Nutrition, Exercise, and Wellness Treatment in bipolar disorder: proof of concept for a consolidated intervention

Factors that influence participation in physical activity for people with bipolar disorder: a synthesis of qualitative evidence

BACKGROUND

Mental health problems contribute significantly to the overall disease burden worldwide and are major causes of disability, suicide, and ischaemic heart disease. People with bipolar disorder report lower levels of physical activity than the general population, and are at greater risk of chronic health conditions including cardiovascular disease and obesity. These contribute to poor health outcomes. Physical activity has the potential to improve quality of life and physical and mental well-being.

OBJECTIVES

To identify the factors that influence participation in physical activity for people diagnosed with bipolar disorder from the perspectives of service users, carers, service providers, and practitioners to help inform the design and implementation of interventions that promote physical activity.

SEARCH METHODS

We searched MEDLINE, PsycINFO, and eight other databases to March 2021. We also contacted experts in the field, searched the grey literature, and carried out reference checking and citation searching to identify additional studies. There were no language restrictions.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that focused on the experiences and attitudes of service users, carers, service providers, and healthcare professionals towards physical activity for bipolar disorder.

DATA COLLECTION AND ANALYSIS

We extracted data using a data extraction form designed for this review. We assessed methodological limitations using a list of predefined questions. We used the "best fit" framework synthesis based on a revised version of the Health Belief Model to analyse and present the evidence. We assessed methodological limitations using the CASP Qualitative Checklist. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) guidance to assess our confidence in each finding. We examined each finding to identify factors to inform the practice of health and care professionals and the design and development of physical activity interventions for people with bipolar disorder.

MAIN RESULTS

We included 12 studies involving a total of 592 participants (422 participants who contributed qualitative data to an online survey, 170 participants in qualitative research studies). Most studies explored the views and experiences of physical activity of people with experience of bipolar disorder. A number of studies also reported on personal experiences of physical activity components of lifestyle interventions. One study included views from family carers and clinicians. The majority of studies were from high-income countries, with only one study conducted in a middle-income country. Most participants were described as stable and had been living with a diagnosis of bipolar disorder for a number of years. We downgraded our confidence in several of the findings from high confidence to moderate or low confidence, as some findings were based on only small amounts of data, and the findings were based on studies from only a few countries, questioning the relevance of these findings to other settings. We also had very few perspectives of family members, other carers, or health professionals supporting people with bipolar disorder. The studies did not include any findings from service providers about their perspectives on supporting this aspect of care. There were a number of factors that limited people's ability to undertake physical activity. Shame and stigma about one's physical appearance and mental health diagnosis were discussed. Some people felt their sporting skills/competencies had been lost when they left school. Those who had been able to maintain exercise through the transition into adulthood appeared to be more likely to include physical activity in their regular routine. Physical health limits and comorbid health conditions limited activity. This included bipolar medication, being overweight, smoking, alcohol use, poor diet and sleep, and these barriers were linked to negative coping skills. Practical problems included affordability, accessibility, transport links, and the weather. Workplace or health schemes that offered discounts were viewed positively. The lack of opportunity for exercise within inpatient mental health settings was a problem. Facilitating factors included being psychologically stable and ready to adopt new lifestyle behaviours. There were positive benefits of being active outdoors and connecting with nature. Achieving balance, rhythm, and routine helped to support mood management. Fitting physical activity into a regular routine despite fluctuating mood or motivation appeared to be beneficial if practised at the right intensity and pace. Over- or under-exercising could be counterproductive and accelerate depressive or manic moods. Physical activity also helped to provide a structure to people's daily routines and could lead to other positive lifestyle benefits. Monitoring physical or other activities could be an effective way to identify potential triggers or early warning signs. Technology was helpful for some. People who had researched bipolar disorder and had developed a better understanding of the condition showed greater confidence in managing their care or providing care to others. Social support from friends/family or health professionals was an enabling factor, as was finding the right type of exercise, which for many people was walking. Other benefits included making social connections, weight loss, improved quality of life, and better mood regulation. Few people had been told of the benefits of physical activity. Better education and training of health professionals could support a more holistic approach to physical and mental well-being. Involving mental health professionals in the multidisciplinary delivery of physical activity interventions could be beneficial and improve care. Clear guidelines could help people to initiate and incorporate lifestyle changes.

AUTHORS' CONCLUSIONS

There is very little research focusing on factors that influence participation in physical activity in bipolar disorder. The studies we identified suggest that men and women with bipolar disorder face a range of obstacles and challenges to being active. The evidence also suggests that there are effective ways to promote managed physical activity. The research highlighted the important role that health and care settings, and professionals, can play in assessing individuals' physical health needs and how healthy lifestyles may be promoted. Based on these findings, we have provided a summary of key elements to consider for developing physical activity interventions for bipolar disorder.

Moving to Improve Mental Health - The Role of Exercise in Cognitive Function: A Narrative Review

This review study investigates how exercise can enhance cognitive ability and mental wellness. Physical activity has been linked to a number of beneficial effects on cognitive function, including increased memory and executive function in adults, improved academic performance in children and adolescents, and potential advantages for people with cognitive impairments or neurodegenerative diseases. Increased cerebral blood flow, the synthesis of neurotrophic factors, and a decrease in oxidative stress and inflammation are the processes driving these effects. Studies have shown that exercise has mood-regulating benefits, with symptoms of anxiety and sadness lessening as a result. These mood-enhancing effects are a result of the endocannabinoid system being activated, endorphins being released, and changes in self-esteem and body image. Exercise therapies have also demonstrated the potential to encourage cognitive health as people age and lower the likelihood of cognitive decline. Exercise has been investigated as an adjuvant treatment for mental health illnesses, such as depression, anxiety disorders, schizophrenia, bipolar disorder, and eating disorders, in addition to its preventive effects. Exercise can improve the effectiveness of treatment and general wellbeing when it is incorporated into comprehensive treatment strategies. To identify the ideal exercise parameters for certain outcomes and overcome barriers to exercise participation, more study is necessary. We can get closer to enhancing general wellbeing and quality of life by including exercise in measures for promoting mental health and cognitive health.

Elevated serum leptin is associated with attenuated reward anticipation in major depressive disorder independent of peripheral C-reactive protein levels

Major depressive disorder (MDD) is associated with immunologic and metabolic alterations linked to central processing dysfunctions, including attenuated reward processing. This study investigated the associations between inflammation, metabolic hormones (leptin, insulin, adiponectin), and reward-related brain processing in MDD patients with high (MDD-High) and low (MDD-Low) C-reactive protein (CRP) levels compared to healthy comparison subjects (HC). Participants completed a blood draw and a monetary incentive delay task during functional magnetic resonance imaging. Although groups did not differ in insulin or adiponectin concentrations, both MDD-High (Wilcoxon p = 0.004, d = 0.65) and MDD-Low (Wilcoxon p = 0.046, d = 0.53) showed higher leptin concentrations than HC but did not differ from each other. Across MDD participants, higher leptin levels were associated with lower brain activation during reward anticipation in the left insula (r = - 0.30, p = 0.004) and left dorsolateral putamen (r = -- 0.24, p = 0.025). In contrast, within HC, higher leptin concentrations were associated with higher activation during reward anticipation in the same regions (insula: r = 0.40, p = 0.007; putamen: r = 0.37, p = 0.014). Depression may be characterized by elevated pro-inflammatory signaling via leptin concentrations through alternate inflammatory pathways distinct to CRP.

