[Predicting bipolar disorder: what can we learn from prospective cohort studies?]

Differential Expression of Proteins Associated with Bipolar Disorder as Identified Using the PeptideShaker Software

The prevalence of bipolar disorder (BD) in modern society is growing rapidly, but due to the lack of paraclinical criteria, its differential diagnosis with other mental disorders is somewhat challenging. In this regard, the relevance of proteomic studies is increasing due to the development of methods for processing large data arrays; this contributes to the discovery of protein patterns of pathological processes and the creation of new methods of diagnosis and treatment. It seems promising to search for proteins involved in the pathogenesis of BD in an easily accessible material-blood serum. Sera from BD patients and healthy individuals were purified via affinity chromatography to isolate 14 major proteins and separated using 1D SDS-PAGE. After trypsinolysis, the proteins in the samples were identified via HPLC/mass spectrometry. Mass spectrometric data were processed using the OMSSA and X!Tandem search algorithms using the UniProtKB database, and the results were analyzed using PeptideShaker. Differences in proteomes were assessed via an unlabeled NSAF-based analysis using a two-tailed Bonferroni-adjusted t-test. When comparing the blood serum proteomes of BD patients and healthy individuals, 10 proteins showed significant differences in NSAF values. Of these, four proteins were predominantly present in BD patients with the maximum NSAF value: 14-3-3 protein zeta/delta; ectonucleoside triphosphate diphosphohydrolase 7; transforming growth factor-beta-induced protein ig-h3; and B-cell CLL/lymphoma 9 protein. Further exploration of the role of these proteins in BD is warranted; conducting such studies will help develop new paraclinical criteria and discover new targets for BD drug therapy.

Systematic Review and Meta-Analysis on MS-Based Proteomics Applied to Human Peripheral Fluids to Assess Potential Biomarkers of Bipolar Disorder

Bipolar disorder (BD) is a clinically heterogeneous condition, presenting a complex underlying etiopathogenesis that is not sufficiently characterized. Without molecular biomarkers being used in the clinical environment, several large screen proteomics studies have been conducted to provide valuable molecular information. Mass spectrometry (MS)-based techniques can be a powerful tool for the identification of disease biomarkers, improving prediction and diagnosis ability. Here, we evaluate the efficacy of MS proteomics applied to human peripheral fluids to assess BD biomarkers and identify relevant networks of biological pathways. Following PRISMA guidelines, we searched for studies using MS proteomics to identify proteomic differences between BD patients and healthy controls (PROSPERO database: CRD42021264955). Fourteen articles fulfilled the inclusion criteria, allowing the identification of 266 differentially expressed proteins. Gene ontology analysis identified complement and coagulation cascades, lipid and cholesterol metabolism, and focal adhesion as the main enriched biological pathways. A meta-analysis was performed for apolipoproteins (A-I, C-III, and E); however, no significant differences were found. Although the proven ability of MS proteomics to characterize BD, there are several confounding factors contributing to the heterogeneity of the findings. In the future, we encourage the scientific community to use broader samples and validation cohorts, integrating omics with bioinformatics tools towards providing a comprehensive understanding of proteome alterations, seeking biomarkers of BD, and contributing to individualized prognosis and stratification strategies, besides aiding in the differential diagnosis.

The mood disorder spectrum vs. schizophrenia decision tree: EDIPHAS research into the childhood and adolescence of 205 patients

BACKGROUND

The early detection of patients at risk of developing schizophrenia and bipolar disorder, and more broadly mood spectrum disorder, is a public health concern. The phenotypical overlap between the prodromes in these disorders calls for a simultaneous investigation into both illness trajectories.

METHOD

This is an epidemiological, retrospective, multicentre, descriptive study conducted in the Grand-Est region of France in order to describe and compare early symptoms in 205 patients: 123 of which were diagnosed with schizophrenia and 82 with bipolar disorder or mood spectrum disorder. Data corresponding to the pre-morbid and prodromal phases, including a timeline of their onset, were studied in child and adolescent psychiatric records via a data grid based on the literature review conducted from birth to 17 years of age.

RESULTS

Two distinct trajectories were highlighted. Patients with schizophrenia tended to present more difficulties at each developmental stage, with the emergence of negative and positive behavioural symptoms during adolescence. Patients with mood spectrum disorder, however, were more likely to exhibit anxiety and then mood-related symptoms. Overall, our results corroborate current literature findings and are consistent with the neurodevelopmental process. We succeeded in extracting a decision tree with good predictability based on variables relating to one diagnosis: 77.6% of patients received a well-indexed diagnosis. An atypical profile was observed in future mood spectrum disorder patients as some exhibited numerous positive symptoms alongside more conventional mood-related symptoms.

