Characterizing decision-making and reward processing in bipolar disorder: A cluster analysis

Factors associated with cognitive impairment for people with mental health disorders: screening from general hospitals and an emergency care unit in Brazil

BACKGROUND

Emergency services and mental health units in general hospitals play a central role in the initial care and treatment of individuals with mental disorders. Early diagnosis and treatment of mental disorders and substance abuse can reduce cognitive deficits in this population. This study aims to investigate the factors associated with cognitive impairment for people with mental health disorders and addictions.

METHODS

This is a cross-sectional study performed in two general hospitals and an Emergency Care Unit (UPA) in cities in the metropolitan region of Porto Alegre, Rio Grande do Sul, Brazil. The interRAI Emergency Screener for Psychiatry (ESP) was used to describe the study population and to build an adjusted logistic model for the risk factors of cognitive impairment.

RESULTS

A total of 324 persons participated in the study (mean age: 41.8 ± 14.27, 50,2% female). The profile of people admitted to the different locations varied in several aspects according to the interRAI scales. The UPA received patients with acute conditions and higher scores on the Aggressive Behavior Scale, Mania Scale, the Scale of Harm to Others, and the Scale of Positive Symptoms. Patients at the university hospital had the highest rates of social withdrawal and a higher proportion of individuals with no insight into their mental health problems. The factors with the highest odds ratio were a diagnosis of schizophrenia (O.R.: 3.07; C.I. 1.13; 8.32), followed by self-care inability (O.R.: 2.87, 1.43; 5.77) and the aggressive behavior scale (2.85, 1.10; 7.44). A history of discharges, the Mania Scale and sleeping problems were also significantly associated with cognitive impairment. People being admitted to the UPA had lower odds of having cognitive impairment (O.R.: 0.18; 0.07; 0.45).

CONCLUSION

People diagnosed with schizophrenia were at very high risk of cognitive impairment. A prior history of discharges, inability to self-care, aggressive behavior, symptoms of mania and sleeping disturbances were also identified as risk factors. The interRAI EPS instrument showed to be useful to identify people with mental health disorders and substance abuse who were at risk of cognitive impairment. By early detecting these clients, professionals can refer them to adequate treatment, before symptoms increase.

Highest correlations between emotion regulation strategies and mood symptoms in bipolar disorder: A systematic review and Bayesian network meta-analysis

Bipolar disorder (BD) is associated with alterations in emotion regulation (ER) strategies, with both depressive and (hypo)manic symptoms correlated with utilization of maladaptive instead of adaptive strategies. However, which ER strategies are the most affected during the most severe mood symptoms remains unclear despite the potentially relevant treatment implications. To this end, we conducted a systematic review and Bayesian network meta-analysis (NMA) of studies documenting correlations between ER and depressive and (hypo)manic symptoms of BD, from inception until November 9th, 2023. We included 15 studies in the review, 14 of which provided data to conduct a Bayesian NMA. Rumination emerged as the ER strategy most strongly associated with both depressive (ES=0.43, 95 %CrI=0.27,0.59) and (hypo)manic symptoms (ES=0.26, 95 %CrI=0.05,0.46) of BD. Other ER strategies showed associations primarily with depressive symptoms. There was no significant heterogeneity or network inconsistency. These findings emphasize the importance of rumination in BD and suggest that altered ER strategies are more evident in depressive symptoms rather than (hypo)manic ones. While promising for targeted interventions, these results are based on cross-sectional data, limiting causal interpretation. Future longitudinal studies are necessary to clarify the temporal dynamics of the relationship between affective symptoms and ER in BD.

