The prevalence of pain in bipolar disorder: a systematic review and large-scale meta-analysis

Pain in alcohol use disorder: Evaluating effects of childhood trauma, perceived stress, and psychological comorbidity

The relationship between pain and alcohol use disorder (AUD) is complex and bidirectional. The current study examines risk factors for pain in a large comprehensively phenotyped sample including individuals from across the spectrum of alcohol use and misuse. Participants (n = 1101) were drawn from the National Institute on Alcohol Abuse and Alcoholism Natural History Protocol and included treatment-seeking AUD inpatients (AUD+Tx, n = 369), individuals with AUD not seeking treatment (AUD+, n = 161), and individuals without AUD (AUD-, n = 571). General linear models were utilized to test the effects of AUD status, history of childhood trauma exposure, perceived stress, and psychological comorbidity on daily percent time in pain, as well as change in daily percent time in pain across the inpatient stay in AUD+Tx individuals. Overall, 60.2% individuals reported any pain, with a significantly higher prevalence in the AUD+Tx group (82.1%) compared to the AUD+ (56.5%) and AUD- (47.1%) groups. Daily percent time in pain was also highest in the AUD+Tx group (30.2%) and was further increased in those with a history of childhood abuse and comorbid posttraumatic stress disorder (PTSD). Years of heavy drinking and craving were also associated with increased percent time in pain in the AUD+Tx group. Percent time in pain decreased following acute withdrawal in the AUD+Tx group but plateaued around 25% just prior to discharge. Individuals seeking inpatient treatment for AUD, especially those with a history of childhood trauma and/or comorbid PTSD, report greater percent time in pain compared to those not seeking treatment and those without AUD. The prolonged experience of pain in abstinent AUD inpatients after the resolution of acute withdrawal may signal the early stages of protracted withdrawal. Integrative treatments targeting pain and other symptoms of protracted withdrawal may be effective in improving overall function in people with severe AUD.

Global trends and hotspots in pain associated with bipolar disorder in the last 20 years: a bibliometric analysis

Purpose

The prevalence of comorbid pain and Bipolar Disorder in clinical practice continues to be high, with an increasing number of related publications. However, no study has used bibliometric methods to analyze the research progress and knowledge structure in this field. Our research is dedicated to systematically exploring the global trends and focal points in scientific research on pain comorbidity with bipolar disorder from 2003 to 2023, with the goal of contributing to the field.

Methods

Relevant publications in this field were retrieved from the Web of Science core collection database (WOSSCC). And we used VOSviewer, CiteSpace, and the R package "Bibliometrix" for bibliometric analysis.

Results

A total of 485 publications (including 360 articles and 125 reviews) from 66 countries, 1019 institutions, were included in this study. Univ Toront and Kings Coll London are the leading research institutions in this field. J Affect Disorders contributed the largest number of articles, and is the most co-cited journal. Of the 2,537 scholars who participated in the study, Stubbs B, Vancampfort D, and Abdin E had the largest number of articles. Stubbs B is the most co-cited author. "chronic pain," "neuropathic pain," "psychological pain" are the keywords in the research.

Conclusion

This is the first bibliometric analysis of pain-related bipolar disorder. There is growing interest in the area of pain and comorbid bipolar disorder. Focusing on different types of pain in bipolar disorder and emphasizing pain management in bipolar disorder are research hotspots and future trends. The study of pain related bipolar disorder still has significant potential for development, and we look forward to more high-quality research in the future.

The Effectiveness of Interventions for Improving Chronic Pain Symptoms Among People With Mental Illness: A Systematic Review

Chronic pain (CP) and mental illness (MI) are leading causes of years lived with disability and commonly co-occur. However, it remains unclear if available interventions are effective in improving pain outcomes in patients with co-existing CP and MI. This systematic review synthesised evidence for the effectiveness of interventions to improve pain outcomes for people with comorbid CP and clinically diagnosed MI. Ten electronic databases were searched from inception until May 2023. Randomised controlled trials (RCTs) were included if they evaluated interventions for CP-related outcomes among people with comorbid CP and clinically diagnosed MI. Pain-related and mental health outcomes were reported as primary and secondary outcomes, respectively. 26 RCTs (2,311 participants) were included. Four trials evaluated the effectiveness of cognitive-behavioural therapy, 6 mindfulness-based interventions, 1 interpersonal psychotherapy, 5 body-based interventions, 5 multi-component interventions, and 5 examined pharmacological-based interventions. Overall, there was considerable heterogeneity in sample characteristics and interventions, and included studies were generally of poor quality with insufficient trial details being reported. Despite the inconsistency in results, preliminary evidence suggests interventions demonstrating a positive effect on CP may include cognitive-behavioural therapy for patients with depression (with a small to medium effect size) and multi-component intervention for people with substance use disorders (with a small effect size). Despite the high occurrence/burden of CP and MI, there is a relative paucity of RCTs investigating interventions and none in people with severe MI. More rigorously designed RCTs are needed to further support our findings. PERSPECTIVE: This systematic review presents current evidence evaluating interventions for CP-related and MH outcomes for people with comorbid CP and clinically diagnosed MI. Our findings could potentially help clinicians identify the most effective treatments to manage these symptoms for this vulnerable patient group.

Prescription opioid dispensing patterns among patients with schizophrenia or bipolar disorder

BACKGROUND

Patients with schizophrenia (SZ) or bipolar disorder (BD) may have increased risk of complications from prescribed opioids, including opioid-induced respiratory depression. We compared prescription opioid pain medication dispensing for patients with SZ or BD versus controls over 5 years to assess dispensing trends.

METHODS

This retrospective, observational study analysed US claims data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases for individuals aged 18-64 years with prevalent SZ or BD for years 2015-2019 compared with age- and sex-matched controls. Baseline characteristics, comorbidities, and medication use were assessed. Proportions of individuals dispensed prescription opioids chronically (ie, ≥70 days over a 90-day period or ≥ 6 prescriptions annually) or nonchronically (≥1 prescription, chronic definition not met) were assessed.

RESULTS

In 2019, the Commercial and Medicaid databases contained records for 4773 and 30,179 patients with SZ and 52,780 and 63,455 patients with BD, respectively. Patients with SZ or BD had a higher prevalence of comorbidities, including pain, versus controls in each analysis year. From 2015 to 2019, among commercially insured patients with SZ, chronic opioid-dispensing proportions decreased from 6.1% (controls: 2.7%) to 2.3% (controls: 1.2%) and, for patients with BD, from 11.4% (controls: 2.7%) to 6.4% (controls: 1.6%). Chronic opioid dispensing declined in Medicaid-covered patients with SZ from 15.0% (controls: 14.7%) to 6.7% (controls: 6.0%) and, for patients with BD, from 27.4% (controls: 12.0%) to 12.4% (controls: 4.7%). Among commercially insured patients with SZ, nonchronic opioid dispensing decreased from 15.5% (controls: 16.4%) to 10.7% (controls: 11.0%) and, for patients with BD, from 26.1% (controls: 17.5%) to 20.0% (controls: 12.2%). In Medicaid-covered patients with SZ, nonchronic opioid dispensing declined from 22.5% (controls: 24.4%) to 15.1% (controls: 12.7%) and, for patients with BD, from 32.3% (controls: 25.9%) to 24.6% (controls: 13.6%).

CONCLUSIONS

The proportions of individuals dispensed chronic or nonchronic opioid medications each year were similar between commercially and Medicaid-insured patients with SZ versus controls and were higher for patients with BD versus controls. From 2015 to 2019, the proportions of individuals who were dispensed prescription opioids chronically or nonchronically decreased for patients with SZ or BD and controls.

Prescriptions of psychotropic and somatic medications among patients with severe mental disorders and healthy controls in a naturalistic study

PURPOSE

Psychotropic and somatic medications are both used in treating severe mental disorders (SMDs). Realistic estimates of the prevalence of use across medication categories are needed. We obtained this in a clinical cohort of patients with SMD and healthy controls (HCs).

MATERIALS AND METHODS

Prescriptions filled at Norwegian pharmacies the year before and after admittance to the Thematically Organized Psychosis (TOP) study were examined in 1406 patients with SMD (mean age 32.5 years, 48.2% women) and 920 HC (34.1 years, 46.2% women). Using data from the Norwegian Prescription Database (NorPD), the number of users in different anatomical therapeutic chemical (ATC) categories was compared using logistic regression. Population estimates were used as reference data.

RESULTS

Use of antipsychotics (N05A), antiepileptics (N03A), antidepressants (N06A), anxiolytics (N05B), hypnotics and sedatives (N05C), anticholinergics (N04A), psychostimulants, attention deficit hyperactivity disorder and nootropic agents (N06B) and drugs for addiction disorders (N07B) was significantly more prevalent in patients with SMD than HC. Use of diabetes treatment (A10), antithrombotic drugs (B01), beta blockers (C07), lipid modifiers (C10), and thyroid and endocrine therapeutics (H03) was also more prevalent in patients with SMD, but with two exceptions somatic medication use was comparable to the general population. Among HC, there was low prevalence of use for most medication categories.

