Efficacy of lurasidone in adults with bipolar depression: A systematic review and meta-analysis of its impact on depressive symptoms and disability

Bipolar depression (BDD) is the predominant polarity in bipolar disorder type I, and poses challenges for diagnosis, treatment, and associated disability. Over the last 20 years, the FDA has approved new drugs for BDD, including lurasidone. This study summarizes the literature on lurasidone's efficacy in treating BDD, with a focus on depressive symptoms and disability. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs), following PRISMA reporting guidelines. Our findings demonstrate that lurasidone reduces depressive symptom in adults with bipolar depression - as assessed by the Montgomery-Åsberg Depression Rating Scale (MD -3.05 [95 % CI, -4.48 to -1.62]) and the Clinical Global Impression-Bipolar Scale (MD -0.42 [-0.60 to -0.25]) - and improves associated disability - as measured by the Sheehan Disability Scale (MD -1.92 [-3.29 to -0.55]). While these results are promising, further RCTs are needed to confirm lurasidone's efficacy and assess its role in long-term therapeutic strategies.

Analysis of maintenance pharmacotherapy in Chinese bipolar disorder patients: Guideline concordance and adjunctive medication use

OBJECTIVE

We collected maintenance treatment medication information from Chinese multicenter bipolar disorder patients, exploring the characteristics of medication use and related factors. We analyzed medication guideline adherence and compared trends in medication use with a study from 2014.

METHODS

323 patients receiving maintenance therapy for bipolar disorder across 20 hospitals have been recruited. Their prescription information was collected to compare with the recommended drug protocols outlined by CANMAT to assess consistency. Additionally, descriptive statistics were conducted to document the quantities and percentages of different classes of medications used. Regression analysis was employed to explore factors influencing medication choices.

RESULT

The rate of medication inconsistency in this study was 12.38 %, characterized by inappropriate use of antidepressants and mood stabilizers. The rate of using additional drugs was 67.80 %, with antipsychotics being the most common adjunctive treatment in the Bipolar I group and antidepressants in the Bipolar II group. Factors influencing the occurrence of adjunctive therapy included previous hospitalization, most recent episode type, and gender. The rate of polypharmacy was 47.10 %, with previous hospitalization and most recent episode type being the main influencing factors.

CONCLUSION

There has been a noticeable improvement in guideline concordance in medication use compared to 2014; however, improper use of antidepressants remains a significant clinical issue. The increasing prevalence of adjunctive medication use underscores the need for more personalized medication recommendations in clinical guidelines.

Trends and determinants of prescription of lithium and antidepressants for bipolar disorder in a large health care system between 2017 and 2022

BACKGROUND

Previous studies raised concerns about declining use of lithium and increased use of antidepressants in treatment of bipolar disorder (BP). We describe recent trends in prescription of psychotropic medications for BP and examine demographic, socioeconomic and clinical factors associated with their prescription.

METHODS

We analyzed data from the electronic health records on 12,824 patients with BP in a large academic health system between 2017 and 2022. We calculated annual prescription rates for BP medications, and then used logistic regression to examine factors associated with their prescription.

RESULTS

We found a modest increase in lithium prescription and a slight decrease for antidepressants. Lithium was prescribed to 27 % of patients, while antidepressants were prescribed to 52 % of patients, nearly half without a concomitant mood stabilizer. Patients who were Black (odds ratio [OR] = 0.70 95 % confidence interval [CI] = 0.65-0.76), had public insurance (OR = 0.87, 95 % CI = 0.81-0.94), lived in areas of higher social deprivation (OR = 0.84, 95 % CI = 0.76-0.93), or were seen in primary care (OR = 0.21, 95 % CI = 0.17-0.24) were less likely to be prescribed lithium. Patients who lived in areas of greater deprivation (OR = 1.42, 95 % CI = 1.20-1.68), were older (60+; OR = 2.64, 95 % CI = 1.96-3.58), and were seen in primary care (OR = 7.46, 95 % CI = 6.43-8.66) were more likely to be prescribed antidepressants without a concomitant mood stabilizer.

CONCLUSIONS

Lithium remains underutilized even though it is a first-line treatment for BP, especially among certain sub-groups. Antidepressants are widely used to treat BP, often without mood stabilizers despite caution by most clinical guidelines. These findings underscore the need for continued efforts to promote use of best evidence-treatments for BP and reduce disparities in their use.

Predictive evidence for the impact of personality styles on depression and functioning in two bipolar disorder cohorts

Predictors for course of illness in bipolar disorder (BD) with replicable effect are difficult to identify. Potential predictors of outcomes for BD that could inform practice include personality traits, particularly Neuroticism. However, models typically fail to consider the joint effect of multiple personality traits. We examine whether personality trait combinations (styles) enhance our ability to prospectively predict symptoms and functioning across time in two independent longitudinal research cohorts. In a discovery sample of 489 and replication sample of 2072 individuals with BD, we assessed impact of personality styles using the NEO PI-R and NEO-FFI on depression and functioning up to 14 years. Using a model considering all ten possible personality style combinations, the number of risk-related personality styles (styles associated with poor outcomes) relative to number of protective-related personality styles (styles associated with better outcomes) showed that for every additional risk relative to protective style count, the incident rate of depression increased by 11.8-15.0 % and the incident rate for poor life functioning increased by 11.1 %. This similar pattern of increased risk styles being associated with significant increases in depression and functioning was replicated in the independent STEP-BD dataset, although with slightly lower incident rate (5 % and 2.9 %). Cross validation of performance from both cohorts showed similar predictive patterns (5-11.2 % increases). The ability to predict future depression and poor functioning from the combined effects of personality traits can be clinically useful for identifying individuals at risk for poorer outcomes. Personality styles should be evaluated when planning long-term care and developing interventions.

Residual subjective depressive symptoms and resilience in patients with bipolar disorder

BACKGROUND

Residual symptoms experienced by patients with bipolar disorder (BD) is a risk factor for illness relapse/recurrence, and these symptoms are associated with a lower quality of life. Resilience allows patients to cope with stress effectively and acts as a protective factor against relapse. Therefore, this study aimed to determine the relationship between resilience and residual subjective depressive symptoms in euthymic patients with BD.

METHODS

A total of 49 euthymic patients with BD completed the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) and the Connor-Davidson Resilience Scale (CD-RISC). Hierarchical multiple regression analysis was performed to investigate the association between QIDS-SR and CD-RISC scores.

RESULTS

The mean Clinical Global Impression for BD (CGI-BP) and QIDS-SR scores were 1.3 ± 0.5 and 8.0 ± 5.8, respectively. Although clinically stable according to objective assessment using the CGI-BP, patients with BD experienced residual subjective depressive symptoms. After adjusting for demographic and clinical characteristics, CD-RISC scores could predict QIDS-SR scores significantly in a hierarchical multiple regression. The association between CD-RISC and QIDS-SR scores did not differ according to CGI-BP scores.

LIMITATIONS

The clinical status was objectively evaluated using the CGI-BP alone. This was a cross-sectional study with a relatively small number of patients with BD, complicating the determination of the exact causal relationship between residual depressive symptoms and resilience.

CONCLUSION

Higher levels of resilience appears to be associated with lower subjective residual depressive symptoms in euthymic patients with BD. Resilience could play a protective role against the residual subjective depressive symptoms experienced by clinically stable patients with BD.

Psychotropic comedication trends in long-term lithium treatment for older adults with bipolar disorder: A 10-year analysis

OBJECTIVES

The prescription of psychotropic comedications in patients with bipolar disorder (BD) evolved between 1995 and 2010. This study provides a comprehensive overview of prescription trends across various classes of psychotropic comedications, alongside lithium treatment, in older adults (aged ≥55 years) with BD, from 2010 to 2019.

METHODS

This naturalistic, retrospective cohort study included 166 older adults (mean age 67.4 years) treated with lithium. Medical files from a large mental healthcare provider in the Netherlands were used to construct Lifecharts. The average proportion of time that different classes of comedications were prescribed during follow-up was calculated.

RESULTS

Patients received psychotropic comedications next to lithium for 75.8 % of total follow-up time. Benzodiazepines were prescribed for 56.2 % of follow-up time, antidepressants for 31.6 %, atypical antipsychotics for 25.9 %, a second mood stabilizer for 18.4 %, and typical antipsychotics for 8.7 %. Most classes of comedications did not show significant changes in prescription trends over the 10-year observation period. Quetiapine at doses below 50 mg/day was prescribed significantly more over time (p = .033), its prescription duration increasing from 2.0 % of total follow-up time in 2010 to 8.1 % in 2019.

LIMITATIONS

Generalizability is limited due to focus on older lithium-treated BD patients, potential selection bias, and retrospective design.

CONCLUSIONS

Long-term lithium treatment in older adults is mostly combined with other psychotropic medications. Frequent and prolonged use of benzodiazepines and significant increase of low-dose quetiapine use are concerning, given their adverse effects and lack of long-term efficacy. Prescription trends observed before 2010 have largely stabilized.

