Substance use disorders in bipolar disorders: Clinical correlates and treatment response to mood stabilizers

Bipolar II disorder: a state-of-the-art review

Bipolar II disorder (BD-II) is currently identified by both the DSM-5 and ICD-11 as a distinct subtype of bipolar disorder, defined by at least one depressive episode and at least one hypomanic episode, with no history of mania. Despite its prevalence and impact, the literature on BD-II remains relatively sparse. This paper provides a comprehensive overview of the available research and current debate on the disorder, including its diagnostic criteria, clinical presentations, comorbidities, epidemiology, risk factors, and treatment strategies. Patients with BD-II often present with recurrent depressive episodes, which outnumber hypomanic episodes by a ratio of 39:1. The condition is therefore often misdiagnosed as major depressive disorder and treated with antidepressant monotherapy, which may worsen its prognosis. The recognition of BD-II is further complicated by the overlap of its symptoms with other disorders, in particular borderline personality disorder. Although BD-II is often perceived as a less severe form of bipolar disorder, evidence suggests significant functional and cognitive impairment, accompanied by an elevated risk of suicidal behavior, including a rate of completed suicide at least equivalent to that observed in bipolar I disorder (BD-I). Psychiatric comorbidities, in particular anxiety and substance use disorders, are common. The disorder is associated with a high prevalence of numerous physical comorbidities, with a particularly high risk of comorbid cardiovascular diseases. Various genetic and environmental risk factors have been identified. Inflammation, circadian rhythm dysregulation and mitochondrial dysfunction are being studied as potential pathophysiological mechanisms. Current treatment guidelines, often extrapolated from BD-I and depression research, may not fully address the unique aspects of BD-II. Nevertheless, substantial evidence supports the value of some pharmacological treatments - primarily mood stabilizers and atypical antipsychotics - augmented by psychoeducation, cognitive behavioral or interpersonal and social rhythm therapy, and lifestyle interventions. Further research on BD-II should be a priority, in order to refine diagnostic criteria, identify potentially modifiable risk factors, and develop targeted interventions.

Nurses' Perceptions of Patients With Co-Occurring Psychiatric and Substance Use Disorders in Psychiatric Settings: A Grounded Theory Study

AIM

To explore psychiatric and mental health nurses' perceptions of patients with co-occurring psychiatric and substance use disorders in psychiatric settings.

DESIGN

An exploratory qualitative study design based on grounded theory, employing Straussian analytic procedures.

METHOD

Semi-structured interviews were conducted with 11 psychiatric and mental health nurses. Participants were recruited at a public psychiatric hospital located in the Paris metropolitan area of France. Face-to-face interviews took place between February 2024 and May 2024. Field notes and interview data were continuously analysed during open, axial and selective coding phases.

RESULTS

The core category identified was 'waiting for a patient's will to change to emerge' when caring for patients with co-occurring substance use disorders. This active waiting period involved a balancing strategy between two discrete care objectives: stabilising the patient's clinical status and keeping the nurse-patient relationship intact. Identifying a patient's will to change provided an opportunity to reconcile these two aspects of psychiatric nursing through the addition of a collaborative component to the relationship.

CONCLUSION

The substantive theory generated by our findings contributes to understanding the interactional and relational processes that occur between nurses and patients presenting with co-occurring substance use disorders in the context of psychiatric care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Implications of our study include the need for further emphasis on collaborative approaches that can be applied even in early or pre-contemplative stages of recovery. Organisational policies should systematically include training in the field of addiction care, given the high prevalence of co-occurring substance use disorders in psychiatric settings.

IMPACT

Our findings can assist nurses in critically examining the challenges they experience when engaging with patients with co-occurring substance use disorders.

