Association of Anxiety Symptoms in Offspring of Bipolar Parents with Serotonin Transporter-Linked Polymorphic Region (5-HTTLPR) Genotype

Parental psychopathology and offspring anxiety disorders in childhood and adolescence: A Finnish nationwide register study

BACKGROUND

Research suggests an association between parental psychiatric disorders and offspring anxiety disorders, yet comprehensive studies are limited. This study aims to investigate the associations between various parental psychiatric disorders and anxiety disorders in their offspring.

METHOD

Using Finnish register data, this nested case-control study analyzed 867,175 singleton live births from 1992 to 2006, identifying 21,671 cases of anxiety disorders diagnosed between 1998 and 2016. Matched with four controls each (n = 72,414) based on age and biological sex, the study adjusted for demographic and prenatal factors using conditional logistic regression models to calculate odds ratios (aORs).

RESULTS

There was a significant association between parental psychiatric disorders and increased risk of anxiety disorders in offspring. The risk was notably higher when both parents had psychiatric disorders (aOR = 5.04; 95 % CI, 4.70-5.39; p < .001). Maternal psychiatric disorders were strongly associated with offspring anxiety than paternal disorders (aOR 1.52; 95 % CI 1.43-1.61; p < .001). This association was consistent regardless of timing of parental diagnosis. Significant associations were observed between any parental psychiatric disorder and increased risks in offspring for specific phobia, social phobia, generalized anxiety disorder, separation anxiety, and panic disorder. Maternal psychiatric disorders showed elevated risk for panic disorder and social phobia among girls and separation anxiety and generalized anxiety among boys.

CONCLUSION

The findings emphasize the significant impact of parental psychiatric health on offspring anxiety disorders, highlighting the influence of genetic and environmental factors. Addressing parental mental health is crucial in preventing childhood anxiety disorders.

The Emergence of Mania After Initiating Escitalopram for Anxiety Disorder

The abrupt transition into mania, known as a bipolar switch, poses a significant challenge in the treatment of mental illnesses. We present a case of a 22-year-old Hispanic female with generalized anxiety disorder (GAD) and autism spectrum disorder (ASD) who developed mania within five days after initiating escitalopram 5 mg. The patient had no reported history of bipolar disorder prior to this episode, and an extensive medical workup ruled out organic causes. The patient was in the acute inpatient psychiatric unit for 25 days and returned to baseline after discontinuation of escitalopram and initiating divalproex and olanzapine. This case underscores the potential risk of a bipolar switch with antidepressant use and highlights the importance of vigilant monitoring and considering underlying bipolarity in such patients.

Pharmacogenetic Factors Influence Escitalopram Pharmacokinetics and Adverse Events in Youth with a Family History of Bipolar Disorder: A Preliminary Study

Introduction: Escitalopram is an effective and generally well-tolerated antidepressant, but children of parents with bipolar disorder (BD) may be at increased risk for adverse events associated with antidepressants, including increased irritability, restlessness, impulsivity, and manic symptoms. This risk may be influenced by polymorphisms in genes encoding cytochrome P450 enzymes (CYP2C19 or CYP2D6), the serotonin transporter (SLC6A4), and the serotonin receptor 2A subtype (HTR2A). We explored whether gene-drug interactions influence the emergence of adverse events in depressed and/or anxious youth with a family history of BD. Materials and Methods: Children and adolescents aged 12-17 years with a first-degree relative with bipolar I disorder were treated with escitalopram and monitored for adverse effects, underwent pharmacogenetic testing, and provided serum escitalopram levels. Emergence of adverse events was determined by study clinicians, and symptoms were tracked using the Treatment-Emergent Activation and Suicidality Assessment Profile (TEASAP) and Pediatric Adverse Events Rating Scale. Clinical Pharmacogenetics Implementation Consortium guidelines were used to determine CYP2C19 and CYP2D6 phenotypes. Results: Slower CYP2C19 metabolizers had greater dose-normalized 24-hour area under the curve (AUC0-24; p = 0.025), trough concentrations (Ctrough; p = 0.013), and elimination half-lives (t1/2; p < 0.001). CYP2D6 phenotype was not significantly associated with any pharmacokinetic parameter. Slower CYP2D6 metabolizers had increased TEASAP akathisia (p = 0.015) scores. HTR2A A/A and A/G genotypes were associated with increased TEASAP "self-injury, suicidality, and harm to others" subscale scores (p = 0.017). Escitalopram maximum concentration, AUC0-24, CYP2C19 phenotype, and SLC6A4 genotype were not associated with adverse events. Conclusions: CYP2C19 phenotype influences escitalopram pharmacokinetics whereas CYP2D6 phenotype does not. Slower CYP2D6 metabolism was associated with increased akathisia, and HTR2A A/A or A/G genotypes were associated with increased risk of self-harm or harm to others. Larger cohorts are needed to identify associations between genetic test results and antidepressant-associated adverse events. Trial Registration: ClinicalTrials.gov identifier: NCT02553161.