PLAIN LANGUAGE SUMMARY

In this study, we examined what types of comedication were used alongside lithium in older adults with bipolar disorder between 2010 and 2019. For this purpose, we reviewed the medical records of 166 patients 55 years or older in the Netherlands. These patients were prescribed additional psychotropic medications along with lithium 75.8 % of the time. Benzodiazepines, often used to treat anxiety and sleep issues but not recommended for long-term use due to adverse effects, were the most frequently prescribed, namely 56.2 % of the time. Antidepressants were prescribed 31.6 % of the time, atypical antipsychotics 25.9 %, a second mood stabilizer 18.4 %, and typical antipsychotics 8.7 %. Although most prescription trends remained stable between 2010 and 2019, prescription time of low-dose quetiapine increased. We conclude that lithium maintenance treatment is mostly combined with other psychotropic comedications in older adults with bipolar disorder. Considering their potential adverse effects and lack of long-term benefits, the increasing use of low-dose quetiapine and the frequent long-term use of benzodiazepines are particularly concerning.

Inhibitory control in Bipolar Disorder disclosed by theta band modulation

BACKGROUND

Cognitive inhibition is key to cognitive control in healthy and psychiatric conditions. Bipolar Disorder (BD) individuals display a range of inhibitory deficits and high levels of impulsivity across all stages of the disease, including euthymia.

METHODS

We tested how the inhibition of heuristics in favor of analytical strategies influences the elaboration of sentences with logical quantifiers by means of a sentence-picture matching task in which the processing of quantified sentences containing the logical universal and particular quantifiers was required. Behavioral and brain oscillatory responses were assessed employing EEG recordings.

RESULTS

In Experiment 1, in a group of healthy volunteers, we demonstrated how the presence of a universal quantifier generates an inhibition, characterized by a high cognitive load, which is resolved at the expense of a poorer behavioral performance compared to a lower cognitive load and neutral control task. In Experiment 2, comparing healthy adults and BD patients, EEG time-frequency analysis showed a different modulation of the theta frequency band localized centrally in the medial frontal areas and representative of the different degrees of cognitive control between groups.

LIMITATIONS

Electrophysiological description should be interpreted with caution in light of the high signal-to-noise ratio determined by the complexity of the task.

CONCLUSIONS

Even in euthymia, BD limited availability of resources for cognitive inhibition impacts the functionality of a fronto-parietal cortical network, responsible for cognitive control, and orchestrated by the activity of frontal areas synchronized in theta and beta frequency.

Quality of life in older adults with mood states associated with bipolar disorder: A secondary analysis of the English longitudinal study of ageing data

OBJECTIVES

To investigate: (i) whether mood states associated with bipolar disorder are associated with poorer quality of life in older adults, and (ii) what are some of the predictors of quality of life in older adults with mood states associated with bipolar disorder.

METHODS

The authors completed a cross-sectional multilevel analysis of panel data from seven waves of The English Longitudinal Study of Ageing dataset. The main analysis included 567 participants who reported experiencing mood states associated with bipolar disorder. Some participants reported this in more than one wave, resulting in 835 observations of mood states associated with bipolar disorder across the seven waves. Quality of life was assessed using the Control, Autonomy, Self-realization, and Pleasure-19 (CASP-19) measure.

RESULTS

The presence of mood states associated with bipolar disorder was significantly associated with poorer quality of life, even after controlling for multiple covariates (age, sex, social isolation, loneliness, alcohol use, education level, and economic status). Loneliness significantly predicted poorer quality of life in older adults with mood states associated with bipolar disorder. In contrast, higher educational attainment and being female predicted better quality of life in this group.

CONCLUSIONS

Older adults with mood states associated with bipolar disorder have potentially worse quality of life compared to the general population, which may be partly driven by loneliness. This has ramifications for the support offered to this population and suggests that treatments should focus on reducing loneliness to improve outcomes.

Flavonoids and their role in oxidative stress, inflammation, and human diseases

Oxidative stress and chronic inflammation are important drivers in the pathogenesis and progression of many chronic diseases, such as cancers of the breast, kidney, lung, and others, autoimmune diseases (rheumatoid arthritis), cardiovascular diseases (hypertension, atherosclerosis, arrhythmia), neurodegenerative diseases (Alzheimer's disease, Parkinson's disease, Huntington's disease), mental disorders (depression, schizophrenia, bipolar disorder), gastrointestinal disorders (inflammatory bowel disease, colorectal cancer), and other disorders. With the increasing demand for less toxic and more tolerable therapies, flavonoids have the potential to effectively modulate the responsiveness to conventional therapy and radiotherapy. Flavonoids are polyphenolic compounds found in fruits, vegetables, grains, and plant-derived beverages. Six of the twelve structurally different flavonoid subgroups are of dietary significance and include anthocyanidins (e.g. pelargonidin, cyanidin), flavan-3-ols (e.g. epicatechin, epigallocatechin), flavonols (e.g. quercetin, kaempferol), flavones (e.g. luteolin, baicalein), flavanones (e.g. hesperetin, naringenin), and isoflavones (daidzein, genistein). The health benefits of flavonoids are related to their structural characteristics, such as the number and position of hydroxyl groups and the presence of C2C3 double bonds, which predetermine their ability to chelate metal ions, terminate ROS (e.g. hydroxyl radicals formed by the Fenton reaction), and interact with biological targets to trigger a biological response. Based on these structural characteristics, flavonoids can exert both antioxidant or prooxidant properties, modulate the activity of ROS-scavenging enzymes and the expression and activation of proinflammatory cytokines (e.g., interleukin-1beta (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α)), induce apoptosis and autophagy, and target key signaling pathways, such as the nuclear factor erythroid 2-related factor 2 (Nrf2) and Bcl-2 family of proteins. This review aims to briefly discuss the mutually interconnected aspects of oxidative and inflammatory mechanisms, such as lipid peroxidation, protein oxidation, DNA damage, and the mechanism and resolution of inflammation. The major part of this article discusses the role of flavonoids in alleviating oxidative stress and inflammation, two common components of many human diseases. The results of epidemiological studies on flavonoids are also presented.

Chronic inflammation response as a key factor in polycystic ovary syndrome among patients with bipolar disorder

BACKGROUND

This study aimed to investigate serum inflammatory factor levels of polycystic ovary syndrome (PCOS) in female patients with bipolar disorder (BD) to explore the related inflammatory molecular mechanisms preliminarily.

METHODS

The study recruited 72 female drug-naïve patients with BD and 98 female healthy controls (HCs). Demographic information, menstrual cycles, sex hormone levels, and ovarian ultrasound data were collected from them. Additionally, their serum inflammatory factor levels and the proteomics of peripheral blood mononuclear cells were analyzed.

RESULTS

The levels of interleukin (IL)-8 and IL-13 were significantly higher in patients with BD than in HCs (p < 0.05), and the IL-8 level was higher in BD patients with PCOS than in those without (adjusted p = 0.07). Bioinformatics analysis revealed that downregulated genes with significant differences between the two groups were all involved in immune-inflammatory-related pathways, and the expression of downregulated genes BTN3A2, MAP2K5, JCHAIN-B, and DMAP1 showed substantial differences and consistent trends between the two groups.

CONCLUSION

IL-8-related chronic inflammatory response is closely associated with PCOS in BD patients, and genes such as BTN3A2 may mediate this chronic inflammatory response by negatively regulating the abnormal differentiation of T helper 17 cells, serving as one of the mechanisms underlying its pathogenesis.

The Potential Benefits of Chromium and Selenium Supplementation Across Psychiatric Disorders and Symptoms

BACKGROUND

The conception of psychiatric disorders as systemic diseases implies an important role of nutrition in mental health. Essential trace elements are present in very small amounts in the body, yet they are essential for many physiological functions.

METHODS

Little is known about the potential role of chromium and selenium supplementation in mental disorders and other populations. To contribute to filling this gap, this review is focused on the possible benefits of chromium and selenium, alone or in combination with pharmacological treatments, in the treatment of mental disorders or psychiatric symptoms.

RESULTS

Chromium and selenium show promising effects on psychiatric symptoms across mental disorders. Selenium may have benefits on anxious-depressive symptoms in healthy populations and groups at risk of nutritional deficits and psychiatric symptoms, for example, women in the post-partum. In addition, chromium was linked to improved insulin sensitivity and glucose metabolism, which can benefit not only metabolic health but also mood regulation, with specific benefits on atypical symptoms of depression, such as appetite/weight gain. Selenium plays a role in reducing oxidative stress and inflammation, which may suggest positive effects on psychopathology and other conditions linked to these mechanisms.

CONCLUSIONS

Both trace elements may affect positively mental health and cardio-metabolic-inflammatory conditions, which have a strong link with psychiatric disorders and their prognosis. Despite the evidence is not conclusive, chromium and selenium supplementation are interesting options to investigate in future research on the personalization of treatment in mental disorders.

Duration of untreated or undiagnosed bipolar disorder and clinical characteristics and outcomes: systematic review and meta-analysis

BACKGROUND

The duration of undiagnosed or untreated bipolar disorder (DUBD) has become a focus of research interest. However, its relationship with clinical characteristics and outcomes remains poorly understood.

AIMS

The objective of this systematic review and meta-analysis was to examine DUBD and explore its relationships with clinical characteristics and outcomes in bipolar disorder.

