Victoria Eileen Cosgrove

All Publications

• Overhauling technology-based interventions for young people with bipolar disorder: lessons learned from adults. Bipolar disorders Van Meter, A., Cosgrove, V. E. 2018

  Abstract

  Gliddon etal.1 adds to a compelling evidence base suggesting that digital interventions like MoodSwings 2.0 have the potential to contribute to long-lasting, clinically meaningful reductions in depression for adults with bipolar disorder (BD). Like MoodSwings, most digital interventions are essentially evidence-based psychosocial programs adapted for online delivery. Some include interaction with a clinician, whereas others are entirely self-guided. From a public health perspective, the allure of empirically-valid digital interventions for BD is considerable; a majority of psychosocial interventions with an evidence base in BD have not been disseminated widely and are principally available at research institutions where they were developed. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/bdi.12716

  View details for PubMedID 30387928

• Online ethics: where will the interface of mental health and the internet lead us? International journal of bipolar disorders Cosgrove, V., Gliddon, E., Berk, L., Grimm, D., Lauder, S., Dodd, S., Berk, M., Suppes, T. 2017; 5 (1): 26-?

  Abstract

  While e-health initiatives are poised to revolutionize delivery and access to mental health care, conducting clinical research online involves specific contextual and ethical considerations. Face-to-face psychosocial interventions can at times entail risk and have adverse psychoactive effects, something true for online mental health programs too. Risks associated with and specific to internet psychosocial interventions include potential breaches of confidentiality related to online communications (such as unencrypted email), data privacy and security, risks of self-selection and self-diagnosis as well as the shortcomings of receiving psychoeducation and treatment at distance from an impersonal website. Such ethical issues need to be recognized and proactively managed in website and study design as well as treatment implementation. In order for online interventions to succeed, risks and expectations of all involved need to be carefully considered with a focus on ethical integrity.

  View details for DOI 10.1186/s40345-017-0095-3

  View details for PubMedID 28480484

• Progressing MoodSwings. The upgrade and evaluation of MoodSwings 2.0: An online intervention for bipolar disorder. Contemporary clinical trials Lauder, S., Cosgrove, V. E., Gliddon, E., Grimm, D., Dodd, S., Berk, L., Castle, D., Suppes, T. S., Berk, M. 2017

  Abstract

  MoodSwings 2.0 is a self-guided online intervention for bipolar disorder. The intervention incorporates technological improvements on an earlier validated version of the intervention (MoodSwings 1.0). The previous MoodSwings trial provides this study with a unique opportunity to progress previous work, whilst being able to take into consideration lesson learnt, and technological enhancements. The structure and technology of MoodSwings 2.0 are described and the relevance to other online health interventions is highlighted. An international team from Australia and the US updated and improved the programs content pursuant to changes in DSM-5, added multimedia components and included larger numbers of participants in the group discussion boards. Greater methodological rigour in this trial includes an attention control condition, quarterly telephone assessments, and red flag alerts for significant clinical change. This paper outlines these improvements, including additional security and safety measures. A 3 arm RCT is currently evaluating the enhanced program to assess the efficacy of MS 2.0; the primary outcome is change in depressive and manic symptoms. To our knowledge this is the first randomized controlled online bipolar study with a discussion board attention control and meets the key methodological criteria for online interventions.

  View details for DOI 10.1016/j.cct.2017.02.008

  View details for PubMedID 28257919

• Toward a Valid Animal Model of Bipolar Disorder: How the Research Domain Criteria Help Bridge the Clinical-Basic Science Divide. Biological psychiatry Cosgrove, V. E., Kelsoe, J. R., Suppes, T. 2016; 79 (1): 62-70

  Abstract

  Bipolar disorder is a diagnostically heterogeneous disorder, although mania emerges as a distinct phenotype characterized by elevated mood and increased activity or energy. While bipolar disorder's cyclicity is difficult to represent in animals, models of mania have begun to decode its fundamental underlying neurobiology. When psychostimulants such as amphetamine or cocaine are administered to rodents, a resulting upsurge of motor activity is thought to share face and predictive validity with mania in humans. Studying black Swiss mice, which inherently exhibit proclivity for reward seeking and risk taking, also has yielded some insight. Further, translating the biology of bipolar disorder in humans into animal models has led to greater understanding of roles for candidate biological systems such as the GRIK2 and CLOCK genes, as well as the extracellular signal-related kinase pathway involved in the pathophysiology of the illness. The National Institute of Mental Health Research Domain Criteria initiative seeks to identify building blocks of complex illnesses like bipolar disorder in hopes of uncovering the neurobiology of each, as well as how each fits together to produce syndromes like bipolar disorder or why so many mental illnesses co-occur together. Research Domain Criteria-driven preclinical models of isolated behaviors and domains involved in mania and bipolar disorder will ultimately inform movement toward nosology supported by neurobiology.