A Double-Blind Randomized Trial to Investigate Mechanisms of Antidepressant-Related Dysfunctional Arousal in Depressed or Anxious Youth at Familial Risk for Bipolar Disorder

Antidepressants are standardly used to treat moderate to severe symptoms of depression and/or anxiety in youth but may also be associated with rare but serious psychiatric adverse events such as irritability, agitation, aggression, or suicidal ideation. Adverse events are especially common in youth with a family history of bipolar disorder (BD) who are at heightened risk for dysfunction in neurobiological systems that regulate emotion and arousal. To further understand this phenomenon, this study will examine (a) baseline risk factors associated with dysfunctional arousal in a sample of youth at high-risk for BD treated with or without an antidepressant, (b) whether antidepressant-related changes in arousal are mediated by changes in prefrontal-limbic circuitry, and (c) whether pharmacogenetic factors influence antidepressant-related changes in arousal. High-risk youth (aged 12-17 years with moderate to severe depressive and/or anxiety symptoms and at least one first-degree relative with bipolar I disorder) will be randomized to receive psychotherapy plus escitalopram or psychotherapy plus placebo. Neuroimaging and behavioral measures of arousal will be collected prior to randomization and at 4 weeks. Samples for pharmacogenetic analysis (serum escitalopram concentration, CYP2C19 metabolizer phenotype, and HTR2A and SLC6A4 genotypes) will be collected at 8 weeks. Youth will be followed for up to 16 weeks to assess change in arousal measures.

The Management of Prodromal Symptoms of Bipolar Disorder: Available Options and Future Perspectives

The onset of prodromal symptoms in subjects who are at familial or clinical risk for bipolar disorder could be considered as an important alarm bell for the development of the disease and should be carefully detected. The management of prodromes in bipolar high-risk patients appears to be an important means of prevention; nevertheless, at the moment, there aren’t clear and widely shared treatment indications. The aim of this review is to summarize the available treatment options (pharmacological, psychosocial and nutraceutical) for the management of prodromal symptoms in subjects who are at familial or clinical risk for bipolar disorder.

Prospective Association between Childhood Behavioral Inhibition and Anxiety: a Meta-Analysis

