Comparing suicide completion rates in bipolar I versus bipolar II disorder: A systematic review and meta-analysis

Association between loneliness and suicidality among general populations and persons with depressive and bipolar disorders: A systematic review

BACKGROUND

Loneliness and suicidality are interrelated phenomena. Several studies suggest that they often co-exist, but the magnitude is unclear. This systematic review aims to analyze this association in general population samples of varying age groups and persons with depressive and bipolar disorders.

METHODS

Search terms in this review included words related to loneliness and suicidality among general populations and depressive and bipolar disorders. Databases included PubMed, PsychINFO, and Web of Science. The search occurred up until May 27, 2024. Screening and data extraction were performed independently. Studies were categorized by age group or clinical diagnosis. Quality assessments were conducted using NIH tools.

RESULTS

Fifty-six studies met eligibility criteria: 52 involved general population samples and 4 involved patients with depressive or bipolar disorders. In healthy adults aged 18 to 64, loneliness mainly showed a moderate positive correlation with suicidality (r = 0.26 to 0.59), while correlations in older adults (aged 65+) (r = 0.498) and in adolescents aged 13-17 were weaker. In depressive and bipolar disorders, correlations ranged from weak to moderate (r = -0.06 to 0.40), with associations stronger in unadjusted models (UOR = 2.8 to 7.07). Furthermore, some studies suggested that depressive symptoms mediate the association between loneliness and suicidality.

CONCLUSION

A moderate and positive association was observed between loneliness and suicidality in healthy adults and patients with depressive disorders. However, the role of bipolar disorders in the association remains unclear. Practitioners should routinely evaluate persons living with depressive or bipolar disorders for loneliness as part of a comprehensive assessment.

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.

Lurasidone response in bipolar type I depression with childhood trauma exposure

IMPORTANCE

Childhood trauma (CT) worse the course of bipolar disorder (BD) and negatively impacts treatment outcomes. Despite the recognized influence of CT on clinical trajectories, limited evidence exists on how it affects specific pharmacological responses in BD.

OBJECTIVE

This study aimed to investigate the effectiveness of lurasidone in BD type I depression, with a focus on how CT exposure impacts treatment response and remission.

DESIGN

A multisite, observational, prospective, comparative effectiveness study over an 8-week period was conducted.

SETTING

A multisite in 4 clinical research sites in Colombia.

PARTICIPANTS

A total of 84 adults with BD type I depression were enrolled (lurasidone = 41, lurasidone with lithium = 43).

INTERVENTION

Over an 8-week period, 41 participants were assigned to the lurasidone arm and 43 to the lurasidone plus lithium arm.

EXPOSURE

Childhood trauma exposure was measured with the Childhood Trauma Questionnaire-Short Form. BD with CT (n = 40) and BD without CT (n = 44) were included.

MAIN OUTCOME AND MEASURES

The primary outcome was changes in Montgomery-Åsberg Depression Rating Scale (MADRS) scores. Secondary outcomes included changes in Clinical Global Impression-Bipolar depression severity scores and responder rates.

RESULTS

Bipolar disorder with CT exposure demonstrated a smaller mean reduction in MADRS scores compared to those without CT exposure for both treatments (monotherapy: Least Square (LS) -3.4, 95% CI, -6.03 to -0.76, P = .013; combination therapy: LS -3.1, 95% CI, -5.36 to -0.63, P = .014). The presence of CT exposure, particularly physical abuse (PA), was associated with poorer response rates. Notably, lurasidone in combination with lithium showed superior outcomes compared to monotherapy, although effectiveness was attenuated in participants with documented CT exposure.

CONCLUSIONS

This study provides real-world evidence suggesting that CT exposure may modify treatment response in BD type I depression. Our findings underscore the importance of CT screening to guide personalized treatment strategies.

RELEVANCE

This study provides evidence that CT, particularly PA, attenuates the antidepressant effects of lurasidone in BD type I depression, leading to lower response and remission rates in both monotherapy and combination therapy with lithium. These findings underscore the clinical importance of screening for CT in BD to guide personalized treatment strategies. Identifying trauma history may help clinicians optimize treatment selection, considering the potential need for combination pharmacotherapy and adjunctive trauma-focused psychotherapeutic interventions to improve outcomes in this vulnerable population.

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.