Structured physical exercise for bipolar depression: an open-label, proof-of concept study

BACKGROUND

Physical exercise (PE) is a recommended lifestyle intervention for different mental disorders and has shown specific positive therapeutic effects in unipolar depressive disorder. Considering the similar symptomatology of the depressive phase in patients with bipolar disorder (BD) and unipolar depressive disorder, it is reasonable to suggest that PE may also be beneficial for bipolar depression. However, there is an absence of studies evaluating the antidepressant effect of a structured PE intervention in BD.

METHODS

This is an open-label, single-arm study trial. Fifteen patients with a diagnosis of BD Type I or Type II, presenting a depressive episode were included in the study. After physical and functional evaluation, patients participated in supervised training sessions with aerobics followed by strength exercises, three times per week, for 12 weeks (36 training sessions). Depressive and manic symptoms were assessed at baseline and 2, 4, 8, and 12 weeks. Additionally, quality of Life and functioning were assessed at baseline and 4, 8, and 12 weeks). Finally, we tested cardiorespiratory fitness, muscle strength and body composition at baseline and week-12.

RESULTS

The mean (± SD) Montgomery Asberg Depression Rating Scale (MADRS) score at baseline was 23.6 ± 8.3 points and after 12 weeks of PE the mean score was 10.2 ± 4.8 points. Nine patients (82%) presented an antidepressant response defined as a reduction of more than 50% of depressive symptoms at week 12 with five of those patients (45%) presenting criteria for full remission. A large and significant Cohen's D Effect Size (pre-post) was verified for MADRS reduction [1.98 (95% Confidence interval = 0.88 to 3.08)]. We did not detect a significant change in manic symptoms, functioning, and quality of life during the 12-week follow-up. At week-12, all patients increased their muscular strength (one repetition maximal test - 1RM) and reduced the percentage of body fat (spectral bioelectrical impedance analysis).

CONCLUSIONS

This study, using rigorous criteria and a structured intervention, provides valid pilot data, showing the feasibility of a structured PE intervention for the treatment of depressive symptoms in BD, and suggesting a potential adjunctive antidepressant effect. Moreover, PE showed a positive impact on muscle strength and body composition. This should be further verified by randomized controlled studies.

Eating Habits and Eating Disorder Associated Behavior in Bipolar Disorder

A relevant comorbidity of bipolar disorder (BD) is eating disorders (EDs). Crossed vulnerability factors as eating disorder-specific symptoms (EDSSs) may trigger the onset of both disorders in either direction. The Structured Inventory for Anorexic and Bulimic Eating Disorders for Self-Report was used to examine the occurrence of EDs in euthymic/subsyndromal individuals with BD ( n = 86) and healthy controls ( n = 86) matched for age and sex. Furthermore, we explored EDSSs with the subscales "general psychopathology and social integration," "bulimic symptoms," "body image and slimness ideal," "sexuality and body weight," "counteract," and "atypical binge." Higher rates of all EDSSs were reported in BD. Younger individuals with BD showed higher expression in "bulimic symptoms," "body image and slimness ideal," and "atypical binge" subscales. No participants fulfilled ED diagnosis. The findings show a link between EDSS and BD. Clinicians should pay attention to a multimodal intervention, considering risk factors, investigating eating habits and ED associated behaviors.

Physical Activity Monitoring Preferences in Adults With Bipolar Disorder

This report investigated physical activity (PA) monitoring preferences and problems among adults with bipolar disorder (BD). Methods: PARC2 study was conducted at the Western Psychiatric Institute and Clinic at the University of Pittsburgh. This secondary data analysis assessed three PA monitors; Body Media SW Pro Armband, Actigraph AM-7164, and Pedometer Omron HJ-720IT. PA monitors were worn simultaneously for 1 week. Participants reported preferences and problems (irritating, cumbersome, movement of the activity monitor, technical difficulties, and impaired functioning) encountered with each activity monitor. Results: Approximately 70% of the participants (n = 66) were middle-aged Caucasian women with a diagnosis of BD I and overweight. Sixty-six adults with BD wore all 3 monitors simultaneously. Twelve (18%) participants had no PA monitoring preference, 28 (42%) preferred the armband, 17 (26%) preferred the pedometer and 9 (14%) preferred the Actigraph. Activity monitoring preferences did not statistically differ by age, gender, race, BMI, diagnosis, or depressive and mania symptoms (p > 0.25). Two-thirds of the participants (64%) had at least one problem with at least one activity monitor. As far as problem categories, more than a quarter of participants reported irritation with the Armband (26%, n = 17) and movement of the pedometer (32%, n = 21). No statistically significant association was observed between activity monitoring preferences and problems (p = 0.72). Discussion: Adults with BD were willing to wear activity monitors even though problems were reported. Preference of physical activity monitors, in descending order, was the armband, pedometer, and Actigraph. One fifth of the adults with BD reported no preferences in activity monitors. The activity monitors selected for investigation included the "gold standard" in activity monitoring (Actigraph) worn at the waist as well as a research grade pedometer that is considerably more affordable, provides activity feedback in real-time, and may be a more feasible option for large scale studies.

Lithium therapy and weight change in people with bipolar disorder: A systematic review and meta-analysis

Lithium remains the gold standard maintenance treatment for Bipolar Disorder (BD). However, weight gain is a side effect of increasing relevance due to its metabolic implications. We conducted a systematic review and meta-analysis aimed at summarizing evidence on the use of lithium and weight change in BD. We followed the PRISMA methodology, searching Pubmed, Scopus and Web of Science. From 1003 screened references, 20 studies were included in the systematic review and 9 included in the meta-analysis. In line with the studies included in the systematic review, the meta-analysis revealed that weight gain with lithium was not significant, noting a weight increase of 0.462 Kg (p = 0158). A shorter duration of treatment was significantly associated with more weight gain. Compared to placebo, there were no significant differences in weight gain. Weight gain was significantly lower with lithium than with active comparators. This work reveals a low impact of lithium on weight change, especially compared to some of the most widely used active comparators. Our results could impact clinical decisions.

"The Food Matches the Mood": Experiences of Eating Disorders in Bipolar Disorder

Approximately 33% of those with bipolar disorder (BD) have a comorbid eating disorder (ED). However, the trajectory of these conditions has received little research attention. Nine participants who met criteria for BD and an ED participated in qualitative interviews exploring experiences of illness onset, the interaction of these conditions, and service provision. Almost all participants in the sample reported minimal to no screening of ED problems, despite their health professionals' frequent discussion of obesity. Findings suggested that ED features were diverse and evolved over time. Mania and depression were connected to ED features such as overeating and restricting, but this differed between and within participants. Most participants disclosed historic trauma which they considered central to their mental health concerns. This clinical group appears to be underserviced. Clinicians and researchers should routinely screen for ED features when treating and diagnosing BD to inform their physical and mental health interventions.

Are eating disorders associated with bipolar disorder type I? Results of a Lebanese case-control study

OBJECTIVES

To assess the association between disordered eating and bipolar disorder (BD).

