Age at onset, course of illness and response to psychotherapy in bipolar disorder: results from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

Collaborative care approaches for people with severe mental illness

BACKGROUND

Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies.

OBJECTIVES

To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community.

SEARCH METHODS

We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro.

MAIN RESULTS

Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years.

AUTHORS' CONCLUSIONS

This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.

Validation of the Bipolar Recovery Questionnaire for the Portuguese Population: Recovery and Predictors in People with Bipolar Disorder

INTRODUCTION

The paradigm in mental health care is progressively moving towards a recovery-focused perspective. Thus, there is a need for validated instruments to measure recovery in bipolar disorder (BD). The Bipolar Recovery Questionnaire (BRQ) is the most used instrument to assess it. The aim of this study was to translate and perform a cross-cultural adaptation of the BRQ to European Portuguese (PT-PT) and to explore further associations of recovery with sociodemographic and emotional regulation, as well as recovery predictors to inform future research and clinical practice.

METHODS

The BRQ was forward-translated and back-translated until a consensus version was found, and a test-retest design was used to assess temporal stability. Participants were recruited in public hospitals and organizations supporting people with BD, either referred by their psychiatrists or psychologists or through self-referral. Eighty-eight individuals diagnosed with BD were recruited to complete a battery of Portuguese-validated self-report questionnaires to assess recovery (BRQ), clinical mood symptoms (Hospital Anxiety and Depression Scale), affect (Positive and Negative Affect Scale), well-being (brief Quality of Life for Bipolar Disorder; Satisfaction with Life Scale) and emotion regulation (Difficulties in Emotion Regulation Scale).

RESULTS

The BRQ showed excellent internal consistency with a Cronbach alpha of 0.92, and test-retest exhibited good reliability (r = 0.88). Construct validity was confirmed through/by positive and moderate correlations with quality of life (QoL; r = 0.58) and positive affect (r = 0.52), and negative moderate correlations with depression (r = -0.64), and negative affect (r = -0.55). Both satisfaction with life (β = 0.38, p = 0.010) and recovery (β = 0.34, p = 0.022) impacted quality of life, supporting the BRQ's incremental validity. Depressive symptoms and emotion dysregulation accounted for 51% of its variance.

CONCLUSION

The BRQ is a valid and reliable instrument to measure recovery in people with BD in the Portuguese population and is suitable for both clinical and research contexts.

Optimizing multi-domain hematologic biomarkers and clinical features for the differential diagnosis of unipolar depression and bipolar depression

There is a lack of objective features for the differential diagnosis of unipolar and bipolar depression, especially those that are readily available in practical settings. We investigated whether clinical features of disease course, biomarkers from complete blood count, and blood biochemical markers could accurately classify unipolar and bipolar depression using machine learning methods. This retrospective study included 1160 eligible patients (918 with unipolar depression and 242 with bipolar depression). Patient data were randomly split into training (85%) and open test (15%) sets 1000 times, and the average performance was reported. XGBoost achieved the optimal open-test performance using selected biomarkers and clinical features-AUC 0.889, sensitivity 0.831, specificity 0.839, and accuracy 0.863. The importance of features for differential diagnosis was measured using SHapley Additive exPlanations (SHAP) values. The most informative features include (1) clinical features of disease duration and age of onset, (2) biochemical markers of albumin, low density lipoprotein (LDL), and potassium, and (3) complete blood count-derived biomarkers of white blood cell count (WBC), platelet-to-lymphocyte ratio (PLR), and monocytes (MONO). Overall, onset features and hematologic biomarkers appear to be reliable information that can be readily obtained in clinical settings to facilitate the differential diagnosis of unipolar and bipolar depression.

A systematic review of interventions in the early course of bipolar disorder I or II: a report of the International Society for Bipolar Disorders Taskforce on early intervention

BACKGROUND

Given the likelihood of progressive illness in bipolar disorder (BD), it is important to understand the benefits and risks of interventions administered early in illness course. We conducted a systematic review of the effectiveness of interventions in the early course of BD I or II.

METHODS

We completed a systematic search on MEDLINE, PsycINFO, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL and Google Scholar from 1/1/1979 till 14/9/2022. We included controlled trials examining intervention effects on symptomatic, course, functional and tolerability outcomes of patients in the 'early course' of BD I or II. We classified patients to be in early course if they (a) were seeking help for the first time for a manic episode, (b) had a lifetime history of up to 3 manic episodes, or (c) had up to 6 lifetime mood episodes. Evidence quality was assessed using the GRADE approach.