CONCLUSION

Patients were using psychiatric medications, but also several types of somatic medications, more often than HC. Still, somatic medication use was mostly not higher than in the general population. The results indicate that HC had low use of most medication types.

Usage Patterns of Traditional Chinese Medicine for Patients with Bipolar Disorder: A Population-Based Study in Taiwan

BACKGROUND

Patients with bipolar disorder (BD) receive traditional Chinese medicine (TCM) for clinical needs unmet with psychotropic medications. However, the clinical characteristics of practices and outcomes of TCM in BD are not fully understood. This cohort study investigated the clinical characteristics, principal diagnoses, TCM interventions, and TCM prescriptions in patients with BD.

METHODS

Data for a total of 12,113 patients with BD between 1996 and 2013 were withdrawn from Taiwan's longitudinal health insurance database 2000 (LHID 2000). The chi-square test was used for categorical variables, and the independent t-test was used for continuous variables. A p-value less than 0.05 indicated significance.

RESULTS

One thousand three hundred nineteen patients who visited TCM clinics after the diagnosis of BD were in the TCM group, while those who never visited TCM were in the non-TCM group (n = 1053). Compared to the non-TCM group, patients in the TCM group had younger average age, a higher percentage of female individuals, more comorbidities of anxiety and alcohol use disorders, and higher mood stabilizer usage rates. The TCM group exhibited pain-related indications, including joint pain, myalgia, myositis, headache, and sleep disturbances. Corydalis yanhusuo and Shu-Jing-Huo-Xue-Tang were the most useful single herbs and herbal formulae.

CONCLUSIONS

Physicians need to be aware of the use of TCM in patients with BD.

Subjects suffering from bipolar disorder taking lithium are less likely to report physical pain: a FACE-BD study

BACKGROUND

Physical pain is a common issue in people with bipolar disorder (BD). It worsens mental health and quality of life, negatively impacts treatment response, and increases the risk of suicide. Lithium, which is prescribed in BD as a mood stabilizer, has shown promising effects on pain.

METHODS

This naturalistic study included 760 subjects with BD ( FACE-BD cohort) divided in two groups: with and without self-reported pain (evaluated with the EQ-5D-5L questionnaire). In this sample, 176 subjects were treated with lithium salts. The objectives of the study were to determine whether patients receiving lithium reported less pain, and whether this effect was associated with the recommended mood-stabilizing blood concentration of lithium.

RESULTS

Subjects with lithium intake were less likely to report pain (odds ratio [OR] = 0.59, 95% confidence interval [CI], 0.35-0.95; p = 0.036) after controlling for sociodemographic variables, BD type, lifetime history of psychiatric disorders, suicide attempt, personality traits, current depression and anxiety levels, sleep quality, and psychomotor activity. Subjects taking lithium were even less likely to report pain when lithium concentration in blood was ≥0.5 mmol/l (OR = 0.45, 95% CI, 0.24-0.79; p = 0.008).

CONCLUSIONS

This is the first naturalistic study to show lithium's promising effect on pain in subjects suffering from BD after controlling for many confounding variables. This analgesic effect seems independent of BD severity and comorbid conditions. Randomized controlled trials are needed to confirm the analgesic effect of lithium salts and to determine whether lithium decreases pain in other vulnerable populations.

Multimorbidity clusters among people with serious mental illness: a representative primary and secondary data linkage cohort study

BACKGROUND

People with serious mental illness (SMI) experience higher mortality partially attributable to higher long-term condition (LTC) prevalence. However, little is known about multiple LTCs (MLTCs) clustering in this population.

METHODS

People from South London with SMI and two or more existing LTCs aged 18+ at diagnosis were included using linked primary and mental healthcare records, 2012-2020. Latent class analysis (LCA) determined MLTC classes and multinominal logistic regression examined associations between demographic/clinical characteristics and latent class membership.

RESULTS

The sample included 1924 patients (mean (s.d.) age 48.2 (17.3) years). Five latent classes were identified: 'substance related' (24.9%), 'atopic' (24.2%), 'pure affective' (30.4%), 'cardiovascular' (14.1%), and 'complex multimorbidity' (6.4%). Patients had on average 7-9 LTCs in each cluster. Males were at increased odds of MLTCs in all four clusters, compared to the 'pure affective'. Compared to the largest cluster ('pure affective'), the 'substance related' and the 'atopic' clusters were younger [odds ratios (OR) per year increase 0.99 (95% CI 0.98-1.00) and 0.96 (0.95-0.97) respectively], and the 'cardiovascular' and 'complex multimorbidity' clusters were older (ORs 1.09 (1.07-1.10) and 1.16 (1.14-1.18) respectively). The 'substance related' cluster was more likely to be White, the 'cardiovascular' cluster more likely to be Black (compared to White; OR 1.75, 95% CI 1.10-2.79), and both more likely to have schizophrenia, compared to other clusters.

CONCLUSION

The current study identified five latent class MLTC clusters among patients with SMI. An integrated care model for treating MLTCs in this population is recommended to improve multimorbidity care.

Association between parental bipolar disorder and increased risk of exposure to prescription opioids for their offspring

PURPOSE

Individuals with bipolar disorder (BD) may have an increased risk of exposure to prescription opioids. However, it is still unknown whether such risk also occurs in their offspring. This study aimed to investigate the risk of exposure to prescription opioid use and related medical conditions in the offspring of parents with BD.

METHODS

This study used the Taiwan National Health Research Database and included offspring who had any parent with a diagnosis of BD. The matched-control cohort was randomly identified from the offspring of parents without any major psychiatric disorders (MPD). We identified data pertaining to opioid prescription and related medical conditions, namely pain disorder, malignancy, autoimmune disease, and arthropathy. The Poisson regression was used to estimate odds ratios and 95% confidence intervals.

RESULTS

In total, 11,935 offspring of parents with BD and 119,350 offspring of parents without any MPD were included. After controlling for demographics and mental disorders, offspring of parents with BD demonstrated higher rates of prescription opioid use than those of parents without MPD, especially the intravenous/intramuscular form of opioids and prescription in hospital settings. In addition, offspring of parents with BD had a higher odds of pain disorders than those of parents without MPD.

CONCLUSION

Our study identifies a higher odd for developing pain disorders and exposure to prescription opioids among children of parents with BD.

Physical Therapy and Mental Health: A Scoping Review

OBJECTIVES

Coexistence of mental and physical health conditions is prevalent. To achieve optimal physical therapy outcomes, neither should be treated in isolation. This review aimed to map intersections between physical therapy and mental health.

METHODS

This was a scoping review searching MEDLINE, CINAHL, PsycInfo, Cochrane, and PEDro databases. Two independent researchers screened studies of physical therapy practice with adolescents/adults with mental health disorders or research using primary mental health outcomes in physical health conditions or clinicians' perspective. Data were extracted on study type, participants, topics, publication year, and country.

RESULTS

The search yielded 3633 studies with 135 included. Five studies included adolescents. More than one-half were published since 2015. Studies specific to participants with mental health diagnoses included schizophrenia (n = 12), depressive disorders (n = 8), eating disorders (n = 6), anxiety disorders (n = 4), bipolar disorders (n = 1), somatic disorders (n = 5), and trauma and stressor-related disorders (n = 8) or varied mental health diagnoses (n = 14). Forty-one studies had primary mental health outcomes or clinical practice approaches with a mental health emphasis with participants with physical health conditions (musculoskeletal [n = 13], neurological [n = 7], other [n = 21]). Systematic reviews or randomized controlled trials predominantly involved exercise therapy and/or physical activity. Descriptions of physical therapists as participants (n = 35) included 4 main topics: (1) mental health screening; (2) knowledge, attitudes, and experiences; (3) key practice components; and (4) research priorities.

CONCLUSION

Physical therapy intersects with people experiencing mental health disorders across a broad spectrum of diagnoses, covering a range of interventions with a small but growing evidence base.

IMPACT

Exercise and physical activity studies dominated the highest levels of evidence and future focus, although economic evaluations and consumer-driven or patient experience studies are needed. There is a contrast between the confidence and knowledge of specialized physical therapists working within mental health settings and those in general practice settings. Inspiring, integrated education is required to further improve health care outcomes following physical therapy for people with mental health disorders or symptoms.

Pain management in people with severe mental illness: an agenda for progress

Supplemental Digital Content is Available in the Text.

