Precursors of bipolar disorders: a systematic literature review of prospective studies

Childhood Clinical Features Preceding the Onset of Bipolar Versus Major Depressive Disorders During Adolescence

OBJECTIVE

To identify childhood psychopathological features that predict the onset of adolescent Bipolar (BD) versus Unipolar Major Depressive Disorder (UD) during adolescence.

METHOD

We analyzed clinical data from 495 juveniles diagnosed with DSM-5 UD (n = 359), and BD (n = 136), using bivariate analysis and multivariate logistic regression model.

RESULTS

BD subjects exhibited earlier onset of any psychiatric feature compared to UD. Antecedents associated with later BD were: oppositional defiant > specific phobias > ADHD > obsessive compulsive (OCD). Antecedents selectively associated with later UD were: social anxiety and separation anxiety. Factors significantly and independently associated with later BD diagnosis were: [a] emotional dysregulation at onset of the mood disorder; [b] first depressive episode with mixed features; [c] antecedent ADHD; [d] antecedent OCD, and [e] antecedent oppositional-defiance.

CONCLUSION

Identifying developmental differences in BD and UD symptoms can aid clinicians in early identification and treatment planning for bipolar disorder in youth.

Differential characteristics of bipolar I and II disorders: a retrospective, cross-sectional evaluation of clinical features, illness course, and response to treatment

BACKGROUND

The distinction between bipolar I and bipolar II disorder and its treatment implications have been a matter of ongoing debate. The aim of this study was to examine differences between patients with bipolar I and II disorders with particular emphasis on the early phases of the disorders.

METHODS

808 subjects diagnosed with bipolar I (N = 587) or bipolar II disorder (N = 221) according to DSM-IV criteria were recruited between April 1994 and March 2022 from tertiary-level mood disorder clinics. Sociodemographic and clinical variables concerning psychiatric and medical comorbidities, family history, illness course, suicidal behavior, and response to treatment were compared between the bipolar disorder types.

RESULTS

Bipolar II disorder patients were more frequently women, older, married or widowed. Bipolar II disorder was associated with later "bipolar" presentation, higher age at first (hypo)mania and treatment, less frequent referral after a single episode, and more episodes before lithium treatment. A higher proportion of first-degree relatives of bipolar II patients were affected by major depression and anxiety disorders. The course of bipolar II disorder was typically characterized by depressive onset, early depressive episodes, multiple depressive recurrences, and depressive predominant polarity; less often by (hypo)mania or (hypo)mania-depression cycles at onset or during the early course. The lifetime clinical course was more frequently rated as chronic fluctuating than episodic. More patients with bipolar II disorder had a history of rapid cycling and/or high number of episodes. Mood stabilizers and antipsychotics were prescribed less frequently during the early course of bipolar II disorder, while antidepressants were more common. We found no differences in global functioning, lifetime suicide attempts, family history of suicide, age at onset of mood disorders and depressive episodes, and lithium response.

CONCLUSIONS

Differences between bipolar I and II disorders are not limited to the severity of (hypo)manic syndromes but include patterns of clinical course and family history. Caution in the use of potentially mood-destabilizing agents is warranted during the early course of bipolar II disorder.

Brain functional activation and first mood episode in youth at risk for bipolar disorder

BACKGROUND

In order to identify biomarkers of prodromal mood disorders, we examined functional brain activation in children and adolescent at familial risk for bipolar disorder.

METHODS

Offspring of parents with bipolar I disorder (at-risk youth; N = 115, mean ± SD age: 13.6 ± 2.7; 54 % girls) and group-matched offspring of healthy parents (healthy controls; N = 58, mean ± SD age: 14.2 ± 3.0; 53 % girls) underwent functional magnetic resonance imaging while performing a continuous performance task with emotional and neutral distracters. At baseline, at-risk youth had no history of mood episodes or psychotic disorders. Subjects were followed longitudinally until developing their first mood episode or being lost to follow-up. Standard event-related region-of-interest (ROI) analyses were performed to compare brain activation at baseline between groups and in survival analyses.

RESULTS

At baseline, at-risk youth exhibited reduced activation to emotional distracters in the right ventrolateral prefrontal cortex (VLPFC) (p = 0.04). Activation was not significantly altered in additional ROIs, including left VLPFC, bilateral amygdala, caudate, or putamen. In those at-risk youth who developed their first mood episode during follow-up (n = 17), baseline increased activation in right VLPFC, right caudate, and right putamen activation predicted the development of a mood episode.

LIMITATIONS

Sample size of converters, loss to follow-up, and number of statistical comparisons.

CONCLUSIONS

We found preliminary evidence that a reduced activation in right VLPFC might be a marker of risk for or resilience to mood disorders in at-risk youth. Conversely, an increased activation in the right VLPFC, caudate, and putamen might indicate an increased risk for the later development of their first mood episode.

Phenotype fingerprinting of bipolar disorder prodrome

BACKGROUND

Detecting prodromal symptoms of bipolar disorder (BD) has garnered significant attention in recent research, as early intervention could potentially improve therapeutic efficacy and improve patient outcomes. The heterogeneous nature of the prodromal phase in BD, however, poses considerable challenges for investigators. Our study aimed to identify distinct prodromal phenotypes or "fingerprints" in patients diagnosed with BD and subsequently examine correlations between these fingerprints and relevant clinical outcomes.

