Occupational disability in bipolar disorder: analysis of predictors of being on severe disablement benefit (PREBIS study data)

Cariprazine as a maintenance therapy in the prevention of mood episodes in adults with bipolar I disorder

INTRODUCTION

Cariprazine treats acute manic and depressive episodes in bipolar I disorder (BP-I), but its efficacy in preventing relapse of mood episode remains unknown.

METHODS

In this phase 3b, double-blind, placebo-controlled study, patients with BP-I with acute manic or depressive episodes (each with/without mixed features), were treated with cariprazine 3.0 mg/day during a 16-week open-label treatment period; those who achieved stable remission within 8 weeks and remained stable for at least another 8 weeks were randomized to receive cariprazine 1.5 or 3.0 mg per day or placebo in the double-blind treatment period for up to 39 weeks. The primary efficacy endpoint was time to relapse of any mood episode. Adverse events (AEs) were assessed.

RESULTS

Patients (440/896) enrolled in the open-label treatment period achieved stability criteria and were randomized to receive cariprazine 3.0 mg/day (n = 148), cariprazine 1.5 mg/day (n = 147), or placebo (n = 145) in the double-blind treatment period. Relapse rates were 17.9%, 16.8%, and 19.7% in the cariprazine 3.0 mg/day, cariprazine 1.5 mg/day, and placebo groups, respectively. Neither dose of cariprazine was more effective than placebo on the primary outcome (3.0 mg/day: HR = 0.89, [95% CI: 0.5, 1.5]; 1.5 mg/day: HR = 0.83, 95% CI [0.5, 1.4]). The most frequently reported AEs (≥5%) were akathisia, headache, insomnia, and nausea in the open-label treatment period and increased weight and insomnia in the double-blind treatment period. In the open-label and double-blind treatment periods, 7.5% and 1.6% of patients experienced an AE leading to discontinuation.

CONCLUSION

Cariprazine was not superior to placebo in the prevention of relapses in this study. Relapse rates were unusually low in the placebo group. Cariprazine was well-tolerated.

The effect of neuroendocrine abnormalities on the risk of psychiatric readmission after hospitalization for bipolar disorder: A retrospective study

BACKGROUND

The correlation between the endocrine system and bipolar disorder(BD) has been well recognized, yet the influence of neuroendocrine hormones on readmission risk post-hospitalization for BD remains largely unexplored. This retrospective cohort study was to scrutinize the impact of neuroendocrine functionality on the readmission of patients with BD post-hospitalization for mental disorders.

METHODS

The dataset was derived from the electronic medical records of the First Affiliated Hospital of Jinan University in Guangzhou, China. Both univariate and multivariate logistic regression analysis were conducted on all patients hospitalized for BD, and from 1 January 2017 to October 2022.

RESULTS

Of the 1110 eligible patients, 83 and 141 patients experienced psychiatric readmissions within 90 and 180 days post-discharge, respectively. Multivariate analysis revealed that high serum TSH levels (aOR = 1.079; 95%CI = 1.003-1.160) and thyroid disease comorbidities (aOR = 2.899; 95%CI = 1.303-6.452) were independently correlated with the risk of 90-day readmission; while increased serum TSH levels (aOR = 1.179; 95%CI = 1.081-1.287) represented a risk factor for 180-day readmission. These results indicate that high serum TSH levels and thyroid disease comorbidities may contribute to an elevated readmission risk in patients with BD following hospitalization.

CONCLUSION

Routinely evaluating and intervening in thyroid function is crucial in the treatment of BD, as it may aid in preventing re-hospitalization.

Unheard voices: The sexual challenges of families of patients with bipolar disorder: A qualitative content analysis

OBJECTIVES

The aim of this study was to explore the voices of the family members of Bipolar Disorder (BD) patients about the challenges ahead of them.

METHODS

In this qualitative study, 22 participants shared their experiences of sexual challenges of patients with BD through in-depth, face-to-face, semi-structured interviews. Qualitative content analysis was used for data analysis.

RESULTS

An overarching theme entitled "Unheard voices" reflected this experience. It comprised four main categories include sexual promiscuity, a change in sexual patterns, sexual support, and sexual indifference. The results revealed that the families of patients with BD have to deal with sexual promiscuity and change in sexual patterns in their family, and the family system attempts to respond to these changes by sexual support mechanisms and sexual indifference.

CONCLUSIONS

Given the significant impact of healthy sexual behaviors on the quality of life of both the individual and the family, therapists and family support systems are advised to strengthen and educate families to support their patients' sexual health and needs and protect their sexual existence; they should also address the sexual challenges faced by these families as a diagnostic and therapeutic priority, and early sexual health interventions should be provided to these families.

Comparing the metabolic pathways of different clinical phases of bipolar disorder through metabolomics studies

This study identified the metabolic biomarkers for different clinical phases of bipolar disorder (BD) through metabolomics. BD patients were divided into three groups: patients with BD and depressive episodes (BE, n = 59), patients with BD and mania/hypomania episodes (BH, n = 16), patients with BD and mixed episodes (BM, n = 10), and healthy controls (HC, n = 10). Serum from participants was collected for metabolomic sequencing, biomarkers from each group were screened separately by partial least squares analysis, and metabolic pathways connected to the biomarkers were identified. Compared with the controls, 3-D-hydroxyacetic acid and N-acetyl-glycoprotein showed significant differences in the BE, BH, and BM groups. This study suggests that different clinical types of BD share the same metabolic pathways, such as pyruvate, glycolysis/gluconeogenesis, and ketone body metabolisms. In particular, abnormal glycine, serine, and threonine metabolism was specific to BM; β-glucose, glycerol, lipids, lactate, and acetoacetate metabolites were specific to depressive episodes; the guanidine acetic acid metabolites specific to BH; and the acetic and ascorbic acids were metabolites specific to manic and BM. We screened potential biomarkers for different clinical phases of BD, which aids in BD typing and provides a theoretical basis for exploring the molecular mechanisms of BD.

Effects of Exercise on Functional Recovery in Patients with Bipolar Depression: A Study Protocol for a Randomized Controlled Trial

Treatment of bipolar disorder is prone to prolongation despite various treatments, including medication. The efficacy of exercise treatment (i.e., interventions involving physical exercise and sports intervention) for major depressive disorders has been reported for depressive symptoms, cognitive function, and sleep disturbances. However, its efficacy for bipolar disorder has yet to be established. We designed a randomized, controlled, double-blind clinical trial that includes 100 patients with bipolar disorder aged 20-65 years. This will be a cluster-randomized, two-group trial that will be conducted in ten psychiatric hospitals. The hospitals will be randomly assigned to an exercise intervention + treatment as usual (exercise) group or a placebo exercise intervention (stretching) + treatment as usual (control) group. Patients will be assessed using an extensive battery of clinical tests, physical parameters, sleep status, biological parameters (cytokines, neurotrophic factors), and genetic parameters (DNA and RNA) at baseline after a 6-week intervention period, at 10-week follow-up, and at 6-month follow-up. This innovative study may provide important evidence for the effectiveness of exercise in the treatment of bipolar depression based on clinical, biological, genetic, and physiological markers.

A retrospective study of psychotropic drug treatments in bipolar disorder at acute and maintenance episodes

BACKGROUND

Bipolar disorder (BD) is predominantly treated with psychotropic drugs, but BD is a complex medical condition and the contribution of psychotropic drugs is not clear. The objectives of this study are: (1) to present psychotropic drugs used in patients with BD; (2) to access changes of psychotropic drug treatments in acute and maintenance episodes.

METHODS

The study retrospectively evaluated the medical records of inpatients in the Ningbo Kangning Hospital from January 2019 to December 2019. The medical history of each subject was collected completely, including sociodemographic (gender, age, marital status, and so on) and clinical characteristics at baseline and within 12 months of admission.

RESULTS

The study ultimately included 204 patients with BD. After 12 months, 73.0% of the patients still took drugs. Mood stabilizers (72-90%) and antipsychotics (77-95%) were still the most important drugs in patients with BD. Antidepressants (34-40%) and benzodiazepines (20-34%) were the other frequently used drug classes. For mood stabilizers, 40-56% of patients were prescribed lithium. For antipsychotic, 54-65% of patients were prescribed quetiapine. Sertraline (6-9%) and fluoxetine (5-9%) were the antidepressant that most frequently prescribed. Lorazepam (10-18%) was the most commonly used benzodiazepine. In psychotropic polypharmacy, the most frequently taken was mood stabilizer plus antipsychotic co-treatment, about 36-44% of all patients. A total of 35-48% of patients treated by two psychotropic drugs and 24-36% received three.