RESULTS

From 4135 unique publications we included 25 reports representing 2212 participants in 16 randomized studies, and 17,714 participants from nine non-randomized studies. Available evidence suggested that in early illness course, lithium use was associated with lower recurrence risk compared with other mood stabilizers. Mood stabilizers were also associated with better global functioning, compared with the use of antipsychotics in the medium term. While summative findings regarding psychological therapies were limited by heterogeneity, family-focused and cognitive-behavioral interventions were associated with reduced recurrence risk or improved symptomatic outcomes. There was some evidence that the same pharmacological interventions were more efficacious in preventing recurrences when utilized in earlier rather than later illness course.

CONCLUSIONS AND RECOMMENDATIONS

While there are promising initial findings, there is a need for more adequately powered trials to examine the efficacy and tolerability of interventions in youth and adults in early illness course. Specifically, there is a compelling need to compare the relative benefits of lithium with other pharmacological agents in preventing recurrences. In addition to symptomatic outcomes, there should be a greater focus on functional impact and tolerability. Effective pharmacological and psychological interventions should be offered to those in early course of BD, balancing potential risks using shared decision-making approaches.

A randomised, double-blind, placebo-controlled study to evaluate the safety and efficacy of lamotrigine in the maintenance treatment of Chinese adult patients with bipolar I disorder

Background

Lamotrigine is approved as a maintenance therapy for bipolar I disorder in many countries, including China in 2021. This study evaluated the efficacy and safety of lamotrigine in controlling relapse and/or recurrence of mood episodes in Chinese patients with bipolar I disorder.

Methods

Patients aged ≥ 18 years with bipolar I disorder who met response criteria (Clinical Global Impression–Severity [CGI-S] score of ≤ 3 for ≥ 4 consecutive weeks) during treatment with lamotrigine in a 6–16 week open-label (OL) phase, and who were maintained for ≥ 1 week on lamotrigine 200 mg/day monotherapy, were randomised (1:1) to continue receiving lamotrigine 200 mg/day or switch to placebo in a 36-week randomised double-blind (RD) phase. The primary efficacy outcome measure was time from entry into the RD phase to intervention for relapse and/or recurrence of a mood episode (TIME). Post hoc analyses assessed the impact of OL baseline mood severity on TIME. Safety assessments were conducted throughout the study.

Results

Of 420 patients treated in the OL phase, 264 were randomised to receive lamotrigine (n = 131) or placebo (n = 133). Overall, 112 patients had an intervention for relapse and/or recurrence of a mood episode (lamotrigine, n = 50/130 [38.5%]; placebo, n = 62/133 [46.6%]), with no significant difference in TIME between groups (adjusted hazard ratio [95% confidence interval (CI)] 0.93 [0.64, 1.35]; p = 0.701). Post hoc analyses indicated a significant difference in TIME, favouring lamotrigine over placebo, for patients with baseline CGI-S score ≥ 4 (hazard ratio [95% CI] 0.52 [0.30, 0.89]; p = 0.018) and with baseline Hamilton Depression Rating Scale ≥ 18 or Young Mania Rating Scale ≥ 10 (0.44 [hazard ratio [95% CI] 0.25, 0.78]; p = 0.005). Lamotrigine was well tolerated with no new safety signals.

Conclusions

Lamotrigine was not significantly superior to placebo in preventing relapse and/or recurrence of mood episodes in this study of Chinese patients with bipolar I disorder but post hoc analyses suggested a therapeutic benefit in patients with moderate/severe mood symptoms at baseline. The discrepancy between these findings and the positive findings of the pivotal studies may be attributable to the symptom severity of the bipolar patients recruited, a high dropout rate, and the comparatively short duration of the RD phase rather than race/ethnicity differences.

Clinical trial registration ClinicalTrial.gov Identifier NCT01602510; 21st May 2012; https://clinicaltrials.gov/ct2/show/NCT01602510.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00266-4.

Bipolar disorder treatment according to illness trajectory: a systematic review of clinical trials

The current bipolar disorder treatment guidelines focus mainly on the prevention of recurrence and stabilization of acute mood episodes while neglecting outcomes related to the longitudinal course of illness. We systematically reviewed studies that assess the impact of disease progression in the treatment of patients with bipolar disorder. We searched PubMed, Embase, and Web of Science for clinical trials that moderated treatment effects by number of previous episodes, disease length, or a clinical staging model. We retrieved 6,156 potential abstracts. After deduplication, 5,376 were screened and eight studies met inclusion criteria. Seven trials moderated results by number of prior episodes, and one of those also used a measure of disease length. One trial used a clinical staging model and yielded informing results. Only three studies evaluated pharmacological interventions, the other five assessing psychotherapeutic modalities. Most of the studies were post-hoc analysis of clinical trials not primarily aimed at studying variables associated with illness trajectory. Overall, a loss of efficacy was found according to clinical progression, which supports early intervention. Tailored recommendations according to disease stages cannot be made. Furthermore, we identified methodological weaknesses and strengths in this subfield of research, suggesting the use of clinical staging models for future studies.