METHODS/DESIGN

A case-control study, conducted between April and September 2018, enrolled 50 patients and 50 controls.

RESULTS

Higher eating attitude test scores were significantly associated with the presence of BD. This association remained after the introduction of other factors (marital status, family history of BD, shopping and gambling addictions, sleep quality, and insomnia severity) that were also associated with the presence of BD.

PRACTICAL IMPLICATIONS

This study suggested that eating disorders are associated with BD type I, independent of mediating factors. Health care providers should consider pharmacological or psychotherapeutic interventions that could treat both syndromes sparingly.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exercise is medicine: a new perspective for health promotion in bipolar disorder

INTRODUCTION

Similar effects in reducing the symptoms of the mood disorder are reported in the literature compared the action of drugs and aerobic exercise sessions, demonstrating the potential of exercise in the control and mood stabilization. Therefore, there are many reasons to believe that the increased cardiorespiratory fitness (VO_2max) can be an important means of protection and a reducing potential of physical and mental damage in bipolar disorders (BD). This review will highlight the current pattern of response of exercise on the pathophysiology of BD, relating the possible mechanisms, and hypotheses based on exercises.

AREAS COVERED

The mechanism of monoaminergic action and its relationship with exercise, role of physical conditioning and increased VO_2Max on neurotrophin release, and new perspectives on long-term exercise will be reviewed.

EXPERT OPINION

The adaptations to training, although little explored in the context of BD, can induce the expression of substances that co-regulate several processes related to the pathophysiology of BD. Furthermore, high intensity interval training (HIIT) can also be adjusted to improve the physical fitness and health in patients with BD. Future research is needed to adopt a training strategy that is both time efficient and adequate for the population in question.

Call to action regarding the vascular-bipolar link: A report from the Vascular Task Force of the International Society for Bipolar Disorders

OBJECTIVES

The association of bipolar disorder with early and excessive cardiovascular disease was identified over a century ago. Nonetheless, the vascular-bipolar link remains underrecognized, particularly with regard to how this link can contribute to our understanding of pathogenesis and treatment.

METHODS

An international group of experts completed a selective review of the literature, distilling core themes, identifying limitations and gaps in the literature, and highlighting future directions to bridge these gaps.

RESULTS

The association between bipolar disorder and vascular disease is large in magnitude, consistent across studies, and independent of confounding variables where assessed. The vascular-bipolar link is multifactorial and is difficult to study given the latency between the onset of bipolar disorder, often in adolescence or early adulthood, and subsequent vascular disease, which usually occurs decades later. As a result, studies have often focused on risk factors for vascular disease or intermediate phenotypes, such as structural and functional vascular imaging measures. There is interest in identifying the most relevant mediators of this relationship, including lifestyle (eg, smoking, diet, exercise), medications, and systemic biological mediators (eg, inflammation). Nonetheless, there is a paucity of treatment studies that deliberately engage these mediators, and thus far no treatment studies have focused on engaging vascular imaging targets.

CONCLUSIONS

Further research focused on the vascular-bipolar link holds promise for gleaning insights regarding the underlying causes of bipolar disorder, identifying novel treatment approaches, and mitigating disparities in cardiovascular outcomes for people with bipolar disorder.

Physical Activity as a Predictor of Clinical Trial Outcomes in Bipolar Depression: A Subanalysis of a Mitochondrial-Enhancing Nutraceutical Randomized Controlled Trial

OBJECTIVES

Individuals with bipolar disorder (BD) generally engage in low levels of physical activity (PA), and yet few studies have investigated the relationship between PA and change in BD symptom severity. The aim of this subanalysis of an adjunctive nutraceutical randomized controlled trial for the treatment of bipolar depression was to explore the relationship between PA, the active adjunctive treatments (a nutraceutical "mitochondrial cocktail"), and clinical outcomes.

METHODS

Participants with bipolar depression were randomized to receive N-acetylcysteine alone, N-acetylcysteine with a combination of nutraceuticals (chosen for the potential to increase mitochondrial activity), or placebo for 16 weeks. Participants (n = 145) who completed the International Physical Activity Questionnaire-Short Form (IPAQ-SF; measured at Week 4) were included in this exploratory subanalysis. Assessments of BD symptoms, functioning, and quality of life were completed at monthly visits up until Week 20. Generalised Estimating Equations were used to explore whether IPAQ-SF scores were a moderator of treatment received on outcomes of the study.

RESULTS

Week-4 PA was not related to changes in Montgomery Åsberg Depression Rating Scale scores across the study until Week 20. However, participants who engaged in more PA and who received the combination treatment were more likely to have a reduction in scores on the Bipolar Depression Rating Scale (P = 0.03). However, this was not consistent in all domains explored using the IPAQ-SF. Participants who engaged in higher levels of PA also experienced greater improvement in social and occupational functioning and less impairment in functioning due to their psychopathology and improvement in quality of life at Week 20, irrespective of treatment.

CONCLUSIONS

This study provides novel evidence of the association between PA and reduction in BD symptoms in a nutraceutical clinical trial. However, further research assessing the potential synergistic effects of PA in BD is required.

The therapeutic potential of exercise for neuropsychiatric diseases: A review

Exercise is known to have a myriad of health benefits. There is much to be learned from the effects of exercise and its potential for prevention, attenuation and treatment of multiple neuropsychiatric diseases and behavioral disorders. Furthermore, recent data and research on exercise benefits with respect to major health crises, such as, that of opioid and general substance use disorders, make it very important to better understand and review the mechanisms of exercise and how it could be utilized for effective treatments or adjunct treatments for these diseases. In addition, mechanisms, epigenetics and sex differences are examined and discussed in terms of future research implications.

Diet quality, dietary inflammatory index and body mass index as predictors of response to adjunctive N-acetylcysteine and mitochondrial agents in adults with bipolar disorder: A sub-study of a randomised placebo-controlled trial

AIMS

We aimed to explore the relationships between diet quality, dietary inflammatory potential or body mass index and outcomes of a clinical trial of nutraceutical treatment for bipolar depression.

METHODS

This is a sub-study of a randomised controlled trial of participants with bipolar depression who provided dietary intake data (n = 133). Participants received 16 weeks adjunctive treatment of either placebo or N-acetylcysteine-alone or a combination of mitochondrial-enhancing nutraceuticals including N-acetylcysteine (combination treatment). Participants were followed up 4 weeks post-treatment discontinuation (Week 20). Diet was assessed by the Cancer Council Victoria Dietary Questionnaire for Epidemiological Studies, Version 2, converted into an Australian Recommended Food Score to measure diet quality, and energy-adjusted dietary inflammatory index score to measure inflammatory potential of diet. Body mass index was also measured. Generalised estimating equation models were used to assess whether diet quality, energy-adjusted dietary inflammatory index score and/or body mass index were predictors of response to significant outcomes of the primary trial: depression symptoms, clinician-rated improvement and functioning measures.

