Subthreshold hypomania during a major depressive episode challenges the bipolar-unipolar dichotomy. In our study we employed a cross-diagnostic cluster analysis - to identify distinct subgroups within a cohort of depressed patients.

A k-means cluster analysis— based on the domain scores of the Mood Spectrum Self-Report (MOODS-SR) questionnaire—was performed on a data set of 300 adults with either bipolar or unipolar depression. After identifying groups, between-clusters comparisons were conducted on MOODS-SR domains and factors and on a set of sociodemographic, clinical and psychometric variables.

Three clusters were identified: one with intermediate depressive and poor manic symptomatology (Mild), one with severe depressive and poor manic symptomatology (Moderate), and a third one with severe depressive and intermediate manic symptomatology (Mixed). Across the clusters, bipolar patients were significantly less represented in the Mild one, while the DSM-5 “Mixed features” specifier did not differentiate the groups. When compared to the other patients, those of Mixed cluster exhibited a stronger association with most of the illness-severity, quality of life, and outcomes measures considered. After performing pairwise comparisons significant differences between “Mixed” and “Moderate” clusters were restricted to: current and disease-onset age, psychotic ideation, suicidal attempts, hospitalization numbers, impulsivity levels and comorbidity for Cluster B personality disorder.

In the present study, a clustering approach based on a spectrum exploration of mood symptomatology led to the identification of three transdiagnostic groups of patients. Consistent with our hypothesis, the magnitude of subthreshold (hypo)manic symptoms was related to a greater clinical severity, regardless of the main categorical diagnosis.

Suicidal ideation (SI) is an important risk factor of death by suicide. Recent data suggest that suicidal depression (i.e., moderate to severe depression with SI) could be a specific depression subtype with worse clinical outcomes than nonsuicidal depression (i.e., without SI).

Among 898 French adult inpatients (67% women, mean age: 41.23 [SD: 14.33]) with unipolar depression, 71.94% had moderate to severe depression (defined using the cut-offs of validated scales: beck depression inventory, clinician-rated 30-item inventory depression symptomatology, and quick inventory of depressive symptomatology) and among them, 63.6% had SI according to the suicidal item (score ≥ 2) of the depression scale they filled in. Clinical features (anxiety, psychological pain, and hopelessness) were assessed at baseline. The occurrence of a suicide attempt (SA) or a suicide event (SE) (i.e., actual, aborted or interrupted SA, or hospitalization for SI) was recorded during the 1-year follow-up. The risk of actual SA and SE was compared between groups with adjusted Cox regression models.

The risk of actual SA and SE during the follow-up was 2- and 1.8-fold higher, respectively, in patients with suicidal depression, independently of potential cofounders such as history of lifetime SA, age, sex, and baseline depression severity.

Suicidal depression is associated with poorer prognosis in terms of actual SA/SE, despite optimal care (i.e., care in a hospital department specialized in the management of suicidal crisis). Specific therapeutic strategies might be needed for these patients.

Psychopathological network model has received attention recently in the traditional debate about the continuity of depression. However, there is little evidence for comparing the network structure of depressive symptoms in several depressive states at different clinical stages. Through this study of a broad sample of patients with nonclinical to clinical depression, we examined differences in the network structure of depressive symptoms.

Four groups of participants, including cohorts of clinical depression (current depression, n = 294; remitted depression, n = 118) and nonclinical depression (subthreshold depression, N = 184; healthy control, n = 257), responded to Beck Depression Inventory-II (BDI-II). After adjusting for age and sex, the residual scores of the 21 BDI-II items were input into a regularized partial correlation network for each group. Then, the estimated edge strengths/densities and node characteristics were compared.

Current depression has a discontinuous structure with a stronger and denser network of symptoms compared with nonclinical groups. Interestingly, remitted depression had improved to the level in healthy controls; however, it retained the same network structure as current depression, which indicates a trace of depression.

We found the traces of depression that remained even after the symptoms disappeared. This study might provide a novel framework for elucidating the development and formation of depression.

Psychiatric comorbidities and suicide attempts are highly prevalent in Bipolar Disorders (BD). We examined the associations between childhood maltreatment, psychiatric comorbidities, and suicide attempts, in terms of lifetime prevalence, sequence of onset, and current symptoms.