  View details for DOI 10.1016/j.biopsych.2015.09.002

  View details for PubMedID 26531027

• Evaluating discussion board engagement in the MoodSwings online self-help program for bipolar disorder: protocol for an observational prospective cohort study BMC PSYCHIATRY Gliddon, E., Lauder, S., Berk, L., Cosgrove, V., Grimm, D., Dodd, S., Suppes, T., Berk, M. 2015; 15

  View details for DOI 10.1186/s12888-015-0630-7

  View details for Web of Science ID 000363120700001

  View details for PubMedID 26462799

• Evaluating discussion board engagement in the MoodSwings online self-help program for bipolar disorder: protocol for an observational prospective cohort study. BMC psychiatry Gliddon, E., Lauder, S., Berk, L., Cosgrove, V., Grimm, D., Dodd, S., Suppes, T., Berk, M. 2015; 15: 243-?

  Abstract

  Online, self-guided programs exist for a wide range of mental health conditions, including bipolar disorder, and discussion boards are often part of these interventions. The impact engagement with these discussion boards has on the psychosocial well-being of users is largely unknown. More specifically we need to clarify the influence of the type and level of engagement on outcomes. The primary aim of this exploratory study is to determine if there is a relationship between different types (active, passive or none) and levels (high, mid and low) of discussion board engagement and improvement in outcome measures from baseline to follow up, with a focus on self-reported social support, stigma, quality of life and levels of depression and mania. The secondary aim of this study is to identify any differences in demographic variables among discussion users.The present study is a sub-study of the MoodSwings 2.0 3-arm randomised controlled trial (discussion board only (arm 1), discussion board plus psychoeducation (arm 2), discussion board, psychoeducation plus cognitive behavioural therapy-based tools (arm 3)). Discussion engagement will be measured via online participant activity monitoring. Assessments include online self-report as well as blinded phone interviews at baseline, 3, 6, 9 and 12 months follow up.The results of this study will help to inform future programs about whether or not discussion boards are a beneficial inclusion in online self-help interventions. It will also help to determine if motivating users to actively engage in online discussion is necessary, and if so, what level of engagement is optimal to produce the most benefit. Future programs may benefit through being able to identify those most likely to poorly engage, based on demographic variables, so motivational strategies can be targeted accordingly.ClinicalTrials.gov NCT02118623 registered April 15 2014 and NCT02106078 registered May 16 2013.

  View details for DOI 10.1186/s12888-015-0630-7

  View details for PubMedID 26462799

  View details for PubMedCentralID PMC4604761

• A randomized, double-blind, placebo-controlled study of ziprasidone monotherapy in bipolar disorder with co-occurring lifetime panic or generalized anxiety disorder. journal of clinical psychiatry Suppes, T., McElroy, S. L., Sheehan, D. V., Hidalgo, R. B., Cosgrove, V. E., Gwizdowski, I. S., Feldman, N. S. 2014; 75 (1): 77-84