RESULTS

In participants taking combination treatment compared to placebo, change in depression scores was not predicted by Australian Recommended Food Score, dietary inflammatory index or body mass index scores. However, participants with better diet quality (Australian Recommended Food Score) reported reduced general depression and bipolar depression symptoms (p = 0.01 and p = 0.03, respectively) and greater clinician-rated improvement (p = 0.02) irrespective of treatment and time. Participants who had a more anti-inflammatory dietary inflammatory index had less impairment in functioning (p = 0.01). Combination treatment may attenuate the adverse effects of pro-inflammatory diet (p = 0.03) on functioning. Participants with lower body mass index who received combination treatment (p = 0.02) or N-acetylcysteine (p = 0.02) showed greater clinician-rated improvement.

CONCLUSION

These data support a possible association between diet (quality and inflammatory potential), body mass index and response to treatment for bipolar depression in the context of a nutraceutical trial. The results should be interpreted cautiously because of limitations, including numerous null findings, modest sample size and being secondary analyses.

Prevalence of Prediabetes and Diabetes Mellitus Type II in Bipolar Disorder

INTRODUCTION

Bipolar disorder (BD) is characterized by recurrent episodes of depression and mania and affects up to 2% of the population worldwide. Patients suffering from bipolar disorder have a reduced life expectancy of up to 10 years. The increased mortality might be due to a higher rate of somatic diseases, especially cardiovascular diseases. There is however also evidence for an increased rate of diabetes mellitus in BD, but the reported prevalence rates vary by large.

MATERIAL AND METHODS

85 bipolar disorder patients were recruited in the framework of the BiDi study (Prevalence and clinical features of patients with Bipolar Disorder at High Risk for Type 2 Diabetes (T2D), at prediabetic state and with manifest T2D) in Dresden and Würzburg. T2D and prediabetes were diagnosed measuring HBA1c and an oral glucose tolerance test (oGTT), which at present is the gold standard in diagnosing T2D. The BD sample was compared to an age-, sex- and BMI-matched control population (n = 850) from the Study of Health in Pomerania cohort (SHIP Trend Cohort).

RESULTS

Patients suffering from BD had a T2D prevalence of 7%, which was not significantly different from the control group (6%). Fasting glucose and impaired glucose tolerance were, contrary to our hypothesis, more often pathological in controls than in BD patients. Nondiabetic and diabetic bipolar patients significantly differed in age, BMI, number of depressive episodes, and disease duration.

DISCUSSION

When controlled for BMI, in our study there was no significantly increased rate of T2D in BD. We thus suggest that overweight and obesity might be mediating the association between BD and diabetes. Underlying causes could be shared risk genes, medication effects, and lifestyle factors associated with depressive episodes. As the latter two can be modified, attention should be paid to weight changes in BD by monitoring and taking adequate measures to prevent the alarming loss of life years in BD patients.

Feasibility and Acceptability of a Lifestyle Intervention For Individuals With Bipolar Disorder

Individuals with bipolar disorder are at greater risk for cardiovascular disease and are less likely to adhere to lifestyle interventions than the general population. To decrease cardiovascular risk and improve adherence to lifestyle interventions, we developed the Nutrition Exercise and Wellness Treatment (NEW Tx). NEW Tx is an 18-session, 20-week cognitive behavioral therapy-based treatment comprising 3 modules: Nutrition, Exercise, and Wellness. To evaluate the feasibility and acceptability of this intervention as well as predictors of treatment satisfaction and expectations, 38 adult outpatients with bipolar disorder were randomized to either NEW Tx or a waitlist control condition. There was no statistically significant difference in dropout rates between the groups (26.3% in NEW Tx, 31.6% in the control condition). In the NEW Tx condition, participants attended a mean of 66.7% of sessions and reported moderate to high satisfaction. There were no study-related adverse events. We also found that expectations, but not perceived credibility (or believability), of NEW Tx (as measured by the Credibility/Expectancy Questionnaire) at baseline predicted treatment satisfaction (as measured by the Care Satisfaction Questionnaire) posttreatment. Manic symptoms at baseline predicted treatment satisfaction, and marital status predicted one's expectations of lifestyle interventions. Data suggest that NEW Tx is a feasible and acceptable intervention for individuals with bipolar disorder and that further research is warranted to explore potential moderators of treatment expectations and credibility in this clinical population.

Lifetime Psychotic Symptoms, Subthreshold Depression and Cognitive Impairment as Barriers to Functional Recovery in Patients with Bipolar Disorder

(1) Background: bipolar disorder (BD) is a chronic disease that often leads to functional impairment. The objective of this study is to elucidate which variables are associated with better functional outcomes in a sample of euthymic patients with BD. (2) Methods: patients were recruited at the Hospital Clinic of Barcelona and they underwent a clinical interview, a functional assessment, and a comprehensive neuropsychological evaluation. After that, patients were divided into two groups according to the Functioning Assessment Short Test total score: functionally remitted vs. functionally impaired. Following this, a multivariate logistic regression was run in order to identify clinical, demographic and cognitive factors associated with functional remission. (3) Results: a total of 420 euthymic patients with BD were assessed for this study, distributed as follows: functionally remitted (n = 221) and functionally impaired (n = 199). Finally, the multivariate logistic regression revealed that only five variables significantly contributed to the model, including: lifetime history of psychotic symptoms (the variable that contributed the most to the model), followed by the Hamilton Depression total score, and cognitive performance (executive functions and verbal memory). (4) Conclusions: treatments to ensure a good functional outcome in BD should specially prevent psychosis, target subthreshold depressive symptoms and enhance cognition, more specifically executive functions and verbal memory.

Pilot study of a lifestyle intervention for bipolar disorder: Nutrition exercise wellness treatment (NEW Tx)

BACKGROUND

Individuals with bipolar disorder (BD) are more likely than the general population to develop risk factors associated with cardiovascular disease, one of the leading causes of morbidity and mortality in this clinical population. To address this disproportionate medical burden, we developed Nutrition Exercise and Wellness Treatment (NEW Tx), a lifestyle intervention for individuals with BD.

METHODS

In this study, participants were randomized to NEW Tx (n = 19) or a treatment as usual waitlist (n = 19). We examine the intervention's efficacy to improve the physical and psychological outcomes of individuals with BD. Assessors were blind to participant condition throughout study duration.

RESULTS

The NEW Tx group reported increased weekly exercise duration and overall functioning, and decreased depression and illness severity over the study duration. However, only improvements in functioning were significantly greater in the NEW Tx group than in the control group. There were no group differences in weight loss or mood symptoms over the study duration.

LIMITATIONS

Limitations to this study include lack of objective measurement of exercise and a small and relatively homogeneous sample.

CONCLUSIONS

These data suggest that a manualized lifestyle intervention for BD may not be ideal to improve lifestyle changes in this clinical population. Further research is needed to pilot personalized approaches to creating a healthy lifestyle in BD.

Losing to Gain: The Effects of a Healthy Lifestyle Intervention on the Physical and Psychosocial Well-being of Clients in a Community-based Mental Health Setting

Individuals with severe and persistent mental illness (SPMI) encounter both poorer physical health and psychosocial well-being in comparison to the general population. Obesity, hypertension, heart disease, and diabetes can result from the symptoms of mental illness, the side effects from psychotropic medications, as well as disparities associated with being mentally ill. Mental health nurses are in a prime position to implement healthy lifestyle interventions (HLIs). This study tested a HLI (physical exercise and nutrition) and examined the effects on physical and psychosocial outcomes in clients obtaining mental health services at a community-based facility. Key findings included a decrease in anxiety and depressive symptoms at 3 months and consistent improvement in self-efficacy for exercise in the intervention group. Bridges and barriers to achieving optimal results in physical and psychosocial well-being were identified. Findings from this study offer insight into designing and executing more effective HLIs with individuals who have SPMI.

