Altered Risk-Taking Behavior in Early-Stage Bipolar Disorder With a History of Psychosis

Highest correlations between emotion regulation strategies and mood symptoms in bipolar disorder: A systematic review and Bayesian network meta-analysis

Bipolar disorder (BD) is associated with alterations in emotion regulation (ER) strategies, with both depressive and (hypo)manic symptoms correlated with utilization of maladaptive instead of adaptive strategies. However, which ER strategies are the most affected during the most severe mood symptoms remains unclear despite the potentially relevant treatment implications. To this end, we conducted a systematic review and Bayesian network meta-analysis (NMA) of studies documenting correlations between ER and depressive and (hypo)manic symptoms of BD, from inception until November 9th, 2023. We included 15 studies in the review, 14 of which provided data to conduct a Bayesian NMA. Rumination emerged as the ER strategy most strongly associated with both depressive (ES=0.43, 95 %CrI=0.27,0.59) and (hypo)manic symptoms (ES=0.26, 95 %CrI=0.05,0.46) of BD. Other ER strategies showed associations primarily with depressive symptoms. There was no significant heterogeneity or network inconsistency. These findings emphasize the importance of rumination in BD and suggest that altered ER strategies are more evident in depressive symptoms rather than (hypo)manic ones. While promising for targeted interventions, these results are based on cross-sectional data, limiting causal interpretation. Future longitudinal studies are necessary to clarify the temporal dynamics of the relationship between affective symptoms and ER in BD.

Aripiprazole once-monthly for the treatment of adult patients with earlier-stage bipolar I disorder: a post hoc analysis of data from a double-blind, placebo-controlled, 52-week randomized withdrawal trial

BACKGROUND

Increased awareness of the factors contributing to the diagnostic disparities seen in bipolar disorder between individuals of different heritage is needed to achieve equity in diagnosis and treatment. One such inequity is the provision of earlier treatment. Earlier treatment of patients diagnosed with bipolar disorder may prolong time to recurrence of mood episodes and reduce functional impairment and other poor outcomes associated with disease progression. The aim of this post hoc analysis was to study the efficacy and safety of long-acting injectable aripiprazole once-monthly 400 mg (AOM 400) in patients with earlier-stage bipolar I disorder (BP-I). Data from a 52-week multicenter, double-blind, placebo-controlled, randomized withdrawal trial of AOM 400 versus placebo in patients with BP‑I (NCT01567527) were analyzed. Those patients in the lowest quartiles for age (18-≤32 years; n = 70) or disease duration (0.13-≤4.6 years; n = 67) at baseline were categorized with earlier-stage BP-I. The primary endpoint was time from randomization to recurrence of any mood episode. Other endpoints included proportion of patients with recurrence of any mood episode, and change from baseline in Young Mania Rating Scale (YMRS) and Montgomery-Åsberg Depression Rating Scale (MADRS) total scores.

RESULTS

Maintenance treatment with AOM 400 significantly delayed time to recurrence of any mood episode versus placebo in patients aged 18-≤32 years (hazard ratio [HR]: 2.46 [95% confidence interval (CI) 1.09, 5.55]; p = 0.0251) or with disease duration 0.13-≤4.6 years (HR: 3.21 [95% CI 1.35, 7.65]; p = 0.005). This was largely driven by a lower proportion of patients in the AOM 400 group with YMRS total score ≥15 or clinical worsening. Changes from baseline in MADRS total score in both earlier-stage groups indicated AOM 400 did not worsen depression versus placebo. The safety profile of AOM 400 was consistent with the original study. Note that the original study included patients who had previously been stabilized on AOM 400 monotherapy, which may have enriched the population with patients who respond to and tolerate AOM 400.

CONCLUSIONS

In this post hoc analysis, AOM 400 prolonged time to recurrence of any mood episode versus placebo in earlier-stage BP-I. These findings support early initiation of maintenance treatment with AOM 400.

Insular and Striatal Correlates of Uncertain Risky Reward Pursuit in Schizophrenia

BACKGROUND AND HYPOTHESIS

Risk-taking in specific contexts can be beneficial, leading to rewarding outcomes. Schizophrenia is associated with disadvantageous decision-making, as subjects pursue uncertain risky rewards less than controls. However, it is unclear whether this behavior is associated with more risk sensitivity or less reward incentivization. Matching on demographics and intelligence quotient (IQ), we determined whether risk-taking was more associated with brain activation in regions affiliated with risk evaluation or reward processing.

STUDY DESIGN

Subjects (30 schizophrenia/schizoaffective disorder, 30 controls) completed a modified, fMRI Balloon Analogue Risk Task. Brain activation was modeled during decisions to pursue risky rewards and parametrically modeled according to risk level.

STUDY RESULTS

The schizophrenia group exhibited less risky-reward pursuit despite previous adverse outcomes (Average Explosions; F(1,59) = 4.06, P = .048) but the comparable point at which risk-taking was volitionally discontinued (Adjusted Pumps; F(1,59) = 2.65, P = .11). Less activation was found in schizophrenia via whole brain and region of interest (ROI) analyses in the right (F(1,59) = 14.91, P < 0.001) and left (F(1,59) = 16.34, P < 0.001) nucleus accumbens (NAcc) during decisions to pursue rewards relative to riskiness. Risk-taking correlated with IQ in schizophrenia, but not controls. Path analyses of average ROI activation revealed less statistically determined influence of anterior insula upon dorsal anterior cingulate bilaterally (left: χ2 = 12.73, P < .001; right: χ2 = 9.54, P = .002) during risky reward pursuit in schizophrenia.

CONCLUSIONS

NAcc activation in schizophrenia varied less according to the relative riskiness of uncertain rewards compared to controls, suggesting aberrations in reward processing. The lack of activation differences in other regions suggests similar risk evaluation. Less insular influence on the anterior cingulate may relate to attenuated salience attribution or inability for risk-related brain region collaboration to sufficiently perceive situational risk.