Staging in bipolar disorder: one step closer to precision psychiatry

Fasting insulinemia as biomarker of illness relapse in patients with severe mental illness?

Severe Mental Illness (SMI) is often associated with metabolic alteration and/or metabolic syndrome, which may determine an increased mortality due to a further increased cardiovascular risk. The relationship with metabolic syndrome is often bidirectional, resulting in a pathoplastic effect of these dysmetabolisms. Among the several hormones involved, insulin appears to play a key role, albeit not entirely clear. The aim of our real-world cross-sectional observational study is to investigate a set of metabolic biomarkers of illness relapse/recurrence/onset in a cohort of 310 adult SMI inpatients consecutively admitted to the Psychiatry Clinic of the Azienda Ospedaliero Universitaria of Marche, in Ancona (Italy), between February 2021 and February 2024. According to the stepwise multivariate regression model, a higher number of acute episodes per year was positively predicted by the age of illness onset, the lifetime number of suicidal attempts and fasting insulinemia and negatively by the participant's age. A second stepwise multivariate regression model using only the metabolic characteristics as independent variables, found that a higher number of acute episodes per year was predicted positively by the fasting insulinemia and red blood cells and negatively by the abdominal circumference. Overall, our findings could provide practical implications for the treatment and management of SMI patients, emphasizing the importance of monitoring and managing metabolic factors, particularly insulinemia, metabolic syndrome and insulin resistance. Finally, insulinemia could potentially act as metabolic biomarker of illness relapse, though more larger and longitudinal studies should be carried out to confirm these results.

Bipolar disorder staging and the impact it has on its management: an update

INTRODUCTION

The longitudinal course of bipolar disorder (BD) is associated with an active process of neuroprogression, characterized by structural brain alterations and progressive functional impairment. In the last decades, a growing need of a standardized staging model for BD arose, with the aim of a more appropriate definition of stage-specific clinical manifestations and the identification of more customized therapeutic tools.

AREAS COVERED

The authors review the literature on clinical aspects, neurobiological correlates and treatment issues related to BD progression. Thereafter, they address the definition, constructs, and evolution of the staging concept, focusing on the clinical applications of BD staging models available in literature.

EXPERT OPINION

Although several staging models for BD have been proposed to date, their application in clinical practice is still relatively scant. This may have a detrimental impact on the clinical and therapeutic management of BD, in terms of early and proper diagnosis as well as tailored treatment interventions according to the different stages of illness. Future research efforts should tend to the integration of recent insights on neuroimaging and epigenetic markers, toward a standardized and multidimensional staging model.

Staging models applied in a sample of patients with bipolar disorder: Results from a retrospective cohort study

BACKGROUND

Bipolar Disorder (BD) is a life-long illness with compelling evidence of progression. Although different staging models have been proposed to evaluate its course, clinical data remain limited. The aim of the present study was to retrospectively assess applicability of available staging approaches and their pattern of progression in a sample of bipolar patients.

METHODS

In a naturalistic sample of 100 BD patients, retrospective assessment of clinical stages was performed at four time points over 10 years, according to four staging models. Staging progression with potential associations between stages and unfavourable illness characteristics were analyzed.

RESULTS

A pattern of stage worsening emerged for each model, with a significant increase at every time point. Greater stage increases emerged in patients with lower educational level, age at first elevated episode ≤35 years, duration of illness ≤25 years, and duration of untreated illness ≤5 years. Lower stage values were associated with BD II, no psychiatric hospitalization, depressive onset and predominant polarity, ≤three lifetime episodes, age at first mood stabilizer >40 years, duration of illness ≤25 years, and engaged/employed status. Higher stage values were associated with lower age at first elevated episode and mood stabilizing treatment instead.

LIMITATIONS

Naturalistic and retrospective design, recruitment at a 2nd level specialistic clinic.

CONCLUSIONS

Reported findings support the progressive nature of BD and the application of staging models for early intervention, suggesting a conceptualization of a standardized approach to better characterize patients, predict their clinical course, and deliver tailored treatment options.

Using classification and regression tree modeling to investigate appetite hormones and proinflammatory cytokines as biomarkers to differentiate bipolar I depression from major depressive disorder

BACKGROUND

Altered immunity and metabolic profiles have been compared between bipolar depression (BD) and major depressive disorder (MDD). This study aimed at developing a composite predictor of appetite hormones and proinflammatory cytokines to differentiate BD from MDD.

METHODS

This cross-sectional study enrolled patients with BD and those with MDD aged 20 to 59 years and displaying depressive episodes. Clinical characteristics (age, sex, body mass index, and depression severity), cytokines (C-reactive protein, interleukin [IL]-2, IL-6, tumor necrosis factor [TNF]-α, P-selectin, and monocyte chemoattractant protein), and appetite hormones (leptin, adiponectin, ghrelin, and insulin) were assessed as potential predictors using a classification and regression tree (CRT) model for differentiating BD from MDD.