REPORTING METHOD

This research adheres to the COREQ (COnsolidated criteria for REporting Qualitative research) Checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Synthesising 30 years of clinical experience and scientific insight on affective temperaments in psychiatric disorders: State of the art

The concept of affective temperament has been extensively discussed throughout the history of psychopathology and represents a cornerstone in the study of mood disorders. This review aims to trace the evolution of the concept of affective temperaments (ATs) from Kraepelin's seminal work to the present day. In the 1980s, Akiskal redefined Kraepelin's concept of affective temperaments (ATs) by integrating the five recognized ATs into the broader framework of the soft bipolar spectrum. This conceptualization viewed ATs as non-pathological predispositions underlying psychiatric disorders, particularly mood disorders. Epidemiological and clinical studies have validated the existence of the five ATs. Furthermore, evidence suggests that ATs may serve as precursors to various psychiatric disorders and influence clinical dimensions such as disease course, psychopathology, and treatment adherence. Additionally, ATs appear to play a significant role in moderating phenomena such as suicide risk and stress coping. Incorporating an evaluation of temperamental bases of disorders into the multidimensional psychiatric diagnostic process could enhance treatment optimization and prognosis estimation.

What Came First, Mania or Depression? Polarity at Onset in Bipolar I and II: Temperament and Clinical Course

(1) Background: Bipolar disorder (BD) is divided into type I (BD-I) and type II (BD-II). Polarity at onset (PO) is a proposal to specify the clinical course of BD, based on the type of the first episode at disorder onset-depressive (D-PO) or manic (M-PO). At the same time, affective temperaments represent preexisting variants of the spectrum of affective disorders. Our objectives were to investigate the hypothesis that temperament may exert an influence on PO, and that this factor can serve as an indicator of the forthcoming course of the disorder, carrying significant therapeutic implications. (2) Methods: We included 191 patients with BD and examined clinical variables and temperament; the latter was assessed using the short version of the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Auto-questionnaire (TEMPS-A-39-SV). We tested the associations between these variables and PO using standard univariate/bivariate methods followed by multivariate logistic regression models. (3) Results: 52.9% of the sample had D-PO and 47.1% had M-PO. D-PO and M-PO patients scored higher for dysthymic and hyperthymic temperaments, respectively (p < 0.001). Also, they differed in BD subtypes, age at first affective episode, illness duration, number of depressive episodes, seasonality, suicide risk, substance use, lithium, and benzodiazepine use (p < 0.05). Only BD-II and age at first depressive episode were predictors of D-PO, whereas BD-I, age at first manic/hypomanic episode, and hyperthymic temperament were predictors of M-PO (p < 0.01). (4) Conclusions: Our findings point to the importance of carefully assessing temperament and PO in patients with BD, to better predict the clinical course and tailor therapeutic interventions to individual patients' needs.

Chronotype is associated with affective temperaments, clinical severity and worse treatment outcomes in bipolar disorders: results from a two-center, cross-sectional study

OBJECTIVE

The present study was aimed at investigating the clinical correlates of evening chronotype in a population of subjects suffering from bipolar disorders (BD).

METHODS

We assessed chronotype using the Morningness-Eveningness Questionnaire. We administered the brief Temperament Evaluation of Memphis, Pisa, and San Diego, the Barratt Impulsiveness Scale, and the Alda Scale to evaluate affective temperaments, impulsiveness, and response to mood stabilisers. We performed bivariate analyses and ran a logistic regression model to analyse clinical variables associated with evening chronotype.

RESULTS

In our sample (n = 178), subjects with an evening chronotype (n = 56, 31.5%) more often suffered from BD type I and reported higher prevalence of seasonality, antidepressant-induced mood switches, psychotic, aggressive, mixed, and anxiety features, and substance use disorders. The number of lifetime suicide attempts and mood episodes was higher in this subgroup. Depressive, cyclothymic, irritable, and anxious temperament scores were higher among evening-chronotype subjects, who also displayed greater levels of impulsiveness and worse treatment response. At the logistic regression, evening chronotype was associated with depressive and irritable temperaments.