CONCLUSION

The first 6 months after treatment is very important to medication adherence. Mood stabilizers and antipsychotic remained the primary treatment for BD. Antipsychotic is on the rise in the treatment of BD.

Validity and Reliability of the Digital Functioning Assessment Short Test (D-FAST) in the Brazilian Sample

Background

The COVID-19 pandemic has caused major disruptions in all aspects of daily functioning, from school and work to interactions with friends and family. The Functioning Assessment Short Test (FAST) is an interviewer-administered scale validated in the psychiatric sample with no previous study assessing its validity and reliability in a digital format. Thus, we aimed to analyse the psychometric properties of the digital version of the FAST and understand the implications of COVID-19 and restrictive measures on functioning.

Methods

Data were collected using an online survey. The psychometric properties of the digital FAST were assessed by confirmatory factor analysis, Cronbach's alpha, and discriminant functional by cluster analysis in a community sample.

Results

Out of the total sample, 2,543 (84.1%) were female, and the mean (SD) age was 34.28 (12.46) years. The digital FAST retained the six factors structure observed in the original version, with Cronbach's alpha above 0.9. In addition, we showed evidence of discriminant validity by differentiating three clusters of psychosocial functioning. Clinical and demographic differences between groups explained, in part, the heterogeneity of functioning, thus providing support for the construct validity of the instrument.

Conclusion

The digital FAST is a simple and easy-to-understand instrument that provides a multidimensional assessment of functioning without the need for an interviewer. Furthermore, our findings may help to better understand the psychosocial implications of the pandemic and the importance of planning specific interventions to rehabilitee the affected group.

Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

BACKGROUND

Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.

AIM

To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.

RESULTS

This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.

CONCLUSION

Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.

The Use of Repetitive Transcranial Magnetic Stimulations for the Treatment of Bipolar Disorder: A Scoping Review

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive neuromodulation technique that involves the application of magnetic pulses on hyperactive or hypoactive cortical brain areas. rTMS is considered a high therapeutic tool in many neuropsychiatric conditions. Despite its wide and continuous usage for the treatment of psychiatric disorders, information about the use of rTMS in bipolar disorders is limited and not well-established in the literature. Objectives: This scoping review aims to explore the literature available regarding the application of rTMS for the management of bipolar disorders, to garner evidence in support of it uses in the management of bipolar disorders, and for recommendations on future clinical and research work. Method: We electronically conducted a data search in five research databases (MEDLINE, CINAHL, Psych INFO, SCOPUS, and EMBASE) using all identified keywords across all the databases to identify evidence-based studies. Articles were included if they were published randomized control designs aimed at the use of rTMS in the management of bipolar disorders. Overall, nine studies were eligible for this review. The search results are up to date as of the final date of data search—20 December 2020. Only full-text published articles written in English were reviewed. Review articles on treatment with rTMS for conditions either than bipolar disorders were excluded. Conclusion: The application of rTMS intervention for bipolar disorders looks promising despite the diversity of its outcomes and its clinical significance. However, to be able to draw a definite conclusion on the clinical effectiveness of the technique, more randomized controlled studies with well-defined stimulation parameters need to be conducted with large sample sizes in the future.

Long-term work disability due to type I and II bipolar disorder: findings of a six-year prospective study

Background

Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, the prevalence and predictors of long-term work disability among patients with type I and II BD have scarcely been studied. We investigated the clinical predictors of long-term work disability among patients with BD.

Methods

The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (n = 191) of adult psychiatric in- and out-patients with DSM-IV type I and II BD in three Finnish cities. Within JoBS we examined the prevalence and predictors of disability pension being granted during a six-year follow-up of the 152 patients in the labor force at baseline and collected information on granted pensions from national registers. We determined the predictors of disability pension using logistic regression models.

Results

Over the 6 years, 44% of the patients belonging to the labor force at baseline were granted a disability pension. Older age; type I BD; comorbidity with generalized anxiety disorder, post-traumatic stress disorder or avoidant personality disorder; and duration of time with depressive or mixed symptoms predicted disability pensions. Including disability pensions granted before baseline increased their total prevalence to 55.5%. The observed predictors were similar.

Conclusion

This regionally representative long-term prospective study found that about half of patients with type I or II bipolar disorder suffer from persistent work disability that leads to disability pension. In addition to the severity of the clinical course and type I bipolar disorder, the longitudinal accumulation of time depressed, psychiatric comorbidity, and older age predicted pensioning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00264-6.

Clinical Value of Inflammatory and Neurotrophic Biomarkers in Bipolar Disorder: A Systematic Review and Meta-Analysis

Bipolar disorder (BD) is a multifactorial chronic psychiatric disease highly defined by genetic, clinical, environmental and social risk factors. The present systematic review and meta-analysis aimed to examine the relationship between inflammatory and neurotrophic factors and clinical, social and environmental factors involved in the development and the characterization of BD. Web of Science, PubMed, PsycINFO, Scopus and Science Direct were searched by two independent reviewers. The systematic review was registered in PROSPERO (CRD42020180626). A total of 51 studies with 4547 patients with a diagnosis of BD were selected for systematic review. Among them, 18 articles were included for meta-analysis. The study found some evidence of associations between BDNF and/or inflammatory factors and different stressors and functional and cognitive impairment, but limitations prevented firm conclusions. The main finding of the meta-analysis was a negative correlation between circulating levels of BDNF and depression severity score (standardized mean difference = −0.22, Confidence Interval 95% = −0.38, −0.05, p = 0.01). Evidence indicates that BDNF has a role in the depressive component of BD. However, the poor consistency found for other inflammatory mediators clearly indicates that highly controlled studies are needed to identity precise biomarkers of this disorder.

Relationship of free thyroxine and triiodothyronine on recurrence in maintenance therapy for bipolar depression

OBJECTIVE

To examine whether thyroid function in the normal range is associated with recurrence of depressive or mania in bipolar disorder patients.

METHODS

104 patients with bipolar disorder in maintenance therapy phase were assigned randomly to mood stabilizer combined with antidepressant group or mood stabilizer group. There were 52 patients in both groups respectively. Clinical symptoms were assessed at baseline, 3rd month, 6th month, 9th month, and 12th month using HAMD-17 and YMRS. Blood samples were analyzed for thyroid function.

RESULTS

There was no statistically significant difference of recurrence rate of depressive episode and mania episode at the end of the 12-months between mood stabilizer combined with antidepressant group and mood stabilizer group. There was significant relation of baseline TT4 (P = 0.020, HR = 0.948), FT3 (P = 0.035, HR = 2.055), and FT4 (P = 0.047, OR=0.769) with the recurrence of depressive episode in mood stabilizer group. The area under curve (AUC) of TT4, FT3, FT4 were 0.685, 0.613, 0.544, respectively. There was significant relation of baseline FT3 (P = 0.044，HR = 4.493) with the recurrence of mania episode for mood stabilizer combined with antidepressants group. The AUC of FT3 was 0.806.

CONCLUSION

Low level of TT4, FT4 and high level of FT3 within normal-range were related with the recurrence of depressive episode in the maintenance treatment with mood stabilizer of bipolar disorder. High level of FT3 within normal-range were related with recurrence of mania when mood stabilizer combined with antidepressants were used in the maintenance treatment of bipolar disorder.

Looking for factors affecting functioning in euthymic patients with bipolar I disorder: the importance of cognitive complaints and BDNF's Val66Met polymorphism

INTRODUCTION

Functioning in Bipolar Disorder (BD) is affected in a substantial proportion of patients. The impact of demographic, clinical, cognitive, and genetic factors on functioning has been shown individually; however, as a complex phenomenon, a global approach to identify the most relevant as well as possible interactions is needed.

METHODS

102 patients with type I BD in euthymia were invited for evaluation of demographic, clinical, and cognitive characteristics as well as genotype for Val66Met polymorphism of BDNF gene to determine those associated with poor functioning according to the FAST scale cut-off score. Clinical evaluation included assessment of residual affective symptoms and anxiety. Cognitive evaluation included the COBRA scale, verbal memory, and executive functions testing.

RESULTS

Residual depressive symptoms, anxiety, cognitive complaints and being a Met carrier were more frequent in the poor functioning group and were entered in a logistic regression model. Being a Met carrier (OR=4.46, CI=1.19-16.67) and cognitive complaints (OR=1.29, CI= 1.13-1.46) were the most important predictors of poor functioning in type I BD.