We assessed 3,047 individuals with BD for suicide attempts, anxiety disorders, substance use disorders, and eating disorders. Participants completed a self-report for the assessment of childhood maltreatment. Associations between childhood maltreatment and characteristics of comorbidities (lifetime prevalence, current symptoms, and age at onset) were examined using logistic regressions and network analyses.

Psychiatric comorbidities were frequent with a mean number per individual of 1.23 (SD = 1.4). Most comorbidities occurred prior to the onset of BD. Participants who reported higher levels of childhood maltreatment had more frequent and multiple comorbidities, which were also more currently active at inclusion. Childhood maltreatment did not decrease the age of onset of comorbidities, but was associated with a faster accumulation of comorbidities prior to the onset of BD. Logistic regression and network analyses showed that emotional abuse and sexual abuse might play a prominent role in the lifetime prevalence of psychiatric comorbidities and suicide attempts.

Childhood maltreatment was associated with suicide attempts, and with frequent, multiple, and persistent psychiatric comorbidities that accumulated more rapidly prior to the onset of BD. Hence, childhood maltreatment should be systematically assessed in individuals with BD, in particular when the course of the disorder is characterized by a high comorbid profile or by a high suicidality.

Bipolar disorder (BD) is recognized to be at high risk for developing negative psychopathological sequelae to potentially traumatic events. Nevertheless, scant data are still available about the effects of the COVID-19 emergency on the clinical course of BD. The present study examined prospectively the development and trajectories of post-traumatic stress, depressive, and anxiety symptoms among subjects with BD that were followed in an outpatient psychiatric clinic at the time of pandemic onset.

A cohort of 89 subjects with BD was enrolled during the first wave of the COVID-19 pandemic, and assessed at baseline (T0), 2-months (T1), and 6-months (T2) follow-up. A K-means cluster analysis was used to identify distinct trajectories of depressive, anxiety, and post-traumatic stress symptoms during the three time points.

We identified three trajectories: the Acute reaction (13.5%); the Increasing severity (23.6%); and the Low symptoms (62.9%) groups, respectively. In the Acute reaction group a significant prevalence of female gender was reported with respect to the Low symptoms one. Subjects in the Increasing severity group reported significantly lower employment rate, and higher rate of relatives at risk for COVID-19 medical complications. Subjects in the Increasing Severity group reported higher rates of previous hospitalization and manic symptoms at baseline than those included in the Low symptoms one.

Our results describe three distinct symptom trajectories during the COVID-19 emergency in a cohort of subjects suffering from BD, suggesting the need of a long-term follow-up for detecting the impact of the COVID-19 pandemic in this vulnerable population.

Metacognitive knowledge (MK; general awareness of cognitive functioning) and metacognitive experience (ME; awareness of cognitive performance on a specific cognitive task) represent two facets of metacognition that are critical for daily functioning, but are understudied in bipolar disorder. This study was conducted to evaluate MK and ME across multiple cognitive domains in individuals diagnosed with bipolar disorder and unaffected volunteers, and to investigate the association between metacognition and quality of life (QoL).

Fifty-seven euthymic participants with bipolar disorder and 55 demographically similar unaffected volunteers provided prediction and postdiction ratings of cognitive task performance across multiple cognitive domains. Self-ratings were compared to objective task performance, and indices of MK and ME accuracy were generated and compared between groups. Participants rated QoL on the Quality of Life in Bipolar Disorder Scale (QoL.BD).

Metacognitive inaccuracies in both MK and ME were observed in participants with bipolar disorder, but only in select cognitive domains. Furthermore, most metacognitive inaccuracies involved underestimation of cognitive ability. Metacognitive indices were minimally associated with medication variables and mood symptoms, but several indices were related to QoL.

Individuals with bipolar disorder demonstrate inaccuracies in rating their cognitive functioning and in rating their online cognitive task performance, but only on select cognitive functions. The tendency to underestimate performance may reflect a negative information processing bias characteristic of mood disorders. Metacognitive variables were also predictive of QoL, indicating that further understanding of cognitive self-appraisals in persons with bipolar disorder has significant clinical relevance.

Increasing age as well as borderline personality pathology are associated with a lower level of health-related quality of life (HR-QoL). Our objective was to investigate whether the presence of borderline personality traits modifies the association between age and HR-QoL in the general population.