Risk of Suicide in Patients With Bipolar Disorder Having Comorbid Chronic Pain Disorders: Insights From the Nationwide Inpatient Sample Data From 2016 to 2018

ABSTRACT

Bipolar disorders (BDs) are associated with significant risk of suicide. BD patients (age ≥18 years) admitted to the hospital were identified from the National Inpatient Sample dataset. Based on the secondary diagnosis of chronic pain disorder (CPD), patients were stratified into two groups (1) BD with CPD (BD + CPD) and (2) BD without CPD (BD - CPD). Groups were matched (1:1) for the type of BD and compared for baseline characteristics and suicidal ideation/attempt (SI/SA). Compared with BD - CPD, most patients in the BD + CPD group were older (mean age, 47.6 vs. 40.4 years), female (58.4% vs. 55.2%), and white (77.2% vs. 66.7%). After adjusting for covariates, compared with the BD - CPD group, the BD + CPD group had 21% more risk of SI/SA (odds ratio, 1.21, p < 0.001). CPD is independently associated with the increased risk of suicide among patients with BD. Thus, comorbid CPD among patients admitted for BD can be an essential risk factor for suicide.

Comorbidity and familial aggregation of back/neck pain in the NIMH Family Study of Affective Spectrum Disorders

OBJECTIVE

Back pain is associated with substantial Global Burden of Disease and is highly comorbid with mood and anxiety symptoms and syndromes. However, mechanisms underlying this association have not been well-elucidated. Here we apply data from the NIMH Family Study of Affective Spectrum Disorders to investigate the comorbidity, familial aggregation, and cross-aggregation of back/neck pain with mood disorder subtypes.

METHODS

The sample includes 519 probands and 560 interviewed first-degree relatives. Lifetime DSM-IV Bipolar I, Bipolar II, and Major Depressive Disorder [MDD] were derived from semi-structured diagnostic interviews. Lifetime history of back or neck pain and its age of onset were self-reported retrospectively. Familial aggregation and cross-aggregation were estimated via mixed effects models in probands and interviewed first-degree relatives, while heritability and co-heritability (endophenotypic ranking value [ERV]) were estimated using full pedigrees.

RESULTS

Over 45% of participants endorsed a history of back/neck pain. Back/neck pain was familial (adjusted odds ratio [aOR] 1.5, p = 0.04; h2 = 0.24, p = 0.009). Back/neck pain in probands was associated with MDD in relatives (aOR 1.5, p = 0.04; ERV = 0.17, p = 0.024), but not with bipolar disorder. Onset of back/neck pain occurred earlier in those with bipolar disorder compared to controls.

CONCLUSION

Findings suggest common familial risk factors underlying back/neck pain with MDD, whereas there was within-individual comorbidity of bipolar with back/neck pain. Future studies that identify common factors that lead to either back/neck pain or MDD can inform prevention and interventions.

Childhood maltreatment and its role in the development of pain and psychopathology

Childhood maltreatment represents a form of trauma capable of altering fundamental neurobiological properties and negatively impacting neurodevelopmental processes. An outcome of childhood maltreatment is the emergence of psychopathology, which might become evident during childhood or adolescence, but might also project into adulthood. In this Review, we propose a biobehavioural framework in which childhood maltreatment and the associated aberrant neurobiological mechanisms and behavioural processes additionally lead to the onset of altered pain processing and, ultimately, the existence of pain syndromes. Considering that subpopulations of maltreated children show preserved function and minimal psychiatric or pain symptoms, compensatory mechanisms-perhaps instilled by robust psychosocial support systems-are also discussed. We present validated tools and experimental methods that could facilitate better comprehension of the interactions between childhood maltreatment, psychopathology, and pain. Such tools and approaches can in parallel be implemented to monitor abnormal pain-related processes and potentially guide early intervention strategies in cases of childhood maltreatment.

Self-Reported Pain and Emotional Reactivity in Bipolar Disorder: A Prospective FACE-BD Study

In patients with bipolar disorder (BD), pain prevalence is close to 30%. It is important to determine whether pain influences BD course and to identify factors associated with pain in BD in order to guide BD management. This naturalistic, prospective study used data on 880 patients with BD from the French FACE-BD cohort who were divided into two groups according to the presence or absence of pain. Multivariate models were used to test whether pain was associated with affective states and personality traits while controlling for confounders. Then, multivariate models were used to test whether pain at baseline predicted global life functioning and depressive symptomatology at one year. At baseline, 22% of patients self-reported pain. The pain was associated with depressive symptomatology, levels of emotional reactivity in a quadratic relationship, and a composite variable of personality traits (affective lability, affective intensity, hostility/anger, and impulsivity). At one year, the pain was predictive of depression and lower global life functioning. Pain worsens mental health and well-being in patients with BD. The role of emotions, depression, and personality traits in pain has to be elucidated to better understand the high prevalence of pain in BD and to promote specific therapeutic strategies for patients experiencing pain.

Altered physical pain processing in different psychiatric conditions

Several reports indicate either increased or decreased pain sensitivity associated with psychiatric disorders. Chronic pain is highly prevalent in many of these conditions. We reviewed the literature regarding experimental pain sensitivity in patients with major depression, bipolar disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder, panic disorder, obsessive-compulsive disorder and schizophrenia. Electronic searches were performed to identify studies comparing experimental pain in patients with these conditions and controls. Across 31 depression studies, reduced pain threshold was noted except for ischemic stimuli, where increased pain tolerance and elevated sensitivity to ischemic pain was observed. A more pervasive pattern of low pain sensitivity was found across 20 schizophrenia studies. The majority of PTSD studies (n = 20) showed no significant differences compared with controls. The limited number of bipolar disorder (n = 4) and anxiety (n = 9) studies precluded identification of clear trends. Wide data variability was observed. Awareness of psychiatric patients' pain perception abnormalities is needed for active screening and addressing physical comorbidities, in order to enhance quality of life, life expectancy and mental health.

The prevalence of painful physical symptoms in major depressive disorder: A systematic review and meta-analysis of observational studies

BACKGROUND

Painful physical symptoms (PPS) are common in patients with major depressive disorder (MDD), but their prevalence has been mixed. This is a systematic review and meta-analysis of the pooled prevalence of PPS in MDD patients.

METHODS

Systematic literature searches were independently conducted in major databases (PubMed, EMBASE, PsycINFO and Web of Science). Data analyses were conducted using a random-effects model.

RESULTS

A total of 20 studies with 53,852 patients were included. The overall prevalence of PPS in MDD patients was 55.2% (95%CI: 47.9-62.3%), with a point prevalence of 64.2% (95%CI: 53.2-73.8%) and a 12-month prevalence of 57.0% (95%CI: 23.9-84.8%). No significant publication bias was found in this meta-analysis.

CONCLUSION

PPS are common in MDD patients. Considering the negative impact of PPS on daily functioning, effective preventive measures and routine screening should be conducted for MDD patients, and timely treatments should be offered to those in need. Registration number: CRD42020179471.

Pain in the bipolar disorder: prevalence, characteristics and relationship with suicide risk

Objective:

to know the prevalence and characteristics of pain, to verify how pain management has been carried out by the health services, and to correlate suicide risk with pain intensity in patients with bipolar disorder.

Method:

an observational study with a quantitative approach. The study included people with bipolar disorder assessed by the McGill-Reduced Pain Questionnaire, Body Diagram, Visual Numerical Scale, and the Suicidal Ideation Scale (Beck).

Results:

the sample of 60 participants was mainly composed of women with a mean age of 40 years old and a mean psychiatric treatment time of approximately 13 years. Of these, 83% reported feeling pain at the time of the interview. Half of the participants indicated that pain interferes with routine and 80% did not receive care in health institutions. The main descriptors that qualify the painful experience were as follows: painful, heavy and sensitive for the sensory descriptors, tiring and punishing in the affective category. Suicide attempt was reported by 57% of the participants. There was a correlation between suicide risk and pain intensity.

Conclusion:

pain presented a high prevalence. Suicide risk was identified in more than half of the participants. Pain intensity showed a significant correlation with suicide risk.