CONCLUSION

The combination of all these data could help promote the early identification of high-risk patients thereby facilitating early prevention and appropriate intervention in order to improve outcomes.

Prodromal symptoms of Chinese patients with bipolar disorder

OBJECTIVE

This study aimed to assess the clinical phenomenology and characteristics of prodromal symptoms in Chinese patients with bipolar disorder (BPD) prior to their index mood episode.

METHODS

Semi-structured interviews [Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R)] were administered to patients within 3 years of BPD (I and II) onset.

RESULTS

120 stable inpatients and outpatients were included (65% males, mean age: 26.5±10.0 years). Feeling extremely energetic (61.8%), overly cheerful (49.1%), racing thoughts (48.2%), overly talkative (47.3%), and decreased need for sleep (43.6%) most frequently preceded the first (hypo)manic episode, whereas depressed mood (78.5%), tiredness (53.9%), reduction of enjoyment (52.3%), trouble concentrating (49.2%) and insomnia (47.7%) often occurred prior to the index depressive episode. The prevalence of anxiety or nervousness (p = 0.009), social isolation (p = 0.004), and losing temper (p < 0.001) differed significantly depending on the different episodes. Prior to any depressive episode, insomnia (p = 0.035) lasted significantly longer and sleeping too much (p = 0.033) was more severe, whereas oppositionality (p < 0.001), hallucinations (p = 0.024) and psychosis index score (p = 0.044) were more severe before any (hypo) manic episode. Furthermore, depressed mood (p = 0.006) was more frequent prior to depression, while anxiety or nervousness (p = 0.018), oppositionality (p = 0.001), and psychosis index score (p = 0.009) were more frequent before any (hypo) manic episode.

CONCLUSIONS

Characteristic affective and psychotic symptoms, including depressed mood and subthreshold hypo (manic) symptoms occurred in the prodromal phase. The pre-depression prodromal symptoms lasted longer than the pre-(hypo) mania prodromal symptoms. Our findings indicated that identifying prodromal symptoms of BPD may be beneficial for early diagnosis and intervention before the development of full episodes.

[Early intervention in bipolar affective disorders: Why, when and how]

OBJECTIVES

Bipolar disorder (BD) is a chronic and severe psychiatric disease. There are often significant delays prior to diagnosis, and only 30 to 40 % of patients will experience complete remission. Since BD occurs most often at a young age, the disorder can seriously obstruct future socio-professional development and integration. Vulnerability-stress model of BD is considered to be the result of an interaction between vulnerability genes and environmental risk factors, which leads to the onset of the disorder most often in late adolescence or early adulthood. The clinical "staging" model of BD situates the subject in a clinical continuum of varying degrees of severity (at-risk status, first episode, full-blown BD). Given the demonstrated effectiveness of early intervention in the early stages of psychotic disorder, we posit that early intervention for early stages of BD (i.e. at-risk status and first episode mania or hypomania) would reduce the duration of untreated illness and optimize the chances of therapeutic response and recovery.

METHODS

We conducted a narrative review of the literature to gather updated data on: (1) features of early stages: risk factors, at-risk symptoms, clinical specificities of the first manic episode; (2) early screening: targeted populations and psychometric tools; (3) early treatment: settings and therapeutic approaches for the early stages of BD.