METHODS

We conducted a systematic search of the literature to identify studies reporting on DUBD and its relationships with clinical characteristics and outcomes including frequency of relapse into mood episodes, severity and persistence of mood symptoms, functional and cognitive measures, suicidality, hospital admission rate, and comorbidities such as substance use disorders.

RESULTS

Thirty articles met inclusion criteria for the systematic review, and 23 studies were included in the three different sets of meta-analyses. The pooled mean DUBD across all studies was 9.10 years. Early onset, depression as the polarity of the first mood episode, lifetime suicide attempts, comorbid anxiety and alcohol use disorders, and family history of bipolar disorder were associated with significantly longer DUBD, whereas diagnosis of bipolar I disorder and lifetime psychotic symptoms were associated with shorter DUBD. Studies that investigated outcomes subsequent to the diagnosis of bipolar disorder yielded conflicting results.

CONCLUSION

DUBD may be associated with certain adverse outcomes. This association indicates the importance of adopting a more comprehensive approach to assessing mood disorders, with an emphasis on prioritising early screening for bipolar disorder. The significant heterogeneity among included studies suggests a need for improved methodological rigour in future research.

The effect of childhood trauma on bipolar depression

Childhood trauma (CT) is associated with an earlier onset and a more severe course of bipolar disorder (BD). However, the specific impact of CT on bipolar depression remains unclear. Herein, this study aimed to investigate the effect of CT using depressive episode frequency as a threshold for disease burden and severity. A cohort of 146 participants with BD was followed for 3 years. The effects of CT on mood episodes, hospital readmissions, suicidal ideation, and behavior were analyzed. A high number of depressive episodes were identified in participants with BD and CT exposure, with the effect being more pronounced in BD II than in BD I. A threshold of ≥4 depressive episodes serves as a sensitivity cutoff point to detect associations with severe outcomes, such as early readmission and suicidal ideation and behavior. The presence of CT increases the risk of experiencing at least one severe outcome by 80%. In our cohort, a cutoff point of ≥4 depressive episodes mediated the effect of CT on at least one severe outcome (early readmission or suicidal ideation and behavior). The study is limited by its non-probabilistic sample, recall bias, and moderate receiver operating characteristic curve value. The findings reinforce the association between CT and BD severity, highlighting the significantly higher number of depressive episodes in individuals with CT. This underscores CT as a risk factor for depressive predominant polarity and more frequent mood episodes in BD.

Associations of multiple trace elements with bipolar disorder in adolescents: A case-control study

BACKGROUND

Bipolar disorder (BD) is a serious mental disorder. Studies have shown an association between trace elements and mental disorders. However, this association has not been thoroughly studied in adolescents with BD. We aimed to investigated the associations between multiple trace elements and adolescent BD.

METHOD

This case-control study included 144 BD patients with BD and 144 matched controls. Seventeen elements in the participants' urine were measured using inductively coupled plasma mass spectrometry (ICP-MS). Least absolute shrinkage and selection operator (LASSO), multivariate logistic regression, restricted cubic spline (RCS), and Bayesian kernel machine regression (BKMR) were used to analyze the association between exposure to single and mixed elements and adolescent BD.

RESULTS

In the single-element models, titanium, manganese, rubidium, and iodine were negatively associated with adolescent BD. In the multi-element model selected by LASSO, titanium (OR = 0.14, 95% CI: 0.04-0.53), manganese (OR = 0.02, 95% CI: 0.01-0.08), and iodine (OR = 0.06, 95% CI: 0.02-0.22) showed a negative correlation with adolescent BD, while magnesium (OR = 11.24, 95% CI: 1.83-69.12), and nickel (OR = 6.86, 95% CI: 1.55-30.29) displayed a positive correlation. The RCS results showed a non-linear correlation between the elements titanium, manganese, iodine, magnesium, nickel, zinc, strontium and adolescent BD. In addition, the BKMR analysis showed a significant joint effect of multiple elements on adolescent BD when the concentrations of the seven elements were at or above the 55th percentile, compared with their median values.

CONCLUSIONS

Our findings revealed that urinary titanium, manganese, and iodine were negatively correlated with adolescent BD, whereas urinary magnesium and nickel were positively correlated with adolescent BD. These results provide evidence of an association between urinary trace elements and adolescent BD.

Comparative efficacy and tolerability of nutraceuticals for depressive disorder: A systematic review and network meta-analysis

BACKGROUND

Nutraceuticals have been taken as an alternative and add-on treatment for depressive disorders. Direct comparisons between different nutraceuticals and between nutraceuticals and placebo or antidepressants are limited. Thus, it is unclear which nutraceuticals are the most efficacious.

METHODS

We conducted a network meta-analysis to estimate the comparative efficacy and tolerability of nutraceuticals for the treatment of depressive disorder in adults. The primary outcome was the change in depressive symptoms, as measured by the standard mean difference (SMD). Secondary outcomes included response rate, remission rate, and anxiety. Tolerability was defined as all-cause discontinuation and adverse events. Frequentist random-effect NMA was conducted.

RESULTS

Hundred and ninety-two trials involving 17,437 patients and 44 nutraceuticals were eligible for inclusion. Adjunctive nutraceuticals consistently showed better efficacy than antidepressants (ADT) alone in outcomes including SMD, remission, and response. Notable combinations were Eicosapentaenoic acid + Docosahexaenoic Acid plus ADT (EPA + DHA + ADT) (SMD 1.04, 95% confidence interval 0.64-1.44), S-Adenosyl Methionine (SAMe) + ADT (0.99, 0.31-1.68), curcumin + ADT (1.03, 0.55-1.51), Zinc + ADT (1.59, 0.63-2.55), tryptophan + ADT (1.24, 0.32-2.16), and folate + ADT (0.64, 0.17-1.10). Additionally, four nutraceutical monotherapies demonstrated superior efficacy compared to ADT: EPA + DHA (0.6, 0.32-0.88), SAMe (0.52, 0.18-0.87), curcumin (0.62, -0.17 to 1.40) and saffron (0.69, 0.34-1.04). It is noted that EPA + DHA, SAMe, and curcumin showed strong performance as either monotherapies or adjuncts to ADT. Most nutraceuticals showed comparable tolerability to placebo.

CONCLUSIONS

This extensive systematic review and NMA of nutraceuticals for treating depressive disorders indicated a number of nutraceuticals that could offer benefits, either as adjuncts or monotherapies.

Beyond the Window of Risk? The Dutch Bipolar Offspring Study: 22-Year Follow-Up

OBJECTIVE

Adolescent offspring of parents with bipolar disorder (BD) are at high risk to develop BD and other psychopathology, yet how this risk continues into middle adulthood remains unknown. This study aimed to determine the window of risk for BD and other psychopathology in offspring of parents with BD followed from adolescence into adulthood.

METHOD

This study reported on the 22-year follow-up assessment of the Dutch Bipolar Offspring Study, a fixed cohort study of 140 participants established in 1997. Offspring (n = 100; mean [SD] age = 38.28 [2.74] years) of parents with bipolar I disorder or bipolar II disorder were assessed at baseline and 1-, 5-, 12-, and 22-year follow-up.

RESULTS

No new BD onsets occurred since the 12-year follow-up (lifetime prevalence = 11%-13%; bipolar I disorder = 4%; bipolar II disorder = 7%). Lifetime prevalence of any mood disorder was 65%; for major depressive disorder, prevalence was 36%; and for recurrent mood episodes, prevalence was 37%. Prevalence of major depressive disorder more than doubled in the past decade. Point prevalence of any psychopathology peaked between 20 and 25 years (38%-46%), subsiding to 29% to 35% per year after age 30. Overall, 71% of offspring contacted mental health services since the last assessment.

CONCLUSION

The risk for homotypic transmission of BD in offspring of parents with BD is highest during adolescence. The heterotypic risk for mood disorder onset and recurrences continues over the life course. Severe mood disorders are often preceded by milder psychopathology, emphasizing the need for early identification and interventions. This study allows for better understanding of the onset and course of mood disorders and specific windows of risk in a familial high-risk population.

PLAIN LANGUAGE SUMMARY

This longitudinal study followed 100 offspring of parents with bipolar disorder, finding that they are at increased risk to develop mood and other disorders themselves. The window of risk, in terms of age of onset for mood disorders is still unclear. The 22-year follow-up of the Dutch Bipolar Offspring Study shows the highest risk for occurences of bipolar disorder was during late adolescence (11-13%) while the risk for onset and recurrences of other mood disorders continues into middle adulthood (65% and 37%, respectively).