  Abstract

  Bipolar disorder often co-occurs with anxiety disorders. Evidence suggests that second-generation antipsychotics (SGAs) may be useful in treating both conditions. This study examined the efficacy of ziprasidone in the treatment of these disorders.This 3-site, randomized, double-blind, placebo-controlled, parallel group, 8-week trial of ziprasidone monotherapy examined 49 subjects with bipolar disorder and lifetime panic disorder (with or without agoraphobia) or generalized anxiety disorder (GAD) experiencing moderately severe anxiety symptoms at entrance into the study. Both bipolar disorder and anxiety diagnoses were based on DSM-IV-TR criteria. Patients were screened and randomized from June 25, 2010, through August 23, 2011. Primary outcome measures were the Clinical Global Impressions-21 Anxiety Scale (CGI-21 Anxiety) and the Sheehan Disability Scale (SDS), with secondary measures monitoring anxiety and mood symptoms.Last-observation-carried-forward analyses demonstrated that patients in the ziprasidone group did not improve significantly more than those in the placebo group on the CGI-21 Anxiety (F1 = 0.34; P = .564) or SDS (F1 = 0.26; P = .611). Secondary analysis using hierarchical linear modeling found similar results (CGI-21 Anxiety: F1 = 1.82; P = .178; and SDS: F1 = 0.70; P = .408). Regardless of group, time in the study was associated with significant decrease in anxiety (F1 = 11.08; P = .001) and total disability (F1 = 26.16; P < .001). Patients in the ziprasidone group showed a greater increase in abnormal involuntary movement, and 81.8% (n = 9) of the subjects who withdrew from the study due to adverse events, serious adverse events, or side effects were in the ziprasidone group.Results suggest that ziprasidone monotherapy was not associated with a clinically significant improvement in anxiety symptoms or improved function for patients with bipolar disorder, lifetime panic disorder or GAD, and concurrent moderately severe anxiety symptoms, and it was associated with a more negative side-effect profile relative to placebo.ClinicalTrials.gov identifier: NCT01172652.

  View details for DOI 10.4088/JCP.12m08297

  View details for PubMedID 24345758

• First controlled treatment trial of bipolar II hypomania with mixed symptoms: Quetiapine versus placebo. Journal of affective disorders Suppes, T., Ketter, T. A., Gwizdowski, I. S., Dennehy, E. B., Hill, S. J., Fischer, E. G., Snow, D. E., Gonzalez, R., Sureddi, S., Shivakumar, G., Cosgrove, V. E. 2013; 150 (1): 37-43

  Abstract

  OBJECTIVES: To compare the efficacy and safety of adjunctive quetiapine (QTP) versus placebo (PBO) for patients with bipolar II disorder (BDII) currently experiencing mixed hypomanic symptoms in a 2-site, randomized, placebo-controlled, double-blind, 8-week investigation. METHODS: Participants included 55 adults (age 18-65 years) who met criteria for BDII on the Structured Clinical Interview for DSM-IV-TR (SCID). Entrance criteria included a stable medication regimen for ?2 weeks and hypomania with mixed symptoms (>12 on the Young Mania Rating Scale [YMRS] and >15 on the Montgomery Asberg Depression Rating Scale [MADRS] at two consecutive visits 1-3 days apart). Participants were randomly assigned to receive adjunctive quetiapine (n=30) or placebo (n=25). RESULTS: Adjunctive quetiapine demonstrated significantly greater improvement than placebo in Clinical Global Impression for Bipolar Disorder Overall Severity scores (F(1)=10.12, p=.002) and MADRS scores (F(1)=6.93, p=.0138), but no significant differences were observed for YMRS scores (F(1)=3.68, p=.069). Side effects of quetiapine were consistent with those observed in previous clinical trials, with sedation/somnolence being the most common, occurring in 53.3% with QTP and 20.0% with PBO. CONCLUSIONS: While QTP was significantly more effective than PBO for overall and depressive symptoms of BDII, there was no significant difference between groups in reducing symptoms of hypomania. Hypomania improved across both groups throughout the study.

  View details for DOI 10.1016/j.jad.2013.02.031

  View details for PubMedID 23521871

• Bipolar depression in pediatric populations : epidemiology and management. Paediatric drugs Cosgrove, V. E., Roybal, D., Chang, K. D. 2013; 15 (2): 83-91

  Abstract

  Depression in children and adolescents with bipolar disorder is more commonly observed than mania or hypomania, and is associated with significant functional disability in multiple environmental realms. Optimal management of pediatric bipolar depression is often defined by its multimodal nature with emphasis on both psychopharmacological and psychosocial treatment. This article provides a brief overview of the epidemiology and clinical course of pediatric bipolar depression, a clinically-oriented guide to the evidence-based psychopharmacological and psychosocial management of bipolar depression in youth, and suggestions on how best to integrate medication and therapy. Recommended treatment for bipolar depression in pediatric populations usually includes both medication and psychosocial interventions given a paucity of double-blind, placebo-controlled psychopharmacological studies. Lithium and lamotrigine are feasible and tentatively efficacious options; however, treatment with quetiapine monotherapy may be no better than placebo. Furthermore, some youth may be at heightened risk for developing manic symptoms after treatment with selective serotonin reuptake inhibitors (SSRIs). Psychotherapy, either alone or adjunctively with medications, provides practitioners with a safe and feasible alternative. Interpersonal and Social Rhythm Therapy for Adolescents (IPSRT-A), Child- and Family-Focused Cognitive Behavioral Therapy (CFF-CBT), Dialectical Behavior Therapy for Adolescents (DBT-A), family psychoeducation, and Family Focused Therapy for Adolescents (FFT-A) are evidence-based treatments available to clinicians treating youth with bipolar depression.