RESULTS

(1) Features of early stages: among genetic risk factors, we highlighted the diagnosis of BD in relatives and affective temperament including as cyclothymic, depressive, anxious and dysphoric. Regarding prenatal environmental risk, we identified peripartum factors such as maternal stress, smoking and viral infections, prematurity and cesarean delivery. Later in the neurodevelopmental course, stressful events and child psychiatric disorders are recognized as increasing the risk of developing BD in adolescence. At-risk symptoms could be classified as "distal" with early but aspecific expressions including anxiety, depression, sleep disturbance, decreased cognitive performance, and more specific "proximal" symptoms which correspond to subsyndromic hypomanic symptoms that increase in intensity as the first episode of BD approaches. Specific clinical expressions have been described to assess the risk of BD in individuals with depression. Irritability, mixed and psychotic features are often observed in the first manic episode. (2) Early screening: some individuals with higher risk need special attention for screening, such as children of people with BD. Indeed, it is shown that children with at least one parent with BD have around 50 % risk of developing BD during adolescence or early adulthood. Groups of individuals presenting other risk factors, experiencing an early stage of psychosis or depressive disorders should also be considered as targeted populations for BD screening. Three questionnaires have been validated to screen for the presence of at-risk symptoms of BD: the Hypomanic Personality Scale, the Child Behavior Checklist-Paediatric Bipolar Disorder, and the General Behavior Inventory. In parallel, ultra-high risk criteria for bipolar affective disorder ("bipolar at-risk") distinguishing three categories of at-risk states for BD have been developed. (3) Early treatment: clinical overlap between first psychotic and manic episode and the various trajectories of the at-risk status have led early intervention services (EIS) for psychosis to reach out for people with an early stage of BD. EIS offers complete biopsychosocial evaluations involving a psychiatric examination, semi-structured interviews, neuropsychological assessments and complementary biological and neuroimaging investigations. Key components of EIS are a youth-friendly approach, specialized and intensive care and client-centered case management model. Pharmaceutical treatments for at-risk individuals are essentially symptomatic, while guidelines recommend the use of a non-antipsychotic mood stabilizer as first-line monotherapy for the first manic or hypomanic episode. Non-pharmacological approaches including psychoeducation, psychotherapy and rehabilitation have proven efficacy and should be considered for both at-risk and first episode of BD.

CONCLUSIONS

EIS for psychosis might consider developing and implementing screening and treatment approaches for individuals experiencing an early stage of BD. Several opportunities for progress on early intervention in the early stages of BD can be drawn. Training first-line practitioners to identify at-risk subjects would be relevant to optimize screening of this population. Biomarkers including functional and structural imaging measures of specific cortical regions and inflammation proteins including IL-6 rates constitute promising leads for predicting the risk of transition to full-blown BD. From a therapeutic perspective, the use of neuroprotective agents such as folic acid has shown particularly encouraging results in delaying the emergence of BD. Large-scale studies and long-term follow-up are still needed to achieve consensus in the use of screening and treatment tools. The development of specific recommendations for the early stages of BD is warranted.

Differences in Demographic and Clinical Characteristics of Patients With Depressive vs. Manic First Episode of Bipolar Disorder

Background: Bipolar disorder is a serious mental disease marked by episodes of depression, mania, hypomania, or mixed states. Patients with bipolar disorder may present with different symptoms at first onset. The aim of this study is to compare demographic and clinical variables based on a patient's first episode of bipolar disorder, including risk of recurrence over a 2-year period. Methods: A large cohort (N = 742) of patients with bipolar disorder in China was analyzed. Patients were divided into two groups according to their first episode of bipolar disorder, either depression or mania. Patients in mixed state first episode were classified based on predominant symptoms. Three hundred eighteen patients of the cohort had a first episode of mania and 424 patients had initial symptoms of depression. Demographic and clinical data were collected. All patients were followed up for 24 months. Data on compliance with follow-up appointments and recurrence of symptoms after 6, 12, 18, and 24 months were collected. Clinical characteristics (course of disease, age of onset, psychiatric family history, etc.) were compared between the mania group and depression groups. Results: More patients with bipolar disorder had a first episode of depression than mania (57.14 vs. 42.86%). Compared with the depression group, the mania group had later age of diagnosis of bipolar disorder [(38.64 ± 13.50) vs. (36.34 ± 14.94), P = 0.028], lower education level [(9.37 ± 4.34) vs. (10.17 ± 4.81), P = 0.017] and longer latency between an initial episode of psychiatric symptoms and formal bipolar diagnosis [(10.80 ± 10.76) vs. (8.85 ± 9.90), P = 0.012]. More patients in the mania group were male and without psychotic symptoms (all P < 0.05). In comparison with the mania group, more patients in the depression group were female, with higher frequency of a reported precipitating event before first mood episode (all P < 0.05). Compared with the depression group, the mania group had more recurrences of illness at the end of 12 months (Z =-2.156, P = 0.031), 18 months (Z =-2.192, P = 0.028), and 24 months (Z = -2.364, P = 0.018). Conclusions: In our study, there are a number of differences in demographic and clinical characteristics of patients with different onset syndromes of bipolar disorder. These differences include gender, education level, diagnosis age, the rate of recurrences, and others. These data of a cohort of Chinese patients add to the growing international literature on the relationship between index episode of bipolar disorder and clinical variables and outcomes. These results and further study may allow clinicians to offer patients and families more reliable prognostic information at the onset of disease.