LIMITATIONS

Cross-sectional study, with select population limiting generalizability of findings.

CONCLUSIONS

A better understanding of underlying factors affecting cognition, including the possible involvement of BDNF Val66Met polymorphism, its systematic evaluation and a continued search for targeted treatment, along with recognition and attention of residual affective and anxious symptoms might improve psychosocial outcomes such as functioning in this population.

The impact of bipolar spectrum disorders on professional functioning: A systematic review

AIMS

The impact of bipolar spectrum (BS) disorders on professional functioning has not been systematically reviewed yet. Since even subsyndromal symptoms may disturb functioning, the determination of the prognostic value of the spectrum of bipolarity for employment seems extremely relevant. The aim of this study was to assess the impact of BS disorders on professional functioning.

MATERIALS AND METHODS

A systematic review of the literature (namely, cohort and cross-sectional studies) investigating a link between BS disorders and employment was performed in accordance with PRISMA guidelines. BS was defined based on the concept of two-dimensional BS by Angst. Occupational outcomes and factors affecting employment were evaluated as well.

RESULTS

Seventy-four studies were included. All disorders comprising BS had a negative impact on occupational status, work performance, work costs, and salary, with the greatest unfavorable effect reported by bipolar disorder (BD), followed by borderline personality disorder (BPD), major depressive disorder (MDD), and dysthymia. Employment rates ranged from 40 to 75% (BD), 33 to 67% (BPD), 61 to 88% (MDD), and 86% (dysthymia). The factors affecting employment most included: cognitive impairments, number/severity of symptoms, namely, subsyndromal symptoms (mainly depressive), older age, education, and comorbidity (substance abuse, personality disorders, anxiety, depression, ADHD, PTSD).

CONCLUSION

Bipolar spectrum symptoms exert a negative impact on professional functioning. Further evaluation of affecting factors is crucial for preventing occupational disability.

Sex differences in cognitive function of first-diagnosed and drug-naïve patients with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a severe mental illness that affects more than 1% the world's population with high recurrence rates and a series of comorbidities. Cognitive dysfunction is an endophenotype of BD, but sex influences in cognitive impairment remains unclear.

METHOD

We evaluated the performance of 139 patients with first-diagnosed, drug-naïve BD (44 males and 95 females) and 92 healthy controls (24 males and 68 females) using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) scale and the Stroop color-word test.

RESULT

Immediate memory, visuospatial/constructional ability, language, attention, delayed memory, total RBANS score, and Stroop color-word scores were significantly lower in patients with first-diagnosed, drug-naïve BD than healthy participants. Thus, male patients had worse attention and delayed memory scores compared with female patients with BD. Importantly, a worse performance in visuospatial/constructional ability was negatively associated with the Young Mania Rating Scale score in male patients only.

CONCLUSION

Male patients with first-diagnosed, drug-naïve bipolar disorder had worse cognitive dysfunction than female patients in attention and delayed memory. Cognitive deficits were correlated with mania severity only in male patients. These findings reveal the sexual dimorphism in the cognitive deficits of early BD patients with mild and moderated symptoms for further pathophysiological exploration.

Comparison of thyroid function in different emotional states of drug-naïve patients with bipolar disorder

BACKGROUND

Previous studies have shown that bipolar disorder is closely related to thyroid dysfunction. Psychiatric drugs have a large or small effect on thyroid function, and thyroid hormone levels can also affect the effect of drug treatment. Therefore, the purpose of this study is assessment the thyroid function of drug-naive bipolar disorder across different mood states, with the expectation of providing support for treatment options.

METHODS

The present study is a cross-sectional study. Patients diagnosed with bipolar disorder according to the International Classification of Diseases diagnostic Criteria, Edition 10 (ICD 10) and who had never received medication were included in the study. The Montgomery Depression Scale (MADRS) was used to assess depressive symptoms and the Young Mania Rating Scale (YMRS) for manic symptoms. Thyroid function indicators include thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), total triiodothyronine (TT3), free thyroxine (FT4), and total thyroxine (TT4). Levels of TSH, TT4, FT4, TT3, and FT3 were measured within 48 h of hospitalization, between 06:00 and 08:00.

RESULTS

The data analysis finally covered the data of 291 subjects (136 in a bipolar manic group, 128 in a bipolar depressive group, and 27 in a bipolar mixed group), including 140 males and 151 females, with an average age of 27.38 ± 8.01. There was no significant difference in age, sex, marital status, work status, family history, and course of illness among the manic group, depressive group, and mixed group. The level of FT3, the rate of thyroid hormone increased secretion, and the total abnormality rate of thyroid hormone secretion in the manic group were significantly higher than those in the depressive group.

CONCLUSION

These findings indicate that thyroid functions were significantly different between depressive and manic episodes in BD patients. In clinical practice, it is necessary to take into account the differences in thyroid hormone levels in patients with BD across different emotional states in choosing drug.

Comparison of Cerebellar Grey Matter Alterations in Bipolar and Cerebellar Patients: Evidence from Voxel-Based Analysis

The aim of this study was to compare the patterns of cerebellar alterations associated with bipolar disease with those induced by the presence of cerebellar neurodegenerative pathologies to clarify the potential cerebellar contribution to bipolar affective disturbance. Twenty-nine patients affected by bipolar disorder, 32 subjects affected by cerebellar neurodegenerative pathologies, and 37 age-matched healthy subjects underwent a 3T MRI protocol. A voxel-based morphometry analysis was used to show similarities and differences in cerebellar grey matter (GM) loss between the groups. We found a pattern of GM cerebellar alterations in both bipolar and cerebellar groups that involved the anterior and posterior cerebellar regions (p = 0.05). The direct comparison between bipolar and cerebellar patients demonstrated a significant difference in GM loss in cerebellar neurodegenerative patients in the bilateral anterior and posterior motor cerebellar regions, such as lobules I-IV, V, VI, VIIIa, VIIIb, IX, VIIb and vermis VI, while a pattern of overlapping GM loss was evident in right lobule V, right crus I and bilateral crus II. Our findings showed, for the first time, common and different alteration patterns of specific cerebellar lobules in bipolar and neurodegenerative cerebellar patients, which allowed us to hypothesize a cerebellar role in the cognitive and mood dysregulation symptoms that characterize bipolar disorder.

Clinical Impact of Psychopathy on Bipolar Disorder

Background and Objectives. Bipolar disorder (BD) is associated with a significant burden due to affective symptoms and behavioral manifestations, but also cognitive and functional impairment. Comorbidity with other psychiatric conditions, including personality disorders, is frequent. The comorbidity with psychopathy deserves special consideration given that both disorders share some clinical characteristics, such as grandiosity, risky behavior or poor insight, among others, that can worsen the outcome of BD. Therefore, this study aimed to evaluate the prevalence of psychopathy in a sample of clinically stabilized patients with BD and its impact on the severity of BD. Materials and Methods. A sample of 111 patients with BD (38 type I and 73 type II) was studied. The Hamilton Depression Rating Scale (HAM-D) and the Young Mania Rating Scale (YMRS) served to assess the severity of BD. Psychopathy was measured by means of the Psychopathic Personality Inventory-Revised (PPI-R). Patients were divided into three groups according to the severity of psychopathy (Group 1: no psychopathy; Group 2: “psychopathic” trait; Group 3: clinical psychopathy). Other measures regarded impulsiveness (Barratt Impulsiveness Scale-11, BIS-11) and empathy (Empathy Quotient, EQ). Comparisons of mania, depression, impulsivity and empathy scores were run with MANOVA considering psychopathy and diagnosis as independent variables. Results. The prevalence of psychopathy was 5.4%. A significant association between the level of psychopathy and YMRS, attentional/cognitive impulsivity and motor impulsivity scores emerged. No interaction between psychopathy and BD diagnosis was found. Post hoc analysis demonstrated significantly higher YMRS scores in Group 3 than in Group 1; that is, patients with psychopathy have more manic symptoms. Conclusion. Psychopathy seems quite frequent among patients with BD. The association of psychopathy with BD results in higher impulsivity and manic symptoms. In light of this, psychopathy should be investigated when assessing patients with BD, regardless of the comorbidity of BD with other personality disorders.