Improving Functioning, Quality of Life, and Well-being in Patients With Bipolar Disorder

People with bipolar disorder frequently experience persistent residual symptoms, problems in psychosocial functioning, cognitive impairment, and poor quality of life. In the last decade, the treatment target in clinical and research settings has focused not only on clinical remission, but also on functional recovery and, more lately, in personal recovery, taking into account patients' well-being and quality of life. Hence, the trend in psychiatry and psychology is to treat bipolar disorder in an integrative and holistic manner. This literature review offers an overview regarding psychosocial functioning in bipolar disorder. First, a brief summary is provided regarding the definition of psychosocial functioning and the tools to measure it. Then, the most reported variables influencing the functional outcome in patients with bipolar disorder are listed. Thereafter, we include a section discussing therapies with proven efficacy at enhancing functional outcomes. Other possible therapies that could be useful to prevent functional decline and improve functioning are presented in another section. Finally, in the last part of this review, different interventions directed to improve patients' well-being, quality of life, and personal recovery are briefly described.

Is it possible for people with severe mental illness to sit less and move more? A systematic review of interventions to increase physical activity or reduce sedentary behaviour

Individuals with severe mental illness (SMI) (schizophrenia-spectrum, bipolar disorder and major depressive disorder) die 10-20 years prematurely due to physical disorders such as cardiovascular disease. Physical activity (PA) is effective in preventing and managing these conditions in the general population, however individuals with SMI engage in substantially less PA and more sedentary behaviour (SB) compared to healthy counterparts. Furthermore, the effectiveness of intervening to increase PA or reduce SB in SMI populations is unknown. Therefore, we systematically reviewed studies measuring changes in PA or SB following behavioural interventions in people with SMI. A systematic search of major databases was conducted from inception until 1/3/2018 for behavioural interventions reporting changes in PA or SB in people with SMI. From 3018 initial hits, 32 articles were eligible, including 16 controlled trials (CT's; Treatment n = 1025, Control n = 1162) and 16 uncontrolled trials (n = 655). Of 16 CTs, seven (47%) reported significant improvements in PA, although only one found changes with an objective measure. Of 16 uncontrolled trials, 3 (20%) found improvements in PA (one with objective measurement). No intervention study had a primary aim of changing SB, nor did any note changes in SB using an objective measure. In conclusion, there is inconsistent and low quality evidence to show that interventions can be effective in changing PA or SB in this population. Future robust randomized controlled trials, using objectively-measured PA/SB as the primary outcome, are required to determine which behavioural interventions are effective in improving the sedentary lifestyles associated with SMI. Systematic review registration- PROSPERO registration number CRD42017069399.

A qualitative study investigating bipolar patients' expectations of a lifestyle intervention: A self-management program

BACKGROUND

There is some evidence supporting the efficacy of lifestyle interventions in changing unhealthy habits and reduce the risk of developing comorbid conditions in Bipolar Disorder (BD).

AIMS

This qualitative study aimed to identify what an optimal lifestyle intervention would look like for individuals with BD.

METHODS

The current findings are based on one focus group and two paired interviews including a total of 10 individuals with BD (44.20 ± 11.11 years; 6 females). Groups' transcripts were analyzed using a narrative approach. Primary themes included facilitating factors and barriers, general content, outcomes, format of the intervention, and background factors.

RESULTS

Participants were in favor of a group-based lifestyle intervention as part of their usual treatment. The optimal group format would include 4 to 10 individuals, and comprise of 12 to 18 sessions lasting 1 to 1.5 h each. Accountability, motivation, interaction, and group activities were identified as contributing to the success of a lifestyle intervention.

CONCLUSIONS

This qualitative study provides important information regarding aspects of lifestyle intervention format and delivery for individuals with BD. We identified barriers and facilitating factors that should be addressed in health promotion interventions delivered within community mental health settings.

The Impact of General Medical Conditions in Obsessive-Compulsive Disorder

OBJECTIVE

The co-occurrence of general medical conditions (GMCs) and major psychiatric disorders is well documented. The aim of this study was to assess the prevalence of GMCs in patients with a primary diagnosis of obsessive-compulsive disorder (OCD) and, secondly, to investigate which clinical variables are associated with the presence of a GMC.

METHODS

Subjects with a primary diagnosis of OCD were included. Socio-demographic and clinical characteristics were collected. GMCs were classified using the ICD-10 and grouped according to the Cumulative Illness Rating Scale (CIRS) in: cardiac, vascular, hematopoietic, respiratory, ear/nose/throat, upper and lower gastrointestinal, hepatic, renal, genitourinary, musculoskeletal, neurologic, endocrine/metabolic. The association between the presence of GMCs and demographic/clinical variables of OCD was investigated.

RESULTS

A total of 162 patients with OCD were included. 78 (48.1%) patients had at least one comorbid GMC. Most frequent GMCs were endocrine/metabolic diseases (25.9%), followed by upper/lower gastrointestinal (20.5%) and cardio-vascular diseases (13.6%). The presence of a GMC was significantly associated with female gender, older age, duration of untreated illness (DUI), and absence of physical activity.

CONCLUSION

Patients with OCD have high rates of comorbid GMCs. A longer DUI is associated with having at least one GMCs; this might be due to the long-lasting adoption of unhealthy lifestyles, not counterbalanced by appropriate treatment and psychoeducation.

Moving Towards Wellness: Physical activity practices, perspectives, and preferences of users of outpatient mental health service

OBJECTIVE

This study assessed the beliefs, barriers and preferences for physical activity (PA) among users of outpatient mental health (MH) services. Outpatient discussions with MH providers were also evaluated.

METHOD

Between September-December 2014, patient advisors approached adult and family members in an academic MH clinic's waiting room on high volume patient visit days during peak clinic hours; 83% participated in the survey. Analyses were restricted to MH services users (n=295).

RESULTS

Fully 84% of respondents reported a link between PA and their mood or anxiety level and 85% wanted to be more active. Less than half currently met US PA guidelines (≥150min/week). Most (52%) reported their mood limited their involvement in PA. Only 37% reported their MH providers regularly discussed PA with them. Beliefs about the benefits of physical activity (p<0.0001), mood limiting their ability to be physically active (p=0.03), and wanting to be more physically active (p=0.02) were significant predictors of PA (min/week) in the multivariate linear regression model.

CONCLUSIONS

Most MH outpatients may need and want assistance in increasing PA. Patient-centered research could inform the development of PA programs in MH settings.

Gender differences in the association between physical activity and cognitive function in individuals with bipolar disorder

INTRODUCTION

Bipolar disorder (BD) is accompanied by a high number of comorbidities and associated with an overall increased mortality. Especially obesity, systemic inflammatory processes and cognitive deficits are highly prevalent and increase with the course of illness. Physical activity (PA) is associated with beneficial effects on somatic comorbidities such as obesity or cardiovascular disease in individuals without psychiatric disorder. Furthermore, PA might increase neurocognitive performance and reduce systemic inflammation.