METHODS

20,000 veterans diagnosed with BD were randomly selected for this study. K-means clustering analysis was performed on temporal graphs of the clinical features of each patient. We applied what we call "temporal blurring" to each patient image in order to allow clustering to focus on the clinical features, and not cluster patients based upon their varying temporal patterns in diagnosis, which lead to the desired types of clusters. We evaluated several outcomes including mortality rate, hospitalization rate, mean number of hospitalizations, mean length of stay, and the occurrence of a psychosis diagnosis within one year following the initial BD diagnosis. To determine the statistical significance of the observed differences for each outcome, we conducted appropriate tests, such as ANOVA or Chi-square.

RESULTS

Our analysis yielded 8 clusters which appear to represent distinct phenotypes with differing clinical attributes. Each of these clusters also has statistically significant differences across all outcomes (p < 0.0001). The clinical features in many of the clusters were consistent with findings in the literature concerning prodromal symptoms in patients with BD. One cluster, notably characterized by patients lacking discernible prodromal symptoms, exhibited the most favorable results across all measured outcomes.

CONCLUSION

Our study successfully identified distinct prodromal phenotypes in patients diagnosed with BD. We also found that these distinct prodromal phenotypes are associated with different clinical outcomes.

Correlates of long duration of untreated illness (DUI) in patients with bipolar disorder: results of an observational study

BACKGROUND

Despite a high number of studies investigating the correlation between long Duration of Untreated Illness (DUI) and poor course of Bipolar Disorder (BD), the results concerning the impact of DUI on some specific factors, such as suicidality and medical comorbidities, are still inconsistent. This cross-sectional observational study aimed at analyzing potential socio-demographic and clinical correlates of long DUI in a large cohort of real-world, well-characterized BD patients.

METHODS

The socio-demographic and clinical characteristics of 897 patients with BD were collected. The sample was divided for analysis in two groups (short DUI vs long DUI) according to a DUI cutoff of 2 years. Comparisons were performed using χ2 tests for categorical variables and the Kruskal-Wallis test for continuous variables. Logistic regression (LogReg) was used to identify explanatory variables associated with DUI (dependent variable).

RESULTS

Six-hundred and sixty patients (75.5%) presented long DUI (> 2 years) and mean DUI was 15.7 years. The LogReg analysis confirmed the association of long DUI with bipolar II disorder (p: 0.016), lower age at onset (p < 0.001), depressive predominant polarity (p: 0.018), depressive polarity onset (p < 0.001), longer duration of illness (p < 0.001), lifetime suicide attempts (p: 0.045) and current medical comorbidities (p: 0.019).

CONCLUSIONS

The present study confirms the association between long DUI and higher risk of suicide attempts in patients with BD. Moreover, an association between long DUI and higher rates of medical conditions has been found.

Predicting bipolar disorder I/II in individuals at clinical high-risk: Results from a systematic review

INTRODUCTION

No systematic review has estimated the consistency and the magnitude of the risk of developing bipolar disorder I-II (BD-I/II) in individuals at clinical high risk for bipolar disorder (CHR-BD).

METHODS

PubMed and Web of Science databases were searched until April 2022 in this pre-registered (PROSPERO CRD42022346515) PRISMA-compliant systematic review to identify longitudinal studies in individuals meeting pre-defined CHR-BD criteria. The risk of bias was assessed using the Newcastle-Ottawa Scale, and results were systematically synthesized around CHR-BD criteria across follow-up periods and different subgroups.

RESULTS

Altogether, 13 studies were included reporting on nine prospective independent cohorts (n = 678 individuals at CHR-BD). The mean age of participants was 15.7 years (range 10.1-22.6 years), and 54.2 % were females. The most common CHR-BD subgroup was subthreshold mania (55.5 %), followed by BD-Not Otherwise Specified (BD-NOS: 33.3 %). Development of BD I/II ranged from 7.1 % to 23.4 % after 2 years. Development of BD-I ranged from 3.4 % at 4 years to 23 % at 8 years. Development of BD-II ranged from 10 % at 2 years to 63.8 % at 4 years. The risk of developing BD-I appeared highest in those meeting BD-NOS criteria (23 % at eight years). Predictors of development of BD were identified but remained mostly unreplicated. The quality of the included studies was moderate (NOS = 5.2 ± 1.1).

CONCLUSIONS

Emerging data from research studies point towards the promising utility of CHR-BD criteria. These studies may pave the way to the next generation of research, implementing detection, prognostication, and preventive interventions in individuals at CHR-BD identified and followed in clinical practice.

Clinical staging and the differential risks for clinical and functional outcomes in young people presenting for youth mental health care

BACKGROUND

Clinical staging proposes that youth-onset mental disorders develop progressively, and that active treatment of earlier stages should prevent progression to more severe disorders. This retrospective cohort study examined the longitudinal relationships between clinical stages and multiple clinical and functional outcomes within the first 12 months of care.

METHODS

Demographic and clinical information of 2901 young people who accessed mental health care at age 12-25 years was collected at predetermined timepoints (baseline, 3 months, 6 months, 12 months). Initial clinical stage was used to define three fixed groups for analyses (stage 1a: 'non-specific anxious or depressive symptoms', 1b: 'attenuated mood or psychotic syndromes', 2+: 'full-threshold mood or psychotic syndromes'). Logistic regression models, which controlled for age and follow-up time, were used to compare clinical and functional outcomes (role and social function, suicidal ideation, alcohol and substance misuse, physical health comorbidity, circadian disturbances) between staging groups within the initial 12 months of care.