A Retrospective Study of the Effects of Psychotropic Drugs on Neuroendocrine Hormones in Patients with Bipolar Disorder

BACKGROUND

Bipolar disorder (BD) is predominantly treated with medication, and previous studies have shown that psychotropic drugs have an effect on the neuroendocrine system. And the objectives of this study were: 1) to assess changes in neuroendocrine hormones of HPA axis and HPT axis in patients with BD after psychotropic drug treatment; 2) to determine differences in the above neuroendocrine hormones between psychotropic drug monotherapy and polytherapy treated patients.

METHODS

This study was a retrospective study that included 188 subjects.

RESULTS

After psychotropic drugs treatment, TSH levels increased significantly from baseline (p<0.001) and FT3, TT3, FT4, TT4, ACTH and CORT levels decreased significantly from baseline (p<0.001, p<0.001, p<0.001, p=0.007, p=0.039, p=0.031). There was no significant difference in hormonal changes between the monotherapy group and the polytherapy group, even though the polytherapy group was further divided into 4 subgroups. And there was no correlation between changes in hormones and treatment duration.

CONCLUSION

Although the incidence of significant HPT axis and HPA axis dysfunction after psychotropic drug treatment is low in patients with BD who have normal baseline neuroendocrine hormone levels, psychotropic drug treatment does suppress HPT axis and HPA axis function irrespective of the use of psychotropic drugs alone or in combination, and duration of psychotropic drug treatment. Therefore, even patients with BD who have normal baseline levels of neuroendocrine hormones should have their neuroendocrine hormone levels regularly monitored after psychotropic drug medication. But, the interval of monitoring can be slightly longer, which can be once every six months after taking psychotropic drugs.

Exploring the Evidence Implicating the Renin-Angiotensin System (RAS) in the Physiopathology of Mood Disorders

Mood disorders include Major Depressive Disorder (MDD), Bipolar Disorder (BD) and variations of both. Mood disorders has a public health significance with high comorbidity, suicidal mortality and economic burden on the health system. Research related to mood disorders has evolved over the years to relate it with systemic conditions. The Renin Angiotensin System (RAS) has been noticed to play major physiological roles beyond renal and cardiovascular systems. Recent studies have linked RAS not only with neuro-immunological processes, but also with psychiatric conditions like mood and anxiety disorders. In this comprehensive review, we integrated basic and clinical studies showing the associations between RAS and mood disorders. Animal studies on mood disorders models - either depression or mania - were focused on the reversal of behavioral and/or cognitive symptoms through the inhibition of RAS components like the Angiotensin- Converting Enzyme (ACE), Angiotensin II Type 1 receptor (AT1) or Mas receptors. ACE polymorphisms, namely insertion-deletion (I/D), were linked to mood disorders and suicidal behavior. Hypertension was associated with neurocognitive deficits in mood disorders, which reversed with RAS inhibition. Low levels of RAS components (renin activity or aldosterone) and mood symptoms improvement with ACE inhibitors or AT1 blockers were also observed in mood disorders. Overall, this review reiterates the strong and under-researched connection between RAS and mood disorders.

Expanding the search for emerging mental ill health to safeguard student potential and vocational success in high school: A narrative review

AIM

Young people experiencing mental ill health are more likely than their healthy aged peers to drop out of high school. This can result in social exclusion and vocational derailment. Identifying young people at risk and taking action before an illness is established or school dropout occurs is an important goal. This study aimed to examine evidence for the risk markers and at risk mental states of the clinical staging model (stage 0-1b) and whether these risk states and early symptoms impact school participation and academic attainment.

METHOD

This narrative review assembles research from both the psychiatry and education literature. It examines stage 0 to stage 1b of the clinical staging model and links the risk states and early symptoms to evidence about the academic success of young people in high school.

RESULTS

In accordance with the clinical staging model and evidence from education literature, childhood trauma and parental mental illness can impact school engagement and academic progress. Sleep disturbance can result in academic failure. Undifferentiated depression and anxiety can increase the risk for school dropout. Subthreshold psychosis and hypomanic states are associated with functional impairment and high rates of Not in Employment, Education, or Training (NEET) but are not recognized in the education literature.

CONCLUSION

Risk markers for emerging mental ill health can be identified in education research and demonstrate an impact on a student's success in high school. Clear referral protocols need to be embedded into school life to reduce risk of progression to later stages of illness and support school participation and success.

Prediction of Suicide-Related Events by Analyzing Electronic Medical Records from PTSD Patients with Bipolar Disorder

Around 800,000 people worldwide die from suicide every year and it’s the 10th leading cause of death in the US. It is of great value to build a mathematic model that can accurately predict suicide especially in high-risk populations. Several different ML-based models were trained and evaluated using features obtained from electronic medical records (EMRs). The contribution of each feature was calculated to determine how it impacted the model predictions. The best-performing model was selected for analysis and decomposition. Random forest showed the best performance with true positive rates (TPR) and positive predictive values (PPV) of greater than 80%. The use of Sertraline, Fentanyl, Aripiprazole, Lamotrigine, and Tramadol were strong indicators for no SREs within one year. The use of Haloperidol, Trazodone and Citalopram, a diagnosis of autistic disorder, schizophrenic disorder, or substance use disorder at the time of a diagnosis of both PTSD and bipolar disorder, predicted the onset of SREs within one year. Additional features with potential protective or hazardous effects for SREs were identified by the model. We constructed an ML-based model that was successful in identifying patients in a subpopulation at high-risk for SREs within a year of diagnosis of both PTSD and bipolar disorder. The model also provides feature decompositions to guide mechanism studies. The validation of this model with additional EMR datasets will be of great value in resource allocation and clinical decision making.

The Early Burden of Disability in Individuals With Mood and Other Common Mental Disorders in Ontario, Canada

IMPORTANCE

Large population-based data on the trajectory to disability after the first diagnosis of a mood disorder are lacking.

OBJECTIVE

To assess the time between an incident mood disorder diagnosis and the receipt of disability services during a follow-up period of as long as 20 years.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used health administrative and social service data from ICES for 1 902 792 adults aged 18 to 59 years living in Ontario, Canada. A narrow cohort of individuals who had a new diagnosis of a mood disorder between October 1, 1997, and March 31, 2007, matched by sex and age to individuals with no history of mood disorder, included 278 296 participants. A broader cohort of individuals who had a new diagnosis of other common mental disorders during the same period, matched by sex and age to individuals with no history of mental disorder diagnosis, included 1 624 496 individuals. All individuals were followed up to a maximum end date of March 31, 2017. Data analysis was conducted from November 2017 to June 2018.

EXPOSURE

Incident diagnosis of mood or common mental disorder.

MAIN OUTCOMES AND MEASURES

Disability outcomes were as follows: (1) entry into the Ontario Disability Support Program (ODSP), signifying long-term inability to work because of a disability, and (2) admission into a long-term care (LTC) residence, signifying the inability to live in independent housing. Cox proportional hazards models were used.

RESULTS

In the full cohort of 1 902 792 individuals, 278 296 participants (14.6%) were included in the mood disorder cohort (mean [SD] age, 37.5 [11.9] years; 157 386 [56.6%] women), and 1 624 496 participants (85.4%) were included in the common mental disorder cohort (mean [SD], 36.5 [11.8] years; 932 545 [57.4%] women). The incidence of ODSP initiation was greater among individuals with mood disorders than those without (51.5 per 10 000 person-years vs 25.5 per 10 000 person-years; adjusted hazard ratio [aHR], 2.03; 95% CI, 1.95-2.11) and for those with common mental disorders (45.0 per 10 000 person-years vs 27.6 per 10 000 person-years; aHR, 1.57; 95% CI, 1.55-1.60). The aHR for admission to LTC was also higher among individuals with mood disorders compared with those without (aHR, 2.20; 95% CI, 1.80-2.69) and those with common mental disorders compared with those without (aHR, 1.21; 95% CI, 1.14-1.29). Individuals with bipolar disorders had greater ODSP rates than individuals with major depressive disorders (crude rate ratio: 4.31 [95% CI, 3.56-5.17] vs 1.82 [95% CI, 1.36-2.43]).

CONCLUSIONS AND RELEVANCE

This cohort study found that mood disorders were associated with elevated and early rates of disability services. Effective early intervention strategies targeting functional impairment in this population are encouraged.

Abnormalities of aquaporin-4 in the cerebellum in bipolar II disorder: An ultra-high b-values diffusion weighted imaging study

BACKGROUND

Cumulative evidence indicated the cerebellum is involved in the pathophysiology of bipolar disorder (BD). It was reported that the apparent diffusion coefficient from ultra-high b-values (ADC_uh) could reflect the function of aquaporin-4 (AQP4) which was involved in neurological disorders. However, no studies have reported the AQP4 alteration in the cerebellum in BD. Therefore, this study aimed to investigate the ADC_uh and AQP4 in the cerebellum in BD-II.