RESULTS

The predicted probability of a composite predictor of ghrelin and TNF-α was significantly greater (for BD: area under curve = 0.877; for MDD: area under curve = 0.914) than that of any one marker (all P > .05) to distinguish BD from MDD. The most powerful predictors for diagnosing BD were high ghrelin and TNF-α levels, whereas those for MDD were low ghrelin and TNF-α levels.

CONCLUSION

A composite predictor of ghrelin and TNF-α driven by CRT could assist in the differential diagnosis of BD from MDD with high specificity. Further clinical studies are warranted to validate our results and to explore underlying mechanisms.

How to treat mania

OBJECTIVE

In this paper, we aimed at reviewing evidence-based treatment options for bipolar mania and proposed tentative evidence-based clinical suggestions regarding the management of a manic episode, especially regarding the choice of the proper mood stabilizer and antipsychotic medication.

METHOD

A narrative review was undertaken addressing 'treatment of bipolar mania'. Findings have been synthesized and incorporated with clinical experience into a model to support different treatment choices.

RESULTS

To date, there is solid evidence supporting the use of several medications, such as lithium, divalproex, and carbamazepine, and antipsychotics, such as chlorpromazine, haloperidol, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, inhaled loxapine, asenapine, and cariprazine in acute mania, and some evidence supporting the use of clozapine or electroconvulsive therapy in treatment-refractory cases. However, in clinical practice, when making decisions about treatment, personalized treatment is needed, according to the different clinical presentations and more complex clinical situations within the manic episode and considering a long-term view and with the objective of not only a symptomatic but also functional recovery. After remission from acute mania, psychoeducation strategies are useful to ensure adherence.

DISCUSSION

Despite the evidence forefficacy of many currently available treatments for mania, the majority of RCTs provide little direction for the clinician as to what steps might be optimal in different presentations of mania as well as in the presence of specific patient characteristics. Manic episodes should be managed on a personalized basis considering the clinical course and patient criteria and with the expectation of maintaining that treatment in the long-term.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016037868.

Classification of patients with bipolar disorder using k-means clustering

Introduction

Bipolar disorder (BD) is a heterogeneous disorder needing personalized and shared decisions. We aimed to empirically develop a cluster-based classification that allocates patients according to their severity for helping clinicians in these processes.

Methods

Naturalistic, cross-sectional, multicenter study. We included 224 subjects with BD (DSM-IV-TR) under outpatient treatment from 4 sites in Spain. We obtained information on socio-demography, clinical course, psychopathology, cognition, functioning, vital signs, anthropometry and lab analysis. Statistical analysis: k-means clustering, comparisons of between-group variables, and expert criteria.

Results and discussion

We obtained 12 profilers from 5 life domains that classified patients in five clusters. The profilers were: Number of hospitalizations and of suicide attempts, comorbid personality disorder, body mass index, metabolic syndrome, the number of comorbid physical illnesses, cognitive functioning, being permanently disabled due to BD, global and leisure time functioning, and patients’ perception of their functioning and mental health. We obtained preliminary evidence on the construct validity of the classification: (1) all the profilers behaved correctly, significantly increasing in severity as the severity of the clusters increased, and (2) more severe clusters needed more complex pharmacological treatment.

Conclusions

We propose a new, easy-to-use, cluster-based severity classification for BD that may help clinicians in the processes of personalized medicine and shared decision-making.

The Staging of Major Mood Disorders: Clinical and Neurobiological Correlates

OBJECTIVE

Staging of psychiatric disorders is gaining momentum and the purpose of this review is to examine whether major mood disorders can be defined according to stages.

METHODS

In April 2018 the PubMed electronic data base was scrutinized by a combination of various search terms like "major depressive disorder and staging," "bipolar disorder and neuroprogression," etc. To incorporate the latest findings the search was limited to the last 10 years. Both original and review articles were examined by reading the abstracts, and papers which were found to be particularly applicable were read in full and their reference lists were also consulted.

RESULTS

A significant increase occurred in the number of papers published on the topic of staging of mood disorders. Staging formats were found for both major mood disorders, with the caveat that many more articles were discovered for bipolar disorder. Current evidence points to allostatic load and neuroprogression as the basis for staging of mood disorders.

CONCLUSION

Principal affective illnesses may be characterized by distinct stages, for instance early, intermediate and late. These phases inform the management so that clinicians should incorporate the staging schema into everyday practice and implement treatment strategies according to the phase of the illness.

The differential association between history of childhood sexual abuse and body mass index in early and late stages of bipolar disorder

BACKGROUND

History of distal stressors such as childhood trauma is a well-established, non-specific vulnerability factor for multiple mental illnesses. The objective of this study was to investigate the possible association between history of childhood trauma and body mass index (BMI) in individuals in early and late stages of bipolar disorder (BD) and to verify is there was any difference in the association of sexual abuse history and obesity in early versus late stages of BD.