Behavioral inhibition (BI) is a risk factor for anxiety. However, the estimates of the strength of this association vary widely. In addition, while BI is a strong predictor of social anxiety disorder (SAD), its association with other anxiety disorders is unclear. The current study sought to establish the relationship between BI and anxiety and to quantify this association for a range of anxiety disorders. We searched PsycInfo, PubMed and Embase for articles published before May 18th, 2019 using search terms for BI, anxiety and prospective study design. We selected articles which assessed the prospective relationship between BI in childhood and anxiety. Using random-effects meta-analysis with robust variance estimation, which allowed for the inclusion of multiple follow-ups of the same sample, we established the association between BI and any anxiety. We also explored the association between BI and individual anxiety disorders. Data from 27 studies consisting of 35 follow-ups of 20 unique samples indicated that BI prospectively increases the odds of anxiety (OR = 2.80, 95% CI 2.03 to 3.86, p < 0.001). There was also a positive association between BI and all individual anxiety disorders, with effect sizes ranging from small in the case of specific phobia (OR = 1.49, 95% CI 1.03 to 2.14, p = 0.03) to large in the case of SAD (OR = 5.84, 95% CI 3.38 to 10.09, p < 0.001). BI in early childhood is a strong risk factor for anxiety. Targeting BI may help reduce the number of children who will develop anxiety disorders.

Asenapine in the Treatment of Bipolar Depression

OBJECTIVES

Asenapine, a potent serotonin 7 (5-HT₇) receptor antagonist, was examined for efficacy as an antidepressant in depressed bipolar subjects. It was predicted that subjects with the genetic variant of the short form of the serotonin transporter (5HTTR) would be more likely to respond.

EXPERIMENTAL DESIGN

A subset of patients participating in a randomized, placebo-controlled study of the efficacy of asenapine in bipolar I depression also underwent genetic testing for the 5HTTR. Montgomery Åsberg Depression Rating Scale (MADRS) score was ≥ 26 prior to randomization to asenapine or placebo for 8 weeks. Gene testing was performed before breaking the blind.

PRINCIPAL OBSERVATIONS

Nine patients completing the study also underwent gene testing. At study end, the average MADRS improvement was -19.80 ± SD 8.59 for the 4 people randomized to asenapine and -3.80 ± 9.01 for the 5 people receiving placebo (P = 0.021, t = 2.88). Anxiety, as measured by the Hamilton Anxiety Rating Scale (HAM-A), also improved in asenapine-treated patients (-15.40 ± 6.15 vs. -2.80 ± 7.95, P = 0.023, t = 2.803). Six participants had the short form of the 5HTTR, and it is believed they influenced the significant outcome in this small sample.

CONCLUSIONS

While this is a very small sample, asenapine appears to have a beneficial effect on both depression and anxiety in depressed bipolar I patients compared to treatment with placebo. Due to the large fraction of subjects with the short form, the hypothesis that the SF-5HTTR might increase asenapine response could not be adequately tested.

Clinical, genetic, and brain imaging predictors of risk for bipolar disorder in high-risk individuals

Introduction: Early detection and intervention in bipolar disorder (BD) might reduce illness severity, slow its progression, and, in specific cases, even ward off the full-blown disorder. Therefore, identifying at-risk individuals and targeting them promptly before the illness onset is of the utmost importance. In the last decades, there has been a significant effort aimed at identifying genetic and molecular factors able to modulate risk and pharmacological outcomes.Areas covered: We performed a narrative review of articles aimed at identifying clinical, genetics, molecular, and brain imaging markers of BD specifically focusing on samples of individuals at high-risk for BD. Special emphasis was put on studies applying an integrative design, e.g. studies combining different markers such as genetic and brain imaging.Expert opinion: Findings from studies in risk individuals are still too sparse to allow drawing definite conclusions. However, the high potentiality of longitudinal studies in individuals considered at risk to develop BD supports the need for more efforts. Future investigations should focus on more homogeneous subpopulations and evaluate the cross-linking between clinical, genetic, and brain morphostructural/functional neuroimaging characteristics as predictors of risk for BD.

Clinical staging model in offspring of parents with bipolar disorder: a systematic review

OBJECTIVE

We sought to systematically review the literature on the psychiatric risk of offspring of parents with bipolar disorder (OPBD) using a developmental psychopathology framework. The review also sought to establish the utility of clinical stage modelling as a framework for identifying precursor disorders to later onset of bipolar disorder (BD) in OPBD.