RESULTS

Of the entire cohort, 2093 young people aged 12-25 years were followed up at least once over the first 12 months of care, with 60.4% female and a baseline mean age of 18.16 years. Longitudinally, young people at stage 2+ were more likely to develop circadian disturbances (odds ratio [OR]=2.58; CI 1.60-4.17), compared with individuals at stage 1b. Additionally, stage 1b individuals were more likely to become disengaged from education/employment (OR=2.11, CI 1.36-3.28), develop suicidal ideations (OR=1.92; CI 1.30-2.84) and circadian disturbances (OR=1.94, CI 1.31-2.86), compared to stage 1a. By contrast, we found no relationship between clinical stage and the emergence of alcohol or substance misuse and physical comorbidity.

CONCLUSIONS

The differential rates of emergence of poor clinical and functional outcomes between early versus late clinical stages support the clinical staging model's assumptions about illness trajectories for mood and psychotic syndromes. The greater risk of progression to poor outcomes in those who present with more severe syndromes may be used to guide specific intervention packages.

The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management

Bipolar disorder is heterogeneous in phenomenology, illness trajectory, and response to treatment. Despite evidence for the efficacy of multimodal-ity interventions, the majority of persons affected by this disorder do not achieve and sustain full syndromal recovery. It is eagerly anticipated that combining datasets across various information sources (e.g., hierarchical "multi-omic" measures, electronic health records), analyzed using advanced computational methods (e.g., machine learning), will inform future diagnosis and treatment selection. In the interim, identifying clinically meaningful subgroups of persons with the disorder having differential response to specific treatments at point-of-care is an empirical priority. This paper endeavours to synthesize salient domains in the clinical characterization of the adult patient with bipolar disorder, with the overarching aim to improve health outcomes by informing patient management and treatment considerations. Extant data indicate that characterizing select domains in bipolar disorder provides actionable information and guides shared decision making. For example, it is robustly established that the presence of mixed features - especially during depressive episodes - and of physical and psychiatric comorbidities informs illness trajectory, response to treatment, and suicide risk. In addition, early environmental exposures (e.g., sexual and physical abuse, emotional neglect) are highly associated with more complicated illness presentations, inviting the need for developmentally-oriented and integrated treatment approaches. There have been significant advances in validating subtypes of bipolar disorder (e.g., bipolar I vs. II disorder), particularly in regard to pharmacological interventions. As with other severe mental disorders, social functioning, interpersonal/family relationships and internalized stigma are domains highly relevant to relapse risk, health outcomes, and quality of life. The elevated standardized mortality ratio for completed suicide and suicidal behaviour in bipolar disorder invites the need for characterization of this domain in all patients. The framework of this paper is to describe all the above salient domains, providing a synthesis of extant literature and recommendations for decision support tools and clinical metrics that can be implemented at point-of-care.

Understanding the development of bipolar disorder and borderline personality disorder in young people: a meta-review of systematic reviews

BACKGROUND

There is ongoing debate on the nosological position of bipolar disorder (BD) and borderline personality disorder (BPD). Identifying the unique and shared risks, developmental pathways, and symptoms in emerging BD and BPD could help the field refine aetiological hypotheses and improve the prediction of the onset of these disorders. This study aimed to: (a) systematically synthesise the available evidence from systematic reviews (SRs) and meta-analyses (MAs) concerning environmental, psychosocial, biological, and clinical factors leading to the emergence of BD and BPD; (b) identify the main differences and common features between the two disorders to characterise their complex interplay and, (c) highlight remaining evidence gaps.

METHODS

Data sources were; PubMed, PsychINFO, Embase, Cochrane, CINAHL, Medline, ISI Web of Science. Overlap of included SRs/MAs was assessed using the corrected covered area process. The methodological quality of each included SR and MA was assessed using the AMSTAR.

RESULTS

22 SRs and MAs involving 249 prospective studies met eligibility criteria. Results demonstrated that family history of psychopathology, affective instability, attention deficit hyperactivity disorder, anxiety disorders, depression, sleep disturbances, substance abuse, psychotic symptoms, suicidality, childhood adversity and temperament were common predisposing factors across both disorders. There are also distinct factors specific to emerging BD or BPD.

CONCLUSIONS

Prospective studies are required to increase our understanding of the development of BD and BPD onset and their complex interplay by concurrently examining multiple measures in BD and BPD at-risk populations.

Suicidal behavior in juvenile bipolar disorder and major depressive disorder patients: Systematic review and meta-analysis

OBJECTIVE

To assess rates and lethality of suicidal behavior in studies of children and adolescents diagnosed with major depressive disorder (MDD) or bipolar disorder (BD).

METHODS

This PROSPERO-registered protocol (CRD-42019159676) systematically reviewed reports on suicidal behavior among juveniles (age ≤ 18 years), and pooled data on risk (% of subjects) and rates (%/year), followed by random-effects meta-analysis and multivariable linear regression modeling.