METHODS

Fifty patients with BD-II as well as 43 healthy controls underwent enhance diffusion weighted imaging (eDWI) with ultra-high b-values. The eDWI parameters including ADC_uh , pure water diffusion (D) and pseudodiffusion (D*) was measured using regions-of-interest analysis in the superior cerebellar peduncles (SCP), middle cerebellar peduncles (MCP) , cerebellar hemisphere, dentate nuclei, tonsil and vermis of the cerebellum.

RESULTS

BD-II exhibited increased ADC_uh values in the bilateral SCP, cerebellar hemisphere, tonsil and right dentate nuclei, and increased D* and D in the bilateral SCP, and decreased D* in the tonsil. Additionally, there were positive correlations between Hamilton Rating Scale for Depression-24 scores and bilateral ADC_uh values in the SCP and cerebellar hemisphere.

CONCLUSIONS

The alteration of the ADC_uh values in the cerebellum may reflect the changes of the AQP4, especially the abnormality of eDWI parameters in the SCP may be a key neurobiological feature of BD-II. The current results provide a novel insight to look into the pathophysiology mechanisms underlying BD-II.

Predictive factors of functional outcome in patients with bipolar I disorder: a five-year follow-up

BACKGROUND

Functional impairment is commonly encountered among patients with bipolar disorder (BD) during periods of remission. The distribution of the impairment of the functional outcome is heterogeneous. The objective of this current investigation was to identify neurocognitive and clinical predictors of psychosocial functioning in a sample of patients with BD.

METHODS

Seventy-six patients (59.2% females) and 40 healthy controls (50% females), aged 18 to 55 years, were assessed using a comprehensive neurocognitive battery (six neurocognitive domains), and the Functioning Assessment Short Test (FAST), at baseline and after a 5-year follow-up. Stepwise regression models were used to identify predictor variables related to psychosocial functioning.

RESULTS

The number of hospitalizations during the follow-up, the change occurred in the neurocognitive composite index (NCI change), and NCI at baseline explained 30.8% of the variance of functioning. The number of hospitalizations during the follow-up was the variable that explained a greater percentage of the variance (16.9%). Verbal memory at baseline and the change in sustained attention during the follow-up explained 10% and 5.9% of the variance of the psychosocial functioning, respectively.

LIMITATIONS

The interval of 5 years between the two assessments could be too short to detect a possible progression in functional outcome for the overall sample.

CONCLUSIONS

The clinical course during the follow-up is the factor that has a greater impact on psychosocial functioning in patients with BD. Thus, the interventions aimed to promote prevention of relapses should be considered as essential for avoiding functional impairment in these patients.

Brain perfusion during manic episode and at 6-month follow-up period in bipolar disorder patients: Correlation with cognitive functions

BACKGROUND

Patterns of altered cerebral perfusion and cognitive dysfunction have been described in Bipolar Disorder (BD) acute episodes and euthymia. Knowledge of the relationship between cognitive function and perfusion in a manic state and status when followed up is still limited.

OBJECTIVE

To describe brain perfusion alterations and its relationship with cognitive impairment in patients with BD during manic episodes and after 6 months.

METHODS

Observational-prospective study in 10 type I BD adults during moderate-severe manic episodes. We assessed sociodemographic data and clinical variables as well as cognitive function through Screening for Cognitive Impairment in Psychiatry (SCIP-S). Finally, we performed a Brain Perfusion SPECT using a Tc99m-ethyl cysteine dimer.

RESULTS

During manic episodes, patients showed cognitive impairment with a mean SCIP-S score of 63.8 ± 17.16. This was positively correlated with perfusion measured as relative reuptake index (RRI) at the right temporal pole (ρ = 0.65 p = .0435) and negatively correlated with right the orbitofrontal cortex (ρ = -0.70 p = .0077) and the right subgenual cingulate cortex (ρ = -0.70 p = .0256). Episode severity measured by the Young Mania Rating Scale (YMRS) positively correlated with RRI at the right temporal pole (ρ = 0.75, p = .01). At follow-up, six patients were taking treatment and were euthymic, we found a negative correlation with the YMRS and RRI at the bilateral orbitofrontal cortex (ρ = -0.8827, p = .019). They did not show significant improvement in cognitive performance at SCIP-S, and there was negative correlation with the following of the SCIP-S subscales; processing speed with the bilateral dorsolateral prefrontal, the bilateral medial prefrontal, the left temporal pole cortex RRI, and verbal fluency with the bilateral anterior cingulate cortex RRI.

CONCLUSION

Cognitive impairment was correlated with brain perfusion patterns at baseline and follow-up. Large sample size studies with longer follow-up are needed to describe the changes in perfusion and cognitive functions in BD.

Asenapine prescribing patterns in the treatment of manic in- and outpatients: Results from the MANACOR study

Background:

Asenapine is the most recent compound that has been FDA- and EMA-approved for treatment of mania. Its efficacy and safety have been assessed in placebo-controlled trials, but little is known about its performance in routine clinical conditions. In this study, we compared features of patients treated with adjunctive asenapine or other adjunctive antipsychotics and the costs of the treatment.

Methods:

A combined prospective and retrospective data collection and analysis was conducted from January 2011 to December 2013 following a clinical interview and assessment of manic and depressive symptoms (YMRS, HDRS-17), clinical state (CGI-BP-M), psychosocial functioning (FAST), sexual dysfunction (PRSexDQ) and health resource costs associated with treatment with adjunctive asenapine versus other adjunctive antipsychotics.

Results:

Hundred and fifty-two patients from different university hospitals were included. Fifty-three patients received adjunctive asenapine and 99 received other adjunctive antipsychotics concomitantly to mood stabilizers. Considering inpatients, those treated with adjunctive asenapine presented a significantly less severe manic episode (P = 0.001), less psychotic symptoms (P = 0.030) and more comorbid personality disorder (P = 0.002). Regarding outpatients, those treated with adjunctive asenapine showed significantly less severe manic episode (P = 0.046), more previous mixed episodes (P = 0.013) and more sexual dysfunction at baseline (P = 0.036). No significant differences were found in mean total costs per day.

Conclusion:

Clinicians tended to use adjunctive asenapine in patients with less severe manic symptoms but more complex clinical profile, including more mixed episodes in the past, concomitant personality disorder, and sexual problems. Treatment with adjunctive asenapine was not associated with higher costs when compared to other options.

Bipolar Disorder and Suicide: a Review

PURPOSE OF REVIEW

Bipolar disorder has the highest rate of suicide of all psychiatric conditions and is approximately 20-30 times that of the general population. The purpose of this review is to discuss findings relevant to bipolar disorder and suicide.

RECENT FINDINGS

Risk factors include male gender, living alone, divorced, no children, Caucasian, younger age (< 35 years), elderly age (> 75 years), unemployment, and a personal history of suicide attempt and family history of suicide attempt or suicide completion, as well as predominant depressive polarity. Suicide is associated with the depressed or mixed subtypes, not mania. Although there are emerging treatments for bipolar depression, such as ketamine and TMS, lithium remains the only medication associated with lowered suicide rates in bipolar disorder. Understanding clinical and demographic risk factors for suicide in bipolar disorder remains the best way to prevent suicidal behavior. Early intervention and treatment with anti-suicidal medications, such as lithium, along with close observation and follow-up is the best way to mitigate suicide in patients with bipolar disorder.

Expert consensus on information sheet proposals for patients under treatment with lithium

INTRODUCTION

Lithium is one of the first therapeutic options for bipolar disorder, which is characterized by recurrent mood swings that strongly reduce quality of life. Our purpose was to achieve professional consensus criteria to define the contents of an information sheet for patients with bipolar disorder that are starting treatment with lithium.

MATERIAL AND METHODS

A modified Delphi method in two rounds was used. The Scientific Committee-made up by nine psychiatrists-created a 20-item questionnaire about the information that must be given to the patient treated with lithium and selected a panel of ambulatory and hospital psychiatric experts to agree on this information. Panelists scored each item based on a Likert scale of 9 points and could add comments in a confidential manner. It was considered consensus in agreement when median scores were within the range of [7-9] and in disagreement within the range of [1-3].