Psychosocial Treatments for Bipolar Disorder in Children and Adolescents

Evidence suggests that adjunctive psychosocial intervention for the treatment of pediatric bipolar spectrum disorders (BPSDs) is effective, feasible, and highly accepted as both an acute and maintenance treatment for youth with BPSD diagnoses as well as a preventive treatment for high-risk youth who are either asymptomatic or exhibit subsyndromal mood symptoms. Here, we provide a comprehensive review of all known evidence-based interventions, including detailed descriptions of treatment targets and core components, results of clinical trials, and updated research on mediators and moderators of treatment efficacy. Treatments are presented systematically according to level of empirical support (i.e., well established, probably efficacious, possibly efficacious, experimental, or questionable); upcoming and ongoing trials are included when possible. In line with a staging approach, preventive interventions are presented separately. Recommendations for best practices based on age, stage, and additional evidence-based child and family factors shown to affect treatment outcomes are provided. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Illness stage and predominant polarity in bipolar disorder: Correlation with burden of illness and moderation of treatment outcome

Bipolar disorder often follows a set progression best described in stages where advanced stages are associated with poorer outcomes. Bipolar disorder is also often characterized by a predominance of episode polarity, where some individuals experience more depressive episodes (termed predominant depressive polarity) while others experience more hypo/manic episodes (termed predominant hypo/manic polarity). We examined the associations between staging and predominant polarity with measures of illness burden and treatment outcome utilizing data from a six-month comparative effectiveness trial of lithium and quetiapine in bipolar disorder (Bipolar CHOICE). We used number of self-reported lifetime mood (depressive and hypo/manic) episodes as a proxy for staging and ratio of depressive to manic episodes to define predominant polarity. Polarity and staging were correlated with several measures of burden of illness. Childhood abuse was correlated with more lifetime mood episodes, while more depressive episodes and depressive polarity were correlated with more anxiety disorder comorbidity. Depressive polarity was also correlated with more past trials of psychotropics, particularly antidepressants. However, neither staging nor predominant polarity moderated the randomized treatment effect of lithium vs. quetiapine. Number of depressive episodes in the past year was identified as a potential predictor of overall worse treatment outcome, regardless of medication condition. In conclusion, though staging and predominant episode polarity correlated with several measures of illness burden, they were not associated with differential treatment outcomes. This could be because many of our patients presented for treatment at advanced stages of illness and further highlights the need for early intervention in bipolar disorder.

Adjuvant psychotherapy in early-stage bipolar disorder: A protocol for systematic review and meta-analysis

OBJECTIVE

There is no systematic review or meta-analysis to evaluate the efficacy of adjuvant psychotherapy in early-stage bipolar disorder. Therefore, the goal of this meta-analysis is to examine the evidence supporting psychotherapy as an efficacious approach to treating bipolar disorder.

METHODS

Seven electronic databases including Web of Science, Embase, PubMed, Wanfang Data, Scopus, Science Direct, Cochrane Library were searched in March 2021 by two independent reviewers. Data extraction was performed independently, and any conflict was resolved before final analysis. Only randomized clinical trials were included in this study. The trial entails 1 primary outcome measure (relapse) and several secondary outcome measures: time to relapse, relapse rate, days missed at work/school (record, interview), and social functioning level. The risk of bias assessment of the included studies was performed by 2 authors independently using the tool recommended in the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

We hypothesized that combined psychotherapy and pharmacological interventions would be superior to pharmacological interventions alone regarding the time to relapse into a manic or depressive episode.

CONCLUSION

This study expects to provide credible and scientific clinical evidence for the efficacy and safety of combined psychotherapy and pharmacological interventions in the treatment of bipolar disorder.

OSF REGISTRATION NUMBER

10.17605/OSF.IO/ZGS6W.

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.

The influence of stage of illness on functional outcomes after psychological treatment in bipolar disorder: A systematic review

OBJECTIVES

The aim of this study was to advance understanding of stage of illness in bipolar disorder (BD), by interrogating the literature for evidence of an influence of stage of illness on functional (ie non-symptom) outcomes following psychosocial intervention.