Symptom modulation and tolerability of intravenous ketamine in treatment-resistant bipolar depression: A retrospective study

Ketamine's use in treating bipolar depression must account for risks, such as switching to manic episodes or worsening symptoms. This study examines ketamine's impact on depressive symptoms, focusing on 'inner tension,' 'sleep reduction,' and 'suicidal ideation' over four weeks in treatment-resistant bipolar disorder (TR-BD) patients. Fifty-nine patients with TR-BD were treated consecutively with ketamine (avg dose 0.8 mg/kg). Results showed significant reductions in MADRS scores without manic switches. Ketamine was well-tolerated despite polypharmacy. Antidepressant treatment of bipolar depression requires great caution because of the risk of switching to manic-mixed episodes and worsening of symptoms such as internal tension, psychomotor agitation, and suicide risk. The aim of this study was to evaluate the efficiency and tolerability of intravenous ketamine in patients with bipolar I or bipolar II disorder and a current treatment-resistant depressive episode (TR-BD), with the aim of examining: 1) the risk of manic switches; 2) the effect on global depressive symptoms as measured by the Montgomery-Åsberg Depression Rating Scale (MADRS); and 3) the specific effects on the MADRS items of internal tension, sleep disturbance, and suicidal ideation over a four-week period. Fiftynine patients with TR-BD (51.4 ± 12.3 years; 30 % female) treated consecutively with intravenous ketamine (mean dose 0.8 mg/kg) were included in this study. No ketamine-treated patient experienced a manic switch during the observation period. A statistically significant decrease (i.e., improvement) in MADRS global score and scores on the Internal Tension, Reduced Sleep, and Suicidal Ideation items was observed from the second week, with no evidence of worsening of the above symptoms. Patient-reported adverse events were generally mild to moderate.

Atypical depression and emotion dysregulation: Clinical and psychopathological features

BACKGROUND

Most atypical depression (AD) cases endorse prominent mood reactivity, anxiety, and interpersonal sensitivity, resembling some of the characteristics of emotional dysregulation (ED). The present study assesses the frequency and clinical features of different levels of ED in ADyes vs. non-AD(ADno) cases.

METHODS

The present cross-sectional study discriminated depressed outpatients screened with the Hamilton Depression rating scale with the Atypical Depression Supplement (SIGH-ADS), Symptom Checklist-90-Revised, Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Auto-questionnaire, 110-item version, 36-item Difficulties in Emotion Regulation Scale (DERS), and Young Mania Rating Scale into people with high (EDhigh) vs. low (EDlow) for a broad range of clinical and psychopathological features. Descriptive statistics were followed by random forest analysis with "out-of-bag"[OOB] computation.

RESULTS

We included 326 patients (MDD = 204[62.60 %], BD-II = 105[32.20 %], and BD-I = 17[5.20 %]). ADyesEDhigh cases had the earliest age at the onset of depression and overall clinical burden. Higher scores at interpersonal sensitivity, somatization, early age at onset of depression, anxious features, non-atypical core of depression, cyclothymic and depressive temperament, DERS total, and strategies scores predicted higher odds of atypical depression (OOB = 0.25). Among other predictors, age at onset of depression somatization and cyclothymic temperament predicted EDhigh group membership (OOB = 0.23). Hyperthymic temperament, the SIGH-ADS atypical balance percentage score, and somatization emerged as top predictors of treatment-resistant-depression (OOB = 0.12) in contrast to the SIGH-ADS-8-item atypical balance, psychotic features, and age at onset for treatment-resistant-bipolar-depression (OOB = 0.16).

LIMITATIONS

Cross-sectional design; treatment-seeking outpatients.

CONCLUSIONS

AD and ED represent intertwined clinical entities potentially relevant to enhanced treatment outcomes, warranting more accurate random-forest models.

Cariprazine as a maintenance treatment in dual schizophrenia: a 6-month observational study in patients with schizophrenia and cannabis use disorder

Schizophrenia is often associated with substance use disorders, particularly cannabis use disorder (CUD). However, treatments frequently fail to address both conditions simultaneously. This study aimed to evaluate the antipsychotic effectiveness of cariprazine in patients with both schizophrenia and CUD in a real-world setting. A 6-month observational study was conducted on 58 patients diagnosed with schizophrenia and CUD, treated with cariprazine. Antipsychotic effectiveness was measured using the Positive and Negative Syndrome Scale and the Clinical Global Impression-Schizophrenia Scale, along with the Improvement and Severity scales. Cannabis consumption and addiction severity were assessed using the Cannabis Abuse Screening Test and the Severity of Dependence Scale, while functioning was evaluated with the Sheehan Disability Inventory. Cariprazine treatment resulted in significant improvements in schizophrenia symptoms (Positive and Negative Syndrome Scale change: -47.88 points, P  < 0.0001; Clinical Global Impression-Schizophrenia Scale change: -8.26 points, P  < 0.0001). Cannabis use and dependence also decreased (Cannabis Abuse Screening Test change: -7.0 points, P  < 0.0001; Severity of Dependence Scale change: -7.88 points, P  < 0.0001), alongside improvements in functioning (Sheehan Disability Inventory change: -9.48 points, P  < 0.0001). These results suggest that cariprazine is effective for both schizophrenia and CUD, though further research is needed to confirm these findings.

A Proposed Algorithm for the Pharmacological Treatment of Generalized Anxiety Disorder in the Older Patient

BackgroundThis is a new algorithm from the Psychopharmacology Algorithm Project at the Harvard South Shore Program, focused on generalized anxiety disorder (GAD) in older adults. Pertinent articles were identified and reviewed.ResultsSelective serotonin reuptake inhibitors (SSRIs) are considered to be first-line medications, with a preference for sertraline or escitalopram. If avoiding sexual side effects is a priority, buspirone is an option for the relatively healthy older adult. If response is inadequate, the second recommended trial is with a different SSRI or one of the serotonin-norepinephrine update inhibitors (SNRIs), venlafaxine or duloxetine. For a third medication trial, additional alternatives added to the previous options now include pregabalin/gabapentin, lavender oil, and agomelatine. If there is an unsatisfactory response to the third option chosen, quetiapine may be considered. We recommend caution with the following for acute treatment in this population: benzodiazepines and hydroxyzine. Other agents given low priority but having some supportive evidence were vilazodone, vortioxetine, mirtazapine, and cannabidiol. Acknowledging that the median age of onset of GAD is in early adulthood, many patients with GAD will have been started on benzodiazepines (or other medications that require caution in the elderly) for GAD at a younger age. These medications may be continued with regular observation to see if the potential harms are starting to exceed the benefits and a switch to other recommended agents may be justified.

Predominant Polarity for Enhanced Phenotyping and Personalized Treatment of Bipolar Disorder: A Narrative Review on Recent Findings

PURPOSE OF REVIEW

This paper explores Predominant Polarity (PP) in Bipolar Disorder (BD), defined as the predominance of either manic or depressive episodes over a patient's course of illness. We examine its clinical relevance, neurobiological foundations, and potential for guiding personalized treatment strategies. The review seeks to determine whether PP is a reliable course specifier and how it can be utilized to improve clinical outcomes.

RECENT FINDINGS

PP has a significant impact on prognosis and treatment planning in BD. Manic and depressive PP are associated with distinct clinical and neurobiological profiles of BD, while individuals without a clear predominance of either episode type represent a more severe to-treat subgroup of patients. The development of the Polarity Index (PI) facilitates treatment decisions based on PP. PP offers a valuable framework for refining BD treatment and understanding its complexity. Future research should focus on refining PP definitions, validating neurobiological markers, and integrating these insights into comprehensive treatment models to improve patient outcomes.

Editorial: Following Offspring of Parents With Bipolar Disorder Into Middle Adulthood: Risk Windows Relevant to Child Psychiatrists

The most important predictor of bipolar disorder (BD) onset is a family history. Based on this premise, several offspring studies have recruited and followed offspring of parents with BD into early adulthood, including the Pittsburgh Bipolar Offspring Study, the Canadian Flourish Cohort, and the Dutch Bipolar Offspring Study (DBOS).1-3 These studies have shed important light on the incidence and prevalence of BD and other psychopathology in these offspring (11%-13% for BD-I/II), as well as the most important symptom-level and diagnostic predictors of BD in these youth.4 However, questions remain: What happens to these offspring as they reach middle adulthood? Do they continue to be at risk for BD and other mood disorders? These questions have critical clinical and research implications. Clinically, a better understanding of risk trajectories may inform monitoring, treatment, and our conversations with affected families. From a research perspective, a better understanding of the risk period informs the age range in which to focus future efforts.

Global Trends in the Use of Pharmacotherapy for the Treatment of Bipolar Disorder

Bipolar Disorder (BD) is a chronic mental health condition characterized by significant mood swings, including periods of mania or hypomania and depression. Affecting approximately 1-2% of the global population, BD is associated with impaired social functioning, decreased quality of life, and an increased risk of suicide. The disorder presents a substantial burden on healthcare systems and imposes significant economic costs due to lost productivity and the need for extensive treatment and support services. This comprehensive review synthesizes global trends in BD pharmacotherapy over the past 1 to 3 years, focusing on emerging medications, novel treatment protocols, and ongoing debates within the field. Additionally, the review explores differences in prescribing patterns across developed and developing countries, introduces the impact of pharmacogenomics and personalized medicine on treatment outcomes. PURPOSE OF REVIEW: The primary purpose of this review is to provide a comprehensive and up-to-date synthesis of the global trends in the use of medications for the treatment of BD over the past 1 to 3 years. This review aims to outline the latest studies, clinical trials, and meta-analyses relevant to BD pharmacotherapy, highlighting new discoveries and advancements. Furthermore, this review will address ongoing debates and controversies in the field, such as the role of antidepressants in BD treatment and the long-term use of antipsychotics, aiming to bridge knowledge gaps and guide future research directions. RECENT FINDINGS: Studies continue to reinforce the efficacy of lithium in mood stabilization and reduction of suicidal behavior, despite its declining use due to safety concerns. Mood stabilizing anticonvulsants like valproate and carbamazepine continue to be vital alternatives, each with distinct side effect profiles necessitating careful patient monitoring. The approval and increasing use of novel atypical antipsychotics, such as lurasidone (2013) and cariprazine (2015), has expanded treatment options, offering efficacy in different phases of BD with relatively favorable side effect profiles. Antidepressants remain contentious, with evidence suggesting their benefits primarily when used in combination with mood stabilizers. Emerging agents like lumateperone (Dec 2021) and esketamine show promise, while pharmacogenomic research is paving the way for more personalized treatments. The landscape of BD pharmacotherapy is marked by significant advancements and ongoing challenges. Lithium and mood stabilizing anticonvulsants remain foundational treatments, albeit with adherence challenges and side effect concerns. The advent of new atypical antipsychotics and novel agents offers promising therapeutic options, while antidepressants continue to be debated. Personalized medicine and pharmacogenomics could emerge as transformative approaches, allowing for more tailored and effective treatments. However, disparities in medication accessibility between developed and developing countries highlight the need for global collaboration to optimize BD management. Continued research and innovation are essential to addressing the complexities of BD and improving patient outcomes worldwide.