RESULTS

Included were 41 reports (1995-2020) from 15 countries involving 104,801 juveniles (102,519 diagnosed with MDD, 2282 with BD), at risk for 0.80-12.5 years. Meta-analytically pooled suicide attempter-rates averaged 7.44%/year [95%CI: 5.63-9.25] with BD and 6.27%/year [5.13-7.41] with MDD. Meta-analysis of 5 studies with both diagnostic groups found significantly greater attempt risk with BD vs. MDD (OR = 1.59 [1.24-2.05], p < 0.0001). In 6 studies, suicide rate with juvenile mood disorders averaged 125 [56.9-236]/100,000/year, similar to adult rates, >30-times greater than in the general juvenile population, and higher among older adolescents. The ratio of attempts/suicides (A/S) was 52.6 among mood-disordered juveniles, indicating greater lethality than among juveniles in the general population (A/S ≥ 250), but somewhat less than in the estimated adult general population (A/S ca. 30).

CONCLUSIONS

Rates of suicide attempts in juveniles with a major mood disorder averaged 6580/100,000/year, were greater in BD versus MDD observed under the same conditions, and greater with shorter periods of observation. Lethality (fatalities per suicide attempt) was greater in juveniles diagnosed with major affective disorders than in the juvenile general population, but less than in adults.

White matter predictors of worsening of subthreshold hypomania severity in non-bipolar young adults parallel abnormalities in individuals with bipolar disorder

BACKGROUND

Identifying neural predictors of worsening subthreshold hypomania severity can help identify risk of progression to BD. While diffusion Magnetic Resonance Imaging (dMRI) studies reported white matter microstructural abnormalities in tracts supporting emotional regulation in individuals with BD, it remains unknown whether similar patterns of white matter microstructure predict worsening of subthreshold hypomania severity in non-BD individuals.

METHODS

dMRI data were collected in: 81 non-BD individuals recruited across a range of subthreshold depression and hypomania, and followed for six months; and independent samples of 75 BD and 58 healthy individuals. All individuals were assessed using standardized diagnostic assessments, mood and anxiety symptom rating scales. Global probabilistic tractography and a tract-profile approach examined fractional anisotropy (FA), a measure of fiber collinearity, in tracts supporting emotional regulation shown to have abnormalities in BD: forceps minor (FMIN), anterior thalamic radiation (ATR), cingulum bundle (CB), and uncinate fasciculus (UF).

RESULTS

Lower FA in left CB (middle, β = -0.22, P = 0.022; posterior, β = -0.32, P < 0.001), right CB (anterior, β = -0.30, P = 0.003; posterior, β = -0.27, P = 0.005), and right UF (frontal, β = -0.29, P = 0.002; temporal, β = -0.40, P < 0.001) predicted worsening of subthreshold hypomania severity in non-BD individuals. BD versus healthy individuals showed lower FA in several of these segments: middle left CB (F = 8.7, P = 0.004), anterior right CB (F = 9.8, P = 0.002), and frontal right UF (F = 7.0, P = 0.009). Non-BD individuals with worsening 6-month hypomania had lower FA in these three segments versus HC and non-BD individuals without worsening hypomania, but similar FA to BD individuals.

LIMITATIONS

Relatively short follow-up.

CONCLUSIONS

White matter predictors of worsening subthreshold hypomania in non-BD individuals parallel abnormalities in BD individuals, and can guide early risk identification and interventions.

Associations of presenting symptoms and subsequent adverse clinical outcomes in people with unipolar depression: a prospective natural language processing (NLP), transdiagnostic, network analysis of electronic health record (EHR) data

OBJECTIVE

To investigate the associations of symptoms of mania and depression with clinical outcomes in people with unipolar depression.

DESIGN

A natural language processing electronic health record study. We used network analysis to determine symptom network structure and multivariable Cox regression to investigate associations with clinical outcomes.

SETTING

The South London and Maudsley Clinical Record Interactive Search database.

PARTICIPANTS

All patients presenting with unipolar depression between 1 April 2006 and 31 March 2018.

EXPOSURE

(1) Symptoms of mania: Elation; Grandiosity; Flight of ideas; Irritability; Pressured speech. (2) Symptoms of depression: Disturbed mood; Anhedonia; Guilt; Hopelessness; Helplessness; Worthlessness; Tearfulness; Low energy; Reduced appetite; Weight loss. (3) Symptoms of mania or depression (overlapping symptoms): Poor concentration; Insomnia; Disturbed sleep; Agitation; Mood instability.

MAIN OUTCOMES

(1) Bipolar or psychotic disorder diagnosis. (2) Psychiatric hospital admission.

RESULTS

Out of 19 707 patients, at least 1 depression, overlapping or mania symptom was present in 18 998 (96.4%), 15 954 (81.0%) and 4671 (23.7%) patients, respectively. 2772 (14.1%) patients subsequently developed bipolar or psychotic disorder during the follow-up period. The presence of at least one mania (HR 2.00, 95% CI 1.85 to 2.16), overlapping symptom (HR 1.71, 95% CI 1.52 to 1.92) or symptom of depression (HR 1.31, 95% CI 1.07 to 1.61) were associated with significantly increased risk of onset of a bipolar or psychotic disorder. Mania (HR 1.95, 95% CI 1.77 to 2.15) and overlapping symptoms (HR 1.76, 95% CI 1.52 to 2.04) were associated with greater risk for psychiatric hospital admission than symptoms of depression (HR 1.41, 95% CI 1.06 to 1.88).