METHODS

A systematic literature search following PRISMA guidelines was conducted to identify empirical studies of psychosocial interventions for established BD. To investigate stage as a predictor of three functional outcomes (general/social functioning, cognitive functioning and quality of life [QoL]), study samples were dichotomised into earlier and later stage using proxy measures identified in existing staging models. Findings were integrated using data-based convergent synthesis.

RESULTS

A total of 88 analyses from 62 studies were identified. Synthesis across studies suggested that psychosocial intervention was more likely to be effective for general functioning outcomes earlier in the course of established BD. No stage-related differences were found for cognitive or QoL outcomes. Exploratory investigations found some evidence of an interaction between specific intervention type and stage of illness in predicting outcomes.

CONCLUSIONS

A novel systematic review provided preliminary evidence that benefits general/social functioning may be more pronounced in earlier versus later stages of established BD. The review also generated hypotheses about a potential three-way interaction, whereby specific psychosocial interventions may be best placed to target functional outcomes in earlier versus later stage BD. The strength of conclusions is limited by the overall low-quality and significant heterogeneity of studies. Further research is urgently required to understand the impact of illness stage on the effectiveness of psychosocial interventions.

Prevalence and clinical correlates of residual symptoms in remitted patients with bipolar disorder: An exploratory study

OBJECTIVE

This cross-sectional study aimed to evaluate the prevalence and factors associated with residual symptoms (both depressive and manic) in subjects with bipolar disorder (BD).

MATERIALS AND METHODS

A total of 844 subjects diagnosed BD with an illness of 2 years' duration and minimum of two lifetime episodes and in clinical remission were evaluated for residual symptoms using Hamilton Depression Rating Scale (HAM-D) and Young Mania Rating Scale (YMRS). Based on the severity of residual symptoms, the study groups were divided into four groups.

RESULTS

Sixty-nine percent of the subjects had residual depressive symptoms (i.e., HAM-D score in the range of 1-7) and 59% had residual manic symptoms (i.e., YMRS score in the range of 1-7). The most common residual depressive symptom was psychic anxiety (34%) followed by impaired insight (29%). The most common manic symptom was poor insight (31%) followed by sleep disturbances (25%). Subjects with both sets of residual symptoms had onset of BD at a relatively young age, when compared to those with only residual depressive symptoms. Presence of any comorbid physical illness and substance abuse disorder was significantly higher in those with both sets of residual symptoms.

CONCLUSIONS

The present study suggests that a substantial proportion of patients with BD have residual symptoms of both types. Comorbid physical illness and substance use were associated with residual symptoms. Identification and management of residual symptoms are highly essential to improve the overall outcome of patients with BD.

Number of episodes in bipolar disorder: The case for more thoughtful conceptualization and measurement

OBJECTIVES

Number of mood episodes (NoE) may be an important prognostic indicator in bipolar disorder, with implications for treatment. However, NoE has been conceptualized and measured inconsistently throughout the literature. This review examines the construct of NoE in bipolar disorder, with the aim of enhancing its conceptualization and measurement.

METHODS

A critical evaluation of literatures on important correlates of NoE, conceptually and phenomenologically overlapping features, and previous studies considering and measuring this construct was undertaken.

RESULTS

The literature indicates that despite frequent use, NoE has been inconsistently defined and measured. Multiple studies have linked NoE with important clinical factors, including relapse, functioning, cognitive impairment and the effectiveness of both pharmacological and psychosocial interventions, yet conclusions are limited by its inconsistent treatment. Additionally, it seems evident that that NoE may best be treated as a fuzzy construct (rather than precise figure), with yet to be defined overlaps with clinical variables such as age at onset and severity. Attempts to measure this construct have varied in comprehensiveness and structure.

CONCLUSIONS

The NoE construct may have important implications for individuals with bipolar disorders. However, more consistent and systematic definition and assessment of NoE is required to advance this literature and clarify its role. Recommendations aimed at advancing the conceptualization and the measurement of NoE are provided. Conceptualization may be advanced by considering and exploring relationships between NoE and factors with which it overlaps, while measurement may best be improved with increased consistency and balancing accuracy with feasibility.

Proxy measures of premortem cognitive aptitude in postmortem subjects with schizophrenia

BACKGROUND

Postmortem human brain studies provide the molecular, cellular, and circuitry levels of resolution essential for the development of mechanistically-novel interventions for cognitive deficits in schizophrenia. However, the absence of measures of premortem cognitive aptitude in postmortem subjects has presented a major challenge to interpreting the relationship between the severity of neural alterations and cognitive deficits within the same subjects.