Differential Physical and Mental Benefits of Physiotherapy Program Among Patients With Schizophrenia and Healthy Controls Suggesting Different Physical Characteristics and Needs

In contrast to several other severe illnesses marked by inflammation and autoimmunity that now have potent and efficient treatments and even cures, schizophrenia (SCZ) is a disease still associated with poor outcome, incapacity, and social burden. Even after decades of research on the brain and behavior, this illness is still associated with profound effects on both mental health and physical health, with recent studies showing that treatment is more efficient when associating drugs with psychological and physical treatments. Most of the studies measured the effects of physical intervention compared with usual care and demonstrated a positive effect as an add-on treatment. What remains unclear is the different effects of the same intervention in normal subjects in a sample of patients with the illness. The study aimed to evaluate the effects of physical intervention over motor functional capacity and mental health in patients with SCZ compared with healthy controls (HC). The outcomes were (a) functional capacity [by 6-min walk test (6MWT)], (b) body flexibility index (Wells' bench), (c) disease severity [by Brief Psychiatric Rating Scale (BPRS)], (d) quality of life [by 36-Item Short Form (SF-36) questionnaire], and (e) physical activity [Simple Physical Activity Questionnaire (SIMPAQ)]. The intervention was associated with significant decrease of body mass index (BMI), blood pressure, disease severity, and improvement in daily life activities. Unexpectedly, it was observed that schizophrenics, compared with matched HC, were at a lower level of performance in the beginning, remained below HC over the studied time despite similar physical intervention, and had different changes. The intervention had lower effects over physical capacity and better effects over quality of life and disease severity. The results confirm previous studies comparing patients receiving physical intervention but suggest that they may receive different types of intervention, suited for their different baseline fitness, motivation, and capacity to engage in physical effort over sustained time. Additionally, they point to extended time of intervention of multidisciplinary treatment (physical and psychological-cognitive techniques) to improve outcomes in SCZ.

Preclinical Considerations about Affective Disorders and Pain: A Broadly Intertwined, yet Often Under-Explored, Relationship Having Major Clinical Implications

Background: Pain, a distinctive undesirable experience, encompasses several different and fluctuating presentations across varying mood disorders. Therefore, the present narrative review aimed to shed further light on the matter, accounting for both experimental animal models and clinical observations about major depressive disorder (MDD) pathology. Method: Major databases were inquired from inception until April 2016 for records about MDD and pain. Results: Pain and MDD are tightly associated with each other in a bi-directional fashion. Several cross-sectional and retrospective studies indicated a high presence of pain in the context of mood disorders, including MDD (up to 65%), but also increased prevalence rates in the case of mood disorders documented among people with a primary diagnosis of either psychological or somatic pain (prevalence rates exceeding 45%). The clinical implications of these observations suggest the need to account for mood and pain manifestations as a whole rather than distinct entities in order to deliver more effective interventions. Limitations: Narrative review, lack of systematic control groups (e.g., people with the primary diagnosis at review, but not the associated comorbidity as a study) to allow reliable comparisons. Prevalence rates and clinical features associated with pain varied across different studies as corresponding operational definitions did. Conclusions: Pain may have a detrimental effect on the course of mood disorders-the opposite holds. Promoting a timely recognition and management of such an often neglected comorbidity would therefore represent a primary goal toward the delivery of effective, multi-disciplinary care.

Prevalence and correlates of bipolar spectrum disorders in Singapore: Results from the 2016 Singapore Mental Health Study (SMHS 2016)

BACKGROUND

Prevalence estimates of Bipolar Spectrum Disorders (BSD) remain scant in Southeast Asia. This study aims to investigate the prevalence of BSD, its correlates with sociodemographic factors, and the associations between the BSD subgroups and clinical severity, impairment, and disability in Singapore.

METHODS

This study utilizes data gathered from the second Singapore Mental Health Study (SMHS)- a nationwide cross-sectional survey conducted between 2016 and 2018 (response rate: 69.5%). Respondents were randomly selected and administered, in a single visit, interviewer-led surveys of the World Health Organization Composite International Diagnostic Interview version 3.0 (CIDI 3.0) in their preferred language (i.e. Chinese, Malay, Tamil, or English). A total of 6126 residents completed the study.

RESULTS

The lifetime weighted prevalence of BSD, Bipolar I, II, and subthreshold bipolar disorder was 3.1%, 1.5%, 0.03%, and 1.6% respectively. A higher prevalence of Bipolar Disorders (BPD) was significantly associated with younger age, being divorced or separated, and being unemployed. Lifetime comorbidity of BSD with at least one other psychiatric or physical condition was 45% and 51% respectively. BSD was most comorbid with Obsessive Compulsive Disorder (psychiatric condition) and Chronic pain (physical condition).

LIMITATIONS

This study relies on self-report data which may be subject to unintended response biases leading to the under or over-reporting of results.

DISCUSSION

In addition to the high prevalence of BPD, there is also a concerning shift and increase in the proportion of those who experience severe symptoms of mania/hypomania and depression. Subthreshold bipolar disorder is found to be clinically significant and cross-culturally valid in a multi-cultural setting.

The role of physical pain in global functioning of people with serious mental illness

While people with serious mental illness (SMI) endorse clinical pain at rates on par or exceeding those in the general population, the association between pain and functioning remains unclear. In this paper we present data on the cross-sectional association between clinical pain and global functioning in a large, mixed diagnostic sample of people with SMI. Eight-hundred ninety-eight people diagnosed with bipolar disorder, major depressive disorder, or schizophrenia were administered the Global Assessment Scale and the 12-item Short Form Survey, which includes an assessment of the extent to which the experience of pain interfered with daily activities over the past month. People with major depressive disorder reported higher pain interference than those with schizophrenia and bipolar disorder. The presence of physical health conditions and psychiatric symptoms were also assessed. After controlling for age, gender, psychiatric symptoms, education level, and physical health problems, pain interference in the past month was associated with significantly lower global functioning. The findings suggest that the experience of pain is associated with poorer global functioning across major SMI diagnoses. Moreover, the impact of pain in global functioning appears independent of physical health problems, and thus may warrant routine screening from mental health providers.

Mood disorders, childhood maltreatment, and medical morbidity in US adults: An observational study

OBJECTIVE

Mood disorders, child maltreatment, and medical morbidity are associated with enormous public health burden and individual suffering. The effect of mood disorders on medical morbidity, accounting for child maltreatment, has not been studied prospectively in a large, representative sample of community-dwelling US adults. This study tested the effects of mood disorders and child maltreatment on medical morbidity, and variation by subtypes.

METHODS

Participants were noninstitutionalized US adults in the National Epidemiologic Survey on Alcohol and Related Conditions (N = 43,093 wave 1, N = 34,653 wave 2). Mood disorders included lifetime DSM-IV episodes of depression, dysthymia, mania, or hypomania. Child maltreatment was defined as sexual, physical, or emotional abuse, or physical or emotional neglect before age 18. Survey-weighted zero-inflated poisson regression was used to study effects on medical morbidity, a summary score of 11 self-reported medical conditions. Results were adjusted for age, sex, ethnicity/race, income, substance use disorders, smoking, and obesity.

RESULTS

Mood disorders and child maltreatment additively associated with medical morbidity at study entry and three years later, with similar magnitude as obesity and smoking. Mania/hypomania (incidence rate ratio [IRR] 1.06, 95% CI 1.01-1.10) and child sexual (IRR 1.08, 95% CI 1.04-1.11) and emotional (IRR 1.05, 95% CI 1.01-1.10) abuse were associated with higher medical morbidity longitudinally.

CONCLUSIONS

Child maltreatment is common, and its long-range negative effect on medical morbidity underscores the importance of trauma-informed care, and consideration of early life exposures. History of mania/hypomania should be considered in medical practice, and physical health must be emphasized in mental health care.

Comparison of psychiatric comorbidity in treatment-seeking, opioid-dependent patients with versus without chronic pain

AIM

To compare psychiatric morbidity in treatment-seeking, opioid-dependent patients with versus without chronic pain.

DESIGN

A retrospective comparative cohort design was used involving record linkage from routinely collected, nationally held data sets. Data were managed within a Scottish Government-certified Safe Haven.

SETTING AND PARTICIPANTS

Participants comprised all patients of an NHS Substance Misuse Service in the East of Scotland (n = 467) who were in treatment during 2005 and had been in treatment for varying lengths of time. Their mean age at study inception was 35.0 years in the chronic pain group and 32.1 years; 68% of the chronic pain group and 74% of the no pain group were male.

MEASUREMENTS

The outcomes were (a) psychiatric comorbidity assessed at study inception using the 28-item General Health Questionnaire and the Clinical Outcomes in Routine Evaluation-Outcome Measure and (b) receipt of at least one prescription for a psychiatric condition during a 5-year period following study inception. The independent variable was chronic pain measured at study inception using the Brief Pain Inventory-Short Form.

FINDINGS

A total of 246 (52.7%) reported chronic pain and 221 (47.3%) did not. A higher proportion of patients with chronic pain had at least one psychiatric morbidity (62.4 versus 46.3%, P < 0.001). At the study inception, a higher proportion of patients with chronic pain were prescribed anxiolytics (49.0 versus 39.1%, P = 0.015) and antimanic drugs (9.9 compared with 4.9%, P = 0.015).

CONCLUSIONS

Patients of opioid treatment services in Scotland who report chronic pain may have a higher prevalence of psychiatric comorbidity than those who do not.

Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness

BACKGROUND

Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia.

METHODS

Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or schizophrenia or schizoaffective disorder (N = 12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses.

RESULTS

Multivariable models indicated that having a MDD (OR = 1.90; 95% CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications.