Frequency-specific changes in prefrontal activity associated with maladaptive belief updating in volatile environments in euthymic bipolar disorder

Bipolar disorder (BD) involves altered reward processing and decision-making, with inconsistencies across studies. Here, we integrated hierarchical Bayesian modelling with magnetoencephalography (MEG) to characterise maladaptive belief updating in this condition. First, we determined if previously reported increased learning rates in BD stem from a heightened expectation of environmental changes. Additionally, we examined if this increased expectation speeds up belief updating in decision-making, associated with modulation of rhythmic neural activity within the prefrontal, orbitofrontal, and anterior cingulate cortex (PFC, OFC, ACC). Twenty-two euthymic BD and 27 healthy control (HC) participants completed a reward-based motor decision-making task in a volatile setting. Hierarchical Bayesian modelling revealed BD participants anticipated greater environmental volatility, resulting in a more stochastic mapping from beliefs to actions and paralleled by lower win rates and a reduced tendency to repeat rewarded actions than HC. Despite this, BD individuals adjusted their expectations of action-outcome contingencies more slowly, but both groups invigorated their actions similarly. On a neural level, while healthy individuals exhibited an alpha-beta suppression and gamma increase during belief updating, BD participants showed dampened effects, extending across the PFC, OFC, and ACC regions. This was accompanied by an abnormally increased beta-band directed information flow in BD. Overall, the results suggest euthymic BD individuals anticipate environmental change without adequately learning from it, contributing to maladaptive belief updating. Alterations in frequency-domain amplitude and functional connectivity within the PFC, OFC, and ACC during belief updating underlie the computational effects and could serve as potential indicators for predicting relapse in future research.

Trajectory of reward-related abnormalities in unaffected relatives of patients with bipolar disorder - A longitudinal fMRI study

First-degree relatives of patients with bipolar disorder are at heightened risk of mood episodes, which may be attributed to the existence of endophenotypes i.e., heritable (neuro)biological changes present in patients and their unaffected relatives (UR). In this longitudinal MRI study, we aim to investigate the trajectories of aberrant reward-related functional changes identified in UR vs healthy controls (HC). Sixty-eight UR and 65 HC of similar age and gender distribution underwent MRI at baseline while performing a card guessing task. Of these, 29 UR and 36 HC were investigated with the same protocol following a 16-month period in average. We first identified brain regions showing group differences in the neural response to expected value (EV) and reward prediction error (PE) at baseline and analyzed how the reward-related response in these regions changed over time in UR vs HC. Relative to HC at baseline, UR showed lower EV signal in the right ventrolateral prefrontal cortex (vlPFC) and paracingulate gyrus and lower PE signal in the left vlPFC and dorsomedial PFC. The trajectories of these abnormalities in UR showed a normalization of the prefrontal EV signals, whereas the PE signals which correlated with depressive symptoms remained stable over time. While the UR showed both blunted EV and PE signals, none of these abnormalities increased over time, which is consistent with the observed stable mood symptoms.

Differences in facial emotion recognition between bipolar disorder and other clinical populations: A systematic review and meta-analysis

Facial emotion (or expression) recognition (FER) is a domain of affective cognition impaired across various psychiatric conditions, including bipolar disorder (BD). We conducted a systematic review and meta-analysis searching for eligible articles published from inception to April 26, 2023, in PubMed/MEDLINE, Scopus, EMBASE, and PsycINFO to examine whether and to what extent FER would differ between people with BD and those with other mental disorders. Thirty-three studies comparing 1506 BD patients with 1973 clinical controls were included in the present systematic review, and twenty-six of them were analyzed in random-effects meta-analyses exploring the discrepancies in discriminating or identifying emotional stimuli at a general and specific level. Individuals with BD were more accurate in identifying each type of emotion during a FER task compared to individuals diagnosed with schizophrenia (SCZ) (SMD = 0.27; p-value = 0.006), with specific differences in the perception of anger (SMD = 0.46; p-value = 1.19e-06), fear (SMD = 0.38; p-value = 8.2e-04), and sadness (SMD = 0.33; p-value = 0.026). In contrast, BD patients were less accurate than individuals with major depressive disorder (MDD) in identifying each type of emotion (SMD = -0.24; p-value = 0.014), but these differences were more specific for sad emotional stimuli (SMD = -0.31; p-value = 0.009). No significant differences were observed when BD was compared with children and adolescents diagnosed with attention-deficit/hyperactivity disorder. FER emerges as a potential integrative instrument for guiding diagnosis by enabling discrimination between BD and SCZ or MDD. Enhancing the standardization of adopted tasks could further enhance the accuracy of this tool, leveraging FER potential as a therapeutic target.