METHODS

To begin addressing this challenge, proxy measures of cognitive aptitude were evaluated in postmortem subjects (N = 507) meeting criteria for schizophrenia, major depressive or bipolar disorder, and unaffected comparison subjects. Specifically, highest levels of educational and occupational attainment of the decedent and their parents were obtained during postmortem psychological autopsies.

RESULTS

Consistent with prior findings in living subjects, subjects with schizophrenia had the lowest educational and occupational attainment relative to all other subject groups, and they also failed to show the generational improvement in attainment observed in all other subject groups.

CONCLUSIONS

Educational and occupational attainment data obtained during postmortem psychological autopsies can be used as proxy measures of premortem cognitive function to interrogate the neural substrate of cognitive dysfunction in schizophrenia.

Does stage of illness influence recovery-focused outcomes after psychological treatment in bipolar disorder? A systematic review protocol

BACKGROUND

There is great interest in the possibility that 'stage of illness' moderates treatment outcomes in bipolar disorder (BD). Much remains unknown about the construct of stage of illness, but there is evidence that effectiveness of psychosocial interventions may depend on factors that are plausible proxy measures of stage of illness (e.g., number of episodes). To date, reviews of this data have focused solely on clinical outcomes (particularly symptoms and relapse rates), but a range of recovery-focused outcomes (including functioning, cognitive functioning, and quality of life) have been measured in individuals with established BD. The aim of the proposed systematic review is to synthesise existing evidence for plausible proxy measures of stage of illness as moderators of recovery-focused and functional outcomes in psychosocial treatment studies of BD.

METHODS

The proposed review will follow PRISMA guidelines; Scopus, PsychINFO, PubMed and Web of Science will be searched for empirical studies of psychosocial interventions used for established (clinical stages 2-4) BD; and findings will be summarised in a narrative synthesis of clinical stage of illness (operationalised in proxy measures identified in existing staging models) as a moderator of recovery-focused and functional outcomes of psychosocial interventions for established bipolar disorder.

DISCUSSION

This review will contribute to the literature by expanding upon previous reviews and potentially inform the psychosocial treatment of established BD. Implications include assisting clinicians, consumers and researchers to identify and select interventions most appropriate to recovery-focused goals based on individuals' clinical status.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016037868.

Factors predicting re-hospitalization for inpatients with bipolar mania--A naturalistic cohort

Patients with bipolar mania often require re-hospitalization, which can be a social-economic burden. This study aimed to investigate the factors affecting time to re-hospitalization for inpatients with acute bipolar mania. In this 6-year naturalistic study we reviewed the charts of inpatients with acute bipolar mania. Potential dichotomous factors including sex, family history of affective disorder, suicide history, and discharge against medical advice, involuntary admission, psychotic features, substance use disorder, and remission at discharge were recorded. Continuous variables including age, age at onset of affective episodes, and number of previous hospitalizations were also recorded. We used survival analysis with a univariate Cox proportional hazard regression model, along with forward multivariate model, to identify the potential factors. Of the 165 patients, 23% achieved symptomatic remission at discharge. In the forward Cox model, psychotic features, discharge against medical advice and higher number of previous hospitalizations were significant risk factors for re-admission. Remission at discharge was significantly associated with preventing re-hospitalization. We identified several predictors for re-hospitalization among inpatients with bipolar mania. Further studies are needed in other real-world settings to validate our results.

The impact of substance use disorders on recovery from bipolar depression: Results from the Systematic Treatment Enhancement Program for Bipolar Disorder psychosocial treatment trial

OBJECTIVE

Up to 60% of patients with bipolar disorder develop a substance use disorder during their lifetime. The purpose of this paper was to assess the impact of substance use disorders on depression recovery among bipolar patients randomly assigned to different psychotropic medications and psychosocial interventions. We hypothesized that patients with a comorbid substance use disorder would benefit less from psychotherapy regardless of treatment intensity/length compared to patients without a comorbid substance use disorder.

METHOD

We conducted post hoc analyses among bipolar disorder patients ( n = 270) with and without comorbid substance use disorders enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder randomized psychosocial intervention trial. All patients entered during or shortly after the onset of a bipolar depressive episode. Logistic regression and Cox proportional hazard models were used to assess whether current or past substance use disorders moderated the response of patients to intensive psychosocial intervention or brief psychoeducation with collaborative care, operationalized as full recovery from an episode of bipolar depression.