OBJECTIVE

The aim of the study was to investigate the association between PA and neurocognitive function in euthymic individuals suffering from BD.

METHODS AND PARTICIPANTS

120 individuals with BD, euthymic at test time, completed the self-reported International Physical Activity Questionnaire (IPAQ) assessing PA of the past seven days and were accordingly assigned to a specific activity category (low, moderate or vigorous). Furthermore, clinical parameters were gathered and cognitive tests analysing verbal-dependent intelligence, attention, executive functioning as well as memory were administered.

RESULTS

Female individuals in the vigorous PA group performed significantly higher in most of the cognitive domains compared to females with moderate or low PA. In males, we only found a significant difference in one test for attention between moderate/vigorous and the low activity group.

CONCLUSION

Differences between PA groups in cognitive performance in female individuals with BD were obvious in almost all cognitive domains. As cognitive deficits are strongly associated with a worse course of disease and outcome, PA might offer a concomitant therapy targeting not only somatic comorbidities such as obesity and cardiovascular disease, but also neurocognition.

Improving physical health of patients with severe mental disorders: a critical review of lifestyle psychosocial interventions

INTRODUCTION

People with severe mental disorders have a mortality rate that is more than two times higher than the general population, with at least a decade of potential years of life lost. People with mental disorders have a significantly higher risk of obesity, hyperglycemia and metabolic syndrome, which are related to modifiable risk factors, such as heavy smoking, poor physical activities, and inappropriate unhealthy diet, which can be improved through lifestyle changes. Areas covered: Lifestyle behaviours are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. In the present review, the authors aim to: 1) critically analyze studies involving multimodal lifestyle interventions; 2) discuss the way forward to integrate these interventions in clinical routine care. Expert commentary: The psychoeducational approaches developed for the improvement of healthy lifestyle behaviours differ for several aspects: 1) the format (individual vs. group); 2) the setting (outpatient vs. inpatient vs. home-based); 3) the professional characteristics of the staff running the intervention (psychiatrists or nurses or dietitians or psychologists); 4) the active ingredients of the intervention (education only or inclusion of motivational interview or of problem solving); 5) the duration of treatment (ranging from 3 months to 2 years).

Do patients with bipolar disorder and subsyndromal symptoms benefit from functional remediation? A 12-month follow-up study

We analyzed the efficacy of functional remediation, in a sample of patients with bipolar disorder who presented with subsyndromal symptoms. From a total sample of 239 patients with bipolar I and II disorder, according to DSM-IV-TR diagnostic criteria, entering a randomized clinical trial, those patients who presented with subsyndromal symptoms were selected based on a method already described by Berk and colleagues was applied. It consists of using the Clinical Global Impression-Bipolar version (CGI-BP) to establish the scores of the Hamilton Depression Rating Scale (HAM-D) and of the Young Mania Rating Scale (YMRS) that correspond with 1 in the CGI-BP. Functional outcome and mood symptoms were assessed at 6 and at 12-month follow-up. A total of 99 patients were selected for this post-hoc analysis, allocated as follows: functional remediation (n=33); psychoeducation (n=37) and treatment as usual (TAU,n=29). The repeated-measures analyses at 12-month follow-up revealed a significant group x time interaction in favour of the patients who received functional remediation when compared to psychoeducation and TAU (F=2.93; p=0.02) at improving psychosocial functioning. Finally, mood symptoms did not significantly change in any of the three groups at any time of follow-up, as shown by the non-significant group x time interaction effect in HAM-D scores (F=1.57; p=0.18) and YMRS scores (F=1.51; p=0.20). Bipolar patients with subsyndromal symptoms improve their functional outcome when exposed to functional remediation regardless of the persistence of mood symptomatology.

Medical comorbidity in bipolar disorder: The link with metabolic-inflammatory systems

BACKGROUND

Bipolar disorder (BD) is associated with chronic low-grade inflammation, several medical comorbidities and a decreased life expectancy. Metabolic-inflammatory changes have been postulated as one of the main links between BD and medical comorbidity, although there are few studies exploring possible mechanisms underlying this relationship. Therefore, the aims of the current narrative review were 1) synthesize the evidence for metabolic-inflammatory changes that may facilitate the link between medical comorbidity and BD and 2) discuss therapeutic and preventive implications of these pathways.

METHODS

The PubMed and Google Scholar databases were searched for relevant studies.

RESULTS

Identified studies suggested that there is an increased risk of medical comorbidities, such as autoimmune disorders, obesity, diabetes and cardiovascular disease in patients with BD. The association between BD and general medical comorbidities seems to be bidirectional and potentially mediated by immune dysfunction. Targeting the metabolic-inflammatory-mood pathway may potential yield improved outcomes in BD; however, further study is needed to determine which specific interventions may be beneficial.

LIMITATIONS

The majority of identified studies had cross-sectional designs, small sample sizes and limited measurements of inflammation.

CONCLUSIONS

Treatment and prevention of general medical comorbidities in mood disorders should include preferential prescribing of metabolically neutral agents and adjunctive lifestyle modifications including increased physical activity, improved diet and decreased substance abuse. In addition, the use of anti-inflammatory agents could be a relevant therapeutic target in future research.

Exercising control over bipolar disorder

Following extensive research exercise has emerged as an effective treatment for major depressive disorder, and it is now a recognised therapy alongside other interventions. In contrast, there is a paucity of research examining the therapeutic effects of exercise for those with bipolar disorder. Given that dysfunctional reward processing is central to bipolar disorder, research suggests that exercise can perhaps be framed as a reward-related event that may have the potential to precipitate a manic episode. The behavioural activation system (BAS) is a neurobehavioural system that is associated with responding to reward and provides an appropriate framework to theoretically examine and better understand the effects of exercise treatment on bipolar disorder. This article discusses recent research findings and provides an overview of the extant literature related to the neurobiological underpinnings of BAS and exercise as they relate to bipolar disorder. This is important clinically because depending on mood state in bipolar disorder, we postulate that exercise could be either beneficial or deleterious with positive or negative effects on the illness. Clearly, this complicates the evaluation of exercise as a potential treatment in terms of identifying its optimal characteristics in this population.

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.

Empirically supported psychosocial interventions for bipolar disorder: Current state of the research

OBJECTIVES

Bipolar disorder requires psychiatric medications, but even guideline-concordant treatment fails to bring many patients to remission or keep them euthymic. To address this gap, researchers have developed adjunctive psychotherapies. The purpose of this paper is to critically review the evidence for the efficacy of manualized psychosocial interventions for bipolar disorder.

METHODS

We conducted a search of the literature to examine recent (2007-present), randomized controlled studies of the following psychotherapy interventions for bipolar disorder: psychoeducation (PE), cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), and family therapies such as family focused therapy (FFT).

RESULTS

All of the psychotherapy interventions appear to be effective in reducing depressive symptoms. Psychoeducation and CBT are associated with increased time to mood episode relapse or recurrence. MBCT has demonstrated a particular effectiveness in improving depressive and anxiety symptoms. Online psychotherapy interventions, programs combining one or more psychotherapy interventions, and targeted interventions centering on particular symptoms have been the focus of recent, randomized controlled studies in bipolar disorder.

