) | 14.85 (12.5) | 20.9 (13.8) | −1.3 | 0.2 |
Number of hospital admissions, mean (SD) | 2.5 (0.8) | 2.4 (1.8) | 0.18 | 0.8 |
Presence of lifetime suicidal behavior, n (%) | 5 (7.1) | 58 (24.7) | 10.1 | 0.001 |
Type of clinical course cycle | ||||
MDI, n (%) | 10 (14.3) | 28 (11.9) | 4.5 | 0.3 ^ |
DMI, n (%) | 4 (5.7) | 34 (14.4) | ||
Irregular cycling, n (%) | 55 (78.6) | 169 (71.6 | ||
Continuous cycling, n (%) | 1 (1.4) | 3 (1.3) | ||
Rapid cycling, n (%) | 0 (0.0) | 2 (0.8) | ||
Clinical Variable | Manic Predominant Polarity50% (n = 118) | Depressive Predominant Polarity50% (n = 236) | χ2 or t/U | p |
Female, n (%) | 61 (51.7) | 233 (64.5) | 6.2 | 0.016 |
Age at interview (years), mean (SD) | 46.4 (15.8) | 52.9 (14.6) | −4.1 | <0.0001 |
Age at onset (years), mean (SD) | 29.1 (13.3) | 30.7 (12.9) | −1.2 | 0.23 |
Presence of family history of any psychiatric disorder, n (%) | 82 (69.5) | 234 (64.8) | 0.9 | 0.37 |
Presence of family history of mood disorder, n (%) | 74 (62.7) | 211 (58.4) | 0.7 | 0.45 |
Presence of family history of bipolar disorder, n (%) | 31 (26.3) | 70 (19.4) | 2.5 | 0.12 |
Number of first- and second-degree family members affected by psychiatric disorders, mean (SD) | 0.8 (0.8) | 0.8 (0.9) | 0.1 | 0.8 |
Number of manic episodes, mean (SD) | 2.8 (3.1) | 0.6 (1.3) | 9882.0 | <0.0001 |
Number of hypomanic episodes, mean (SD) | 2.9 (3.4) | 2.3 (2.6) | 21,103.0 | 0.87 |
Number of depressive episodes, mean (SD) | 2.7 (2.5) | 6.2 (4.2) | 7898.0 | <0.0001 |
Total number of episodes, mean (SD) | 8.8 (6.0) | 9.5 (6.5) | −1.0 | 0.3 |
Illness duration (years), mean (SD) | 17.1 (13.2) | 22.1 (13.4) | −3.6 | <0.0001 |
Number of hospital admissions, mean (SD) | 2.7 (0.9) | 2.7 (2.2) | 126.0 | 0.34 |
Presence of lifetime suicidal behavior, n (%) | 19 (16.1) | 92 (25.6) | 4.5 | 0.034 |
Type of clinical course cycle | ||||
MDI, n (%) | 39 (33.1) | 77 (21.3) | 11.9 | 0.018^ |
DMI, n (%) | 9 (7.6) | 58 (16.1) | ||
Irregular cycling, n (%) | 69 (58.5) | 215 (59.6) | ||
Continuous cycling, n (%) | 1 (0.8) | 4 (1.1) | ||
Rapid cycling, n (%) | 0 (0.0) | 7 (1.9) |
Outcome (Dependent Variable) | Independent Variable | β | SE | OR | 95% CI Lower | 95% CI Upper | p |
---|---|---|---|---|---|---|---|
Depressive predominant polarity2/3 | Age at interview | 0.04 | 0.01 | 1.04 | 1.02 | 1.06 | <0.0001 |
Presence of lifetime suicidal behavior | −1.54 | 0.5 | 0.2 | 0.08 | 0.6 | 0.002 | |
Depressive predominant polarity50% | Age at interview | 0.02 | 0.009 | 1.02 | 1.001 | 1.04 | 0.035 |
Presence of lifetime suicidal behavior | −0.6 | 0.29 | 0.5 | 0.3 | 0.96 | 0.035 |
Polarity Index | Manic Predominant Polarity2/3 (n = 16) | Depressive Predominant Polarity2/3 (n = 148) | No Predominant Polarity2/3 (n = 186) | F | p |
Polarity index (Popovic), mean (SD) | 1.84 (0.57) | 1.56 (0.83) | 1.61 (0.62) | 1.18 | 0.31 |
Polarity index (Carvalho), mean (SD), mean rank | 1.37 (1.18) | 1.52 (1.59) $ | 1.57 (1.24) | 0.16 | 0.85 |
Polarity Index | Manic Predominant Polarity50% (n = 36) | Depressive Predominant Polarity50% (n = 218) | No Predominant Polarity50% (n = 96) | F or χ2 | p |
Polarity index (Popovic), mean (SD) | 1.91 (0.77) | 1.54 (0.76) | 1.61 (0.57) | 4.038 | 0.018 |
Polarity index (Carvalho), mean (SD), mean rank | 1.79 (1.94), 170.89 | 1.49 (1.41), 169.69 $ | 1.56 (1.09), 188.55 | 2.68 | 0.26 |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Albert, U.; Manchia, M.; Burato, S.; Carpiniello, B.; Di Salvo, G.; Pinna, F.; Rosso, G.; Maina, G. Predominant Polarity and Polarity Index of Maintenance Treatments for Bipolar Disorder: A Validation Study in a Large Naturalistic Sample in Italy. Medicina 2021, 57, 598. https://doi.org/10.3390/medicina57060598
Albert U, Manchia M, Burato S, Carpiniello B, Di Salvo G, Pinna F, Rosso G, Maina G. Predominant Polarity and Polarity Index of Maintenance Treatments for Bipolar Disorder: A Validation Study in a Large Naturalistic Sample in Italy. Medicina. 2021; 57(6):598. https://doi.org/10.3390/medicina57060598
Chicago/Turabian StyleAlbert, Umberto, Mirko Manchia, Sofia Burato, Bernardo Carpiniello, Gabriele Di Salvo, Federica Pinna, Gianluca Rosso, and Giuseppe Maina. 2021. "Predominant Polarity and Polarity Index of Maintenance Treatments for Bipolar Disorder: A Validation Study in a Large Naturalistic Sample in Italy" Medicina 57, no. 6: 598. https://doi.org/10.3390/medicina57060598