CONCLUSIONS

The presence of mania or overlapping symptoms in people with unipolar depression is associated with worse clinical outcomes. Symptom-based approaches to defining clinical phenotype may facilitate a more personalised treatment approach and better predict subsequent clinical outcomes than psychiatric diagnosis alone.

A systematic review and meta-analysis of sleep and circadian rhythms disturbances in individuals at high-risk of developing or with early onset of bipolar disorders

Sleep and circadian rhythms disturbances (SCRD) in young people at high risk or with early onset of bipolar disorders (BD) are poorly understood. We systematically searched for studies of self, observer or objective estimates of SCRD in asymptomatic or symptomatic offspring of parents with BD (OSBD), individuals with presentations meeting recognized BD-at-risk criteria (BAR) and youth with recent onset of full-threshold BD (FT-BD). Of 76 studies eligible for systematic review, 35 (46%) were included in random effects meta-analyses. Pooled analyses of self-ratings related to circadian rhythms demonstrated greater preference for eveningness and more dysregulation of social rhythms in BAR and FT-BD groups; analyses of actigraphy provided some support for these findings. Meta-analysis of prospective studies showed that pre-existing SCRD were associated with a 40% increased risk of onset of BD, but heterogeneity in assessments was a significant concern. Overall, we identified longer total sleep time (Hedges g: 0.34; 95% confidence intervals:.1,.57), especially in OSBD and FT-BD and meta-regression analysis indicated the effect sizes was moderated by the proportion of any sample manifesting psychopathology or receiving psychotropic medications. This evolving field of research would benefit from greater attention to circadian rhythm as well as sleep quality measures.

High risk for psychiatric disorders in bipolar offspring. A four years prospective study

Bipolar disorder (BD) has a large hereditary component. It is a disorder that begins in early adulthood, but about which it has been described a premorbid period preceding the onset of BD. During this herald expression psychiatric disorders and symptoms, such as depressive, manic, psychotic, anxious and others, may appear.

OBJECTIVE

To determine the psychopathological profile of a Bipolar Offspring (BO) group compared with the Community Control Offspring (CCO) group, and its evolution over time, including subthreshold symptoms and mental disorders.

METHODS

We conducted an observational mixed cohort study, with a prospective design. We included subjects from six to 30 years of age, from the region of Antioquia, Colombia. A total of 131 subjects from the risk group BO and 150 subjects from the CCO group were evaluated through validated psychiatric diagnostic interviews (K-SADS-PL and DIGS) at baseline and at 4 years follow up. All interviews were carried out by a staff blind to parent diagnoses. Follow-up assessment were complete in 72% of the offspring. Forty-two subjects were excluded as they surpassed the age of 30 years, and only 46 subjects were not followed (change of address or did not consent to participate).

RESULTS

Compared with the CCO group, the BO group had a higher frequency of affective disorder, psychotic disorder, externalizing disorders and use of the psychoactive substances during both assessments at time 1 and 2. The magnitude of the differences between the groups increased when they reach time 2. The BO group had a greater risk for presenting subthreshold symptoms and definitive psychiatric disorders, such as affective disorders, psychotic disorders and externalizing disorders. In addition, the BO group had a younger age of onset for psychoactive substances consumption.

CONCLUSION

During the follow-up period, the BO group had a higher risk of presenting mental disorders compared with the CCO group. The most relevant symptoms and disorders that could precede the onset of BD were depressive, bipolar not otherwise specified, psychotic and substance use.

Cortical mediation of relationships between dopamine receptor D2 and cognition is absent in youth at risk of bipolar disorder

Bipolar disorder is associated with cognitive deficits and cortical changes for which the developmental dynamics are not well understood. The dopamine D2 receptor (DRD2) gene has been associated with both psychiatric disorders and cognitive variability. Here we examined the mediating role of brain structure in the relationship between DRD2 genomic variation and cognitive performance, with target cortical regions selected based on evidence of association with DRD2, bipolar disorder and/or cognition from prior literature. Participants (n = 143) were aged 12-30 years and comprised 62 first-degree relatives of bipolar patients (deemed 'at-risk'), 55 controls, and 26 patients with established bipolar disorder; all were unrelated Caucasian individuals with complete data across the three required modalities (structural magnetic resonance imaging, neuropsychological and genetic data). A DRD2 haplotype was derived from three functional polymorphisms (rs1800497, rs1076560, rs2283265) associated with alternative splicing (i.e., D2-short/-long isoforms). Moderated mediation analyses explored group differences in relationships between this DRD2 haplotype, three structural brain networks which subsume the identified cortical regions of interest (frontoparietal, dorsal-attention, and ventral-attention), and three cognitive indices (intelligence, attention, and immediate memory). Controls who were homozygous for the DRD2 major haplotype demonstrated greater cognitive performance as a result of dorsal-attention network mediation. However, this association was absent in the 'at-risk' group. This study provides the first evidence of a functional DRD2-brain-cognition pathway. The absence of typical brain-cognition relationships in young 'at-risk' individuals may reflect biological differences that precede illness onset. Further insight into early pathogenic processes may facilitate targeted early interventions.