Clinical characteristics and cognitive function in bipolar disorder patients with different onset symptom

Background

In recent years, studies on the clinical features and cognitive impairment of patients with different first-episode types of bipolar disorder have received increasing attention. The patients with bipolar disorder may present with different symptoms at first onset. The aim of this study is to assess the cognitive functions of a patient's index episode of bipolar disorder, depression or mania, on risk factors of effecting on cognitive functions.

Method

One hundred sixty eight patients with bipolar disorder diagnosed for the first time were enrolled in the study. All patients were divided into two groups according to their index episode of bipolar disorder, either depression or mania. Seventy three patients of the cohort had an index episode mania and 95 patients had initial symptoms of depression. Demographic and clinical disease characteristic data of all enrolled patients were collected. Meanwhile, 75 healthy controls were included. Demographic data of controls were collected. The cognitive functions of all patients and controls were detected by continuous performance test (CPT), digital span test (DST) and Wisconsin card sorting test (WCST). The main cognitive functions data were compared among the mania group, depression group and control group. The relevant risk factors affecting cognitive function were analyzed.

Results

(1) Most patients with bipolar disorder had an index episode depression (56.55% vs. 43.45%). Compared with the depression group, the mania group had later age of onset [(24.01 ± 4.254) vs. (22.25 ± 6.472), t = 2. 122, p = 0.035]. The education level of patient groups was lower than control group (p < 0.001). (2) The healthy control group's DST, WCST and CPT scores were better than the patient groups (All p < 0.05). The mania group's DST (forward, reverse, sum), WCST (total responses, completed classifications, correct responses, incorrect responses, percentage of correct responses, completed the number of responses required for classification, the percentage of conceptualization level, the number of persistent responses, non-persistent errors), CPT (2 digit score, 3 digit score, 4 digit score) was better than the depression group (p < 0.05). (3) In mania group, correlation analysis showed that all CPT parameter, inverse digit span, and the sum of DST was negatively correlated with the education level (All p < 0.05). The CPT-4 digit score was negatively correlated with onset age (p < 0.05). In the WCST, the number of correct responses, the percentage of correct responses and the percentage of conceptualization level were positively correlated with the BRMS score (All p < 0.05). The number of false responses and persistent responses were negatively correlated with the BRMS score (All p < 0.05). The number of persistent errors and percentage of persistent errors was positively correlated with education years (All p < 0.05). In depression group, there was a positive correlation between inverse digit span and the education level (p < 0.05).

Conclusion

In our study, there were cognitive impairments in attention, memory, and executive function of patients with different onset syndromes of bipolar disorder. Compared with the mania group, the degree of cognitive impairments in bipolar patients with the depressive episode was more severe. The risk factors affecting cognitive impairments included the age of onset, education level, number of hospitalizations and severity of illness.

Trajectory of aberrant reward processing in patients with bipolar disorder - A longitudinal fMRI study

BACKGROUND

Bipolar disorder (BD), and especially the mania phenotype, is characterized by heightened reward responsivity and aberrant reward processing. In this longitudinal fMRI study, we investigated neuronal response during reward anticipation as the computed expected value (EV) and outcome evaluation as reward prediction error (RPE) in recently diagnosed patients with BD.

METHODS

Eighty remitted patients with BD and 60 healthy controls (HC) underwent fMRI during which they performed a card guessing task. Of these, 41 patients and 36 HC were re-scanned after 16 months. We compared reward-related neural activity between groups at baseline and longitudinally and assessed the impact of mood relapse.

RESULTS

Patients showed lower RPE signal in areas of the ventrolateral prefrontal cortex (vlPFC) than HC. In these regions, the HC showed decrease in RPE signal over time, which was absent in patients. Patients further exhibited decreased EV signal in the occipital cortex across baseline and follow-up. Patients who remained in remission showed normalization of the EV signal at follow-up. Baseline activity in the identified regions was not associated with subsequent relapse.