Anti-suicidal effectiveness of clozapine, lithium, and valproate in patients with schizophrenia and bipolar disorder: A real-world nationwide study

Despite advances in psychiatric treatment, individuals with schizophrenia (SZ) and bipolar disorder (BD) continue to experience alarmingly high suicide rates. Clozapine, lithium, and valproate are medications that may potentially reduce suicide in these populations, but evidence is limited and often inconsistent. This study aimed to evaluate the anti-suicidal effectiveness of these medications using a nationwide health insurance database in South Korea. A retrospective cohort study was conducted using data from the National Health Information Database. This study included 102,540 patients with SZ and 96,336 patients with BD diagnosed between 2007 and 2010. We assessed the association between suicide mortality and recent prescriptions of clozapine, lithium, and valproate, as well as other psychotropic drugs. Suicide hazard ratios (HR) were calculated using a time-dependent Cox regression analysis. Suicide rates per 100,000 person-years were 308.0 for SZ and 285.1 for BD. After adjustment for confounders, lithium and valproate prescriptions were associated with significantly lower suicide hazard ratios in both SZ (HR of lithium: 0.58, 95 % CI: 0.46-0.72; HR of valproate: 0.61, 95 % CI: 0.52-0.71) and BD (HR of lithium: 0.54, 95 % CI: 0.44-0.65; HR of valproate: 0.66, 95 % CI: 0.57-0.76). Clozapine was associated with a lower suicide hazard in patients with SZ but remained statistically non-significant. Lithium and valproate have significant anti-suicidal effects in patients with SZ and BD, underscoring the potential role of mood stabilizers in suicide prevention among them.

Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD): Building a Global Consortium Benefiting People with Bipolar Disorder in Later Life

PURPOSE OF REVIEW

Findings from the Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) project, including sociodemographic and clinical information from older age bipolar disorder (OABD) and healthy participants around the globe (approximately N = 5000) were reviewed. Data was collected in multiple waves to create a large integrated dataset.

RECENT FINDINGS

BD does not seem to fade with age. BD subtype and early/late onset did not show significant differences in daily functioning. Physical comorbidities were more frequent in OABD compared with controls. Women with OABD had an earlier age at onset and more psychiatric hospitalizations. GAGE-BD is the largest OABD cohort. Dataset results offer a unique and comprehensive resource for understanding the long-term trajectory of BD and the specific needs of this population. Findings are vital for guiding future research and improving care strategies for aging individuals with BD.

The effect of systematic antidepressant treatments in the early stages on sleep and impulsivity in bipolar euthymic patients: A cross-sectional study

BACKGROUND AND OBJECTIVES

Due to early misdiagnosis, bipolar patients who had a depressive episode as their initial onset often received systematic antidepressant treatments and continued to suffer from sleep disturbances and elevated impulsivity, even during euthymic state. The study aims to assess the effect of systematic antidepressant treatments in the early stages on sleep and impulsivity in bipolar euthymic patients, and further explore the potential mediating role of sleep in the relationship between early antidepressant uses and impulsivity.

METHODS

A total of 124 bipolar euthymic patients were enrolled. Based on the early use of antidepressants, patients were divided into AT group (systematic antidepressant treatment group) and NT group (no systematic antidepressant treatment group). Sleep quality and impulsivity were assessed using Pittsburgh Sleep Quality Index and Barratt Impulsivity Scale Questionnaire version 11, respectively. Statistical analyses were conducted using the t-test, Chi-square test, and Mann-Whitney U test, and mediation analysis was performed using bootstrapping.

RESULTS

Patients in the AT group showed poorer sleep quality and higher impulsivity than those in the NT group. Patients' sleep quality was positively correlated with impulsivity. Sleep quality mediated the relationship between antidepressant uses and impulsivity, including both overall impulsivity and non-planning impulsivity.

CONCLUSIONS

This study suggests a correlation between early-stage antidepressant use, sleep quality, and impulsivity of bipolar euthymic patients, highlighting the importance of early diagnosis of bipolar disorder and appropriate antidepressant prescriptions. Furthermore, improving sleep quality would be effective in reducing the risk of impulsive behaviors.

Characteristics of deaths related to lithium toxicity in Australia, 2000-2024

OBJECTIVES

To determine: (1) the characteristics, clinical presentation and circumstances of death for deaths related to lithium toxicity in Australia, 2000-2024; (2) the toxicology of cases; and (3) the major autopsy findings.

METHODS

A retrospective study of all cases of death aged ⩾15 years associated with lithium toxicity in Australia, 2000-2024, retrieved from the National Coronial Information System.

RESULTS

We identified 93 cases, with a mean age of 48.7 years (range, 18-89), 12% being aged under 30 years and 51% being male. A diagnosis of bipolar disorder was documented in 52%, with 28% having a documented psychotic disorder. The circumstances of death were unintentional toxicity (58%), intentional toxicity (23%) and undetermined intent (19%). The median blood lithium concentration was 0.68 mmol/L (range, 0.01-17.3). Concentrations were higher for ante-mortem versus post-mortem samples (2.3 vs 0.5 mmol/L), intentional overdose versus unintentional (2.2 vs 0.5 mmol/L) and cases in which lithium was the sole drug detected versus multiple drugs (2.1 vs 0.6 mmol/L). Other drugs were present in the majority (87%), most commonly antipsychotics (67%) and antidepressants (57%). Cardiomegaly was diagnosed in 22% and nephro/arteriosclerosis in 26%.

DISCUSSION

Toxicity remains a rare event compared to exposure to lithium, with intentional cases comprising a fifth of the series. Deaths were not the sole preserve of the middle-aged or elderly.

Comparative efficacy and safety of alternatives to sodium valproate in the management of bipolar affective disorder in people of child-bearing age: a narrative review by the European Society of Clinical Pharmacy's mental health specialist interest group

BACKGROUND

The European Medicines Agency has recommended a series of restrictions on the use of sodium valproate (valproate) following research linking its exposure in utero to adverse congenital and neurodevelopmental effects in offspring. Recent research has highlighted a potential increased risk of neurodevelopmental disorders in children born to males taking valproate prior to conception. Clinicians and patients require guidance regarding suitable alternatives.

AIM

To provide an overview of suitable alternatives to valproate in the management of bipolar disorder.

METHOD

A narrative review was conducted. Only medications with an established evidence base in managing different phases of bipolar disorder and endorsed within clinical practice guidelines were considered. Eligible guidelines included those (i) where recommendations were informed by a formal guideline development process and (ii) published in English within the last 15 years. REPROTOX® was chosen as the primary information source regarding reproductive safety of alternative medications.

RESULTS

Of all second-generation antipsychotics, quetiapine should be considered a first-line alternative to valproate. Lithium has been associated with an increased risk of cardiac malformations, especially Ebstein anomaly, following in utero exposure. However, given its robust efficacy as an antimanic agent and the absolute risk of cardiac abnormalities being low, it's use can still be considered in individuals of child-bearing potential with appropriate monitoring. Carbamazepine treatment should be avoided due to concerns for teratogenicity. Although considered safe in pregnancy, lamotrigine is largely effective at preventing relapse of bipolar depression. Thus, lamotrigine offers limited clinical utility as an alternative to valproate.

CONCLUSION

Specific recommendations are made regarding alternatives to valproate in managing bipolar disorder.

Genetically informed disassortative brain morphometric similarities revealing suicide risk in bipolar disorder

BACKGROUND

Cortical structure alterations in bipolar disorder (BD) have consistently been reported in association with suicide with high heritability. Currently, multifaceted genetic landscape responsible for replicable neuroanatomical alterations with suicidal effects is poorly explored to develop personalized risk assessments in clinic.