CONCLUSIONS

Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients. Future research is needed to evaluate the effectiveness of involving mental health clinicians in these efforts.

A modality-specific dysfunction of pain processing in schizophrenia

Clinical observations showed that schizophrenia (SCZ) patients reported little or no pain under various conditions that are commonly associated with intense painful sensations, leading to a higher risk of morbidity and mortality. However, this phenomenon has received little attention and its underlying neural mechanisms remain unclear. Here, we conducted two experiments combining psychophysics, electroencephalography (EEG), and functional magnetic resonance imaging (fMRI) techniques to investigate neural mechanisms of pain insensitivity in SCZ patients. Specifically, we adopted a stimulus–response paradigm with brief stimuli of different sensory modalities (i.e., nociceptive, non‐nociceptive somatosensory, and auditory) to test whether pain insensitivity in SCZ patients is supra‐modal or modality‐specific, and used EEG and fMRI techniques to clarify its neural mechanisms. We observed that perceived intensities to nociceptive stimuli were significantly smaller in SCZ patients than healthy controls, whereas perceived intensities to non‐nociceptive somatosensory and auditory stimuli were not significantly different. The behavioral results were confirmed by stimulus‐evoked brain responses sampled by EEG and fMRI techniques, thus verifying the modality‐specific nature of the modulation of nociceptive information processing in SCZ patients. Additionally, significant group differences were observed in the spectral power of alpha oscillations in prestimulus EEG and the seed‐based functional connectivity in resting‐state fMRI (seeds: the thalamus and periaqueductal gray that are key nodes in ascending and descending pain pathways respectively), suggesting a possible contribution of cortical–subcortical dysfunction to the phenomenon. Overall, our study provides insight into the neural mechanisms of pain insensitivity in SCZ and highlights a need for systematic assessments of their pain‐related diseases.

Examination of pain threshold and neuropeptides in patients with acute suicide risk

INTRODUCTION

One of the main challenges in suicide prevention is the limited understanding of the biological mechanisms underlying suicide. Recent findings suggest impairments in pain processing in acutely suicidal patients. However, little is known about the biological factors that may drive these discrete physiological abnormalities. In this study, we examined plasma peptides involved in analgesic and inflammatory responses and physical pain threshold in acutely suicidal patients.

METHODS

Thirty-seven depressed patients of both sexes hospitalized for severe suicidal ideation or a recent suicide attempt were characterized clinically including history of suicidal ideation and behavior. Psychological and physical pain, and pressure pain threshold was also measured. Plasma levels of β-endorphin, neurotensin, agouti-related protein (AgRP), C-reactive protein (CRP), adrenocorticotropic hormone (ACTH), and brain-derived neurotrophic factor (BDNF) were run in Milliplex multiplex assays.

RESULTS

The number of lifetime suicide attempts was positively correlated with β-endorphin (r = 0.702; p = 0.007), and neurotensin (r = 0.728, p = 0.007) plasma levels. Higher pain threshold was measured in the suicide attempt group as compared to the suicidal ideation group. Pain threshold was strongly and negatively associated with CRP plasma levels (r = -0.548; p < 0.001). In patients reporting chronic pain, lower AgRP levels and lower pain threshold were observed (t = 4.472; p = 0.001).

CONCLUSION

Our results suggest that abnormalities in the opioid and neurotensin systems may underlie the increase in pain threshold found in suicide attempters, and possibly risk for suicidal behavior. Targeting pain circuits and systems may provide therapeutic mechanisms for suicide prevention.

SCN11A mRNA levels in female bipolar disorder PBMCs as tentative biomarker for distinct patient sub-phenotypes

Bipolar disorder (BD) is a complex neuropsychiatric disorder characterized by recurrent mania and depression episodes and requiring lifelong treatment with mood stabilizing drugs. Several lines of evidence, including with BD patient iPSC-derived neurons, suggest that neuronal hyperexcitability may underlie the key clinical symptoms of BD. Indeed, higher mRNA levels of SCN11A, coding for the voltage-gated sodium channel Na_V 1.9 implicated in nociception, were detected in iPSC-derived neurons from BD patients, and were normalized by in vitro lithium. Here we studied SCN11A expression in peripheral blood mononuclear cells (PBMCs) from well-phenotyped female BD patients and controls and evaluated their association with several clinical sub-phenotypes. We observed higher mRNA levels of SCN11A in PBMCs from female BD patients with no records of alcohol dependence (p = .0050), no records of psychosis (p = .0097), or no records of suicide attempts (p = .0409). A trend was observed for higher SCN11A expression (FD = 1.91; p = .052) in BD PBMCs compared with controls. Datamining of published postmortem gene expression datasets indicated higher SCN11A expression in dorsolateral prefrontal cortex and orbitofrontal cortex tissues from BD patients compared with controls. Higher phenotype-associated expression levels in PBMC from BD patients were also observed for ID2 (alcohol dependence, suicide attempts) and HDGFRP3 (seasonal BD pattern). Our findings suggest that higher PBMC SCN11A expression levels may be associated with certain behavioral BD sub-phenotypes, including lack of alcohol dependence and psychosis, among BD patients. The Na_V 1.9 voltage-gated sodium channel thus deserves consideration as a tentative phenotype modifier in BD.

Genome-wide association study of multisite chronic pain in UK Biobank

Chronic pain is highly prevalent worldwide and represents a significant socioeconomic and public health burden. Several aspects of chronic pain, for example back pain and a severity-related phenotype ‘chronic pain grade’, have been shown previously to be complex heritable traits with a polygenic component. Additional pain-related phenotypes capturing aspects of an individual’s overall sensitivity to experiencing and reporting chronic pain have also been suggested as a focus for investigation. We made use of a measure of the number of sites of chronic pain in individuals within the UK general population. This measure, termed Multisite Chronic Pain (MCP), is a complex trait and its genetic architecture has not previously been investigated. To address this, we carried out a large-scale genome-wide association study (GWAS) of MCP in ~380,000 UK Biobank participants. Our findings were consistent with MCP having a significant polygenic component, with a Single Nucleotide Polymorphism (SNP) heritability of 10.2%. In total 76 independent lead SNPs at 39 risk loci were associated with MCP. Additional gene-level association analyses identified neurogenesis, synaptic plasticity, nervous system development, cell-cycle progression and apoptosis genes as enriched for genetic association with MCP. Genetic correlations were observed between MCP and a range of psychiatric, autoimmune and anthropometric traits, including major depressive disorder (MDD), asthma and Body Mass Index (BMI). Furthermore, in Mendelian randomisation (MR) analyses a causal effect of MCP on MDD was observed. Additionally, a polygenic risk score (PRS) for MCP was found to significantly predict chronic widespread pain (pain all over the body), indicating the existence of genetic variants contributing to both of these pain phenotypes. Overall, our findings support the proposition that chronic pain involves a strong nervous system component with implications for our understanding of the physiology of chronic pain. These discoveries may also inform the future development of novel treatment approaches.

Chronic pain is common worldwide and imposes a significant burden from a public health and socioeconomic perspective. The reasons why some individuals develop chronic pain and others do not are not fully understood. In this study we searched for genetic variants associated with chronic pain in a large general-population cohort. We also assessed how this genetic variation was correlated with a range of other diseases and traits, such as depression and BMI, and we tested for causal relationships between depression and chronic pain. We found that chronic pain was associated with several genes involved in brain function and development and was correlated with mental health and autoimmune traits (including depression, PTSD and asthma). We also found evidence for causal relationships between chronic pain and major depressive disorder. This work provides new insights into the genetics and underlying biology of chronic pain and may help to inform new treatment strategies.

A quantitative assessment of the views of mental health professionals on exercise for people with mental illness: perspectives from a low-resource setting

Background

Exercise is nowadays considered as an evidence-based treatment modality in people with mental illness. Nurses and occupational therapists working in low-resourced mental health settings are well-placed to provide exercise advice for people with mental illness.

Objectives

We examined the current exercise prescription practices employed by Ugandan health care professionals when working with people with mental illness, and identified perceived barriers to exercise prescription and exercise participation for people with mental illness.

Methods

In this study, 31 Ugandan health care professionals 20 men; 31.2 ± 7.1 years completed the Exercise in Mental Illness Questionnaire- Health Professionals Version EMIQ-HP.

Results

The vast majority of the respondents 29/31, 94% reported they prescribed exercise at least “occasionally” to people with mental illness. Exercise-prescription parameters used were consistent with those recommended for people with mental illness. Regarding barriers to exercise participation, coping with side effects of psychotropic medication at the individual level and reducing stigma at community level should be prioritized.

Conclusion

A health care reform to enable collaboration with exercise professionals, such as exercise physiologists or physiotherapists, might increase exercise uptake for people with mental illness, thereby improving health outcomes for this vulnerable population.