CONCLUSIONS

Psychotherapy interventions for the treatment of bipolar disorder have substantial evidence for efficacy. The next challenge will to disseminate these psychotherapies into the community.

Exercise in bipolar patients: A systematic review

BACKGROUND

Sedentary lifestyle is frequent in psychiatric disorders, however the directions of this association and benefits of physical activity are unclear. This is a systematic review about exercise in patients with bipolar disorder.

METHODS

We performed a systematic literature search of studies published in English (1995 Jan to 2016 Jan) in PubMed, and Cochrane Library combining the medical terms 'physical activity' or 'sedentary' or 'physical exercise' with 'bipolar disorder' or 'mania' or 'bipolar depression'.

RESULTS

Thirty-one studies were selected and included 15,587 patients with bipolar disorder. Sedentary lifestyle varied from 40% to 64.9%. Physical activity was associated with less depressive symptoms, better quality of life and increased functioning. Some evidence indicates a relationship between vigorous exercises and mania. Three prospective cohorts were reported; and no prospective randomized controlled trial was identified. Three studies focused on biomarkers in bipolar patients; and one reported the relationship between exercise and sleep in this group. Two assessed physical exercise in adolescents.

LIMITATIONS

(1) Differences between studies preventing a unified analysis; (2) most studies were cross-sectional; (3) motivation for exercising is a selection bias in most studies; (4) no intervention study assessing only physical exercise; (5) lack of studies comparing exercise across mood states.

CONCLUSION

Generally, exercise was associated with improved health measures including depressive symptoms, functioning and quality of life. Evidence was insufficient to establish a cause-effect relationship between mood and physical exercise. Future research including randomized trials is needed to clarify the role of physical activity in bipolar patients.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Autonomous motivation is associated with the maintenance stage of behaviour change in people with affective disorders

The present study examined whether in people with affective disorders motives for adopting and maintaining physical activity recommendations (as formulated by the self-determination theory) differed across the stages of behaviour change (identified by the transtheoretical model). A total of 165 (105♀) persons (45.6±14.2years) with affective disorders [major depressive disorder (n=96) or bipolar disorder (n=69)] completed the Behavioural Regulation in Exercise Questionnaire-2 and the Patient-centred Assessment and Counselling for Exercise questionnaire. Discriminant and multivariate analyses demonstrated that persons with affective disorders at the early stages of change have less autonomous and more controlled physical activity motives than those at the later stages. Our results suggest that autonomous motivation may have an important role to play in the maintenance of health recommendations in persons with affective disorders. Longitudinal and intervention studies should be designed in people with affective disorders to identify the causal pathways between motives for maintaining health recommendations, effective changes in health behaviour and physical and mental health outcomes.

Top 10 research questions to promote physical activity in bipolar disorders: A consensus statement from the International Organization of Physical Therapists in Mental Health

BACKGROUND

Research has only recently started to consider the importance and applicability of physical activity (PA) for people with bipolar disorder (BD). The aim of the current study is to highlight 10 pertinent PA research questions in people with BD.

METHODS

The International Organization of Physical Therapy in Mental Health executed a consultation with all National organizations (n=13) to identify the most salient questions to guide future research on PA in BD.

RESULTS

We identified the following 10 questions: (1) What are the benefits of PA for people with BD? (2) What are the most prominent safety issues for PA prescription in BD? (3) What is the optimal PA prescription for people with BD? (4) What are the key barriers to PA among people with BD? (5) What are the most effective motivational strategies for ensuring PA adoption and maintenance in BD? (6) How do we translate PA research into community practice? (7) If one treatment goal is increased physical activity, what type of professionals are needed as part of a multidisciplinary team? (8) How do we incorporate PA as a vital sign in clinical practice? (9) How can we prevent sedentary behavior in BD? (10) What is the most appropriate PA assessment method?

LIMITATIONS

We did not consult people with BD.

CONCLUSIONS

Addressing these questions is critical for developing evidence-based approaches for promoting and sustaining an active lifestyle in BD. Ultimately, achieving this will reduce the burden of cardiovascular disease and improve the quality of life of this population.

Binge eating and emotional eating behaviors among adolescents and young adults with bipolar disorder

BACKGROUND

This study investigates nutritional behavior among adolescents and young adults with bipolar disorder (BP) in comparison to those without history of major psychiatric disorder.

METHODS

131 participants (82 BP, 49 controls) with a mean age of 16.11 ± 1.61 years were included. The self-reported Quick Weight, Activity, Variety & Excess (WAVE) Screener was used to assess dietary habits, yielding a total nutritional score as well as Excess, Variety, and Household Food Insecurity subscale scores. Specifically, the Variety subscale was used to measure daily consumption of essential nutrients; the Excess subscale measured unhealthy eating behaviors such as binge eating and excessive intake of fat and sugar; and the Household Food Insecurity subscale was used to detect food insecurity. Within-group analysis was conducted on participants with BP to identify correlates of unhealthy diet.

RESULTS

BP participants scored significantly lower than controls on the WAVE (t=2.62, p=0.010), specifically the Excess subscale (t=3.26, p=0.001). This was related to higher prevalence of binge eating and emotional eating behaviors among participants with BP compared to controls. Within-group analyses showed that self-reported emotional dysregulation/impulsivity was associated with maladaptive nutritional behaviors (t=3.38, p=0.035).

LIMITATIONS

Cross-sectional design. Within-group analyses were underpowered. Diet quality was measured using a brief self-report screener.

CONCLUSION

Adolescents and young adults with BP have poorer nutritional behaviors compared to controls, and this difference is related to stress-induced eating. This demonstrates the need to screen for stress-induced eating and to intervene when needed in order to optimize nutritional behaviors among adolescents and young adults with BP.

Lifestyle interventions targeting dietary habits and exercise in bipolar disorder: A systematic review

BACKGROUND

Bipolar disorder (BD) is a serious mental illness associated with a high risk of medical comorbidities, long-term disability and premature death. This systematic review examined the current literature on therapeutic interventions targeting nutrition, physical activity and wellness in BD and collecting health-related measures such as mood and course of illness.

METHODS

Scopus (all databases), Pubmed and Ovid Medline were systematically searched with no language or year restrictions, up to June 2015, for studies focusing on lifestyle interventions in BD. Search terms were related to bipolar disorder, nutrition, physical activity, wellbeing, psychosocial interventions and course of illness. We hand searched content pages of Bipolar Disorders and Journal of Affective Disorders and checked references of relevant reviews and dissertations to identify additional papers.

RESULTS

After applying inclusion and exclusion criteria to identified hits, this literature search retrieved six papers. Overall findings point towards a beneficial role of lifestyle interventions on mood, weight, blood pressure, lipid profile, physical activity and overall wellbeing. Methodological limitations include small sample size, gender ratio imbalance, inconsistencies in terms of laboratory measures, and lack of randomized controlled trials and absence of follow-up and longitudinal studies to determine the benefits of these factors on clinical and functional outcomes over time

CONCLUSIONS

Lifestyle interventions in BD targeting nutrition, exercise, wellbeing alongside beliefs, coping strategies and attitudes towards health show promise in reducing the risk of comorbid ailments in BD. There is still a strong need for studies a) developing interventions which are informed by the patient's input and b) examining the effectiveness of such interventions targeting general wellness using well-controlled trials.