METHODS

Anatomically informed suicidal effects quantified with morphometric similarity network (MSN) upon structural MRI was evaluated in two independent BD cohorts consisted of patients with or without suicide attempt (SA and NSA) (discovery: 63 BD-SAs\72 BD-NSAs with 6 potential suicide-related SNPs examined in 46 BD-SAs\55 BD-NSAs; replication: 23 BD-SAs\23 BD-NSAs) and 119 healthy controls. In discovery study, transcriptomic and neurotransmitter correlates of suicide-relevant MSN deficits were examined by partial least squares regression on Allen Human Brain Atlas and dominance analysis on 9 distinct neurotransmitter systems. Molecularly informed MSN deficits were orthogonally validated by estimating genetic risks from targeted SNP genotyping utilizing a multi-level mediation analysis. Reproducible pattern of genetically decoding suicide-relevant MSN changes was validated in replication study.

RESULTS

Opioid receptor was consistently suggested to be responsible for the reproducible suicide-relevant MSN alterations identified in entorhinal and left lateral occipital cortices. MSN deficits of entorhinal cortex positively mediated the effects of genetic risks of OPRM1 on suicide attempted (portion of mediated = 61.3%, β=6.99e-2, p=.02, 95% CI = [3.34e-2, 0.11]).

CONCLUSION

Abnormal cytoarchitecture communities, especially maladaptive changes in neuronal communication between entorhinal cortex and reward circuit regulated by opioid receptors reflected by enhanced morphometric similarities could mediate the effect on increased suicidal tendencies involved in OPRM1 gene variants in BD.

The experience of self-monitoring using the PolarUs bipolar disorder self-management app: a qualitative report of impacts and unmet needs

BACKGROUND

Self-monitoring is key to detecting and preventing mood episodes in bipolar-disorder (BD). An increasing number of smartphone apps have been developed to facilitate this aspect of self-management; however, the feasibility and efficacy of these interventions is heterogenous. To improve understanding of the subjective experience of app-based self-monitoring interventions for BD, the present study describes a qualitative investigation of the perspectives of individuals participating in an evaluation of a novel self-management app.

METHODS

Twenty-five individuals with BD were given access to PolarUs, an app-based self-management intervention, and were later questioned about perceptions of and engagement with this tool. Thematic analysis was used to identify important aspects of the experience of self-monitoring as part of an app-based intervention.

RESULTS

Four themes describing experiences of self-monitoring were generated. These included increased self-awareness, the use of self-monitoring to guide self-management, positive and negative emotional responses to self-monitoring, and unmet needs for self-monitoring apps. Three subthemes describing unmet needs were identified, including the provision of proactive coping suggestions, support reviewing data, and tracking additional symptoms, behaviours and life areas.

CONCLUSIONS

The present study highlights the importance of taking the subjective experience of users into account during the development, evaluation, and implementation of app-based monitoring interventions in BD. Implications for the use of passively collected data and personalisation of app delivery are discussed.

Systemic Inflammation and Anhedonic Responses to an Inflammatory Challenge in Adults With Major Depressive Disorder: A Randomized Controlled Trial

OBJECTIVE

The authors sought to determine whether an inflammatory challenge with lipopolysaccharide (LPS) differentially impacts symptoms of anhedonia in participants with major depressive disorder with high (≥3 mg/L) and low (≤1.5 mg/L) serum C-reactive protein (CRP) concentrations.

METHODS

Sixty-eight participants with major depressive disorder were randomly assigned, in a 1:1 ratio, to receive LPS (0.8 ng/kg body weight) or placebo (saline) in a parallel-group double-blind design. Participants were stratified according to baseline CRP concentrations, yielding four groups: high-CRP LPS (N=13), low-CRP LPS (N=19), high-CRP placebo (N=13), and low-CRP placebo (N=19). Blood was sampled at baseline, at 1, 1.5, 3.5, 6, and 24 hours, and 1 week after LPS or saline administration, with concurrent assessment of psychological outcomes. The primary outcome measure was the Snaith-Hamilton Pleasure Scale (SHAPS), and the primary contrast of interest was the change between baseline and 1.5 hours (peak of the inflammatory response) in the high-CRP versus low-CRP groups receiving LPS. Secondary outcomes included the Montgomery-Åsberg Depression Rating Scale (MADRS) and serum levels of three cytokines: interleukin-6 (IL-6), IL-10, and tumor necrosis factor (TNF). Data were analyzed with linear mixed models.

RESULTS

Significantly greater increases in self-reported anhedonia (on the SHAPS) and IL-6 levels were observed between baseline and 1.5 hours in the high-CRP versus low-CRP LPS groups. There were no significant differences for TNF and IL-10. The MADRS was not administered at 1.5 hours; secondary analyses showed a significant group-by-condition-by-time interaction driven by a greater decrease in MADRS scores between baseline and 24 hours in the high-CRP group.

CONCLUSIONS

Depressed individuals with systemic inflammation appeared to be biologically primed to respond more strongly to inflammatory stimuli, and psychologically, this sensitization impacted the symptom of anhedonia, the primary outcome.

Physical activity in amyotrophic lateral sclerosis: a systematic review of the methodologies used to assess a possible association

Growing evidence suggests that strenuous physical activity (PA) may be associated with an increased risk of developing Amyotrophic Lateral Sclerosis (ALS), a fatal neurodegenerative disease. However, there are inconsistent findings across studies that may reduce our understanding of any potential associations. We propose that these differences may reflect the tools used to record historical PA. We conducted a systematic review evaluating the risk of developing ALS due to PA. The inclusion criteria were met by 22/113 studies, and an association between increasing PA and ALS was found in 15 studies. Studies that found a positive association were more likely to have longer recall periods and convert data into Metabolic Equivalent of Task values. Studies that did not find an association with increasing PA were more likely to use questionnaires with no validity or reliability data. Questionnaires with validity data all showed at least a moderate correlation of PA compared to objective measures, with reliability ranging from poor to good. Study designs included prospective cohort and case-control, which may also contribute to heterogeneity in findings. This work highlights the need for consensus on the type of questionnaire to use to assess potential associations between PA and ALS.

Potential causal association between the oral microbiome and bipolar disorder

BACKGROUND

The oral microbiome can influence the growth, development, and regulation of the nervous system through various pathways; however, its relationship with bipolar disorder (BD) remains ambiguous. This study aims to investigate the causal relationship between the oral microbiome and BD through Mendelian randomization (MR) analysis.

METHODS

Data regarding single nucleotide polymorphisms (SNPs) in GWAS summary statistics for oral microbiota and BD were obtained from two studies: one reported the association between the oral microbiome and the human genome, encompassing both the dorsum of the tongue and saliva microbiomes. The other study investigated the association between BD and the human genome, categorizing BD into BD I and BD II for separate analyses. Thus, three data components were utilized: BD, BD I, and BD II. In this study, GWAS data for saliva and dorsum of the tongue microbiomes were analyzed separately for BD, BD I, and BD II. The inverse variance weighted (IVW) method was used to assess the causal relationship between the oral microbiome and BD. Analyses were conducted only when the number of instrumental variable SNPs was no less than two. The MR-Egger regression and IVW methods were employed to evaluate heterogeneity, whereas the MR-Egger intercept test was utilized to assess pleiotropy. For MR results exhibiting heterogeneity or pleiotropy, sensitivity analyses were performed using the weighted median, simple mode, weighted mode, MR-Egger test, and leave-one-out methods. Furthermore, funnel plots were employed to evaluate publication bias. Reverse MR analysis was also performed to investigate the potential bidirectional interactions between BD and the oral microbiota.

RESULTS

A causal relationship exists between the oral microbiome and BD. The effects of the microbiome from different regions of the oral cavity on BD are variable, with a more pronounced impact noted on BD I. This study identified two overlapping causal relationships shared between BD I and BD II, both exhibiting the same directional influence: ①Salivary s Prevotella aurantiaca SGB 2854 (Taxonomy ID: 596085, species); ② Tongue s Prevotella sp000467895 SGB 1817 (Taxonomy ID: 838, genus). Additionally, there are two overlapping bacteria with opposing directional effects: ① Salivary g Eggerthia (Taxonomy ID: 1279384, genus); ② Salivary s unclassified SGB 2636. Three differential bacteria that exclusively regulate one subtype were identified: ① Salivary s Lachnoanaerobaculum sp000296385 SGB 3537 (Taxonomy ID: 1164882, genus); ② Tongue s unclassified SGB 689; ③ Tongue s unclassified SGB 572. Among these, the genus g Eggerthia in saliva inhibits BD I while promoting BD II; conversely, salivary s unclassified SGB 2636 inhibits BD II while promoting BD I. The analysis of tongue s unclassified SGB 489 and s unclassified SGB 1215 demonstrated pleiotropy without causal significance. The reverse MR analysis identified that BD I may influence four microbial species, including f Leptotrichiaceae (Taxonomy ID: 1129771, family), f Streptococcaceae (Taxonomy ID: 1300, family), s unclassified SGB 1210, and s unclassified SGB 1950. There may be a bidirectional causal relationship between s unclassified SGB 1950 and BD I. Additionally, Reverse Mendel suggested that there was no significant causal relationship between BD and salivary and dorsal tongue microbes.

CONCLUSION

Our Mendelian randomization results indicate a causal relationship between the oral microbiome and the development of BD. However, the microbial profiles associated with the different subtypes, BD I and BD II, differ significantly; even within the same genus, the direction of influence on BD I and BD II varies, suggesting that the underlying mechanisms for the development of BD I and BD II may differ substantially.