RESULTS

Current comorbid substance use disorders significantly predicted likelihood of recovery (odds ratio = 2.25, p = 0.025) and time to recovery (odds ratio = 1.71, p = 0.006) from bipolar depression. We found that 74.5% of patients with a current substance use disorder, compared to 56.5% without a current substance use disorder, recovered from bipolar depression. Past substance use disorders did not predict likelihood of recovery or time to recovery. Current substance use disorders did not significantly moderate response to intensive psychotherapy versus collaborative care.

CONCLUSION

Contrary to our hypotheses, bipolar disorder participants with a current comorbid substance use disorder were more likely to recover from psychosocial treatment for bipolar depression than patients without a current comorbid substance use disorder. If this finding is replicated, it has implications for the ordering of treatment for patients with comorbid bipolar disorder and substance use disorders.

Symptom Dimensions and Trajectories of Functioning Among Bipolar Youth: A Cluster Analysis

BACKGROUND

Accurate assessment of pediatric bipolar disorder (BD) is important for allocating appropriate treatment, but it is complicated by significant heterogeneity in symptom presentation and high rates of comorbidity. Investigating clinical subtypes of the disorder may help to clarify diagnostic boundaries and inform targeted treatment. This study used a full diagnostic instrument to examine symptom patterns among youth with BD.

METHOD

Trained interviewers completed the Washington University Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) with 71 children (7 to 13 y of age) and families as part of the baseline assessment for a randomized clinical trial of Child- and Family-focused Cognitive-Behavioral Therapy (CFF-CBT) compared with treatment as usual (TAU) for pediatric BD. All participants met DSM-IV-TR criteria for a bipolar spectrum disorder. Hierarchical and K-means cluster analyses were performed. Resultant clusters were compared on symptom severity and psychosocial functioning at baseline and across treatment.

RESULTS

Two distinct symptom profiles emerged: "dysregulated/defiant" and "classic presentation." The dysregulated/defiant cluster was characterized by more externalizing and disruptive behaviors, whereas the classic cluster presented with more severe depression, hallmark manic symptoms, anxiety, and inattention. CFF-CBT consistently promoted psychosocial coping skills, such as problem solving and self-control, for the dysregulated/defiant cluster. TAU also promoted these skills among the individuals in the classic presentation group but not those with symptoms in the dysregulated/defiant cluster.

DISCUSSION

Pediatric BD may be characterized by distinct phenotypes with unique etiologies and pathways to impairment. The use of a parametric approach to classify the diverse symptom presentations helped yield valuable insights into how to promote the best prognosis for improved functional outcomes in CFF-CBT versus TAU for youth with pediatric BD.

Episode accumulation associated with hastened recurrence and delayed recovery in bipolar disorder

AIMS

Assess episode accumulation (≥ 10 prior mood episodes) associations with demographic/baseline clinical characteristics and mood episode recurrence/recovery in bipolar disorder (BD).

METHODS

Stanford BD Clinic outpatients enrolled during 2000-2011 were assessed with Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation. Among recovered and syndromal mood episode patients, we assessed episode accumulation associations with demographic/baseline clinical characteristics and with recurrence/recovery (by Kaplan-Meier survival analyses, with mediators assessed with Cox Proportional Hazard Ratio (HR) analyses).

RESULTS

Among all 450 BD outpatients, almost twice as many had versus lacked episode accumulation (65.8% versus 34.2%), which was less common among 92 recovered versus 193 syndromal mood episode patients (51.1% versus 69.9%). Among recovered patients, episode accumulation was associated with 14/18 (77.7%) demographic/other baseline clinical characteristics, and hastened mood episode recurrence. Among syndromal mood episode patients, episode accumulation was associated with 13/18 (72.2%) demographic/other baseline clinical characteristics, and delayed mood episode recovery.

LIMITATIONS

American tertiary BD clinic referral sample.

CONCLUSION

Studies are needed to confirm episode accumulation is associated with hastened mood episode recurrence and delayed mood episode recovery in BD, and to further explore its' associations with hastened mood elevation recurrence and delayed recovery from depressive and mood elevation episodes, considered separately.

Psychodynamic Treatment of the Criminal Offender: Making the Case for Longer-Term Treatment in a Longer-Term Setting

In recent years, prisons and jails have become de facto psychiatric hospitals, responsible for the care and treatment of individuals with serious mental illness. Historically, cognitive-behaviorally informed therapeutic approaches have been the treatment of choice among mental health practitioners in correctional settings. However, inmate-clients often present with complex diagnostic issues that are arguably better served by long-term treatment options, such as psychodynamic psychotherapy. We first review the nature of psychotherapy in the correctional setting, as well as treatment barriers and challenges faced by both mental health providers and inmate-clients. We then review treatment studies that examine the efficacy of various therapeutic techniques in correctional/forensic contexts. Finally, we argue that, due to the complex nature of psychopathology, average length of time incarcerated, and treatment issues that arise in this multifaceted and challenging setting, mental health treatment providers should consider providing psychodynamic treatment modalities when working with incarcerated individuals. We also argue that more research is needed to examine the efficacy of these treatment approaches with inmate-clients.