The need to improve detection and treatment of physical pain of homeless people with schizophrenia and bipolar disorders. Results from the French Housing First Study

OBJECTIVE

The aim of this study was to investigate the prevalence and associated factors of physical pain in a large multicenter sample of Homeless Schizophrenia and Bipolar (HSB) patients.

METHODS

This multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. Pain was measured by EQ5D-3 L questionnaire with no specified period or location. In addition, sociodemographic information, duration of homelessness, illness severity using the Modified Colorado Symptom Index (MCSI) and drug information were collected.

RESULTS

Overall, 655 HSB patients, mean age 38.8 years and 82.6% men were included, 448 (68.9%) were diagnosed with schizophrenia and 202 (31.1%) with bipolar disorder. More than half patients (N = 337, 51.5%) reported moderate to extreme physical pain while only 2.7% were administered analgesic drugs. In the multivariate analysis, self-reported moderate to extreme physical pain was associated with antidepressant consumption (adjusted odd ratio aOR = 2.56[1.25;5.26], p = .01), female gender (aOR = 1.72[1.03;2.86], p = .04), bipolar disorders (vs. schizophrenia) (aOR = 1.81[1.19;2.77], p = .006), older age (aOR = 1.03 [1.01;1.05], p = .01), with higher MCSI psychotic score (a0R = 1.04[1.01;1.06],p = .002), independently of the number of days in the street during the last 180 days, MCSI depression score, alcohol and substance use disorders, psychotropic drugs and analgesic treatments. No association with education level, antipsychotics, mood stabilizers, anxiolytic, hypnotic or medication adherence was found (all p > .05).

CONCLUSION

Physical pain was highly reported in homeless patients with severe mental illness with insufficient care. Physical pain should be systematically explored and treated in this population. Bipolar disorders, antidepressant consumption and female gender may be targeted in priority. Age and psychotic symptomatology were found to influence self-reported pain in a marginal way.

Physical effort exertion and pain: Links with trait-based risk for psychopathology

People with serious mental illness (SMI) are at an increased risk for physical health complications, such as cardiovascular disease and obesity. Low levels of physical activity is a major contributor to these health complications. One factor associated with limited physical activity in the broader sedentary population is pain. While preliminary findings suggest an association between lack of physical activity and pain in SMI, conclusions are still unclear. Thus, the goal of this correlational study was to examine associations between trait-based risk for psychopathology (hypomanic personality, schizotypy, and anhedonic depression) and the experience of pain following a physical endurance/effort task. Healthy participants (N = 43; 18 females) completed self-report measures of trait-based risk for psychopathology. They also reported on the experience of pain before and after the Time To Exhaustion (TTE) test. Findings revealed that risk for psychosis and anhedonic depression were associated with increases in pain following the TTE test, accounting for other key variables, such as age and self-reported physical exercise. Risk for mania was unrelated to changes in pain. These results suggest that the experience of pain in relation to physical endurance/effort may contribute to diminished physical activity among people at risk for SMI.

Sociodemographic characteristics, health conditions, and functional impairment among older adults with serious mental illness reporting moderate-to-severe pain

OBJECTIVE

To compare adults aged ≥50 years with serious mental illness reporting moderate-to-severe pain to older adults with serious mental illness without pain with respect to sociodemographic characteristics, health conditions, and functional impairment.

METHOD

Secondary data analyses were conducted using baseline assessments of 183 participants recruited for the Helping Older People Experience Success (HOPES) study from three community mental health centers. The primary outcome was self-reported, nonexperimentally induced, moderate-to-severe pain (referent = no-to-mild pain). Predictor variables consisted of sociodemographic characteristics, health conditions, and functional impairment. We conducted univariable and multivariable logistic regression analyses to examine the associations between these variables.

RESULTS

Sixty-one participants (33.3%) from our sample reported pain. Pain was associated with all of the sociodemographic and health-related factors in univariable analyses. In the multivariable model, only older age, pain-related activity interference, and physical and emotional health-related social limitations were significantly associated with pain.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The presence of moderate-to-severe pain in older adults with serious mental illness is associated with pain-attributable impairment of activities and social problems above and beyond the substantial functional limitations routinely experienced by this high-risk, high-need group. Given the high rates of preexisting conditions and persistent social impairment among these older adults, our findings suggest that pain may contribute to worse overall functional outcomes. Future research and clinical interventions focused on improving outcomes should include an evaluation of pain as a contributor to decreased functioning and assess the need for early intervention, nonpharmacological pain management, or other health promotion services in psychiatric rehabilitation. (PsycINFO Database Record

Sexual Functions in Male and Female Patients With Bipolar Disorder During Remission

INTRODUCTION

Bipolar disorder is an episodic mood disorder that causes unusual shifts in mood and affects the ability to carry out day-to-day tasks.

AIM

Evaluation of the sexual function in men and women with bipolar disorder during remission.

METHODS

60 men and women with bipolar disorder and 60 age-matched control subjects were included. A Structured Clinical Interview of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition was performed to confirm the diagnosis, and Hamilton Depression Rating Scale (HAM-D) to assess the depressive symptoms and Young Mania Rating Scale (YMRS) to assess the manic symptoms. We assessed sexual function in both sexes using international indices of erectile function for men and sexual function of women.

MAIN OUTCOME MEASURES

Scores of HAM-D, YMRS, Arabic versions of International Index of Erectile Function (IIEF) and female sexual function (FSFI).

RESULTS

Depressive symptoms showed insignificant adverse correlation with the IIEF in men, whereas they revealed adverse significant correlations with the items of female sexual function index (FSFI) except pain (correlation coefficients [r] = 0.349 [P = .059], r = 0.680 [P < .001], r = 0.574 [P = .001], r = 0.517 [P = .003], r = 0.569 [P = .001], r = 0.532 [P = .002], r = 0.609 [P < .001], r = 0.342 [P = .065], respectively). Interestingly, the manic symptoms were associated with sexual hyperfunctioning in the men and were insignificantly correlated with the different items of FSFI in the women (r = 0.414 [P = .023], r = 0.043 [P = .821], r = 0.100 [P = .601], r = 0.108 [P = .571], r = 0.183 [P = .332), r = 0.086 [P = .651], r = 0.022 (P = .907), r = 0.109 [P = .565], respectively). There was a positive correlation between the affected women's satisfaction and their partners' score (r = 0.374, P =.042). Finally, the mean score of pain was statistically higher in the female cases than the normal ones (mean ± SD = 3.6 ± 0.4, 3.4, ± 0.6; P = .036).

CLINICAL IMPLICATIONS

A different approach may be mandatory for manic female patients.

STRENGTHS & LIMITATIONS

This study is one of the few studies that evaluated the sexual function in patients with bipolar disorder especially during remission. Some limitations of this study must be mentioned. We failed to evaluate the female partners of the diseased males. Quality of life of the recruited patients was not assessed. Finally, the study included patients who were not drug free.

CONCLUSION

Manic symptoms in female bipolar I patients are associated with sexual hypofunctioning. Elkhiat YI, Seif AFA, Khalil MA, et al. Sexual functions in male and female patients with bipolar disorder during remission. J Sex Med 2018;15:1111-1116.

Comparative Effect of Collaborative Care, Pain Medication, and Duloxetine in the Treatment of Major Depressive Disorder and Comorbid (Sub)Chronic Pain: Results of an Exploratory Randomized, Placebo-Controlled, Multicenter Trial (CC:PAINDIP)

OBJECTIVE

Evidence exists for the efficacy of collaborative care (CC) for major depressive disorder (MDD), for the efficacy of the consequent use of pain medication against pain, and for the efficacy of duloxetine against both MDD and neuropathic pain. Their relative effectiveness in comorbid MDD and pain has never been established so far. This study explores the effectiveness of CC with pain medication and duloxetine, and CC with pain medication and placebo, compared with duloxetine alone, on depressive and pain symptoms. This study was prematurely terminated because of massive reorganizations and reimbursement changes in mental health care in the Netherlands during the study period and is therefore of exploratory nature.

METHODS

Three-armed, randomized, multicenter, placebo-controlled trial at three specialized mental health outpatient clinics with patients who screened positive for MDD. Interventions lasted 12 weeks. Pain medication was administered according to an algorithm that avoids opiate prescription as much as possible, where paracetamol, COX inhibitors, and pregabalin are offered as steps before opiates are considered. Patients who did not show up for three or more sessions were registered as non-compliant. Explorative, intention-to-treat and per protocol, multilevel regression analyses were performed. The trial is listed in the trial registration (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1089; NTR number: NTR1089).

RESULTS

Sixty patients completed the study. Patients in all treatment groups reported significantly less depressive and pain symptoms after 12 weeks. CC with placebo condition showed the fastest decrease in depressive symptoms compared with the duloxetine alone group (b = -0.78; p = 0.01). Non-compliant patients (n = 31) did not improve over the 12-week period, in contrast to compliant patients (n = 29). Pain outcomes did not differ between the three groups.