Cross-sectional data from 5,303 respondents (aged 21–72 years) of the Netherlands Mental Health Survey and Incidence Study-2 were analyzed. Borderline personality traits were assessed with the International Personality Disorder Examination questionnaire. Mental and physical HR-QoL were measured with the Medical Outcomes Study Short Form Health Survey. Multiple linear regression analysis was used to examine the association of borderline personality traits, age and their interaction on mental as well as physical HR-QoL, adjusted for demographic variables as well as somatic and mental disorders.

A total of 1,520 (28.7%) respondents reported one or more borderline personality traits of which 58 (1.1%) reported five or more indicative of a borderline personality disorder. A higher age was associated with lower physical HR-QoL. This negative association became significantly stronger in the presence of borderline personality traits. The association between increasing age and mental HR-QoL was positive in the absence of borderline personality traits and negative in the presence of borderline personality traits.

Borderline personality traits negatively interfere with the association between age and HR-QoL irrespective of somatic and mental disorders. Attention of clinicians and researchers for subthreshold borderline personality pathology is needed in middle-aged and older persons.

Depressive symptoms are highly prevalent among partnered dementia caregivers, but the mechanisms are unclear. This study examined the mediating role of loneliness in the association between dementia and other types of care on subsequent depressive symptoms.

Prospective data from partnered caregivers were drawn from the English Longitudinal Study of Aging. The sample consisted of 4,672 partnered adults aged 50–70 living in England and Wales, followed up between 2006–2007 and 2014–2015. Caregiving was assessed across waves 3 (2006–2007), 4 (2008–2009), and 5 (2010–2011), loneliness at wave 6 (2012–2013), and subsequent depressive symptoms at wave 7 (2014–15). Multivariable logistic regression models were used to assess the association between caregiving for dementia and depressive symptoms compared to caregiving for other illnesses (e.g., diabetes, coronary heart disease (CHD), cancer, and stroke). Binary mediation analysis was used to estimate the indirect effects of caregiving on depressive symptoms via loneliness.

Care for a partner with dementia was associated with higher odds of depressive symptoms at follow-up compared to those not caring for a partner at all (odds ratio [OR] = 2.6, 95% confidence intervals [CI]: 1.4, 5.1). This association was partially mediated by loneliness (34%). Care for a partner with other conditions was also associated with higher odds of depressive symptoms compared to non-caregiving partners (OR = 1.7, 95% CI: 1.2, 2.5), but there was no evidence of an indirect pathway via loneliness.

Loneliness represents an important contributor to the relationship between dementia caregiving and subsequent depressive symptoms; therefore, interventions to reduce loneliness among partnered dementia caregivers should be considered.

Changes in inflammatory and metabolic markers are implicated in the pathogenesis in both the development and progression of bipolar disorder (BD). Notwithstanding, these markers have not been investigated in newly diagnosed BD.

We compared high-sensitive C-reactive protein (hs-CRP) and homocysteine (Hcy) levels in 372 patients with newly diagnosed BD, 106 unaffected first-degree relatives (URs), and 201 healthy control persons (HCs). Within the patient group, we also investigated possible associations between hs-CRP and Hcy, respectively, with illness-related characteristics and psychotropic medication.

No statistically significant differences in Hcy and hs-CRP levels were found when comparing BD and URs with HCs. Similarly, there were no differences when comparing only patients in remission or patients with affective symptoms, respectively, with HCs. Hcy levels were found to be 11.9% (95% CI: 1.030–1.219) higher in patients with BD when compared with their URs (p = 0.008), when adjusting for folate and cobalamin status, age, sex, and self-reported activity levels. Hcy levels were significantly associated with folate, cobalamin, gender, and age in all models (p < 0.05).

Our results do not support hs-CRP or Hcy as markers in newly diagnosed BD.

Increasing educational attainment (EA) could decrease the occurrence of depression. We investigated the relationship between EA and depressive symptoms in older individuals across four European regions.

We studied 108,315 Europeans (54% women, median age 63 years old) from the Survey on Health, Ageing and Retirement in Europe assessing EA (seven educational levels based on International Standard Classification of Education [ISCED] classification) and depressive symptoms (≥4 points on EURO-D scale). Logistic regression estimated the association between EA and depressive symptoms, adjusting for sociodemographic and health-related factors, testing for sex/age/region and education interactions.