Manic and Depressive Symptoms in Children Diagnosed with Noonan Syndrome

Noonan syndrome (NS) is a dominant clinically variable and genetically heterogeneous developmental disorder caused by germ-line mutations encoding components of the Ras–MAPK signaling pathway. A few studies have investigated psychopathological features occurring in individuals with NS, although they were poorly analyzed. The aim of the present work is to investigate the psychopathological features in children and adolescents with NS focusing on depressive and hypo-manic symptoms. Thirty-seven subjects with molecularly confirmed diagnosis were systematically evaluated through a psychopathological assessment. In addition, an evaluation of the cognitive level was performed. Our analyses showed a high recurrence of attention deficit and hyperactivity disorder symptoms, emotional dysregulation, irritability, and anxiety symptomatology. The mean cognitive level was on the average. The present study provides new relevant information on psychopathological features in individuals with NS. The implications for clinicians are discussed including the monitoring of mood disorders in a clinical evolution.

Mania symptoms in a Swedish longitudinal population study: The roles of childhood trauma and neurodevelopmental disorders

BACKGROUND

Adult psychiatric disorders are associated with both childhood traumatic experiences (CTEs) and neurodevelopmental disorders (NDDs). CTEs and NDDs frequently co-occur in childhood, but their combined risk effect on the emergence of juvenile mania symptoms has not yet been examined.

METHODS

In a population-representative Swedish twin study, CTEs and NDDs were assessed in 3,348 nine-year old twins born between 1998 and 2001, and treated as dichotomous predictors (any CTEs, any NDDs). Follow-up data were gathered at age 15 through parental reports of mania symptoms, yielding a symptom count score.

RESULTS

Both CTEs and NDDs at age 9 contributed uniquely to an increase in mania symptoms at age 15. Children with both risk factors had 1.6 times the rate of mania symptoms as children with CTEs-only (Incidence rate ratio [IRR] 1.63, 95% CI 1.37-1.93), and 1.3 times the rate of mania symptoms as children with NDDs-only (IRR 1.26, 95% CI 1.06-1.50). There was no evidence for an interactive effect of CTEs and NDDs. NDDs showed a trend towards having a larger effect on mania symptoms than CTEs (NDDs-only vs. CTEs-only: IRR 1.29, 95% CI 0.99-1.68).

LIMITATIONS

Although it is a strength of the study that the data on exposures and outcome were collected prospectively, parental recall of CTEs was required and CTEs may be under-reported.

CONCLUSIONS

NDDs are at least as important as CTEs in the development of mania symptoms, and their risk is additive. Those with a history of both CTEs and NDDs should be monitored closely for the development of more severe psychiatric presentations.

Suicidal ideation and attempts in unipolar versus bipolar depression: analysis of 131,740 adolescent inpatients nationwide

Objective To evaluate the risk of suicidal ideation and suicidal attempt in adolescents with unipolar depression (UD) versus bipolar depression (BD). Method We included 131,740 adolescents (12-17y), with primary diagnoses of UD (92.6%) and BD (7.4%) from the nationwide inpatient sample. We calculated odds ratio (OR) for suicidal behaviors using logistic regression adjusted for demographic confounders and comorbidities. Results Suicidal ideation and suicidal attempt were seen in 14.5% and 38.6% respectively of total inpatients and both were seen in higher proportion of UD. Females have higher odds for suicidal attempt (OR 1.13, 95%CI 1.09-1.16) compared to males. After adjusting for confounders, UD had a marginally higher odds (OR 1.06, 95%CI 1.02-1.11) of suicidal attempt and 1.2 times higher odds (95%CI 1.11-1.26) of suicidal ideation compared to BD. Among adolescents with suicidal attempt, 93.2% had bipolar depression and 6.8% had unipolar depression.The majority of suicidal attempt in the inpatient setting was seen in females, with bipolar depression (74.6% vs. 67.3% in unipolar). Conclusion Our finding is clinically relevant and accentuates the need for early identification of BD, accurate differentiation of UD versus BD for targeted and adequate treatment to minimize suicidal behaviors, treat and manage them per treatment guidelines, and evolving research.

The Factor Structure of the Mood Disorder Questionnaire in Tunisian Patients

Background:

The Mood Disorder Questionnaire (MDQ) is a frequently used screening tool for the early detection of Bipolar Disorder (BD), which is often unrecognized or misdiagnosed at its onset. In this study, data from Tunisia has been used to evaluate the psychometric properties of the Arabic MDQ.

Methods:

The sample included 151 patients with a current major depressive episode. The Arabic adapted version of the Structured Clinical Interview for DSM-IV-TR was used to formulate a diagnosis, yielding 62 patients with BD and 89 with unipolar Major Depressive Disorder (MDD). Principal component analysis with parallel analysis was used to establish the spontaneous distribution of the 13 core items of the MDQ. Confirmatory Factor Analysis (CFA) was used to check the available factor models. Receiver Operating Characteristic (ROC) analysis was used to assess the capacity of the MDQ to distinguish patients with BD from those with MDD.

Results:

Cronbach’s α in the sample was 0.80 (95%CI: 0.75 to 0.85). Ordinal α was 0.88. Parallel analysis suggested two main components, which explained 59% of variance in the data. CFA found a good fit for the existing unidimensional, the two-factor, and the three-factor models. ROC analysis showed that at a threshold of 7, the MDQ was able to distinguish patients with BD from those with MDD with extraordinary negative predictive value (0.92) and a positive diagnostic likelihood ratio of 3.8.