Novel and Emerging Treatments for Agitation in Schizophrenia and Bipolar Disorder

Background: Agitation is a frequent and challenging symptom in schizophrenia and bipolar disorder, characterized by heightened motor activity, emotional distress, and potential aggression. This symptom is most observed during acute episodes, representing a significant burden on patients, caregivers, and healthcare systems. Agitation is a leading cause of emergency department visits and psychiatric hospitalizations, necessitating prompt and effective interventions to ensure safety and mitigate its far-reaching impact. Traditional treatments, including high-potency antipsychotics and benzodiazepines, remain first-line options but are associated with significant drawbacks such as sedation, extrapyramidal symptoms, tolerance, and limited applicability in certain patient populations, especially those with respiratory or cardiac depression and the elderly. Non-pharmacologic strategies like de-escalation techniques and environmental modifications are invaluable but may be impractical in acute care settings, as speed and efficiency are critical in emergent settings. These limitations, including the onset of extrapyramidal symptoms with high-dose antipsychotics and the development of tolerance with benzodiazepines, highlight gaps in care, including the need for faster-acting, safer, and more patient-friendly alternatives that reduce reliance on physical restraints and invasive interventions. Methods: This review explores the evolution of treatments for agitation, focusing on alternative and innovative approaches. To highlight these treatments, an extensive review of the literature was conducted utilizing PubMed, Google Scholar, Embase.com, and other search engines. Results: Key developments include sublingual dexmedetomidine, recently FDA-approved, which offers sedation without respiratory depression and a non-invasive administration route. Similarly, subcutaneous olanzapine provides a more convenient alternative to intramuscular injections, reducing injection-related complications. Other emerging treatments such as gabapentin, pregabalin, and ketamine show promise in addressing agitation in specific contexts, including comorbid conditions and treatment-resistant cases. A comparative analysis of these therapies highlights their mechanisms of action, clinical evidence, and practical challenges. Conclusions: Future directions emphasize intranasal delivery systems, novel pharmacologic agents, and potential roles for cannabinoids in managing agitation. These innovations aim to balance rapid symptom control with improved patient safety and experience. The set back with these emerging techniques is a lack of standardized dosing and protocols. They also face ethical concerns, including the chance of misuse or abuse, as well as regulatory barriers, as they lack FDA approval and their legality changes between states. This review underscores the clinical, practical, and ethical considerations in advancing care for agitated patients, paving the way for more effective and compassionate management strategies in psychiatric settings.

Refining Criteria for a Neurodevelopmental Subphenotype of Bipolar Disorders: A FondaMental Advanced Centers of Expertise for Bipolar Disorders Study

BACKGROUND

Bipolar disorder (BD) is a complex and heterogeneous psychiatric disorder. It has been suggested that neurodevelopmental factors contribute to the etiology of BD, but a specific neurodevelopmental phenotype (NDP) of the disorder has not been identified. Our objective was to define and characterize an NDP in BD and validate its associations with clinical outcomes, polygenic risk scores, and treatment responses.

METHODS

We analyzed the FondaMental Advanced Centers of Expertise for Bipolar Disorders cohort of 4468 patients with BD, a validation cohort of 101 patients with BD, and 2 independent replication datasets of 274 and 89 patients with BD. Using factor analyses, we identified a set of criteria for defining NDP. Next, we developed a scoring system for NDP load and assessed its association with prognosis, neurological soft signs, polygenic risk scores for neurodevelopmental disorders, and responses to treatment using multiple regressions, adjusted for age and gender with bootstrap replications.

RESULTS

Our study established an NDP in BD consisting of 9 clinical features: advanced paternal age, advanced maternal age, childhood maltreatment, attention-deficit/hyperactivity disorder, early onset of BD, early onset of substance use disorders, early onset of anxiety disorders, early onset of eating disorders, and specific learning disorders. Patients with higher NDP load showed a worse prognosis and increased neurological soft signs. Notably, these individuals exhibited a poorer response to lithium treatment. Furthermore, a significant positive correlation was observed between NDP load and polygenic risk score for attention-deficit/hyperactivity disorder, suggesting potential overlapping genetic factors or pathophysiological mechanisms between BD and attention-deficit/hyperactivity disorder.

CONCLUSIONS

The proposed NDP constitutes a promising clinical tool for patient stratification in BD.

Bipolar disorder at mixed states and major depressive disorder with mixed features differ in peripheral biochemical parameters

BACKGROUND

Little is known about the peripheral biochemicals between bipolar disorder at mixed episodes (BDM) and major depressive disorder with mixed features (MDM). This retrospective study was aimed to compare the peripheral biochemical parameters between patients with BDM and MDM.

METHODS

This study included data from 269 BDM patients and 86 MDM patients. Biochemical markers covering immune-inflammatory, liver function, metabolic, and thyroid hormone indices were analyzed. Logistic regression models were employed to evaluate associations between biochemical markers and diagnosis. Network analysis and Principal Component Analysis (PCA) was also performed to investigate the relationships among these parameters.

RESULTS

BDM patients had higher neutrophil percentage (NEUT%), white blood cell count (WBC), free triiodothyronine (FT3) and free thyroxine (FT4), while MDM patients exhibited higher levels of C-reactive protein (CRP), direct bilirubin (DBIL) and prealbumin (PA). NEUT%, WBC, FT3 and FT4 showed positive association with the diagnosis of BDM, while PA and DBIL displayed negative correlation with BDM. No significant differences in either network structure or global strength were found between BDM and MDM groups.

CONCLUSION

Peripheral biochemical markers, particularly those related to the immune-inflammatory factors and thyroid hormones, differ between BDM and MDM, which could contribute to better understanding of potential status mechanism under the disorders.

TRIAL REGISTRATION

International Clinical Trials Registry Platform: NCT03949218. Registered on 13/05/2019.

Recommendations for defining treatment outcomes in major psychiatric disorders using real-world data

Although information from real-world data can be used to identify factors that aid treatment choice, there are no guidelines for the use of such data. The aim of this Review is to summarise and evaluate definitions of treatment outcomes for antidepressants, antipsychotics, and mood stabilisers when using real-world data, and to suggest standards for the field. Given that no standards for the use of these data in estimating treatment outcomes exist, variability is high for treatment outcome definitions. We make recommendations for different scenarios of available data and highlight the importance of using other sources of information to validate proxy measures such as continued treatment, switching between medications, or polypharmacy of psychotropic medications. Well defined and validated treatment outcome measures that incorporate real-world data could facilitate the development of precision psychiatry approaches and support regulatory decision making regarding psychopharmacological agents.

The MinDag app for symptom monitoring and feedback to patients and clinicians during the initial treatment of bipolar disorder - a feasibility study

BACKGROUND

The app "MinDag" (MyDay) was developed as a tool for monitoring mood, symptoms and illness-relevant behaviour in the initial treatment of bipolar disorder. Digital self-monitoring may provide patients and clinicians with valuable data for tailoring treatment interventions. This study aims to evaluate the practical use and clinical implications of integrating MinDag in the early treatment of bipolar disorder from the perspectives of both patients and clinicians.

METHODS

The MinDag app includes six content modules covering mood, sleep, functioning/activities, substance use, emotional reactivity, and psychotic symptoms. Patients were asked to use the app for six months, and automated feedback based on the app registrations was delivered to the patients' clinicians biweekly. The study involved quantitative evaluations completed by patients (n = 20), as well as interviews with patients (n = 7) and clinicians (n = 2).

RESULTS

Overall, the patients reported that they felt that MinDag was safe, relevant and easy to use, although technical difficulties such as too many automated reminders and need for reinstallations were reported. The patients appreciated the potential for increased awareness of their mental health, but expressed a desire for direct access to their data. Clinicians found the visual reports and feedback useful for tailoring treatment, even though the alert system for high-risk variables needed refinement. The quantitative evaluations indicated a positive general reception, with suggestions for improvement in usability and accessibility.

CONCLUSION

The MinDag app shows promise as a tool for enhancing the treatment of bipolar disorder by facilitating self-monitoring and providing actionable data to clinicians. However, technical issues and the need for direct patient access to data must be addressed. Development of digital tools to support the treatment of bipolar disorder and other mental health conditions is resource demanding, and there is a need to clarify criteria to establish proof of concept to guide the selection of tools for upscaling and implementation.

Discovery of non-steroidal aldo-keto reductase 1D1 inhibitors through automated screening and in vitro evaluation

Steroid hormones regulate a wide range of physiological processes in the human body. However, exposure to xenobiotics can disrupt the hormonal balance by inhibition of enzymes involved in hormone synthesis or metabolism. Aldo-keto reductase 1D1 (AKR1D1) plays a key role in bile acid and steroid hormone metabolism by catalyzing the reduction of the double bond between C4 and C5 atoms of Δ(4)-steroids. In our previous work, we developed a model to screen for steroid-like xenobiotics that inhibit AKR1D1. In the current study, we used this model to screen for novel non-steroidal inhibitors. By applying an automatized screening approach, based on molecular docking and scoring in combination with post-docking refinement, 45 compounds were detected as potential hits and selected for in vitro evaluation. Among them, zardaverine was identified as the most potent inhibitor, with an IC50 value of 2.32 ± 1.27 μM. Other moderate inhibitors included carbamazepine, larotrectinib, endosulfan II, megastigmatrienone A, and mizolastine. The structural diversity of the identified inhibitors demonstrates that the binding site of AKR1D1 is rather promiscuous and can accommodate a broad range of ligands. These findings underscore the importance of toxicity screening and potential to identify structurally different AKR1D1 inhibitors.