LIMITATIONS

Follow-up scans were only available in a relatively small sample. Medication status, follow-up time and BD illness duration prior to diagnosis varied.

CONCLUSIONS

Lower RPE signal in the vlPFC in patients with BD at baseline and its lack of normative reduction over time may represent a trait marker of dysfunctional reward-based learning or habituation. The increase in EV signal in the occipital cortex over time in patients who remained in remission may indicate normalization of reward anticipation activity.

Identifying social cognition subgroups in euthymic patients with bipolar disorder: a cluster analytical approach

BACKGROUND

Bipolar disorder (BD) is associated with social cognition (SC) impairments even during remission periods although a large heterogeneity has been described. Our aim was to explore the existence of different profiles on SC in euthymic patients with BD, and further explore the potential impact of distinct variables on SC.

METHODS

Hierarchical cluster analysis was conducted using three SC domains [Theory of Mind (ToM), Emotional Intelligence (EI) and Attributional Bias (AB)]. The sample comprised of 131 individuals, 71 patients with BD and 60 healthy control subjects who were compared in terms of SC performance, demographic, clinical, and neurocognitive variables. A logistic regression model was used to estimate the effect of SC-associated risk factors.

RESULTS

A two-cluster solution was identified with an adjusted-performance group (N = 48, 67.6%) and a low-performance group (N = 23, 32.4%) with mild deficits in ToM and AB domains and with moderate difficulties in EI. Patients with low SC performance were mostly males, showed lower estimated IQ, higher subthreshold depressive symptoms, longer illness duration, and poorer visual memory and attention. Low estimated IQ (OR 0.920, 95% CI 0.863-0.981), male gender (OR 5.661, 95% CI 1.473-21.762), and longer illness duration (OR 1.085, 95% CI 1.006-1.171) contributed the most to the patients clustering. The model explained up to 35% of the variance in SC performance.

CONCLUSIONS

Our results confirmed the existence of two discrete profiles of SC among BD. Nearly two-thirds of patients exhibited adjusted social cognitive abilities. Longer illness duration, male gender, and lower estimated IQ were associated with low SC performance.

Präzisionspsychiatrie und der Beitrag von Brain Imaging und anderen Biomarkern

'Precision Psychiatry' as the psychiatric variant of 'Precision Medicine' aims to provide high-level diagnosis and treatment based on robust biomarkers and tailored to the individual clinical, neurobiological, and genetic constitution of the patient. The specific peculiarity of psychiatry, in which disease entities are normatively defined based on clinical experience and are also significantly influenced by contemporary history, society and philosophy, has so far made the search for valid and reliable psychobiological connections difficult. Nevertheless, considerable progress has now been made in all areas of psychiatric research, made possible above all by the critical review and renewal of previous concepts of disease and psychopathology, the increased orientation towards neurobiology and genetics, and in particular the use of machine learning methods. Notably, modern machine learning methods make it possible to integrate high-dimensional and multimodal data sets and generate models which provide new psychobiological insights and offer the possibility of individualized, biomarker-driven single-subject prediction of diagnosis, therapy response and prognosis. The aim of the present review is therefore to introduce the concept of 'Precision Psychiatry' to the interested reader, to concisely present modern, machine learning methods required for this, and to clearly present the current state and future of biomarker-based 'precision psychiatry'.

Impulsivity, decision-making and risk-taking behaviour in bipolar disorder: a systematic review and meta-analysis