CONCLUSIONS

Subjects with evening chronotype display higher clinical severity and worse BD course. Clinicians should evaluate the presence of evening chronotype in BD subjects, especially in those with irritable or depressive temperament.Key pointsEvening chronotype is a frequent clinical feature in subjects suffering from bipolar disorders (BD);Affective temperaments, particularly depressive and irritable, are associated with evening chronotype in BD;Evening chronotype underpins higher severity of the clinical picture in BD, as well as a worse response to mood stabiliser treatment;Circadian preferences should be systematically assessed in subjects suffering from BD, with particular attention to evening preference.

Machine Learning Prediction of Comorbid Substance Use Disorders among People with Bipolar Disorder

Substance use disorder (SUD) is a common comorbidity in individuals with bipolar disorder (BD), and it is associated with a severe course of illness, making early identification of the risk factors for SUD in BD warranted. We aimed to identify, through machine-learning models, the factors associated with different types of SUD in BD. We recruited 508 individuals with BD from a specialized unit. Lifetime SUDs were defined according to the DSM criteria. Random forest (RF) models were trained to identify the presence of (i) any (SUD) in the total sample, (ii) alcohol use disorder (AUD) in the total sample, (iii) AUD co-occurrence with at least another SUD in the total sample (AUD+SUD), and (iv) any other SUD among BD patients with AUD. Relevant variables selected by the RFs were considered as independent variables in multiple logistic regressions to predict SUDs, adjusting for relevant covariates. AUD+SUD could be predicted in BD at an individual level with a sensitivity of 75% and a specificity of 75%. The presence of AUD+SUD was positively associated with having hypomania as the first affective episode (OR = 4.34 95% CI = 1.42-13.31), and the presence of hetero-aggressive behavior (OR = 3.15 95% CI = 1.48-6.74). Machine-learning models might be useful instruments to predict the risk of SUD in BD, but their efficacy is limited when considering socio-demographic or clinical factors alone.

Sex Differences in Bipolar Disorders: Impact on Psychopathological Features and Treatment Response

INTRODUCTION

Sex differences were demonstrated in bipolar disorders (BD) concerning epidemiological, clinical, and psychopathological characteristics, but consensus is lacking. Moreover, data concerning the influence of sex on treatment response in BD is contrasting. The present cross-sectional study aimed to analyze sex differences in a population of BD subjects, with specific focus on psychopathological features and treatment response.

MATERIALS AND METHODS

Subjects diagnosed with BD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th version (DSM-5) were recruited. Socio-demographic and clinical characteristics were collected. The Hamilton Rating Scale for Depression, the Mania Rating Scale (MRS), the brief version of the Temperament Evaluation of Memphis, Pisa and San Diego-Münster version (briefTEMPS-M), and the Barratt Impulsiveness Scale-11 items (BIS-11) were used for psychopathological assessment. Treatment response was appraised with the Alda Scale. We performed bivariate analyses to compare socio-demographic, clinical, and psychopathological characteristics between men and women (p < 0.05). A logistic regression was run to analyze features that were significantly associated with female sex.

RESULTS

Among the recruited 219 BD subjects, 119 (54.3%) were females. Women had a lower scholarity (p = 0.015) and were less frequently employed (p = 0.001). As for psychopathological features, a higher MRS total score (p < 0.001) was detected among women, as well as higher BIS-11 total score (p = 0.040), and briefTEMPS-M score for anxious temperament (p = 0.006). Men showed higher prevalence of DSM-5 mixed features (p = 0.025), particularly during a depressive episode (p = 0.014). Women reported longer duration of untreated illness (DUI) (p < 0.001). There were no sex differences in the Alda Scale total score when considering the whole sample, but this was significantly higher among men (p = 0.030) when evaluating subjects treated with anticonvulsants. At the logistic regression, female sex was positively associated with longer DUI (p < 0.001; OR 1.106, 95% CI 1.050-1.165) and higher MRS total score (p < 0.001; OR 1.085, 95% CI 1.044-1.128) and negatively associated with employment (p = 0.003; OR 0.359, 95% CI 0.185-0.698) and DSM-5 mixed features (p = 0.006; OR 0.391, 95% CI 0.200-0.762).