  View details for DOI 10.1007/s40272-013-0022-8

  View details for PubMedID 23529869

• Characteristics of responders and non-responders to risperidone monotherapy or placebo in co-occurring bipolar disorder and anxiety disorder EUROPEAN PSYCHIATRY Seo, J. S., Jamieson, K., Cosgrove, V., Gwizdowski, I. S., Yang, H., Sheehan, D. V., McElroy, S. L., Suppes, T. 2013; 28 (3): 190-196

  Abstract

  Clinical characteristics predicting response and remission to psychopharmacological treatment of bipolar disorder (BD) and co-occurring anxiety disorders have been understudied. We hypothesized that non-response to risperidone or placebo in individuals with co-occurring BD and anxiety symptoms would be associated with a more severe clinical course of BD, and certain demographic variables. This study was a secondary analysis of a randomized, double-blind, parallel, 8-week study comparing risperidone monotherapy and placebo in individuals with BD plus current panic disorder, current generalized anxiety disorder (GAD), or lifetime panic disorder (n=111) [31]. We compared clinical characteristics of responders (50% improvement on the Hamilton Anxiety Scale [HAM-A]) and non-responders as well as remitters (HAM-A<7) and non-remitters in risperidone treatment (n=54) and placebo (n=57) groups. For non-responders in the risperidone group, co-occurring lifetime panic disorder was significantly more common than for non-responders in the placebo group. Apart from this, no significant differences in course of illness or demographics were found either between or across groups for patients with BD and co-occurring anxiety symptoms receiving risperidone or placebo in this acute phase study.

  View details for DOI 10.1016/j.eurpsy.2011.08.001

  View details for Web of Science ID 000316737800008

  View details for PubMedID 22130178

• Early Intervention for Symptomatic Youth at Risk for Bipolar Disorder: A Randomized Trial of Family-Focused Therapy JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY Miklowitz, D. J., Schneck, C. D., Singh, M. K., Taylor, D. O., George, E. L., Cosgrove, V. E., Howe, M. E., Dickinson, L. M., Garber, J., Chang, K. D. 2013; 52 (2): 121-131

  Abstract

  Depression and brief periods of (hypo)mania are linked to an increased risk of progression to bipolar I or II disorder (BD) in children of bipolar parents. This randomized trial examined the effects of a 4-month family-focused therapy (FFT) program on the 1-year course of mood symptoms in youth at high familial risk for BD, and explored its comparative benefits among youth in families with high versus low expressed emotion (EE).Participants were 40 youth (mean 12.3±2.8 years, range 9-17) with BD not otherwise specified, major depressive disorder, or cyclothymic disorder who had a first-degree relative with BD I or II and active mood symptoms (Young Mania Rating Scale [YMRS]>11 or Child Depression Rating Scale>29). Participants were randomly allocated to FFT-High Risk version (FFT-HR; 12 sessions of psychoeducation and training in communication and problem-solving skills) or an education control (EC; 1-2 family sessions).Youth in FFT-HR had more rapid recovery from their initial mood symptoms (hazard ratio = 2.69, p = .047), more weeks in remission, and a more favorable trajectory of YMRS scores over 1 year than youth in EC. The magnitude of treatment effect was greater among youth in high-EE (versus low-EE) families.FFT-HR may hasten and help sustain recovery from mood symptoms among youth at high risk for BD. Longer follow-up will be necessary to determine whether early family intervention has downstream effects that contribute to the delay or prevention of full manic episodes in vulnerable youth.

  View details for DOI 10.1016/j.jaac.2012.10.007

  View details for Web of Science ID 000314430000004

  View details for PubMedID 23357439

  View details for PubMedCentralID PMC3558946

• Informing DSM-5: biological boundaries between bipolar I disorder, schizoaffective disorder, and schizophrenia. BMC medicine Cosgrove, V. E., Suppes, T. 2013; 11: 127-?