RESULTS

A high level of consensus was reached. In the first round, there was agreement on 17 out of 20 items and, after the second round, there was disagreement on just one item containing information about the discovery of lithium. Finally, said item was modified in the Patient's Information Sheet based on the comments suggested by the panelists.

CONCLUSIONS

This study allowed to create an information sheet for patients with bipolar disorder under treatment with lithium, with information agreed upon by a group of experts from different health care settings.

Work motivation in patients with bipolar disorder: Associated factors

BACKGROUND

Occupational functioning is severely impaired in patients with bipolar disorder (BD). Work motivation (WM), defined as the psychological processes that determine the direction, intensity, and persistence of action within the work, is an essential component of work-related functioning.

AIM

To assess whether WM is affected in patients with BD and which clinical and sociodemographic factors are related to low WM.

METHODS

In all, 95 euthymic BD patients were invited to answer the Motivation for Work Questionnaire and the Rating Scale on Subjective Cognitive Deficits in Bipolar Disorder (COBRA).

RESULTS

A total of 49.5% ( n = 47) of the patients were classified in the Low Motivated (LM) group. Unemployment and the report of more subjective cognitive complaints were predictors of poor WM in this sample ((OR) = 3.01 and 7.10, respectively).

CONCLUSIONS

Perceived cognitive deficits related to the disorder and current unemployment negatively impact WM in patients with BD. In addition to symptomatic recovery, the need of the inclusion of personal and occupational areas in the comprehensive treatment of patients with BD is necessary.

Clinical course predicts long-term outcomes in bipolar disorder

BACKGROUND

The long-term outcomes of bipolar disorder range from lasting remission to chronic course or frequent recurrences requiring admissions. The distinction between bipolar I and II disorders has limited utility in outcome prediction. It is unclear to what extent the clinical course of bipolar disorder predicts long-term outcomes.

METHODS

A representative sample of 191 individuals diagnosed with bipolar I or II disorder was recruited and followed for up to 5 years using a life-chart method. We previously described the clinical course over the first 18 months with dimensional course characteristics and latent classes. Now we test if these course characteristics predict long-term outcomes, including time ill (time with any mood symptoms) and hospital admissions over a second non-overlapping follow-up period in 111 individuals with available data from both 18 months and 5 years follow-ups.

RESULTS

Dimensional course characteristics from the first 18 months prospectively predicted outcomes over the following 3.5 years. The proportion of time depressed, the severity of depressive symptoms and the proportion of time manic predicted more time ill. The proportion of time manic, the severity of manic symptoms and depression-to-mania switching predicted a greater likelihood of hospital admissions. All predictions remained significant after controlling for age, sex and bipolar I v. II disorder.

CONCLUSIONS

Differential associations with long-term outcomes suggest that course characteristics may facilitate care planning with greater predictive validity than established types of bipolar disorders. A clinical course dominated by depressive symptoms predicts a greater proportion of time ill. A clinical course characterized by manic episodes predicts hospital admissions.

Use of the Functioning Assessment Short Test (FAST) in defining functional recovery in bipolar I disorder. Post-hoc analyses of long-term studies of aripiprazole once monthly as maintenance treatment

PURPOSE

There is growing agreement that definitions of "recovery" in bipolar-I disorder (BP-I) should include functional outcomes beyond sustained symptomatic remission. In this post-hoc analysis, we assessed functional recovery rates according to the validated Functioning Assessment Short Test (FAST) in participants with BP-I after 52 weeks of maintenance treatment with aripiprazole once monthly (AOM).

PATIENTS AND METHODS

Rates of functional recovery with AOM 400 were investigated in two 52-week studies. NCT01567527 was a placebo-controlled, double-blind, randomized-withdrawal study and NCT01710709 was an open-label study. Functional recovery, assessed at the end of the respective maintenance phases, was defined as a total FAST score of ≤11 for 8 consecutive weeks.

RESULTS

Post-hoc analyses included 229 patients from the randomized-withdrawal study (AOM 400 n=116; placebo n=113). The open-label study included 402 patients (including 321 de novo patients and 81 rollover patients who had completed the randomized-withdrawal study). In the randomized-withdrawal study, functional recovery was achieved by 30.2% (n=35) of the AOM 400 group compared with 24.8% (n=28) in the placebo group. The difference was not statistically significant (p=0.39). In the open-label study, 36% (n=116) of de novo patients and 43% (n=35) of rollover patients had functionally recovered after 52 weeks of AOM 400 treatment.

CONCLUSION

These data highlight the utility of a sustained FAST total score of ≤11 as a definition of recovery and emphasize the possibility of achieving this ambitious treatment goal with effective long-term treatment.

Factors associated with poor functional outcome in bipolar disorder: sociodemographic, clinical, and neurocognitive variables

OBJECTIVE

The current investigation aimed at studying the sociodemographic, clinical, and neuropsychological variables related to functional outcome in a sample of euthymic patients with bipolar disorder(BD) presenting moderate-severe levels of functional impairment.

METHODS

Two-hundred and thirty-nine participants with BD disorders and with Functioning Assessment Short Test(FAST) scores equal or above 18 were administered a clinical and diagnostic interview, and the administration of mood measure scales and a comprehensive neuropsychological battery. Analyses involved preliminary Pearson bivariate correlations to identify sociodemographic and clinical variables associated with the FAST total score. Regarding neuropsychological variables, a principal component analysis (PCA) was performed to group the variables in orthogonal factors. Finally, a hierarchical multiple regression was run.

RESULTS

The best fitting model for the variables associated with functioning was a linear combination of gender, age, estimated IQ, Hamilton Depression Rating Scale (HAM-D), number of previous manic episodes, Factor 1 and Factor 2 extracted from the PCA. The model, including all these previous variables, explained up to 29.4% of the observed variance.

CONCLUSIONS

Male gender, older age, lower premorbid IQ, subdepressive symptoms, higher number of manic episodes, and lower performance in verbal memory, working memory, verbal fluency, and processing speed were associated with lower functioning in patients with BD.

Psychosocial functioning in patients with psychotic and non-psychotic bipolar I disorder. A comparative study with individuals with schizophrenia

BACKGROUND

More than 50% of individuals with bipolar disorder (BD) do not reach full psychosocial functioning, even during periods of euthymia. It has been suggested that history of psychotic symptoms is one of the factors which are associated with a worse functional outcome. The objective was to compare psychosocial functioning between patients with BD, with (BD-P), and without (BD-NP) a history of psychotic symptoms, and to examine whether the history of psychotic symptoms, or other clinical or neurocognitive variables predict psychosocial functioning.

METHODS

Psychosocial functioning and neurocognition were examined in 100 euthymic patients with bipolar I disorder (50 BD-P, and 50 BD-NP), compared to 50 stabilised patients with schizophrenia (SZ), and 51 healthy controls (HC).

RESULTS

1) There were no differences between BD-P and BD-NP in the GAF-F score or in the FAST total score. 2) The two groups of patients with BD had better scores than SZ both in the GAF-F, and in all measures of the FAST, except for the subscale leisure time. 3) The neurocognitive composite index, verbal memory and subclinical depressive symptoms were the variables which explained a higher percentage of the variance of functional outcome.

LIMITATIONS

The cross-sectional design, and the relatively small sample size are the main limitations.

CONCLUSIONS

A history of psychotic symptoms has no relevant impact on the level of psychosocial functioning in BD. Neurocognitive dysfunction and subclinical depressive symptoms are the variables that best explain the functional impairment. These findings have important clinical implications.

Bipolar disorders

Bipolar disorders are chronic and recurrent disorders that affect >1% of the global population. Bipolar disorders are leading causes of disability in young people as they can lead to cognitive and functional impairment and increased mortality, particularly from suicide and cardiovascular disease. Psychiatric and nonpsychiatric medical comorbidities are common in patients and might also contribute to increased mortality. Bipolar disorders are some of the most heritable psychiatric disorders, although a model with gene-environment interactions is believed to best explain the aetiology. Early and accurate diagnosis is difficult in clinical practice as the onset of bipolar disorder is commonly characterized by nonspecific symptoms, mood lability or a depressive episode, which can be similar in presentation to unipolar depression. Moreover, patients and their families do not always understand the significance of their symptoms, especially with hypomanic or manic symptoms. As specific biomarkers for bipolar disorders are not yet available, careful clinical assessment remains the cornerstone of diagnosis. The detection of hypomanic symptoms and longtudinal clinical assessment are crucial to differentiate a bipolar disorder from other conditions. Optimal early treatment of patients with evidence-based medication (typically mood stabilizers and antipsychotics) and psychosocial strategies is necessary.