Higher EA was associated with lower odds of depressive symptoms, independent of sociodemographic and health-related factors. A threshold of the lowest odds of depressive symptoms was detected at the first stage of tertiary education (OR 0.60; 95% confidence interval [CI] 0.55–0.65; p < 0.001; relative to no education). Central and Eastern Europe showed the strongest association (OR for high vs. low education 0.37; 95% CI 0.33–0.40; p < 0.001) and Scandinavia the weakest (OR for high vs. low education 0.69; 95% CI 0.60–0.80; p < 0.001). The association was strongest among younger individuals. There was a sex and education interaction only within Central and Eastern Europe.

Level of EA is reflected in later-life depressive symptoms, suggesting that supporting individuals in achieving EA, and considering those with lower EA at increased risk for depression, could lead to decreased burden of depression across the life course. Further educational support in Central and Eastern Europe may decrease the higher burden of depressive symptoms in women.

Standard depression rating scales like the Hamilton Depression Rating Scale and the Montgomery–Åsberg Depression Rating Scale were developed more than 40 years ago. They are mandatory in clinical trials but are for a variety of reasons seldom used in clinical practice. Moreover, most clinicians are less familiar with more recent trends or with some dilemmas in assessment tools for major depression.

Narrative review.

Asssessment tools can be observer-rating or self-rating scales, disease-specific or non–disease-specific scales, subjective scales or objective lab assessments, standard questionnaires or experience sampling methods. An overarching question is to what degree current assessment methods really address the individual patient’s needs and treatment expectations.

The present paper aims to offer a framework for understanding the current trends in assessment tools that can orientate and guide the clinician.

Birth weight influences not only brain development, but also mental health outcomes, including depression, but the underlying mechanism is unclear.

The phenotypic data of 12,872–91,009 participants (59.18–63.38% women) from UK Biobank were included to test the associations between the birth weight, depression, and brain volumes through the linear and logistic regression models. As birth weight is highly heritable, the polygenic risk scores (PRSs) of birth weight were calculated from the UK Biobank cohort (154,539 participants, 56.90% women) to estimate the effect of birth weight-related genetic variation on the development of depression and brain volumes. Finally, the mediation analyses of step approach and mediation analysis were used to estimate the role of brain volumes in the association between birth weight and depression. All analyses were conducted sex stratified to assess sex-specific role in the associations.

We observed associations between birth weight and depression (odds ratio [OR] = 0.968, 95% confidence interval [CI] = 0.957–0.979, p = 2.29 × 10−6). Positive associations were observed between birth weight and brain volumes, such as gray matter (B = 0.131, p = 3.51 × 10−74) and white matter (B = 0.129, p = 1.67 × 10−74). Depression was also associated with brain volume, such as left thalamus (OR = 0.891, 95% CI = 0.850–0.933, p = 4.46 × 10−5) and right thalamus (OR = 0.884, 95% CI = 0.841–0.928, p = 2.67 × 10−5). Additionally, significant mediation effects of brain volume were found for the associations between birth weight and depression through steps approach and mediation analysis, such as gray matter (B = –0.220, p = 0.020) and right thalamus (B = –0.207, p = 0.014).

Our results showed the associations among birth weight, depression, and brain volumes, and the mediation effect of brain volumes also provide evidence for the sex-specific of associations.

To examine the association between childhood trauma and work functioning, and to elucidate to what extent this association can be accounted for by depression and/or anxiety.

Data of 1,649 working participants were derived from the Netherlands Study of Depression and Anxiety (NESDA, n = 2,981). Childhood trauma (emotional neglect, psychological, physical, and sexual abuse before age 16) was assessed with a structured interview and work functioning, in terms of absenteeism and presenteeism, with the Health and Labor Questionnaire Short Form (SF-HLQ) and the World Health Organization Disability Assessment Schedule II (WHODAS-II), respectively. Depressive and/or anxiety disorders were assessed with the Composite Interview Diagnostic Instrument (CIDI). Mediation analyses were conducted.

At baseline, 44.8% reported to have experienced childhood trauma. Workers with the highest childhood trauma level showed significantly (p < 0.001) more absenteeism as well as more presenteeism. Mediation analyses revealed that indirect effects between the childhood trauma index and both work indices were significantly mediated by current depressive disorder (p = 0.023 and p < 0.001, respectively) and current comorbid depression-anxiety (p = 0.020 and p < 0.001, respectively), with the latter accounting for the largest effects (PM = 0.23 and PM = 0.29, respectively). No significant mediating role in this relationship was found for current anxiety disorder and remitted depressive and/or anxiety disorder.