Age of onset of bipolar disorder: Combined effect of childhood adversity and familial loading of psychiatric disorders

BACKGROUND

Family history and adversity in childhood are two replicated risk factors for early onset bipolar disorder. However, their combined impact has not been adequately studied.

METHODS

Based on questionnaire data from 968 outpatients with bipolar disorder who gave informed consent, the relationship and interaction of: 1) parental and grandparental total burden of psychiatric illness; and 2) the degree of adversity the patient experienced in childhood on their age of onset of bipolar disorder was examined with multiple regression and illustrated with a heat map.

RESULTS

The familial loading and child adversity vulnerability factors were significantly related to age of onset of bipolar and their combined effect was even larger. A heat map showed that at the extremes (none of each factor vs high amounts of both) the average age of onset differed by almost 20 years (mean = 25.8 vs 5.9 years of age).

LIMITATIONS

The data were not based on interviews of family members and came from unverified answers on a patient questionnaire.

CONCLUSIONS

Family loading for psychiatric illness and adversity in childhood combine to have a very large influence on age of onset of bipolar disorder. These variables should be considered in assessment of risk for illness onset in different populations, the need for early intervention, and in the design of studies of primary and secondary prevention.

A cluster analytic approach to identifying predictors and moderators of psychosocial treatment for bipolar depression: Results from STEP-BD

BACKGROUND

We sought to address how predictors and moderators of psychotherapy for bipolar depression - identified individually in prior analyses - can inform the development of a metric for prospectively classifying treatment outcome in intensive psychotherapy (IP) versus collaborative care (CC) adjunctive to pharmacotherapy in the Systematic Treatment Enhancement Program (STEP-BD) study.

METHODS

We conducted post-hoc analyses on 135 STEP-BD participants using cluster analysis to identify subsets of participants with similar clinical profiles and investigated this combined metric as a moderator and predictor of response to IP. We used agglomerative hierarchical cluster analyses and k-means clustering to determine the content of the clinical profiles. Logistic regression and Cox proportional hazard models were used to evaluate whether the resulting clusters predicted or moderated likelihood of recovery or time until recovery.

RESULTS

The cluster analysis yielded a two-cluster solution: 1) "less-recurrent/severe" and 2) "chronic/recurrent." Rates of recovery in IP were similar for less-recurrent/severe and chronic/recurrent participants. Less-recurrent/severe patients were more likely than chronic/recurrent patients to achieve recovery in CC (p=.040, OR=4.56). IP yielded a faster recovery for chronic/recurrent participants, whereas CC led to recovery sooner in the less-recurrent/severe cluster (p=.034, OR=2.62).

LIMITATIONS

Cluster analyses require list-wise deletion of cases with missing data so we were unable to conduct analyses on all STEP-BD participants.

CONCLUSIONS

A well-powered, parametric approach can distinguish patients based on illness history and provide clinicians with symptom profiles of patients that confer differential prognosis in CC vs. IP.

Age at onset in patients with bipolar I and II disorder: a comparison of large sample studies

BACKGROUND

Bipolar Disorder (BD) is a leading cause of disability worldwide and factors contributing to its burden include chronic relapsing course, comorbidity, suicide risk, and early age at onset (AAO). In particular, recent investigation has shown that BD onset may occur earlier than previously believed, even though whether BDI and II are different in such regard is still debated. Reduced samples may, moreover, limit the confidence in the published studies, with geographic issues, in turn, representing potentially conditioning factors. The present review was aimed to select and analyze large sample studies comparing AAO in BDI vs II patients.

METHODS

A PubMed literature search was performed, considering English-written articles published up to December 2015, comparing AAO in BDI vs II patients with sample size≥100 subjects per group.

RESULTS

Seventeen studies were considered suitable for revision, with 8 studies reporting statistically significant differences and 9 not. Among studies reporting statistically significant differences, mostly conducted in Europe, 6 showed an earlier AAO in BDI, while 2 in BDII subjects.

LIMITATIONS

Only studies with large samples included, considering AAO as a continuous variable, and providing a comparison between the bipolar subtypes.