Despite the robust body of work on cognitive aspects of bipolar disorder (BD), a clear profile of associated impairments in impulsivity, decision-making and risk-taking from studies that use behavioural measures has yet to be established. A systematic review, across four electronic databases (PsycINFO, MEDLINE/PubMed, ScienceDirect and Scopus), of literature published between January 1999 and December 2018 was carried out in accordance with the PRISMA statement. The protocol was registered on PROSPERO (CRD42018114684). A fixed-effect and random-effects meta-analysis using the Hedges' g (ES) estimate was performed. The analysis revealed significant impairment in BD individuals with medium effect sizes in various aspects of impulsivity - response inhibition (ES = 0.49; p < 0.0001), delay of gratification (ES = 0.54; p < 0.0001) and inattention (ES = 0.49; p < 0.0001) - and in decision-making (ES = 0.61, p = 0.0002), but no significant impairment in risk-taking behaviour (ES = 0.41; p = 0.0598). Furthermore, we found significant heterogeneity between studies for decision-making and risk-taking behaviour but not for impulsivity. Impaired risk-taking behaviour was significant in a subgroup of BD-I and euthymic individuals (ES = 0.92; p < 0.0001) with no significant heterogeneity. A stratification analysis revealed comparable results in euthymic and non-euthymic individuals for impulsivity. Our findings suggest that behaviour impulsivity is elevated in all phases of BD, representing a core and clinically relevant feature that persists beyond mood symptoms. More studies about decision-making and risk-taking are necessary to establish if they are impaired in BD and to analyze the role of mood state.

Resting-state functional connectivity of neural circuits associated with primary and secondary rewards in patients with bipolar disorder

Objective

We used resting-state functional connectivity (rsFC) to evaluate the integrity of the neural circuits associated with primary and secondary rewards in bipolar disorder (BD) with different mood phases.

Methods

Sixty patients with BD [21 patients with depressive episode of BD (BDD) and 41 patients with maniac episode of BD (BDM)] and 42 healthy controls (HCs) underwent resting-state functional magnetic resonance imaging. rsFC was assessed using region of interest-wise analyses.

Results

Attenuation of rsFC at the orbitofrontal cortex (OFC) and the left ventral striatum (LVS) was observed in the secondary reward circuit of patients with BD compared to that of HCs. Among BDD, BDM and HCs, the rsFC between OFC and LVS in BDM was intermediate, while the rsFC between OFC and right ventral striatum/right amygdala in BDM was the highest; the corresponding rsFC values in BDD were the lowest. Furthermore, a positive correlation was found between rsFC and Young Mania Rating Scale scores in BDM.

Conclusions

This study suggests that there may be an abnormal rsFC between OFC and LVS in the second reward of patients with BD and the discrepant patterns of rsFC may exist between different mood states in patients with BD.

Neuropsychology of Bipolar Disorder

Bipolar disorder is associated with significant dysfunction in a broad range of neuropsychological domains and processes. Deficits have been reported to occur in symptomatic states (depression, [hypo]mania) as well as in remission (euthymia), having consequences for psychological well-being and social and occupational functioning. The profile and magnitude of neuropsychological deficits in bipolar disorder have been explored in a number of systematic reviews and meta-analyses. After discussing these briefly, this chapter will focus on examining the clinical and demographic factors that influence and modify the pattern and magnitude of deficits, as well as reviewing methods of assessment and analysis approaches which may improve our understanding of these problems.

Affective cognition in bipolar disorder: A systematic review by the ISBD targeting cognition task force

BACKGROUND

Impairments in affective cognition are part of the neurocognitive profile and possible treatment targets in bipolar disorder (BD), but the findings are heterogeneous. The International Society of Bipolar Disorder (ISBD) Targeting Cognition Task Force conducted a systematic review to (i) identify the most consistent findings in affective cognition in BD, and (ii) provide suggestions for affective cognitive domains for future study and meta-analyses.

METHODS

The review included original studies reporting behavioral measures of affective cognition in BD patients vs controls following the procedures of the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement. Searches were conducted on PubMed/MEDLINE, EMBASE, and PsychInfo from inception until November 2018.

RESULTS

A total of 106 articles were included (of which nine included data for several affective domains); 41 studies assessed emotional face processing; 23 studies investigated reactivity to emotional words and images; 3 investigated explicit emotion regulation; 17 assessed implicit emotion regulation; 31 assessed reward processing and affective decision making. In general, findings were inconsistent. The most consistent findings were trait-related difficulties in facial emotion recognition and implicit emotion regulation, and impairments in reward processing and affective decision making during mood episodes. Studies using eye-tracking and facial emotion analysis revealed subtle trait-related abnormalities in emotional reactivity.