METHODS

Seventy-one euthymic BD-type I patients and eighty-one healthy controls were evaluated using the Childhood Trauma Questionnaire (CTQ) and body mass index (BMI). The association between BMI and CTQ total and subscores were evaluated dividing BD population in early-stage BD-I (less than 10 years since onset of disease) or late-stage BD (more than 10 years).

RESULTS

BD individuals had higher rates of history of childhood trauma than HC, especially sexual and emotional abuse, after adjusting for confounders. We observed a moderating effect of group on the association between BMI and sexual abuse (SA), but not on other modalities of childhood trauma, after adjustments for age, gender, ethnicity, education, alcohol and tobacco use.

LIMITATIONS

Our sample included a predominance of female individuals. The study cross-sectional design does not allow concluding a cause-effect relationship. In dividing the BD subgroups in relation with the time since the onset, we supposed that the natural course of BD is linear. The CTQ is subject to recall bias.

CONCLUSION

There is a relationship between childhood sexual abuse and BMI, but the direction of the association varies across the different stages of BD-I.

Staging, Neurocognition and Social Functioning in Bipolar Disorder

Introduction: Bipolar disorder (BD) is associated with significant neurocognitive and functional impairment, which may progress across stages. The 'latent stage' of BD remains understudied. This cross-sectional study assessed staging, neurocognition and social functioning among BD patients and their healthy siblings. Methods: Four groups were included: euthymic type I BD patients in the early (n = 25) and late (n = 23) stages, their healthy siblings (latent stage; n = 23) and healthy controls (n = 21). All 92 subjects underwent a comprehensive neuropsychological battery of processing speed, verbal learning/memory, visual memory, working memory, verbal fluency, executive cognition, and motor speed. Social functioning was assessed using the FAST scale. Results: Siblings' social functioning was identical to that of controls, and significantly better than both early- (p < 0.005) and late- (p < 0.001) stage patients. Although all patients were strictly euthymic, those at late stages had a significantly worse social functioning than early-stage patients (p < 0.001). Compared to controls, increasingly greater neurocognitive dysfunction was observed across stages of BD (F = 1.59; p = 0.005). Healthy siblings' performance lied between those of controls and patients, with deficits in tasks of processing speed, executive attention, verbal memory/learning, and visual memory. Both early- and late-stage patients had a more severe and widespread dysfunction than siblings, with no significant differences between them. Conclusions: Genetic vulnerability to BD-I seems to be associated with neurocognitive impairments, whereas social dysfunction would be the result of the clinical phenotype. Staging models of BD should take into account these divergent findings in the latent stage.

Toward Precision Psychiatry in Bipolar Disorder: Staging 2.0

Personalized treatment is defined as choosing the "right treatment for the right person at the right time." Although psychiatry has not yet reached this level of precision, we are on the way thanks to recent technological developments that may aid to detect plausible molecular and genetic markers. At the moment there are some models that are contributing to precision psychiatry through the concept of staging. While staging was initially presented as a way to categorize patients according to clinical presentation, course, and illness severity, current staging models integrate multiple levels of information that can help to define each patient's characteristics, severity, and prognosis in a more precise and individualized way. Moreover, staging might serve as the foundation to create a clinical decision-making algorithm on the basis of the patient's stage. In this review we will summarize the evolution of the bipolar disorder staging model in relation to the new discoveries on the neurobiology of bipolar disorder. Furthermore, we will discuss how the latest and future progress in psychiatry might transform current staging models into precision staging models.

Systemic challenges in bipolar disorder management: A patient-centered approach

OBJECTIVES

As part of a series of Patient-Centered Outcomes Research Institute-funded large-scale retrospective observational studies on bipolar disorder (BD) treatments and outcomes, we sought the input of patients with BD and their family members to develop research questions. We aimed to identify systemic root causes of patient-reported challenges with BD management in order to guide subsequent studies and initiatives.

METHODS

Three focus groups were conducted where patients and their family members (total n = 34) formulated questions around the central theme, "What do you wish you had known in advance or over the course of treatment for BD?" In an affinity mapping exercise, participants clustered their questions and ranked the resulting categories by importance. The research team and members of our patient partner advisory council further rated the questions by expected impact on patients. Using a Theory of Constraints systems thinking approach, several causal models of BD management challenges and their potential solution were developed with patients using the focus group data.

RESULTS

A total of 369 research questions were mapped to 33 categories revealing 10 broad themes. The top priorities for patient stakeholders involved pharmacotherapy and treatment alternatives. Analysis of causal relationships underlying 47 patient concerns revealed two core conflicts: for patients, whether or not to take pharmacotherapy, and for mental health services, the dilemma of care quality vs quantity.

CONCLUSIONS

To alleviate the core conflicts identified, BD management requires a coordinated multidisciplinary approach including: improved access to mental health services, objective diagnostics, sufficient provider visit time, evidence-based individualized treatment, and psychosocial support.