CONCLUSIONS

Our findings suggest that AAO per se does not seem to reliably differentiate BDI from BDII patients and that such variable should likely be investigated in the context of other clinical characteristics, in order to assess its overall influence over BD course. Geographic factors may, in turn, play a potential role with future investigation warranted to further explore this specific issue.

Medical burden, body mass index and the outcome of psychosocial interventions for bipolar depression

OBJECTIVE

Individuals with bipolar disorder experience a disproportionately high incidence of medical co-morbidity and obesity. These health-related problems are a barrier to recovery from mood episodes and have been linked with unfavorable responses to pharmacological treatment. However, little is known about whether and how these characteristics affect responses to adjunctive psychotherapy.

METHOD

Embedded in the Systematic Treatment Enhancement Program for Bipolar Disorder was a randomized controlled trial of psychotherapy for bipolar depression comparing the efficacy of intensive psychotherapy plus pharmacotherapy with collaborative care (a three-session psycho-educational intervention) plus pharmacotherapy. We conducted a post-hoc analysis to evaluate whether medical burden and body mass index predicted and/or moderated the likelihood of recovery and time until recovery from a depressive episode among patients in the two treatments.

RESULTS

Participants who had medical co-morbidity and body mass index data constituted 199 of the 293 patients in the original Systematic Treatment Enhancement Program for Bipolar Disorder trial. Higher medical burden predicted a lower likelihood of recovery from depression in both treatment conditions (odds ratio = 0.89), but did not moderate responses to intensive psychotherapy vs collaborative care. Intensive psychotherapy yielded superior recovery rates for individuals of normal body mass index (odds ratio= 2.39) compared with collaborative care, but not among individuals who were overweight or obese.

CONCLUSION

Medical co-morbidity and body weight impacts symptom improvement and attention to this co-morbidity may inform the development of more personalized treatments for bipolar disorder.

The Burden of Repeated Mood Episodes in Bipolar I Disorder: Results From the National Epidemiological Survey on Alcohol and Related Conditions

The aim of this study was to examine the association between previous mood episodes and clinical course/functioning in a community sample (National Epidemiological Survey on Alcohol and Related Conditions [NESARC]). Subjects (n = 909) met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria for bipolar I disorder and provided data on number of previous episode recurrences. Number of previous mood episodes was used to predict outcomes at wave 1 and wave 2 of the NESARC. Previous mood episodes accounted for small but unique variance in outcomes. Recurrence was associated with poorer functioning, psychiatric and medical comorbidity, and increased odds of suicidality, disability, unemployment, and hospitalization at wave 1. Recurrences were associated with greater risk for new onset suicidality, psychiatric comorbidity, disability, unemployment, and poor functioning by wave 2. The course of bipolar disorder does worsen with progressive mood episodes but is attenuated in community, relative to clinical samples. Interventions to prevent future relapse may be particularly important to implement early in the course of illness.

Clinical characteristics of bipolar disorder: a comparative study between Argentina and the United States

BACKGROUND

Bipolar disorder presents with diverse clinical manifestations. Numerous investigators have sought to identify variables that may predict a more severe illness course.

METHODS

With the objective of studying the clinical characteristics of bipolar patients between South and North America, a comparison was performed between a sample from Argentina (n = 449) and a sample from the United States (n = 503) with respect to demographics and clinical characteristics, including presence of comorbidities.

RESULTS

The Argentinian sample had more unfavorable demographics and higher rates of prior psychiatric hospitalization and prior suicide attempt but a better social outcome. However, the sample from the United States had a higher rate of prior year rapid cycling, as well as younger bipolar disorder onset age (mean ± SD, 17.9 ± 8.4 vs. 27.1 ± 11.4 years) and more severe clinical morbidity, though there was no significant difference in terms of the total duration of the illness. Argentinian compared to American patients were taking more mood stabilizers and benzodiazepines/hypnotics, but fewer antipsychotics and other psychotropic medications, when considering patients in aggregate as well as when stratifying by illness subtype (bipolar I versus bipolar II) and by illness onset age (≤21 vs. >21 years). However, there was no significant difference in rate of antidepressant prescription between the two samples considered in aggregate.

CONCLUSIONS

Although possessing similar illness durations, these samples presented significant clinical differences and distinctive prescription patterns. Thus, though the Argentinian compared to North American patients had more unfavorable demographics, they presented a better social outcome and, in several substantive ways, more favorable illness characteristics. In both samples, early onset (age ≤ 21 years) was a marker for poor prognosis throughout the illness course, although this phenomenon appeared more robust in North America.