Persons with childhood trauma have significantly reduced work functioning in terms of absenteeism and presenteeism. This seems to be largely accounted for by current depressive disorders and current comorbid depression-anxiety.

Impairments in social and nonsocial cognition have been demonstrated in both patients suffering from bipolar disorder (BD) and their unaffected relatives and might therefore represent a heritable marker of risk. This study investigated the relevance of emotional intelligence (EI) as part of the emotion processing domain of social cognition in this regard.

A total of 54 outpatients suffering from BD, 54 unaffected siblings, and 80 control subjects were investigated using the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and the Brief Assessment of Cognition in Schizophrenia (BACS). Analyses of covariance (ANCOVAs) were performed with adjustment for the BACS composite score. The three groups were compared by one-way analysis of variance or chi-square test, depending on the variable type. As the three groups differed significantly in their level of education, additional ANCOVAs with adjustment for education were performed.

Patients achieved significantly lower levels of overall EI and overall nonsocial cognitive functioning compared to unaffected siblings and controls, whereas performance of the latter two groups was comparable in both domains.

Due to comparable levels of EI in unaffected siblings of patients suffering from BD and control subjects, EI assessed by means of the MSCEIT does not represent an endophenotype for BD.

This study aimed to identify clinical and cognitive factors associated with increased risk for difficult-to-treat depression (DTD) or treatment-resistant depression (TRD).

A total of 229 adult outpatients with major depression were recruited from the mental health unit at a public hospital. Participants were subdivided into resistant and nonresistant groups according to their Maudsley Staging Model score. Sociodemographic, clinical, and cognitive (objective and subjective measures) variables were compared between groups, and a logistic regression model was used to identify the factors most associated with TRD risk.

TRD group patients present higher verbal memory impairment than the nonresistant group irrespective of pharmacological treatment or depressive symptom severity. Logistic regression analysis showed that low verbal memory scores (odds ratio [OR]: 2.02; 95% confidence interval [CI]: 1.38–2.95) together with high depressive symptom severity (OR: 1.29; CI95%: 1.01–1.65) were associated with TRD risk.

Our findings align with neuroprogression models of depression, in which more severe patients, defined by greater verbal memory impairment and depressive symptoms, develop a more resistant profile as a result of increasingly detrimental neuronal changes. Moreover, our results support a more comprehensive approach in the evaluation and treatment of DTD in order to improve illness course. Longitudinal studies are warranted to confirm the predictive value of verbal memory and depression severity in the development of TRD.

Patients with schizophrenia display experiential anomalies in their feelings and cognitions arising in the domain of their lived body. These abnormal bodily phenomena (ABP) are not part of diagnostic criteria for schizophrenia. One of the reasons is the difficulty to assess specific ABP for schizophrenia spectrum disorders. The present study aimed to explore the presence in patients with schizophrenia of specific ABP.

We used a semistructured interview—the Abnormal Bodily Phenomena questionnaire (ABPq), an instrument devised to detect and measure ABP specific to patients with schizophrenia. Fifty-one outpatients affected by schizophrenia and 28 euthymic outpatients affected by bipolar disorder type I with psychotic features (BD-pf-e) were recruited. Before assessing the specificity for schizophrenia of the observed ABP, we tested the internal consistency and the convergent validity of the ABPq in patients with schizophrenia. Specificity was assessed by examining potential differences in ABPq among the patients with schizophrenia in remission (SCZ-r) and BD-pf-e.

The ABPq shows strong internal consistency and convergent validity. As to the specificity, ABP measured by ABPq were more frequent and severe in SCZ-r than in BD-pf-e. In particular, all ABPq dimensions, except “Coherence,” had at least mild severity in over 50% of SCZ-r, while dimensions with at least mild severity were observed in 5–10% of the BD-pf-e.

These findings can contribute to establish more precise phenomenal boundaries between schizophrenia and bipolar disorder, to explore the borders between nonpsychotic and psychotic forms of ABP, between ABP and negative and disorganized symptoms, and to enlighten core aspects of schizophrenia.

Mood instability and sleep disturbance are common symptoms in people with mental illness. Both features are clinically important and associated with poorer illness trajectories. We compared clinical outcomes in people presenting to secondary mental health care with mood instability and/or sleep disturbance with outcomes in people without either mood instability or sleep disturbance.