METHODS

A systematic search was performed using EMBASE, PsychINFO and Medline. Reference lists of included studies and previous reviews were also searched. Studies were included if they reported diagnostic outcomes for child, adolescent and young adult offspring of parents diagnosed with BD.

RESULTS

Twenty-six studies were identified representing 21 individual cohorts. The review identified that OBPD present as a high-risk group for a range of mood and non-mood disorders in childhood, adolescence and young adulthood. The trajectory of risk was from non-mood disorders in childhood via non-bipolar mood disorders in early adolescence towards mania/hypomania in late adolescence and early adulthood. From a clinical staging perspective, childhood anxiety disorders were associated with later onset of BD. Recurrent substance use disorder was identified as a risk in OPBD during late adolescence and early adulthood. Quality ratings indicated that studies were methodologically robust.

CONCLUSIONS

Our review provides evidence for a developmental psychopathology trajectory of precursor risks to BD in OPBD. There is support for clinical stage modelling as a conceptual framework for understanding developmental risk in OPBD and as a tool for developing early and individualized intervention strategies.

Antidepressant-Induced Activation in Children and Adolescents: Risk, Recognition and Management

The tolerability of antidepressants is poorly characterized in children and adolescents with depressive and anxiety disorders. Among adverse events that affect the tolerability of antidepressants in youth is activation, a cluster of symptoms that represent a hyperarousal event characterized by impulsivity, restlessness, and/or insomnia. This cluster of symptoms was first identified as a side effect of selective serotonin and selective serotonin norepinephrine inhibitors (SSRIs and SSNRIs) in the early 1990s; however, activation remains poorly characterized in terms of prevalence, risk factors, and pathophysiology. This article describes the pathophysiology of antidepressant-related activation, predictors of activation and its clinical management in youth with depressive and anxiety disorders who are treated with antidepressant medications.

Psychiatric Disorders and Quality of Life in the Offspring of Parents with Bipolar Disorder

OBJECTIVE

To determine current and lifetime psychopathology and assess quality of life (QoL) in offspring of a parent with bipolar disorder (BD).

METHODS

We investigated 43 offspring of bipolar parents (high-risk offspring [HRO]) (mean age 12.5 ± 3.1; range 6.7-17.9 years) and 43 comparison offspring matched for sex, age, and IQ of healthy parents. Lifetime and current presence of Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) diagnoses were assessed using Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL). We administered parent and self-report versions of General Behavior Inventory and the Screen for Child Anxiety-Related Emotional Disorders (SCARED). QoL was evaluated using the self-report questionnaire KIDSCREN-52.

RESULTS

Thirty-seven HRO (86%) and 18 controls (42%) met DSM-5 criteria for at least one lifetime psychiatric diagnosis (adjusted OR = 7.20; 95% CI 2.27-22.81). Compared to controls, HRO had higher lifetime frequency of any mood disorder (33% vs. 2%, p < 0.001), anxiety disorder (60% vs. 14%, p < 0.001), and attention-deficit/hyperactivity disorder (26% vs. 5%, p = 0.01). After adjustment for confounders, only mood (OR = 13.05; 95% CI 1.41-120.60) and anxiety (OR = 9.69; 95% CI 2.75-34.31) disorders remained significantly more frequent in the HRO group. In comparison with controls, HRO scored lower in the following domains: QoL, social support and relationship with peers (p = 0.003; Cohen's d = 0.91), parent relationships and home life (p = 0.008; d = 0.67), as well as self-perception (p = 0.04; d = 0.55).

CONCLUSIONS

In agreement with other studies, we found a higher rate of lifetime anxiety and mood disorders in children and adolescents at confirmed familial risk for BD. Reduction in QoL was already evident across a number of domains. Adult psychiatrists should incorporate into their assessment procedures targeted questions on the presence of psychopathology in offspring of their adult patients with severe mental disorders and child services should bridge with adult services providing accessible services to children of affected parents.