Conclusion:

The Arabic version of the MDQ showed good measurement properties in terms of reliability, factorial validity and discriminative properties.

High Risk for Psychiatric Disorders in Bipolar Offspring. A Four Years Prospective Study

Bipolar disorder (BD) has a large hereditary component. It is a disorder that begins in early adulthood, but about which it has been described a premorbid period preceding the onset of BD. During this herald expression psychiatric disorders and symptoms, such as depressive, manic, psychotic, anxious and others, may appear.

OBJECTIVE

To determine the psychopathological profile of a Bipolar Offspring (BO) group compared with the Community Control Offspring (CCO) group, and its evolution over time, including subthreshold symptoms and mental disorders.

METHODS

We conducted an observational mixed cohort study, with a prospective design. We included subjects from six to 30 years of age, from the region of Antioquia, Colombia. A total of 131 subjects from the risk group BO and 150 subjects from the CCO group were evaluated through validated psychiatric diagnostic interviews (K-SADS-PL and DIGS) at baseline and at 4 years follow up. All interviews were carried out by a staff blind to parent diagnoses. Follow-up assessment were complete in 72% of the offspring. Forty-two subjects were excluded as they surpassed the age of 30 years, and only 46 subjects were not followed (change of address or did not consent to participate).

RESULTS

Compared with the CCO group, the BO group had a higher frequency of affective disorder, psychotic disorder, externalizing disorders and use of the psychoactive substances during both assessments at time 1 and 2. The magnitude of the differences between the groups increased when they reach time 2. The BO group had a greater risk for presenting subthreshold symptoms and definitive psychiatric disorders, such as affective disorders, psychotic disorders and externalizing disorders. In addition, the BO group had a younger age of onset for psychoactive substances consumption.

CONCLUSION

During the follow-up period, the BO group had a higher risk of presenting mental disorders compared with the CCO group. The most relevant symptoms and disorders that could precede the onset of BD were depressive, bipolar not otherwise specified, psychotic and substance use.

Demographic and Clinical Characteristics, Including Subsyndromal Symptoms Across Bipolar-Spectrum Disorders in Adolescents

Objectives: Bipolar disorder (BD) is a debilitating illness that often starts at an early age. Prevention of first and subsequent mood episodes, which are usually preceded by a period characterized by subthreshold symptoms is important. We compared demographic and clinical characteristics including severity and duration of subsyndromal symptoms across adolescents with three different bipolar-spectrum disorders. Methods: Syndromal and subsyndromal psychopathology were assessed in adolescent inpatients (age = 12-18 years) with a clinical mood disorder diagnosis. Assessments included the validated Bipolar Prodrome Symptom Interview and Scale-Prospective (BPSS-P). We compared phenomenology across patients with a research consensus conference-confirmed DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnoses of BD-I, BD-not otherwise specified (NOS), or mood disorder (MD) NOS. Results: Seventy-six adolescents (age = 15.6 ± 1.4 years, females = 59.2%) were included (BD-I = 24; BD-NOS = 29; MD-NOS = 23) in this study. Median baseline global assessment of functioning scale score was 21 (interquartile range = 17-40; between-group p = 0.31). Comorbidity was frequent, and similar across groups, including disruptive behavior disorders (55.5%, p = 0.27), anxiety disorders (40.8%, p = 0.98), and personality disorder traits (25.0%, p = 0.21). Mania symptoms (most frequent: irritability = 93.4%, p = 0.82) and depressive symptoms (most frequent: depressed mood = 81.6%, p = 0.14) were common in all three BD-spectrum groups. Manic and depressive symptoms were more severe in both BD-I and BD-NOS versus MD-NOS (p < 0.0001). Median duration of subthreshold manic symptoms was shorter in MD-NOS versus BD-NOS (11.7 vs. 20.4 weeks, p = 0.002) and substantial in both groups. The most used psychotropics upon discharge were antipsychotics (65.8%; BD-I = 79.2%; BD-NOS = 62.1%; MD-NOS = 56.5%, p = 0.227), followed by mood stabilizers (43.4%; BD-I = 66.7%; BD-NOS = 31.0%; MD-NOS = 34.8%, p = 0.02) and antidepressants (19.7%; BD-I = 20.8%; BD-NOS = 10.3%; MD-NOS = 30.4%). Conclusions: Youth with BD-I, BD-NOS, and MD-NOS experience considerable symptomatology and are functionally impaired, with few differences observed in psychiatric comorbidity and clinical severity. Moreover, youth with BD-NOS and MD-NOS undergo a period with subthreshold manic symptoms, enabling identification and, possibly, preventive intervention of those at risk for developing BD or other affective episodes requiring hospitalization.

Cohort profile: the Brain and Mind Centre Optymise cohort: tracking multidimensional outcomes in young people presenting for mental healthcare

PURPOSE

The Brain and Mind Centre (BMC) Optymise cohort assesses multiple clinical and functional domains longitudinally in young people presenting for mental health care and treatment. Longitudinal tracking of this cohort will allow investigation of the relationships between multiple outcome domains across the course of care. Subsets of Optymise have completed detailed neuropsychological and neurobiological assessments, permitting investigation of associations between these measures and longitudinal course.

PARTICIPANTS

Young people (aged 12-30) presenting to clinics coordinated by the BMC were recruited to a research register (n=6743) progressively between June 2008 and July 2018. To date, 2767 individuals have been included in Optymise based on the availability of at least one detailed clinical assessment.