Social and academic premorbid adjustment domains predict different functional outcomes among youth with first episode mania

BACKGROUND

Premorbid characteristics may help predict the highly variable functional and illness outcomes of young people with early stage Bipolar Disorder (BD). We sought to examine the relationships between premorbid adjustment and short to medium-term outcomes after a first treated episode of mania.

METHODS

We examined the baseline and 18-month follow-up characteristics of 117 participants with first episode of mania, treated at two tertiary early intervention services in Melbourne, Australia. The baseline demographic, family history, diagnoses, comorbidity and clinical features were determined using unstructured questionnaires and structured diagnostic interviews. Premorbid adjustment was determined using the Premorbid Adjustment Scale (PAS), the components of which were identified using a principal component analysis. Eighteen-month follow-up outcome measures included the Clinical Global Impressions scale, Social and Occupational Functioning Assessment Scale and the Heinrichs' Quality of Life Scale (QLS). Correlations and linear regressions were utilised to examine the relationships between component scores and outcomes, while controlling for baseline and follow-up confounders.

RESULTS

The social adjustment component of the PAS correlated with the interpersonal relations (r_s = -0.46, p<0.001) domain of QLS while the academic adjustment component of the PAS correlated with the vocational functioning domain of QLS (r_s =-0.39, p = 0.004). Premorbid adjustment did not predict illness severity or objective functioning.

LIMITATIONS

Lack of information on cognition, personality factors and prodromal symptoms limited the assessment of their impact on outcomes.

CONCLUSIONS

Impairments in domains of premorbid adjustment may be early markers of persistent difficulties in social and vocational functioning and may benefit from targeted interventions.

High cognitive reserve in bipolar disorders as a moderator of neurocognitive impairment

BACKGROUND

Cognitive reserve (CR) reflects the capacity of the brain to endure neuropathology, minimize clinical manifestations and successfully complete cognitive tasks. The present study aims to determine whether high CR may constitute a moderator of cognitive functioning in bipolar disorder (BD).

METHODS

102 patients with BD and 32 healthy controls were enrolled. All patients met DSM-IV criteria for I or II BD and were euthymic (YMRS≤6 and HDRS≤8) during a 6-month period. All participants were tested with a comprehensive neuropsychological battery, and a Cerebral Reserve Score (CRS) was estimated. Subjects with a CRS below the group median were classified as having low CR, whereas participants with a CRS above the median value were considered to have high CR.

RESULTS

Participants with BD with high CR displayed a better performance in measures of attention (digits forward: F=4.554, p=0.039); phonemic and semantic verbal fluency (FAS: F=9.328, p=0.004; and Animal Naming: F=8.532, p=0.006); and verbal memory (short cued recall of California Verbal Learning Test: F=4.236, p=0.046), after multivariable adjustment for potential confounders, including number of admissions and prior psychotic symptoms.

LIMITATIONS

The cross-sectional design of the study does not allow the establishment of causal inferences. Additionally, the small size of the sample may have limited some results.

CONCLUSIONS

High cognitive reserve may therefore be a valuable construct to explore for predicting neurocognitive performance in patients with BD regarding premorbid status.

Treatment of Functional Impairment in Patients with Bipolar Disorder

Traditionally, functional impairment has received little attention in bipolar disorder, despite the fact that many patients experience significant impairments in daily life. In the last decade, research has changed its focus from clinical remission to functional recovery in bipolar patients as a priority. A literature review of this topic will allow us provide an overview of the relevance of functional impairment as well as the potential factors that can predict or contribute to low functioning in bipolar disorder (BD). Treatment approaches should consider not only euthymia as a goal but also cognitive and functional improvement of patients with such a complex disorder. Functional remediation and psychoeducation among psychological interventions may help to enhance functioning. The combination of cognitive enhancers and cognitive/functional remediation programs may help in improving cognitive and functional impairments. Early interventions are essential to prevent cognitive deficits and disability.

Bipolar disorder

Bipolar disorder is a recurrent chronic disorder characterised by fluctuations in mood state and energy. It affects more than 1% of the world's population irrespective of nationality, ethnic origin, or socioeconomic status. Bipolar disorder is one of the main causes of disability among young people, leading to cognitive and functional impairment and raised mortality, particularly death by suicide. A high prevalence of psychiatric and medical comorbidities is typical in affected individuals. Accurate diagnosis of bipolar disorder is difficult in clinical practice because onset is most commonly a depressive episode and looks similar to unipolar depression. Moreover, there are currently no valid biomarkers for the disorder. Therefore, the role of clinical assessment remains key. Detection of hypomanic periods and longitudinal assessment are crucial to differentiate bipolar disorder from other conditions. Current knowledge of the evolving pharmacological and psychological strategies in bipolar disorder is of utmost importance.

Epidemiology and burden of bipolar disorder in Africa: a systematic review of data from Africa

BACKGROUND

Bipolar disorder impacts negatively on the patient, the family, as well as the society. It taxes the health care services due to a combination of the illness with associated medical and psychiatric comorbidities. In Africa, unfortunately, knowledge of the epidemiology and burden of bipolar disorder is based mainly on studies from the USA and Europe. In this systematic review of literature from Africa, we highlight the epidemiology and burden of bipolar disorder.

METHODS

A systematic review of publications from Africa relating to the epidemiology and burden of bipolar disorder was conducted.

RESULT

Data from community surveys conducted in Nigeria and Ethiopia indicated a lifetime prevalence estimate of 0.1 % to 1.83 for bipolar disorder. Missed diagnosis rate of bipolar disorder was up to 36.2 %. In one study, 8.1 % of the males and 5.4 % of the females reported a previous suicide attempt. A study showed that up to 60 % of patients with bipolar disorder had at least one comorbidity. There were no reports on all-cause mortality and cost of illness.

CONCLUSION

Bipolar disorder is a major mental health problem in Africa. Scientific findings on bipolar disorder from Africa are consistent with the existing literature from other parts of the world. There still exists a dearth of high quality studies addressing the epidemiological, clinical, social, and economic burden of the disorder.

Predictors of long-term work disability among patients with type I and II bipolar disorder: a prospective 18-month follow-up study

OBJECTIVES

Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, vocational ability and predictors of long-term work disability have rarely been studied among patients with BD. We investigated clinical predictors of work disability among patients with BD in psychiatric care.

METHODS

The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (N = 191) representing adult (18-59 years) psychiatric inpatients and outpatients with DSM-IV bipolar I disorder (BD-I) and bipolar II disorder (BD-II) in three Finnish cities. Within the JoBS, we investigated the prevalence of disability pensions at baseline, and predictors for being granted a disability pension during an 18-month follow-up of the 151 patients in the labor force at baseline. Cox models were used to determine predictors for onset of disability pension.

RESULTS

At baseline, 21% (40/191) of the patients already had a disability pension. During the follow-up, a further 38 patients (25% of the 151 followed) were granted a new disability pension. The predictors included older age, male gender, depressive index episode, higher number of psychiatric hospitalizations, generalized anxiety disorder, avoidant personality disorder, and depressive burden during follow-up. However, the predictors differed depending on bipolar subtype, age, and gender.

CONCLUSIONS

BD-I and BD-II are associated with a major risk of long-term work disability, the proportion of patients with a disability pension rising to 41% in the medium-term follow-up of the Finnish cohort investigated in the present study. Severe clinical course, depression, comorbidities, age, and gender are likely to be the main predictors but predictors may vary depending on the subgroup.

A bipolar II cohort (ABC): The association of functional disability with gender and rapid cycling

BACKGROUND

Bipolar II disorder (BP II) is a chronic, frequently co-morbid, and complex disorder with similar rates of attempted suicide to BP I. However, case identification for BP II studies that is based on clinician diagnosis alone is prone to error. This paper reports on differences between clinical and research diagnoses and then describes the clinical characteristics of a carefully defined BP II cohort.

METHODS

A cohort of rigorously defined BP II cases were recruited from a range of primary and secondary health services in the North of England to participate in a programme of cross-sectional and prospective studies. Case identification, and rapid cycling, comorbidities and functioning were examined.

RESULTS

Of 355 probable clinical cases of BP II disorder, 176 (∼50%) met rigorous diagnostic criteria. The sample mean age was ∼44 years, with a mean duration of mood disorder of ∼18 years. Two thirds of the cohort were female (n=116), but only 40% were in paid employment. Current and past year functioning was more impaired in females and those with rapid cycling.