CONCLUSION

In MDD and pain, patient's compliance and placebo effects are more important in attaining effect than choice of one of the treatments. Active pain management with COX inhibitors and pregabalin as alternatives to tramadol or other opiates might provide an attractive alternative to the current WHO pain ladder as it avoids opiate prescription as much as possible. The generalizability is limited due to the small sample size. Larger studies are needed.

Predictors and outcomes of somatization in bipolar I disorder: A latent class mixture modeling approach

BACKGROUND

Mood disorders are often associated with somatic symptoms. The role of somatic symptoms on disease progression in unipolar depression is substantially better characterized than that role in bipolar disorder. Moreover, the contribution of comorbid anxiety disorders and medical illness is not well understood.

METHOD

We investigated 527 patients with bipolar I disorder clustered within 102 families using a latent class approach. Predictors were added stepwise into the model. Anxiety and commonly associated medical illnesses were added as covariates.

RESULTS

The rate of somatic symptoms in this sample was 73% (mean 1.7 symptoms), and 27.3% had a comorbid anxiety disorder. A two-class model, with a subgroup at high-risk for somatization, gave the best fit to the data. Multilevel mixture modeling accounted for family clusters. Somatic symptoms were independently associated with disease severity, defined as earlier age of first seeking psychiatric help (x = 21.7 vs x = 24.7, p = 0.005) and first psychiatric hospitalization (x = 25.7 vs x = 28.2, p = 0.03), greater probability of attempting suicide (x = 0.41 vs x = 0.32, p = 0.047), and rapid-cycling disease course (x = 0.57 vs x = 0.36, p < 0.001). Persons with few or no somatic symptoms were more likely to be hospitalized for severe mania (x = 0.63 vs x = 0.51; p = 0.013), but did not significantly differ in hospitalization for severe depression.

LIMITATIONS

The study is correlational. Information on pharmacologic interventions and comorbid diseases was limited.

CONCLUSIONS

Somatic symptoms in bipolar disorder could be an independent indicator for disease severity, suicidality, and rapid-cycling disease course. In severe mental illness, somatic and psychological symptoms must be jointly addressed.

Physiotherapy for people with mental health problems in Sub-Saharan African countries: a systematic review

Background

There is a need for psychosocial interventions to address the escalating mental health burden in Sub-Saharan Africa (SSA). Physiotherapists could have a central role in reducing the burden and facilitating recovery within the multidisciplinary care of people with mental health problems. The aim of this systematic review was to explore the role of physiotherapists within the current mental health policies of SSA countries and to explore the current research evidence for physiotherapy to improve functional outcomes in people with mental health problems in SSA.

Methods

The Mental Health Atlas and MiNDbank of the World Health Organization were screened for the role of physiotherapy in mental health plans. Next, we systematically searched PubMed from inception until August 1st, 2017 for relevant studies on physiotherapy interventions in people with mental health problems in SSA. The following search strategy was used: "physiotherapy" OR "physical therapy" OR "rehabilitation" AND "mental" OR "depression" OR "psychosis" OR "schizophrenia" OR "bipolar" AND the name of the country.

Results

The current systematic review shows that in 22 screened plans only 2 made reference to the importance of considering physiotherapy within the multidisciplinary treatment. The current evidence (N studies = 3; n participants = 94) shows that aerobic exercise might reduce depression and improve psychological quality of life, self-esteem, body image and emotional stress in people with HIV having mental health problems. In people with depression moderate to high but not light intensity aerobic exercise results in significantly less depressive symptoms (N = 1, n = 30). Finally, there is evidence for reduction in post-traumatic stress symptoms (avoidance and arousal), anxiety and depression following body awareness related exercises (N = 1, n = 26).

Conclusions

Our review demonstrated that physiotherapy is still largely neglected in the mental health care systems of SSA. This is probably due to poor knowledge of the benefits of physiotherapy within mental health care by policymakers, training institutes, and other mental health care professionals in SSA. Based on the current scientific evidence, this paper recommends the adoption of physiotherapy within mental health care services and investment in research and in training of professionals in SSA.

Neural Activation During Tonic Pain and Interaction Between Pain and Emotion in Bipolar Disorder: An fMRI Study

Objective: Pain and affective disorders have clear clinical relevance; however, very few studies have investigated the association between pain and bipolar disorder. This study investigated the brain activity of patients with bipolar disorder (BPs) undergoing tonic pain and assessed the interaction between pain and emotion. Methods: Ten BPs and ten healthy controls (HCs) were exposed to emotional pictures (positive, neutral, or negative), tonic pain only (pain session), and emotional pictures along with tonic pain (combined session). A moderate tonic pain was induced by the infusion of hypertonic saline (5% NaCl) into the right masseter muscle with a computer-controlled system. Whole-brain blood oxygenation level dependent (BOLD) signals were acquired using 3T functional resonance imaging (fMRI). Results: Ten BPs and ten healthy participants were included in the final analysis. During the pain session, BPs accepted more saline, but showed lower pain rating scores than HCs. When experiencing pain, BPs showed a significant decrease in the BOLD signal in the bilateral insula, left inferior frontal gyrus (IFG), and left cerebellum as compared with HCs. In the combined session, the activated regions for positive mood (pain with positive mood > baseline) in BPs were the left cerebellum, right temporal gyrus, and left occipital gyrus; the activated regions for negative mood (pain with negative mood > baseline) were the right occipital gyrus, left insula, left IFG, and bilateral precentral gyrus. Conclusions: This study presents the preliminary finding of the interaction between pain and emotion in BPs. BPs exhibited lower sensitivity to pain, and the activation of insula and IFG may reflect the interaction between emotion and pain stimulus.

Physical activity and metabolic disease among people with affective disorders: Prevention, management and implementation

BACKGROUND

One in ten and one in three of people with affective disorders experience diabetes and metabolic syndrome respectively. Physical activity (PA) and sedentary behaviour (SB) are key risk factors that can ameliorate the risk of metabolic disease among this population. However, PA is often seen as luxury and/or a secondary component within the management of people with affective disorders.

METHODS

The current article provides a non-systematic best-evidence synthesis of the available literature, detailing a number of suggestions for the implementation of PA into clinical practice.

RESULTS

Whilst the evidence is unequivocal for the efficacy of PA to prevent and manage metabolic disease in the general population, it is in its infancy in this patient group. Nonetheless, action must be taken now to ensure that PA and reducing SB are given a priority to prevent and manage metabolic diseases and improve wider health outcomes. PA should be treated as a vital sign and all people with affective disorders asked about their activity levels and if appropriate advised to increase this. There is a need for investment in qualified exercise specialists in clinical practice such as physiotherapists to undertake and oversee PA in practice. Behavioural strategies such as the self-determined theory should be employed to encourage adherence. Funding is required to develop the evidence base and elucidate the optimal intervention characteristics.

CONCLUSION

PA interventions should form an integral part of the multidisciplinary management of people with affective disorders and our article outlines the evidence and strategies to implement this in practice.

Self-poisoning suicide deaths in people with bipolar disorder: characterizing a subgroup and identifying treatment patterns

OBJECTIVE

To characterize self-poisoning suicide deaths in BD compared to other suicide decedents.

METHODS

Extracted coroner data from all suicide deaths (n = 3319) in Toronto, Canada from 1998 to 2012. Analyses of demographics, clinical history, recent stressors, and suicide details were conducted in 5 subgroups of suicide decedents: BD self-poisoning, BD other methods, non-BD self-poisoning, non-BD other methods, and unipolar depression self-poisoning. Toxicology results for lethal and present substances were also compared between BD and non-BD self-poisoning subgroups as well as between BD and unipolar depression self-poisoning subgroups.

RESULTS

Among BD suicide decedents, self-poisoning was significantly associated with female sex, past suicide attempts, and comorbid substance abuse. In both the BD and non-BD self-poisoning groups, opioids were the most common class of lethal medication. For both groups, benzodiazepines and antidepressants were the most common medications present at time of death, and in 23% of the BD group, an antidepressant was present without a mood stabilizer or antipsychotic. Only 31% of the BD group had any mood stabilizer present, with carbamazepine being most common. No antidepressant, mood stabilizer, or antipsychotic was present in 15.5% of the BD group. Relative to unipolar depression self-poisoning group, the BD self-poisoning group evidenced higher proportion of previous suicide attempt(s) and psychiatry/ER visits in the previous week.

CONCLUSION

People with BD who die by suicide via self-poisoning comprise a distinct but understudied group. The predominant absence of guideline-concordant pharmacologic care comprises a crucial target for future policy and knowledge translation efforts.