Data were from electronic health records of 31,391 patients ages 16–65 years presenting to secondary mental health services between 2008 and 2016. Mood instability and sleep disturbance were identified using natural language processing. Prevalence of mood instability and sleep disturbance were estimated at baseline. Incidence rate ratios were estimates for clinical outcomes including psychiatric diagnoses, prescribed medication, and hospitalization within 2-years of presentation in persons with mood instability and/or sleep disturbance compared to individuals without either symptom.

Mood instability was present in 9.58%, and sleep disturbance in 26.26% of patients within 1-month of presenting to secondary mental health services. Compared with individuals without either symptom, those with mood instability and sleep disturbance showed significantly increased incidence of prescription of any psychotropic medication (incidence rate ratios [IRR] = 7.04, 95% confidence intervals [CI] 6.53–7.59), and hospitalization (IRR = 5.32, 95% CI 5.32, 4.67–6.07) within 2-years of presentation. Incidence rates of most clinical outcomes were considerably increased among persons with both mood instability and sleep disturbance, relative to persons with only one symptom.

Mood instability and sleep disturbance are present in a wide range of mental disorders, beyond those in which they are conventionally considered to be symptoms. They are associated with poor outcomes, particularly when they occur together. The poor prognosis associated with mood instability and sleep disorder may be, in part, because they are often treated as secondary symptoms. Mood instability and sleep disturbance need better recognition as clinical targets for treatment in their own right.

Aberrant activity of the subcallosal cingulate (SCC) is a common theme across pharmacologic treatment efficacy prediction studies. The functioning of the SCC in psychotherapeutic interventions is relatively understudied, as are functional differences among SCC subdivisions. We conducted functional connectivity analyses (rsFC) on resting-state functional magnetic resonance imaging (fMRI) data, collected before and after a course of cognitive behavioral therapy (CBT) in patients with major depressive disorder (MDD), using seeds from three SCC subdivisions.

Resting-state data were collected from unmedicated patients with current MDD (Hamilton Depression Rating Scale-17 > 16) before and after 14-sessions of CBT monotherapy. Treatment outcome was assessed using the Beck Depression Inventory (BDI). Rostral anterior cingulate (rACC), anterior subcallosal cingulate (aSCC), and Brodmann’s area 25 (BA25) masks were used as seeds in connectivity analyses that assessed baseline rsFC and symptom severity, changes in connectivity related to symptom improvement after CBT, and prediction of treatment outcomes using whole-brain baseline connectivity.

Pretreatment BDI negatively correlated with pretreatment rACC ~ dorsolateral prefrontal cortex and aSCC ~ lateral prefrontal cortex rsFC. In a region-of-interest longitudinal analysis, rsFC between these regions increased post-treatment (p < 0.05FDR). In whole-brain analyses, BA25 ~ paracentral lobule and rACC ~ paracentral lobule connectivities decreased post-treatment. Whole-brain baseline rsFC with SCC did not predict clinical improvement.

rsFC features of rACC and aSCC, but not BA25, correlated inversely with baseline depression severity, and increased following CBT. Subdivisions of SCC involved in top-down emotion regulation may be more involved in cognitive interventions, while BA25 may be more informative for interventions targeting bottom-up processing. Results emphasize the importance of subdividing the SCC in connectivity analyses.

Aberrant emotional reactivity is a putative endophenotype for bipolar disorder (BD), but the findings of behavioral studies are often negative due to suboptimal sensitivity of the employed paradigms. This study aimed to investigate whether visual gaze patterns and facial displays of emotion during emotional film clips can reveal subtle behavioral abnormalities in remitted BD patients.

Thirty-eight BD patients in full or partial remission and 40 healthy controls viewed 7 emotional film clips. These included happy, sad, and neutral scenarios and scenarios involving winning, risk-taking, and thrill-seeking behavior of relevance to the BD phenotype. Eye gaze and facial expressions were recorded during the film clips, and participants rated their emotional reactions after each clip.

BD patients showed a negative bias in both facial displays of emotion and self-rated emotional responses. Specifically, patients exhibited more fearful facial expressions during all film clips. This was accompanied by less positive self-rated emotions during the winning and happy film clips, and more negative emotions during the risk-taking/thrill-related film clips.

These findings suggest that BD is associated with trait-related abnormalities in subtle behavioral displays of emotion processing. Future studies comparing patients with BD and unipolar depression are warranted to clarify whether these differences are specific to BD. If so, assessments of visual gaze and facial displays of emotion during emotional film clips may have the potential to be implemented in clinical assessments to aid diagnostic accuracy.