  Abstract

  The fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) opted to retain existing diagnostic boundaries between bipolar I disorder, schizoaffective disorder, and schizophrenia. The debate preceding this decision focused on understanding the biologic basis of these major mental illnesses. Evidence from genetics, neuroscience, and pharmacotherapeutics informed the DSM-5 development process. The following discussion will emphasize some of the key factors at the forefront of the debate.Family studies suggest a clear genetic link between bipolar I disorder, schizoaffective disorder, and schizophrenia. However, large-scale genome-wide association studies have not been successful in identifying susceptibility genes that make substantial etiological contributions. Boundaries between psychotic disorders are not further clarified by looking at brain morphology. The fact that symptoms of bipolar I disorder, but not schizophrenia, are often responsive to medications such as lithium and other anticonvulsants must be interpreted within a larger framework of biological research.For DSM-5, existing nosological boundaries between bipolar I disorder and schizophrenia were retained and schizoaffective disorder preserved as an independent diagnosis since the biological data are not yet compelling enough to justify a move to a more neurodevelopmentally continuous model of psychosis.

  View details for DOI 10.1186/1741-7015-11-127

  View details for PubMedID 23672587

• Association between 5HTT, DAT1, and DRD4 and bipolar disorder in youth PSYCHIATRIC GENETICS Cosgrove, V. E., Miklowitz, D. J., Rhee, S. H., Hawkey, C., Corley, R., Haberstick, B., Smolen, A. 2012; 22 (6): 304-304

  View details for DOI 10.1097/YPG.0b013e3283539517

  View details for Web of Science ID 000310756500008

  View details for PubMedID 22668826

• Biological Evidence for a Neurodevelopmental Model of Pediatric Bipolar Disorder ISRAEL JOURNAL OF PSYCHIATRY AND RELATED SCIENCES Roybal, D. J., Singh, M. K., Cosgrove, V. E., Howe, M., Kelley, R., Barnea-Goraly, N., Chang, K. D. 2012; 49 (1): 28-43

  Abstract

  Bipolar disorder (BD) is a chronic illness with high morbidity and mortality. Pediatric onset BD has a more severe course of illness with higher rates of relapse and psychosocial impairment. Discovering interventions early in the course of BD in youth is paramount to preventing full illness expression and improve functioning in these individuals throughout the lifespan. It is therefore important to understand the mechanisms involved in the development of BD in order to determine which youth are at most risk and provide biological targets for early intervention. To serve this cause, we propose a neurodevelopmental model of BD, based on the existing data that implicate prefrontal-subcortical network dysfunction, caused by pre-existing genetic susceptibility and triggered by pathological reactions to stress and chronic inflammatory processes.

  View details for Web of Science ID 000308697600004

• Family Support and Depressive Symptoms: A 23-Year Follow-Up JOURNAL OF CLINICAL PSYCHOLOGY Kamen, C., Cosgrove, V., McKellar, J., Cronkite, R., Moos, R. 2011; 67 (3): 215-223

  Abstract

  We examined change in family support and depressive symptoms over the course of 23 years and included the potential moderators of gender and participation in treatment. A sample of 373 depressed individuals provided data in five waves, with baseline, 1-year, 4-year, 10-year, and 23-year follow-ups. Multilevel modeling was used to evaluate longitudinal relationships between variables. Higher family support was associated with less depression at baseline and predicted a steeper trajectory of recovery from depression over 23 years. This relationship was moderated by gender, such that women with supportive families reported the most rapid recovery from depression. Evaluating family context may be clinically relevant when beginning treatment with a depressed patient, particularly for female patients.

  View details for DOI 10.1002/jclp.20765

  View details for Web of Science ID 000286693800001

  View details for PubMedID 21254050

• Structure and Etiology of Co-occurring Internalizing and Externalizing Disorders in Adolescents JOURNAL OF ABNORMAL CHILD PSYCHOLOGY Cosgrove, V. E., Rhee, S. H., Gelhorn, H. L., Boeldt, D., Corley, R. C., Ehringer, M. A., Young, S. E., Hewitt, J. K. 2011; 39 (1): 109-123