Biomarker identification in bipolar disorder

Bipolar disorder (BD) is a severe psychiatric condition whose pathophysiology is complex and multifactorial. Genetic, environmental and social risk factors play a role in its development as well as in its progressive course. Research is currently focusing on the identification of the biological basis underlying these processes in order to suggest novel biomarkers capable to predict BD etiopathogenesis and staging. Staging has been recognized as of great value for the treatment and management of many illnesses and might also be suitable for mental health issues, particularly in disorders like BD, which progress from an initial mild phase to a more severe and thus difficult-to-treat situation. Thus, it would be of great help the characterization of to suggest better treatment requirements and improve prognosis across the different stages of the illness. Here, we summarize current research on the biological hypotheses of BD and the biomarkers associated with its progression, reviewing clinical studies available in the literature.

Impact of postmenopause on bipolar depression: Insights from a prospective study

BACKGROUND

Existing research on menopause and Bipolar Disorder indicates a general exacerbation in depressive symptoms but lacks clear distinctions between menopausal stages, despite their specific hormonal and symptomatic profiles. This study assesses how postmenopause versus the reproductive phase impacts the progression and antidepressant responsiveness of bipolar depression in women with Bipolar I Disorder.

METHODS

This prospective cohort study included 364 women with moderate to severe depressive episodes. Participants were classified into postmenopausal and reproductive groups based on the Stages of Reproductive Aging Workshop + 10 criteria. Over four weeks, all participants received a personalized treatment, with depressive symptoms assessed weekly.

RESULTS

Similar depression severity was observed between groups at the outset of the study. However, women in postmenopause experienced worse treatment responses and lower remission rates, despite the application of more complex treatment strategies. Notably, the impact of postmenopause on treatment outcomes, despite a small effect size, proved independent of age and comorbidities.

CONCLUSIONS

This exploratory research is the first to specifically assess the impact of postmenopause on bipolar depression, revealing its independent and negative influence on treatment outcomes. The small outcomes differences observed between groups, achieved through the use of more complex treatment strategies, suggest that developing tailored therapeutic protocols could significantly improve the clinical management of these patients.

Co-Occurring Bipolar and Substance Use Disorders: A Review of Impacts, Biopsychosocial Mechanisms, Assessment, and Treatment

Individuals with bipolar disorder are at significant risk for having a co-occurring substance use disorder-particularly, alcohol and cannabis use disorders. Having a co-occurring substance use disorder is associated with a more pernicious clinical course, lower quality of life, and poorer treatment outcomes. Despite its increased morbidity, there is little research and clinical evidence-based guidelines on the treatment of individuals with co-occurring bipolar and substance use disorders. This review details current knowledge on the prevalence, clinical correlates, and biopsychosocial mechanisms underlying co-occurring bipolar and substance use disorders. The authors present recent research that highlights underlying mechanisms of comorbidity, including aberrant reward processing, stress sensitization, early childhood maltreatment, and gene-environment interactions. Next, the authors review current evidence-based recommendations for the assessment and treatment of co-occurring bipolar and substance use disorder, highlighting areas of needed future clinical research.

Neurodegenerative and neuroinflammatory changes in SOD1-ALS patients receiving tofersen

The initiation of tofersen, a new specific antisense oligonucleotide (ASO) for SOD1 pathology, marked a significant turning point for SOD1-ALS patients. While clinical trials and early access program studies reported a significant reduction in plasma and cerebrospinal fluid (CSF) neurofilament levels, neuroinflammation following prolonged treatment was never assessed. In this multicenter study, we evaluated a cohort of 18 SOD1-ALS patients treated with tofersen, analyzing correlations between biomarkers of neurodegeneration/neuroinflammation and clinical variables indicative of disease progression. NfL, NfH, CHI3L1, and Serpina1 levels in serum and CSF were determined by semi-automated immunoassays (Ella™ technology). Generalized linear mixed models were employed to investigate longitudinal trends of these biomarkers. Our data highlighted a progressive decrease in CSF neurofilament levels during tofersen treatment (MR = 0.97, 95% CI 0.94-0.99, p = 0.006 and MR = 0.98, 95% CI 0.95-1.00, p = 0.076 for NfL and NfH in CSF, respectively). Conversely, CSF levels of SerpinA1 and CHI3L1 increased over time (MR = 1.12, 95% CI 1.08-1.16, p < 0.0001 and MR = 1.039, 95% CI 1.015-1.062, p = 0.001 for SerpinA1 and CHI3L1 in CSF, respectively), but these modifications were most apparent after six and twelve months of therapy, respectively. Disease progression rate did not correlate with these biomarker trends. We observed a significant decrease in neurofilament levels during Tofersen treatment, alongside an increase in neuroinflammatory markers, potentially linked to an immune response triggered by ASO treatment. Given the limited data on tofersen's long-term efficacy in ALS due to its recent introduction, identifying biomarkers that predict clinical outcomes such as diminished therapeutic response or adverse effects is crucial. These biomarkers may help to better understand the underlying pathomechanisms of ALS and tofersen's role in modulating disease progression.

Prescription sequences in bipolar disorder - A nationwide Danish register-based study of 19,927 individuals followed for 10 years

Evidence-based use of pharmacological interventions in bipolar disorder is of paramount clinical importance. We aimed to uncover precription sequences in a large cohort of patients from the first diagnosis of bipolar disorder. Using Danish nationwide registers, we identified individuals with a first-time hospital diagnosis of bipolar disorder between January 1st, 2001, and December 31st, 2016. Redemeed prescriptions of litihum, anticonvulsants, antipsychotics, and antidepressants from five years before to five years after diagnosis were retreived. The data were analysed with descriptive statistics, sunburst plots, and Cox proportioal hazard models. The full study population consisted of 19,927 individuals. Before diagnosis, antidepressants were the predominantly prescribed group (46.9 % as first drug). After diagnosis, a major trend towards mood stabilising strategies was observed. although only 18.7 % received lithiumas first prescription. In analyses stratified for illness phase, lithium was more frequently prescribed as first drug after depression than after hypomania/mania, in which antidepressants were used as first drug in 10-15 % of the cases. Treatment sequences were highly heterogeneous (2,459 distinct sequences for the 19,927 individuals under investigation). Lithium appeared to carry the overall highest risk of treatment shift. We conclude that in accordance with national and international guidelines, a diagnosis of bipolar disorder leads to a relevant change of treatment strategy towards mood stabilising drugs. However, lithium continues to be underused;antidepressants probably used too frequently, and treatment sequences are highly heterogeneous and not adjusted according to illness phase. These results point to a potential for optimising the real-world pharmacological management of bipolar disorder.

Neurocognitive and psychosocial functioning profiles in bipolar disorder and comorbid attention deficit hyperactivity disorder: A systematic review and meta-analysis

Bipolar disorder (BD) and attention deficit hyperactivity disorder (ADHD) are chronic psychiatric conditions with significant impacts on neurocognitive and psychosocial functioning. Co-occurrence of BD and ADHD (BD-ADHD) presents unique clinical challenges and could exacerbate cognitive and functional impairments. This systematic review and meta-analysis aimed to provide an updated synthesis of the differences in neurocognitive and psychosocial functioning between patients with BD-ADHD, BD, ADHD, and healthy controls (HC). A comprehensive systematic search identified 5639 records, with 34 studies meeting the inclusion criteria for a systematic review and 31 for the meta-analysis. There were no significant differences in cognitive performance across none of the evaluated cognitive domains between BD-ADHD and BD patients. BD-ADHD patients exhibited significantly lower visual memory (SMD=-0.29, 95 % CI=-0.53,-0.04; p = 0.022) compared to ADHD patients. Compared to HC, BD-ADHD patients showed poorer performance in processing speed (SMD=-0.54, 95 % CI= -0.86,-0.22; p < 0.001), sustained attention (SMD=-0.40, 95 % CI=-0.62, -0.19; p < 0.001), visual memory (SMD=-0.47, 95 % CI=-0.69,-0.26; p < 0.001), working memory (SMD=-0.79, 95 % CI=-1.13,-0.44; p < 0.001), cognitive flexibility and higher-order executive functions (SMD=-0.52, 95 % CI=-0.84,-0.20; p = 0.001), and verbal memory (SMD=-0.95, 95 % CI=-1.43,-0.47; p < 0.001). Psychosocial functioning was significantly worse in BD-ADHD patients compared to BD (SMD=-0.46; p < 0.001), ADHD (SMD=-1.00; p < 0.001), and HC (SMD=-3.54; p < 0.001). Our results suggest that the co-occurrence of BD and ADHD is associated with significant neurocognitive and psychosocial impairments. These findings underscore the need for targeted interventions to address the unique challenges of this comorbid condition, informing clinical practice and guiding future research.