CONCLUSIONS

The clinical presentation of BD may differ depending on sex. The severity of BD should not be neglected among women, who may also display worse treatment response to anticonvulsants.

COVID-19 and Youth Psychopathological Distress in Umbria, Central Italy: A 2-Year Observational Study in a Real-World Setting

INTRODUCTION

Adolescents and young adults represent a vulnerable population in the context of the Coronavirus disease 2019 (COVID-19) pandemic. The present retrospective study aims to investigate the pandemic's psychological impact on adolescents and young adults by analyzing data from an outpatient mental health service dedicated to youths in Umbria, central Italy.

MATERIALS AND METHODS

The clinical charts of subjects aged 14-24 who first accessed the service in the timeframe between March 1st, 2019, and February 28th, 2021, were reviewed. Subjects were divided into two subgroups according to the period of time when they accessed the service (pre-COVID-19 vs. during- COVID-19 outbreak). Bivariate analyses were performed using the Chi-square test and the Welch's t-test. A secondary analysis was performed considering only subjects suffering from psychiatric disorders. Furthermore, data concerning individuals who were already followed by the service before the pandemic were analyzed by the McNemar's test and the t-paired test to assess changes in treatment features.

RESULTS

The number of new accesses during the pandemic period remained stable. After the emergency onset, youths accessing the service showed a higher prevalence of anxiety disorders (p = 0.022). During the COVID-19 period, services were more frequently delivered by using a digital mental health approach (p = 0.001). Psychopharmacological treatment was more frequently prescribed among subjects that were referred to the service after the pandemic onset (p = 0.033). As for substance use, a highly significant reduction in opioid use was observed (p = 0.003). Family therapy was delivered less frequently in the during-COVID-19 subgroup, especially in the subpopulation of subjects suffering from psychiatric disorders (p = 0.013). When considering subjects referred to the service in the pre-COVID-19 period, the number of interventions provided to this population increased after the pandemic outbreak (p = 0.038).

CONCLUSION

In the context of the COVID-19-related public health crisis, youths represent an at-risk population for which pathways to care should be reinforced, and targeted interventions, including psychosocial treatments, should be implemented.

Bipolar Disorder and Polysubstance Use Disorder: Sociodemographic and Clinical Correlates

INTRODUCTION

Patients with bipolar disorder (BD) often show comorbidity with substance use disorder (SUD) with a negative impact on clinical course, prognosis, and functioning. The role of polysubstance use disorder (polySUD) is understudied. The aim of the present paper is to evaluate the sociodemographic and clinical characteristics associated with BD and comorbid SUD, focusing on polySUD, in order to phenotype this specific group of patients and implement adequate treatment and prevention strategies.

METHODS

A cross-sectional study was conducted involving 556 patients with a primary diagnosis of BD (376 without SUD, 101 with SUD, and 79 with polySUD). A semi-structured interview was administered to collect sociodemographic variables, clinical characteristics, and pharmacological treatment. ANOVA and chi-square tests were used to compare the three groups. Significantly different variables were then inserted in multivariate logistic regression.

RESULTS

Patients affected by BD and polySUD were younger, and more frequently males and single, than patients with SUD or without SUD. Indeed, the prevalence of patients affected by BD and polySUD living in residential facilities was higher than in the other groups. Moreover, earlier age at onset, higher prevalence of psychotic and residual symptoms, involuntary hospitalization, and a family history of psychiatric disorders were associated with polySUD in patients suffering from BD. Lastly, patients with BD and polySUD were more likely to take four or more medications, particularly benzodiazepines and other drugs. At the multinomial regression, younger age, male gender, early age at onset, psychotic and residual symptoms, positive family history of psychiatric disorders, and use of benzodiazepines remained significantly associated with polySUD in patients with BD.

CONCLUSION

Our findings show a specific profile of patients with BD and polySUD. It is important to conduct research on this topic in order to adopt specific therapeutic strategies, minimize the use of polypharmacy, and aim at full remission and mood stabilization.