  Abstract

  Several studies suggest that a two-factor model positing internalizing and externalizing factors explains the interrelationships among psychiatric disorders. However, it is unclear whether the covariation between internalizing and externalizing disorders is due to common genetic or environmental influences. We examined whether a model positing two latent factors, internalizing and externalizing, explained the interrelationships among six psychiatric disorders (major depressive disorder, generalized anxiety disorder, separation anxiety disorder, attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder) in adolescents, and whether there are common genetic and environmental influences on internalizing and externalizing latent factors. Multivariate behavior genetic analyses of data from 1162 twin pairs and 426 siblings ascertained from the general population via the Colorado Center for Antisocial Drug Dependence (CADD) were conducted. We found support for a model positing two latent factors (internalizing and externalizing). These factors were moderately heritable and influenced by significant common genetic and nonshared environmental influences. These findings suggest that co-occurrence of internalizing and externalizing psychopathology in adolescents results from both genetic and environmental influences.

  View details for DOI 10.1007/s10802-010-9444-8

  View details for Web of Science ID 000287149500010

  View details for PubMedID 20683651

• Suicidal ideation and depressive symptoms among bipolar patients as predictors of the health and well-being of caregivers BIPOLAR DISORDERS Chessick, C. A., Perlick, D. A., Miklowitz, D. J., Dickinson, L. M., Allen, M. H., Morris, C. D., Gonzalez, J. M., Marangell, L. B., Cosgrove, V., Ostacher, M. 2009; 11 (8): 876-884

  Abstract

  Few studies have addressed the physical and mental health effects of caring for a family member with bipolar disorder. This study examined whether caregivers' health is associated with changes in suicidal ideation and depressive symptoms among bipolar patients observed over one year.Patients (N = 500) participating in the Systematic Treatment Enhancement Program for Bipolar Disorder and their primary caregivers (N = 500, including 188 parental and 182 spousal caregivers) were evaluated for up to one year as part of a naturalistic observational study. Caregivers' perceptions of their own physical health were evaluated using the general health scale from the Medical Outcomes Study 36-item Short-Form Health Survey. Caregivers' depression was evaluated using the Center for Epidemiological Studies of Depression Scale.Caregivers of patients who had increasing suicidal ideation over time reported worsening health over time compared to caregivers of patients whose suicidal ideation decreased or stayed the same. Caregivers of patients who had more suicidal ideation and depressive symptoms reported more depressed mood over a one-year reporting period than caregivers of patients with less suicidal ideation or depression. The pattern of findings was consistent across parent caregivers and spousal caregivers.Caregivers, rightly concerned about patients becoming suicidal or depressed, may try to care for the patient at the expense of their own health and well-being. Treatments that focus on the health of caregivers must be developed and tested.

  View details for Web of Science ID 000271899700008

  View details for PubMedID 19922556

• Early childhood temperament and the covariation between internalizing and externalizing behavior in school-aged children TWIN RESEARCH AND HUMAN GENETICS Rhee, S. H., Cosgrove, V. E., Schmitz, S., Haberstick, B. C., Corley, R. C., Hewitt, J. K. 2007; 10 (1): 33-44

  Abstract

  There is significant covariation between internalizing and externalizing behavior, although there is also evidence that internalizing behavior is a protective factor against externalizing behavior. Several researchers have posited that the examination of the relationship between temperament or personality and behavior problems may help explain these seemingly contradictory results. Specifically, negative emotionality or neuroticism has been cited as a temperament characteristic that internalizing and externalizing behavior share in common, whereas behavioral inhibition may be related only to internalizing behavior. We examined the degree to which the covariation between internalizing and externalizing behavior assessed from age 4 to 12 years can be explained by temperament characteristics assessed from age 14 to 36 months. Additionally, we assessed the extent to which this relationship is due to genetic or environmental factors, analyzing data from 225 monozygotic and 185 dizygotic twin pairs assessed by the Colorado Longitudinal Twin Study. In males, a portion of the covariation between internalizing and externalizing behavior was explained by shared environmental influences in common with emotionality and shared environmental influences in common with shyness. In females, most of the covariation between internalizing and externalizing behavior was explained by shared environmental influences in common with emotionality. A possible limitation of this study is that the covariation between temperament and behavior problems may be due to shared measurement variance, as parent ratings were used to assess both temperament and behavior problems.

  View details for Web of Science ID 000244823800005

  View details for PubMedID 17539363

• Bipolar disorder: current treatments and new strategies. Cleveland Clinic journal of medicine Sachs, G. S., Cosgrove, V. E. 1998; 65: SI31-7

  View details for PubMedID 12033204