Getting to wellness: The potential of the athletic model of marginal gains for the treatment of bipolar disorder

OBJECTIVE

People with bipolar disorder frequently have persistent symptoms, continued problems functioning and comorbid medical conditions. We propose applying the athletic coaching concept of marginal gains to help patients address these challenges to achieve wellness.

METHOD

We review the concept of marginal gains and potential interventions to improve long-term outcomes for bipolar patients.

RESULTS

Evidence exists to help bipolar patients with diet and exercise, gradual behavioral change, mobile applications and peer support.

CONCLUSION

Marginal gains, small and doable improvements across a broad range of areas, have great potential to improve the lives of people with bipolar disorder.

Predictors of functional outcome after a manic episode

BACKGROUND

The identification of functional outcome predictors after acute episodes of bipolar disorders (BD) may allow designing appropriate treatment aiming at restoring psychosocial functioning. Our objective was to identify the best functional outcome predictors at a 6-month follow-up after an index manic episode.

METHODS

We conducted a naturalistic trial (MANACOR) focusing on the global burden of BD, with special emphasis on manic episode-associated costs. We observed patients with BD seen in services of four hospitals in Catalonia (Spain).The total sample included 169 patients with chronic DSM-IV-TR BD I suffering from an acute manic episode who were followed-up for 6 months. In this subanalysis we report the results of a stepwise multiple regression conducted by entering in the model those clinical and sociodemographic variables that were identified through preliminary bivariate Pearson correlations and using total scores on the Functioning Assessment Short Test (FAST) at the 6-month follow-up as the dependent variable.

RESULTS

Number of previous depressive episodes (Beta=3.25; t=3.23; p=0.002), presence of psychotic symptoms during the manic index episode (Beta=7.007; t=2.2; p=0.031) and the Body Mass Index (BMI) at baseline (Beta=0.62; t=2.09; p=0.041) were best predictors of functional outcome after a manic episode.

LIMITATIONS

The main limitations of this study include the retrospective assessment of the episodes, which can be a source of bias, and the 6-month follow-up might have been too short for assessing the course of a chronic illness.

CONCLUSIONS

Psychotic symptoms at index episode, number of past depressive episodes, and BMI predict worse outcome after 6 months follow-up after a manic episode, and may constitute the target of specific treatment strategies.

Could autonomous motivation hold the key to successfully implementing lifestyle changes in affective disorders? A multicentre cross sectional study

There is a need for theoretically-based research on the motivational processes linked to the adoption and maintenance of an active lifestyle in people with affective disorders. Within the Self-Determination Theory (SDT) framework, we investigated the SDT tenets in people with major depressive disorder or bipolar disorder by examining the factor structure of the Behavioural Regulation in Exercise Questionnaire-2 (BREQ-2) and by investigating associations between motivation, the Positive and Negative Affect Scale (PANAS) and International Physical Activity Questionnaire (IPAQ) scores. A total of 165 patients (105 ♀) (45.6 ± 14.2 years) agreed to participate. An exploratory factor analysis demonstrated sufficient convergence with the original factor for amotivation, and external and introjected regulation. The items of identified and intrinsic regulation loaded on the same factor, which was labelled autonomous regulation. Significant correlations were found between the total IPAQ score and the subscales amotivation, external regulation, introjected regulation and autonomous regulation. The relative autonomy index (RAI) was associated with the PANAS scores. Differences in RAI were found between physically inactive and active participants. Our results suggest that in people with affective disorders the level of autonomous motivation may play an important role in the adoption and maintenance of health promoting behaviours.

Eating behavior and obesity in bipolar disorder

OBJECTIVES

Individuals with bipolar disorder are more frequently overweight or obese than the general population, but the reasons for this association are unknown. The aim of this study is to further understand the etiology of overweight and obesity in bipolar disorder.

METHODS

We invited patients in a specialty outpatient bipolar clinic to complete the Eating Inventory. Patients provided self-reported restraint, disinhibition, and perceived hunger as well as general perceptions of dietary intake.

RESULTS

Sixty-two individuals (37 female) between the ages of 18 and 67 (M = 41.5, SD = 13.38) and with an average body mass index (BMI) of 27.18 (SD = 5.71) completed the survey. Disinhibition and perceived hunger were positively correlated with BMI and self-reported difficulty eating healthy foods. Restraint was positively correlated with healthy eating (ps < .05). Stepwise linear regressions revealed that hunger was the most significant predictor of BMI (F(1) = 8.134, p = .006). Those participants with bipolar I or II disorder reported greater hunger scores (p < .01) and difficulty eating healthily (p < .05) than those without a full diagnosis.

CONCLUSIONS

These results suggest that disinhibition and perception of hunger may be linked to the disproportionately high rate of obesity in bipolar disorder.

A brief review of exercise, bipolar disorder, and mechanistic pathways

Despite evidence that exercise has been found to be effective in the treatment of depression, it is unclear whether these data can be extrapolated to bipolar disorder. Available evidence for bipolar disorder is scant, with no existing randomized controlled trials having tested the impact of exercise on depressive, manic or hypomanic symptomatology. Although exercise is often recommended in bipolar disorder, this is based on extrapolation from the unipolar literature, theory and clinical expertise and not empirical evidence. In addition, there are currently no available empirical data on program variables, with practical implications on frequency, intensity and type of exercise derived from unipolar depression studies. The aim of the current paper is to explore the relationship between exercise and bipolar disorder and potential mechanistic pathways. Given the high rate of medical co-morbidities experienced by people with bipolar disorder, it is possible that exercise is a potentially useful and important intervention with regard to general health benefits; however, further research is required to elucidate the impact of exercise on mood symptomology.

Medical burden in bipolar disorder: findings from the Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder study (Bipolar CHOICE)

OBJECTIVES

Individuals with bipolar disorder have high rates of other medical comorbidity, which is associated with higher mortality rates and worse course of illness. The present study examined common predictors of medical comorbidity.

METHODS

The Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder study (Bipolar CHOICE) enrolled 482 participants with bipolar I or bipolar II disorder in a six-month, randomized comparative effectiveness trial. Baseline assessments included current and lifetime DSM-IV-TR diagnoses, demographic information, psychiatric and medical history, severity of psychiatric symptoms, level of functioning, and a fasting blood draw. Medical comorbidities were categorized into two groups: cardiometabolic (e.g., diabetes, hyperlipidemia, and metabolic syndrome) and non-cardiovascular (e.g., seizures, asthma, and cancer). Additionally, we looked at comorbid substance use (e.g., smoking and drug dependence).

RESULTS

We found that 96.3% of participants had at least one other medical comorbidity. Older age predicted a greater likelihood of having a cardiometabolic condition. Early age of onset of bipolar symptoms was associated with a lower chance of having a cardiometabolic condition, but a greater chance of having other types of medical comorbidity. Additional predictors of other medical comorbidities in bipolar disorder included more time spent depressed, less time spent manic/hypomanic, and longer duration of illness. Medications associated with weight gain were associated with low high-density lipoprotein and abnormal triglycerides.

CONCLUSIONS

There appears to be a substantial medical burden associated with bipolar disorder, highlighting the need for collaborative care among psychiatric and general medical providers to address both psychiatric and other medical needs concomitantly in this group of patients.