Are school difficulties an early sign for mental disorder diagnosis and suicide prevention? A comparative study of individuals who died by suicide and control group

BACKGROUND

Suicide is the third leading cause of death worldwide among youth aged 10- to 19, and mental disorders are often associated in the etiology of suicidal behavior. Mental disorders are often under-diagnosed and under-treated in young people, a situation likely to increase the severity of the disorder and suicide risk. Presence of school difficulties may, in some cases, be a consequence of mental disorder, and theses difficulties are observable. Therefore, early detection and early intervention of school difficulties may alleviate the development of mental disorders and suicide vulnerability. The aim of this study is to understand the link between school difficulties and suicide risk.

METHODS

We used the data bank gathered by the McGill Group on Suicide Studies over the past two decades through interviews with the relatives of individuals who died by suicide and with individuals from the community as a control group. We included data on common sociodemographic characteristics, life events and mental health characteristics identified before age 18, among individuals who died before the age of 35 or were interviewed before the age of 35. We identified 200 individuals who died by suicide and 97 living controls. We compared groups according to gender and characteristics.

RESULTS

Within the total sample, 74% were male, 13% had met with academic failure, 18% had engaged in inappropriate behavior at school, and 18% presented combined school difficulties. Combined school difficulties (academic failure and inappropriate behavior) for both sexes and academic failure alone for males were associated with higher suicide risk before the age of 35. School difficulties generally began in early childhood and were linked to mental disorders/difficulties and substance abuse before age 18.

CONCLUSIONS

This study underlines the importance for parents, teachers, and educators to identify children with school difficulties-academic failure and behavioral difficulties at school-as early as possible in order to be able to propose adapted interventions. Early identification and proper diagnosis may prevent chronicity of some disorders, accumulation of adverse events, and even suicide.

Do some anxiety disorders belong to the prodrome of bipolar disorder? A clinical study combining retrospective and prospective methods to analyse the relationship between anxiety disorder and bipolar disorder from the perspective of biorhythms

BACKGROUND

In clinical practice, some patients diagnosed with anxiety disorder (AD) may develop bipolar disorder (BD) many years later, and some cases of AD may be cured by the use of mood stabilizers. However, the relationship between AD and BD should be explored further.

METHOD

To track how many cases of AD turned to BD and to discover the differences between them, we recruited 48 patients diagnosed with BD, who were assigned to the BD group for the retrospective analysis, and we also recruited 186 patients diagnosed with AD at enrolment; this latter group was asked to complete follow-up surveys conducted 3 months, 6 months, 12 months and 18 months after the primary stage of the study. We defined another two groups according to the usage of mood stabilizers, the rates of reduction in scores on the Hamilton Anxiety Scale and Yale-Brown Obsessive Compulsive Scale, and the changes in Clinical Global Impression scores at different follow-up times: the anxiety group and the atypical BD group (who used mood stabilizers to treat AD). All subjects also completed the NEO Five-Factor Inventory and supplied blood samples to be tested for several endocrine indices (TSH, T3, FT3, T4, FT4, ACTH,PTC) and inflammatory cytokines (IL-6, IL-8, IL-10, TNF-α, CRP) at enrolment.

RESULTS

In total, 14 subjects developed BD by the end of the study. One hundred eleven subjects were included in the anxiety group. Sixty-three subjects were assigned to the atypical BD group, and they had similar features to the 48 subjects in the BD group in terms of personality traits, abnormality rates of endocrine indices and levels of inflammatory cytokines. From the anxiety group to the atypical BD group and then the BD group, the age of first onset gradually decreased, while the frequency of onset and the score of suicidal ideation gradually increased. Furthermore, the atypical BD group showed markedly higher levels of TSH, IL-6, TNF-α and CRP than the other two groups.

CONCLUSIONS

Some ADs with unique features might belong to the prodromal stage or the atypical presentation of BD, and recognizing these ADs early will economize many medical resources.

Prodrome or risk syndrome: what's in a name?

Background

In the last decade, an increasing number of publications have examined the precursors of bipolar disorders (BD) and attempted to clarify the early origins and illness trajectory. This is a complex task as the evolution of BD often shows greater heterogeneity than psychosis, and the first onset episode of BD may be dominated by depressive or manic features or both. To date, most of the published reviews have not clarified whether they are focused on prodromes, risk syndromes or addressing both phenomena. To assist in the interpretation of the findings from previous reviews and independent studies, this paper examines two concepts deemed critical to understanding the pre-onset phase of any mental disorder: prodromes and risk syndromes. The utility of these concepts to studies of the evolution of bipolar disorder (BD) is explored.