A systematic review of physical activity policy recommendations and interventions for people with mental health problems in Sub-Saharan African countries

Introduction

There is a need for interventions to address the escalating mental health burden in Sub-Saharan Africa (SSA). Implementation of physical activity (PA) within the rehabilitation of people with mental health problems (PMHP) could reduce the burden and facilitate recovery. The objective of the current review was to explore (1) the role of PA within mental health policies of SSA countries, and (2) the current research evidence for PA to improve mental health in SSA.

Methods

We screened the Mental Health Atlas and MiNDbank for mental health policies in SSA countries and searched PubMed for relevant studies on PA in PMHP in SSA.

Results

Sixty-nine percent (=33/48) of SSA countries have a dedicated mental health policy. Two of 22 screened mental health policies included broad physical activity recommendations. There is clear evidence for the role of PA in the prevention and rehabilitation of depression in SSA.

Conclusion

Despite the existing evidence, PA is largely a neglected rehabilitation modality in the mental health care systems of SSA. Continued education of existing staff, training of specialized professionals and integration of PA for mental health in public health awareness programs are needed to initiate and improve PA programs within the mental health care systems of SSA.

Medically unexplained somatic symptoms and bipolar spectrum disorders: A systematic review and meta-analysis

BACKGROUND

Patients with bipolar spectrum disorders (BSD) frequently report medically unexplained somatic symptoms. However, the prevalence and the consequences for treatment and outcome are currently unknown.

METHODS

To estimate the prevalence of somatic symptoms in BSD, we conducted a systematic review and meta-analysis of empirical studies published between 1980 and 2015. The odds for somatic symptoms in BSD were compared with unipolar depression (UPD) and general population or mixed psychiatric controls. Studies were retrieved from four electronic databases utilizing Boolean operations and reference list searches. Pooled data estimates were derived using random-effects methods.

RESULTS

Out of 2634 studies, 23 were eligible for inclusion, yielding an N of 106,785 patients. The estimated prevalence of somatic symptoms in BSD was 47.8%. The estimated prevalence of BSD in persons with somatic symptoms was 1.4%. Persons with BSD had a higher prevalence of somatic symptoms compared with population or mixed psychiatric controls (OR 1.82, 95% CI 1.14-2.92). Persons with BSD had a similar prevalence of somatic symptoms compared with UPD controls (OR 0.99, 95% CI 0.68-1.44).

LIMITATIONS

This study is correlational; thus causal inferences cannot be made. Reporting of somatic symptoms likely varies with BSD severity and subtype. Some studies reported insufficient information regarding comorbid medical conditions and medications.

CONCLUSIONS

Persons with BSD suffer from somatic symptoms at a rate nearly double that of the general population, a rate similar to persons with UPD. Our results suggest the utility of an integrated care model in which primary care and specialist physicians collaborate with mental health professionals to jointly address psychological and bodily symptoms.

Physical Exercise for Treatment of Mood Disorders: A Critical Review

PURPOSE OF THE REVIEW

The purpose of this review is to critically assess the evidence for exercise as an adjunct intervention for major depressive disorder and bipolar disorder, chronic conditions characterized by frequent comorbid conditions as well as interepisodic symptoms with poor quality of life and impaired functioning. Individuals with these mood disorders are at higher risk of cardiovascular disease and premature death in part because of increased rates of obesity, inactivity, and diabetes mellitus compared to the general population. Exercise may not only mitigate the increased risk of cardiovascular disease, but could also potentially improve the long term outcomes of mood disorders.

RECENT FINDINGS

We conducted a literature review on the impact of exercise on mood disorders and associated comorbid conditions as well as possible biological mechanisms. We found that exercise impacts both the physical health parameters of mood disorders as well as mental health outcomes. Exercise also positively impacts conditions frequently comorbid with mood disorders (i.e. anxiety, pain, and insomnia). There are multiple candidate biomarkers for exercise, with brain-derived neurotrophic factor and oxidative stress as two main promising components of exercise's anti-depressant effect.

SUMMARY

Exercise appears to be a promising adjunct treatment for mood disorders. We conclude with recommendations for future research of exercise as an adjunct intervention for mood disorders.

Physical activity and sedentary behavior in people with bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Mortality rates are approximately two to three times higher in people with bipolar disorder (BD) than in general population. Lack of physical activity (PA) and sedentary behavior (SB) are independent risk factors for cardiovascular disease and premature mortality.

AIMS

We conducted a meta-analysis to investigate PA and SB levels and its predictors in BD.

METHODS

Major electronic databases were searched from inception till 02/2016 for articles measuring PA and SB with a self-report questionnaire (SRQ) or objective measure (e.g. accelerometer) in BD. A random effects meta-analysis and meta-regression analysis were conducted.

RESULTS

Six studies were eligible including 279 (129♂) people with BD (mean age=43.9 years; range: 32.0-51.5 years). The trim and fill analysis demonstrated people with BD spent in total 210.1min (95%CI=146.3-273.9min) per day being physically active and 613.3min (95%CI=389.9-836.6min) during waking hours being sedentary. No significant difference in total PA per day was observed between people with BD and controls (g=-0.62, 95% CI=-1.55 to 0.31, I(2)=88.5%, n BD =82, n controls =86). Objective measures of PA recorded significantly lower levels (P=0.03) compared to self-report PA. Meta-regression demonstrated that older age and a higher body mass index predicted lower PA levels.

LIMITATIONS

Only a limited number of studies were identified assessing SB in people with BD.

CONCLUSIONS

Adults with BD engage in high levels of sedentary behavior during waking hours. Given that sedentary behavior is an independent predictor of cardiovascular disease, future lifestyle interventions specifically targeting the prevention of sedentary behavior are warranted.

Sitting time, physical fitness impairments and metabolic abnormalities in people with bipolar disorder: An exploratory study

A sedentary lifestyle is an independent risk factor for cardiovascular disease and mortality. Little is known however about sedentary behavior in people with bipolar disorder (BD). The primary aim of this study was to explore associations between sitting time (as a proxy for a sedentary lifestyle) and physical fitness and metabolic parameters in BD. A secondary aim was to investigate associations between psychiatric symptoms, psychotropic medication use and sitting time. Thirty-nine (21♀) participants (43.7±12.4 years) completed a full metabolic screening, the sitting time item of the International Physical Activity Questionnaire, the Quick Inventory of Depressive Symptomatology self-report and the Hypomania Checklist-32. Additionally participants performed the Eurofit-test battery and 6-min walk test. The mean time spent sitting per day for the entire sample was 7.0±3.0h. A higher body mass index, worse physical fitness and higher antipsychotic medication dose were identified as independent predictors of higher levels of sitting behavior. The model explained 76.5% of the variability in the sitting time. Given that a sedentary lifestyle is an independent predictor of cardiovascular disease, future interventions specifically targeting time spend sitting are warranted in BD, with a particular emphasis on those with high body mass index and low fitness levels.

How common is bipolar disorder in general primary care attendees? A systematic review and meta-analysis investigating prevalence determined according to structured clinical assessments

OBJECTIVE

There are mounting calls for bipolar disorder to be managed in primary care, yet the exact prevalence remains unclear. We conducted a meta-analysis to investigate the prevalence of bipolar disorder in general primary care attendees without other comorbid psychiatric diagnosis.

METHOD

We systematically searched major electronic databases from inception till 03/2015. Articles were included that reported the prevalence of bipolar disorder determined in line with structured clinical assessment in primary care settings. Two independent authors conducted searches, completed methodological appraisal and extracted data. A random effects meta-analysis and meta-regression were performed.

RESULTS

Sixteen studies were included accounting for 425,691 participants (mean age = 41.1 years [standard deviation = 7.2 years] 33.3% males). Overall, the global prevalence of bipolar disorder was 1.9% (95% confidence interval = [0.6, 5.4]). The prevalence of bipolar disorder in studies recording a current diagnosis was 3.7% (95% confidence interval = [1.9, 6.0]) and 0.7% (95% confidence interval = [0.2, 1.5]) in studies considering a 12-month period. A diagnosis of bipolar disorder appeared higher in North America (3.7%, 95% confidence interval = [0.9, 8.1]) compared to Europe (0.8%, 95% confidence interval = [0.3, 1.5]). Meta-regression suggests that a more recent publication date (co-efficient = 0.089, 95% confidence interval = [0.0173, 0.1654], z = 2.19, p = 0.01, R(2) = 0.21) and younger age of participants (co-efficient -0.0851, 95% confidence interval = [-0.1696, 0.005], z = -1.97, p = 0.04, R(2) = 0.24) moderated a higher prevalence of bipolar disorder.

CONCLUSION

The global prevalence of bipolar disorder in primary care is 1.9%, with potentially higher prevalence rates in North America compared to Europe. A more recent study publication date is a significant predictor of higher prevalence of bipolar disorder. Potential reasons/drivers of this are considered within the text.