CONCLUSION

The ISBD Task Force recommends facial expression recognition, implicit emotion regulation, and reward processing as domains for future research and meta-analyses. An important step to aid comparability between studies in the field would be to reach consensus on an affective cognition test battery for BD.

Social cognition in bipolar disorder: the role of sociodemographic, clinical, and neurocognitive variables in emotional intelligence

OBJECTIVE

The main aims of this study were to examine the differences in the Emotional Intelligence (EI), the emotional domain of social cognition (SC), between euthymic patients with bipolar disorder (BD) and healthy controls (HC) and to evaluate the contribution of sociodemographic, clinical, and neuropsychological variables to EI.

METHODS

We recruited 202 patients with BD and 50 HC. EI was evaluated using the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT). The sociodemographic, clinical, and neurocognitive variables that showed a significant association with EI were entered into hierarchical multiple regression analysis.

RESULTS

BD patients obtained significantly lower scores compared to HC in the Emotional Intelligence Quotient (EIQ) and in the Understanding Emotions branch score. The best fitting model for the variables associated with EI in the patients group was a linear combination of gender, estimated IQ, family history of affective diagnosis, and executive function. The model, including these previous variables, explained up to 27.6% of the observed variance (R²  = 0.276, F = 16.406, P < 0.001).

CONCLUSIONS

The identification of variables associated with deficit in EI, such as male gender, lower estimated IQ, family history of affective diagnosis. and lower executive function performance, may help in selecting treatment targets to improve SC, and especially EI, in patients with BD.

Neurocognition and functional outcome in patients with psychotic, non-psychotic bipolar I disorder, and schizophrenia. A five-year follow-up

Background:

Bipolar disorder (BD) and schizophrenia (SZ) are characterized by neurocognitive and functional deficits with marked heterogeneity. It has been suggested that BD with a history of psychotic symptoms (BD-P) could constitute a phenotypically homogeneous subtype characterized by greater neurocognitive and functional impairments, or by a distinct trajectory of such deficits. The aim of this study was to compare the neurocognitive and functional course of euthymic BD-P, euthymic BD patients without a history of psychosis (BD-NP), stabilized patients with schizophrenia and healthy subjects, during a five-year follow-up.

Methods:

Neurocognitive and psychosocial function was examined in 100 euthymic patients with BD (50 BD-P, 50 BD-NP), 50 stabilized patients with schizophrenia (SZ), and 51 healthy controls (HC) at baseline (T1), and after a 5-year follow-up (T2).

Results:

The course of both neurocognitive performance and functional outcome of patients with SZ and BD (BD-P and BD-NP) is stable. The profile of neurocognitive impairment of patients with SZ or BD (BD-P and BD-NP), is similar, with only quantitative differences circumscribed to certain domains, such as working memory. The subgroup of patients with BD-NP does not show functional deterioration.

Conclusions:

We have not found evidence of progression in the neurocognitive or psychosocial impairment in any of the three groups of patients, although it cannot be dismissed the possibility of a subset of patients with a progressive course. Other longitudinal studies with larger samples and longer duration are necessary to confirm these findings.

Toward Precision Psychiatry in Bipolar Disorder: Staging 2.0

Personalized treatment is defined as choosing the "right treatment for the right person at the right time." Although psychiatry has not yet reached this level of precision, we are on the way thanks to recent technological developments that may aid to detect plausible molecular and genetic markers. At the moment there are some models that are contributing to precision psychiatry through the concept of staging. While staging was initially presented as a way to categorize patients according to clinical presentation, course, and illness severity, current staging models integrate multiple levels of information that can help to define each patient's characteristics, severity, and prognosis in a more precise and individualized way. Moreover, staging might serve as the foundation to create a clinical decision-making algorithm on the basis of the patient's stage. In this review we will summarize the evolution of the bipolar disorder staging model in relation to the new discoveries on the neurobiology of bipolar disorder. Furthermore, we will discuss how the latest and future progress in psychiatry might transform current staging models into precision staging models.