LIMITATIONS

This paper describes only the preliminary assessments of the cohort, so it was not possible to examine additional factors that may contribute to the explained variance in functioning.

CONCLUSIONS

This carefully ascertained cohort of BP II cases show few gender differences, except for levels of functional impairment. Interestingly, the most common problem identified with using case note diagnoses of BP II arose because of failure to record prior episodes of mania, not failure to identify hypomania.

Functional impairment in adolescents and young adults with emerging mood disorders

BACKGROUND

Between 30 and 60% of adults with unipolar or bipolar disorders exhibit impairments across multiple domains. However, little is known about impaired functioning in youth with mood disorders.

AIMS

To examine the prevalence of objective, subjective and observer-rated disability in a large, representative sample of young people with a primary mood disorder.

METHOD

Individuals aged 16-25 years presenting to youth mental health services for the first time with a primary mood disorder participated in a systematic diagnostic and clinical assessment. Impairment was assessed using objective (unemployment or disability payments), observer- (Social and Occupational Functioning Assessment Scale; SOFAS) and self-rated measures (role functioning according to the Brief Disability Questionnaire).

RESULTS

Of 1241 participants (83% unipolar; 56% female), at least 30% were functionally impaired on the objective, self-rated and/or observer-rated measures, with 16% impaired according to all three criteria. Even when current distress levels were taken into account, daily use of cannabis and/or nicotine were significantly associated with impairment, with odds ratios (OR) ranging from about 1.5 to 3.0. Comorbid anxiety disorders were related to lower SOFAS scores (OR = 2-5).

CONCLUSIONS

Levels of disability were significant, even in those presenting for mental healthcare for the first time. Functional impairment did not differ between unipolar and bipolar cases, but some evidence suggested that females with bipolar disorder were particularly disabled. The prevalence of comorbid disorders (50%) and polysubstance use (28%) and their association with disability indicate that more meaningful indicators of mood episode outcomes should focus on functional rather than symptom-specific measures. The association between functioning and nicotine use requires further exploration.

Verbal memory as a mediator in the relationship between subthreshold depressive symptoms and functional outcome in bipolar disorder

BACKGROUND

Most studies on the factors involved in the functional outcome of patients with bipolar disorder have identified subsyndromal depressive symptoms and cognitive impairment as key players. However, most studies are cross-sectional and very few have analyzed the interaction between cognition and subclinical depression. The present study aimed to identify the role of cognition, and particularly verbal memory, and subthreshold depressive symptoms in the functional outcome of patients with bipolar I and II disorder at one year follow-up.

METHOD

A confirmatory analysis was performed using the path analysis. A total of 111 euthymic patients were included to test the role of verbal memory as a mediator in the relationship of subthreshold depressive symptoms and functional outcome at one year follow-up. Measures of verbal memory, subthreshold depressive symptoms and functioning (at baseline, at 6 months and at one year follow-up) were gathered through the use of a neuropsychological assessment and validated clinical scales.

RESULTS

The hypothesized mediation model displayed a good fit to data (Chi=0.393, df=2, p=0.625; RMSEA<0.001 with CI: 0.001-0.125 and CFI=1.00). Functional outcome at one year follow-up was predicted by the functional outcome at baseline, which in turn, was related to subthreshold depressive symptoms at baseline and to the verbal composite memory scores as a mediator variable.

CONCLUSION

The results of this study prospectively confirm previous findings on the disabling role of subthreshold depressive symptoms and verbal memory impairment on psychosocial functioning. However, these results come from a sample with moderate to severe functional impairment; hence, as a limitation, this may hinder the generalization of these results.

The impact of repeated manic episodes and executive dysfunction on work adjustment in bipolar disorder

The aim of this study was to study the clinical and neurocognitive variables that best explain poor work adjustment in a sample of bipolar I euthymic patients. Eighty-five euthymic patients at the Hospital Clinic of Barcelona were assessed for this study by means of a comprehensive neuropsychological battery and a work-focused interview to determine work adjustment. Clinical and sociodemographic variables were also collected. Direct logistic regression was performed to assess the impact of demographic, clinical and neuropsychological variables on the likelihood of presenting poor work adjustment. The model that best fitted contained five variables (Hamilton Depression Rating scores, number of manic episodes, number of perseverative errors in the Wisconsin Card Sorting Test (WCST), number of depressive episodes and Trail Making Test-part B). However, only two out of these variables made a unique statistically significant contribution to the model, which were number of manic episodes (OR 1.401; CI 1.05-1.86; p = 0.021) and number of perseverative errors in the WCST (OR 1.062; CI 1.00-1.12; p = 0.044). The model explained up to 36 % of the variance in work adjustment. This study highlights the role of manic relapses and neurocognitive impairment, specifically the role of executive function, in work adjustment.

Antidepressants for bipolar disorder: A meta-analysis of randomized, double-blind, controlled trials

OBJECTIVE

To examine the efficacy and safety of short-term and long-term use of antidepressants in the treatment of bipolar disorder.

DATA SOURCES

A literature search of randomized, double-blind, controlled trials published until December 2012 was performed using the PubMed, ISI Web of Science, Medline and Cochrane Central Register of Controlled Trials databases. The keywords "bipolar disorder, bipolar I disorder, bipolar II disorder, bipolar mania, bipolar depression, cyclothymia, mixed mania and depression, rapid cycling and bipolar disorder", AND "antidepressant agent, antidepressive agents second- generation, antidepressive agents tricyclic, monoamine oxidase inhibitor, noradrenaline uptake inhibitor, serotonin uptake inhibitor, and tricyclic antidepressant agent" were used. The studies that were listed in the reference list of the published papers but were not retrieved in the above-mentioned databases were supplemented.

STUDY SELECTION

Studies selected were double-blind randomized controlled trials assessing the efficacy and safety of antidepressants in patients with bipolar disorder. All participants were aged 18 years or older, and were diagnosed as having primary bipolar disorder. Antidepressants or antidepressants combined with mood stabilizers were used in experimental interventions. Placebos, mood stabilizers, antipsychotics and other antide pressants were used in the control interventions. Studies that were quasi-randomized studies, or used antidepressants in combination with antipsychotics in the experimental group were excluded. All analyses were conducted using Review Manager 5.1 provided by the Cochrane Collaboration.

MAIN OUTCOME MEASURES

The primary outcome was the response and switching to mania. The secondary outcomes included remission, discontinuation rate, and suicidality.

RESULTS

Among 5 001 treatment studies published, 14 double-blind randomized controlled trials involving 1 244 patients were included in the meta-analysis. Eleven short-term studies and three maintenance studies were included. Studies suggested that patients treated with antidepressants were not significantly more likely to achieve higher response and remission rates in the short-term or long-term treatment than patients treated with placebo and other medications. Antidepressants were not associated with an increased risk of discontinuation, relapse or suicidality. When one antidepressant was compared with another, no significant difference in efficacy and tolerability was found.

CONCLUSION

Existing evidence of efficacy does not support the short-term or long-term application of antidepressant therapy in patients with bipolar disorder, although the tolerability and safety of antidepressants have been generally acknowledged. There is a need for large-sample, double-blind, randomized controlled trials to elucidate the role of antidepressants in patients with different subcategories of bipolar disorder.

Use of asenapine in clinical practice for the management of bipolar mania

Bipolar disorder is a chronic mental illness associated with high levels of somatic morbidity, comorbidity and mortality. Treatment guidelines for bipolar mania generally recommend initiating first-line therapy with a second-generation antipsychotic or mood stabiliser, either alone or in combination. Asenapine is a second-generation antipsychotic with a unique receptor binding profile, licensed for the treatment of manic episodes in adults with bipolar I disorder. 'Real-world' data are needed to complement evidence from clinical trials, in order to provide clinicians with pragmatic information regarding the likely risks and benefits of using a new agent in clinical practice. Evidence from real-world case reports demonstrates that - as in clinical trials - asenapine is effective in treating mania and mixed episodes associated with bipolar I disorder, whether used as monotherapy or in combination with a mood stabiliser. It has a rapid onset of antimanic effect and an early improvement is associated with treatment outcome. Asenapine also shows promise in controlling depressive symptoms and clinically challenging mixed states. Asenapine has a favourable tolerability profile, compared with other first-line agents, having a minimal impact on weight and metabolic parameters. Asenapine should be considered a first-line treatment option for adults with bipolar I disorder.