Unmet needs in the assessment and management of bipolar I depression

The International College of Neuropsychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 4: Unmet Needs in the Treatment of Bipolar Disorder and Recommendations for Future Research

BACKGROUND

The current fourth paper on the International College of Neuropsychopharmacology guidelines for the treatment of bipolar disorder reports on the unmet needs that became apparent after an extensive review of the literature and also serves as a conclusion to the project of the International College of Neuropsychopharmacology workgroup.

MATERIALS AND METHODS

The systematic review of the literature that was performed to develop the International College of Neuropsychopharmacology guidelines for bipolar disorder identified and classified a number of potential shortcomings.

RESULTS

Problems identified concerned the reliability and validity of the diagnosis of bipolar disorder and especially of bipolar depression. This, in turn, has profound consequences for early detection and correct treatment of the disorder. Another area that needs improvement is the unsatisfactory efficacy and effectiveness of therapeutic options, especially in special populations such as those with mixed features and rapid cycling course. Gender issues and adherence problems constitute an additional challenge. The literature suggests that while treatment providers are concerned more with treatment-related issues, patients and their caregivers worry more about issues pertaining to the availability of services and care, quality of life, and various types of burden. The workgroup identified additional unmet needs related to the current standard of research in bipolar disorder. These include the fragmentation of bipolar disorder into phases that are handled as being almost absolutely independent from each other, and thus the development of an overall therapeutic strategy on the basis of the existing evidence is very difficult. Trials are not always designed in a way that outcomes cover the most important aspects of bipolar disorder, and often the reporting of the results is biased and unsatisfactory. The data on combination treatments and high dosages are sparse, whereas they are common in real world practice.

CONCLUSIONS

The workgroup endorses the full release of raw study data to the scientific community, and the development of uniform clinical trial standards (also including more realistic outcomes) and the reporting of results. The 2 large appendices summarize the results of this systematic review with regard to the areas of lack of knowledge where further focused research is necessary.

Mood disorders: neurocognitive models

OBJECTIVES

In recent years, a number of neurocognitive models stemming from psychiatry and psychology schools of thought have conceptualized the pathophysiology of mood disorders in terms of dysfunctional neural mechanisms that underpin and drive neurocognitive processes. Though these models have been useful for advancing our theoretical understanding and facilitating important lines of research, translation of these models and their application within the clinical arena have been limited-partly because of lack of integration and synthesis. Cognitive neuroscience provides a novel perspective for understanding and modeling mood disorders. This selective review of influential neurocognitive models develops an integrative approach that can serve as a template for future research and the development of a clinically meaningful framework for investigating, diagnosing, and treating mood disorders.

METHODS

A selective literature search was conducted using PubMed and PsychINFO to identify prominent neurobiological and neurocognitive models of mood disorders.

RESULTS

Most models identify similar neural networks and brain regions and neuropsychological processes in the neurocognition of mood, however, they differ in terms of specific functions attached to neural processes and how these interact. Furthermore, cognitive biases, reward processing and motivation, rumination, and mood stability, which play significant roles in the manner in which attention, appraisal, and response processes are deployed in mood disorders, are not sufficiently integrated. The inclusion of interactions between these additional components enhances our understanding of the etiology and pathophysiology of mood disorders.

CONCLUSIONS

Through integration of key cognitive functions and understanding of how these interface with neural functioning within neurocognitive models of mood disorders, a framework for research can be created for translation to diagnosis and treatment of mood disorders.

Physiological Correlates of Bipolar Spectrum Disorders and their Treatment

Bipolar spectrum disorders (BSDs) are associated with great personal and socioeconomic burden, with patients often facing a delay in detection, misdiagnosis when detected, and a trial-and-error approach to finding the most appropriate treatment. Therefore, improvement in the assessment and management of patients with BSDs is critical. Should valid physiological measures for BSDs be identified and implemented, significant clinical improvements are likely to be realized. This chapter reviews the physiological correlates of BSDs and treatment, and in doing so, examines the neuroimaging, electroencephalogram, and event-related potential, and peripheral physiological correlates that both characterize and differentiate BSDs and their response to treatment. Key correlates of BSDs involve underlying disturbances in prefrontal and limbic network neural activity, early neural processing, and within the autonomic nervous system. These changes appear to be mood-related and can be normalized with treatment. We adopt an "embodied" perspective and propose a novel, working framework that takes into account embodied psychophysiological mechanisms in which the physiological correlates of BSD are integrated. This approach may in time provide the objective physiological measures needed to improve assessment and decision making when treating patients with BSDs. Future research with integrative, multimodal measures is likely to yield potential applications for physiological measures of BSD that correlate closely with diagnosis and treatment.