Findings

The term “prodrome” is commonly used to describe the symptoms and signs that precede episode onset. If strictly defined, the term should only be applied retrospectively as it refers to cohorts of cases that all progress to meet diagnostic criteria for a specific disorder and gives insights into equifinality. Whilst prodromes may reliably predict individual relapses, the findings cannot necessarily be extrapolated to identify prospectively who will develop a first episode of a specific disorder from within a given population. In contrast, ‘risk syndrome’ is a term that encompasses sub-threshold symptom clusters, but has often been extended to include other putative risk factors such as family history, or other variables expressed continuously in the population, such as personality traits. Only a minority of individuals ‘at risk’ make the transition to a specific mental disorder. By prospectively observing those cases where the risk syndrome does not progress to severe disorder or progress to a non-BD condition, we gain insights into the discriminant validity of different pre-BD characteristics, pluripotentiality of outcomes, and protective factors and resilience.

Conclusion

We emphasize the clinical and research utility of prodromes and risk syndromes, examine examples of the conflation of the concepts, and highlight the rationale for regarding them as discrete entities.

Association between childhood dimensions of attention deficit hyperactivity disorder and adulthood clinical severity of bipolar disorders

BACKGROUND

Clinical features of attention deficit hyperactivity disorder can be frequently observed in cases with bipolar disorders and associated with greater severity of bipolar disorders. Although designed as a screening tool for attention deficit hyperactivity disorder, the Wender Utah Rating Scale could, given its factorial structure, be useful in investigating the early history of impulsive, inattentive or mood-related symptoms among patients with bipolar disorders.

METHODS

We rated the Wender Utah Rating Scale in 276 adult bipolar disorder cases and 228 healthy controls and tested its factorial structure and any associations with bipolar disorder phenomenology.

RESULTS

We confirmed a three-factor structure for the Wender Utah Rating Scale (' impulsivity/temper', ' inattentiveness' and ' mood/self-esteem'). Cases and controls differed significantly on Wender Utah Rating Scale total score and sub-scale scores ( p-values < 10^-5). About 23% of bipolar disorder cases versus 5% of controls were classified as ' WURS positive' (odds ratio = 5.21 [2.73-9.95]). In bipolar disorders, higher Wender Utah Rating Scale score was associated with earlier age at onset, severity of suicidal behaviors and polysubstance misuse; multivariate analyses, controlling for age and gender, confirmed the associations with age at onset ( p = 0.001) and alcohol and substance misuse ( p = 0.001).

CONCLUSION

Adults with bipolar disorders who reported higher levels of childhood symptoms on the Wender Utah Rating Scale presented a more severe expression of bipolar disorders in terms of age at onset and comorbidity. The Wender Utah Rating Scale could be employed to screen for attention deficit hyperactivity disorder but also for ' at-risk behaviors' in adult bipolar disorder cases and possibly for prodromal signs of early onset in high-risk subjects.

The role of rumination in illness trajectories in youth: linking trans-diagnostic processes with clinical staging models

Research in developmental psychopathology and clinical staging models has increasingly sought to identify trans-diagnostic biomarkers or neurocognitive deficits that may play a role in the onset and trajectory of mental disorders and could represent modifiable treatment targets. Less attention has been directed at the potential role of cognitive-emotional regulation processes such as ruminative response style. Maladaptive rumination (toxic brooding) is a known mediator of the association between gender and internalizing disorders in adolescents and is increased in individuals with a history of early adversity. Furthermore, rumination shows moderate levels of genetic heritability and is linked to abnormalities in neural networks associated with emotional regulation and executive functioning. This review explores the potential role of rumination in exacerbating the symptoms of alcohol and substance misuse, and bipolar and psychotic disorders during the peak age range for illness onset. Evidence shows that rumination not only amplifies levels of distress and suicidal ideation, but also extends physiological responses to stress, which may partly explain the high prevalence of physical and mental co-morbidity in youth presenting to mental health services. In summary, the normative developmental trajectory of rumination and its role in the evolution of mental disorders and physical illness demonstrates that rumination presents a detectable, modifiable trans-diagnostic risk factor in youth.