Therapeutic Potential of Saffron Extract in Mild Depression: A Study of Its Role on Anhedonia in Rats and Humans

Drugs generally used in major depressive disorder are considered inappropriate for the more common milder forms. The efficacy of saffron extracts has been demonstrated in mild to moderate depression and in preclinical models of depression. However, evidence of saffron activity on reduced hedonic responsiveness and motivational anhedonia is limited. Since dopamine transmission dysfunctions are crucially involved in anhedonia and saffron seems to positively modulate dopamine release, we studied the potential antidepressant and anti-anhedonic effects of a standardized formulation of saffron extract in preclinical models of anhedonia-like behaviors, and patients diagnosed with unipolar or bipolar depression. We tested saffron activity in a rat model of stress-induced motivational anhedonia using sucrose self-administration protocols and investigated the molecular underpinnings of this effect focusing on DARPP-32 phosphorylation pattern in response to a reinforcer and BDNF-TrkB signaling, in the nucleus accumbens and medial prefrontal cortex. In parallel, with a pilot double-blind placebo-controlled study we investigated whether saffron add-on therapy reduced symptoms of depression and anhedonia, measured by the Montgomery-Åsberg Depression Rating Scale. Repeated saffron administration restored motivation and reactivity to reward-associated cues in anhedonic rats, likely modulating dopaminergic transmission and BDNF-TrkB signaling. In depressed patients, an 8-week saffron add-on therapy induced a global improvement in depressive symptoms and a significant reduction in anhedonia. The study supports a pro-motivational effect of saffron and suggests a potentially useful saffron-based augmentation strategy in anhedonic patients, albeit with limitations due to small sample size and short trial duration.

Neural oscillation in bipolar disorder: a systematic review of resting-state electroencephalography studies

Bipolar disorder (BD) is a severe psychiatric disease with high rates of misdiagnosis and underdiagnosis, resulting in a significant disease burden on both individuals and society. Abnormal neural oscillations have garnered significant attention as potential neurobiological markers of BD. However, untangling the mechanisms that subserve these baseline alternations requires measurement of their electrophysiological underpinnings. This systematic review investigates consistent abnormal resting-state EEG power of BD and conducted an initial exploration into how methodological approaches might impact the study outcomes. This review was conducted in Pubmed-Medline and Web-of-Science in March 2024 to summarize the oscillation changes in resting-state EEG (rsEEG) of BD. We focusing on rsEEG to report spectral power in different frequency bands. We identified 10 studies, in which neural oscillations was compared with healthy individuals (HCs). We found that BD patients had abnormal oscillations in delta, theta, beta, and gamma bands, predominantly characterized by increased power, indicating potential widespread neural dysfunction, involving multiple neural networks and cognitive processes. However, the outcomes regarding alpha oscillation in BD were more heterogeneous, which is thought to be potentially influenced by the disease severity and the diversity of samples. Furthermore, we conducted an initial exploration into how demographic and methodological elements might impact the study outcomes, underlining the importance of implementing standardized data collection methods. Key aspects we took into account included gender, age, medication usage, medical history, the method of frequency band segmentation, and situation of eye open/eye close during the recordings. Therefore, in the face of abnormal multiple oscillations in BD, we need to adopt a comprehensive research approach, consider the multidimensional attributes of the disease and the heterogeneity of samples, and pay attention to the standardized experimental design to improve the reliability and reproducibility of the research results.

A Virtual Reality Cognitive Stimulation Program as an Effective Tool Against Residual/Prodromal Depressive Symptoms in Bipolar Disorders

Background: Bipolar disorder (BD) is a severe psychiatric illness characterized by a chronic course and recurrent episodes, including residual depressive symptoms even during euthymic phases. These symptoms, although not meeting criteria for a depressive episode, are linked to relapse risk and impaired social functioning. This study aims to assess whether Virtual Reality Cognitive Remediation Training reduces depressive symptoms below the clinical threshold in individuals with BD. Methods: This post hoc analysis focuses on the secondary outcome (PHQ9) of a randomized-controlled trial. Participants were recruited from the Center of Liaison Psychiatry and Psychosomatics in Italy. The experimental group received Virtual Reality Cognitive Remediation, while the control group received standard treatment Results: Data from 39 individuals in the experimental group and 25 in the control group were analyzed. A greater reduction in PHQ-9 scores (>9) was observed in the experimental group (71.8% to 48.7%) compared to the control group. Significant improvements in total PHQ-9 scores and specific symptoms were noted in the experimental group compared to the control group. Conclusions: The study highlights the significant impact of virtual reality intervention on reducing depressive symptoms in bipolar disorder. This promising outcome underscores the potential preventive role of cognitive stimulation in relapse prevention. The intervention could offer valuable benefits for both treatment and prevention strategies in bipolar disorder.