MEASURES

Trained researchers use a clinical research proforma to extract key data from clinical files to detail social and occupational functioning, clinical presentation, self-harm and suicidal thoughts and behaviours, alcohol and other substance use, physical health comorbidities, personal and family history of mental illness, and treatment utilisation at the following time points: baseline, 3, 6, 12, 24, 36, 48, and 60 months, and time last seen.

FINDINGS TO DATE

There is moderate to substantial agreement between raters for data collected via the proforma. While wide variations in individual illness course are clear, social and occupational outcomes suggest that the majority of cohort members show no improvement in functioning over time. Differential rates of longitudinal transition are reported between early and late stages of illness, with a number of baseline factors associated with these transitions. Furthermore, there are longitudinal associations between prior suicide attempts and inferior clinical and functional outcomes.

FUTURE PLANS

Future reports will detail the longitudinal course of each outcome domain and examine multidirectional relationships between these domains both cross-sectionally and longitudinally, and explore in subsets the associations between detailed neurobiological measures and clinical, social and functional outcomes.

The Impact of Subsyndromal Bipolar Symptoms on Patient's Functionality and Quality of Life

Subsyndromal symptoms have rarely been in the focus of bipolar research. This may be, in part, due to the fact that there is neither a uniform definition nor do they constitute an indication of regulatory and commercial interest. Nevertheless, they do have a decisive impact on the long-term course of bipolar disorder (BD), and the degree of functionality and quality of life (QoL) is more likely determined by their presence or absence than by acute episodes. Summarizing the literature an estimated 20-50% of patients suffer inter-episodically or chronically from subsyndromal BD. The most prominent symptoms that interfere with functionality are subsyndromal depression, disturbances of sleep, and perceived cognitive impairment, whereas anxiety negatively impacts on QoL. In the absence of evidence-based pharmacological treatments for subsyndromal BD, clinical practice adopts guidelines designed for treatment-resistant full-blown episodes of BD, supplemented by cognitive-behavioral, family focused or social-rhythm-based psychotherapies.

Structural Brain Alterations in Youth With Psychosis and Bipolar Spectrum Symptoms

OBJECTIVE

Adults with established diagnoses of serious mental illness (bipolar disorder and schizophrenia) exhibit structural brain abnormalities, yet less is known about how such abnormalities manifest earlier in development.

METHOD

Cross-sectional data publicly available from the Philadelphia Neurodevelopmental Cohort (PNC) were analyzed. Structural magnetic resonance neuroimaging data were collected on a subset of the PNC (N = 989; 9-22 years old). Cortical thickness, surface area (SA), and subcortical volumes were calculated. Study participants were assessed for psychiatric symptomatology using a structured interview and the following groups were created: typically developing (n = 376), psychosis spectrum (PS; n = 113), bipolar spectrum (BP; n = 117), and BP + PS (n = 109). Group and developmental differences in structural magnetic resonance neuroimaging measures were examined. In addition, the extent to which any structural aberration was related to neurocognition, global functioning, and clinical symptomatology was examined.

RESULTS

Compared with other groups, PS youth exhibited significantly decreased SA in the orbitofrontal, cingulate, precentral, and postcentral regions. PS youth also exhibited deceased thalamic volume compared with all other groups. The strongest effects for precentral and posterior cingulate SA decreases were seen during early adolescence (13-15 years old) in PS youth. The strongest effects for decreases in thalamic volume and orbitofrontal and postcentral SA were observed in mid-adolescence (16-18 years) in PS youth. Across groups, better overall functioning was associated with increased lateral orbitofrontal SA. Increased postcentral SA was associated with better executive cognition and less severe negative symptoms in the entire sample.

CONCLUSION

In a community-based sample, decreased cortical SA and thalamic volume were present early in adolescent development in youth with PS symptoms, but not in youth with BP symptoms or with BP and PS symptoms. These findings point to potential biological distinctions between PS and BP conditions, which could suggest additional biomarkers relevant to early identification.

A systematic review on sleep alterations anticipating the onset of bipolar disorder

Background:

Sleep alterations are frequent occurrence in Bipolar Disorder (BD), both in acute and interepisodic phases. Sleep alterations have been also described both long before BD onset, as aspecific risk syndromes, or as immediate prodromes of BD onset. The aim of the present study is to systematically review the relationship between sleep alterations anticipating for the full-blown onset of BD, both in general and according to specific polarities of onset.

Methods:

A systematic literature research according to PRISMA statement and considering: 1. prospective studies about BD patients’ offspring with sleep alterations who later developed BD. 2. prospective studies assessing patients with sleep disorders who later developed BD. 3. retrospective studies on BD patients where sleep alterations before BD onset of the disease were reported.

Results:

A total of 16 studies were included in this review. Sleep disturbances may frequently appear 1 year before the onset of BD or more, often during childhood or adolescence. A decreased need for sleep may precede the onset of the illness, specially a manic episode, while insomnia appears to anticipate either a manic or a depressive episode. Hypersomnia seems to precede bipolar depressive episodes.

Conclusions:

Sleep alterations frequently appear long before the onset of BD, and appear to be related specifically to the polarity of the index episode. The detection and treatment of sleep alterations in special high risk populations may help achieving an earlier detection of the illness.

Clinical and Environmental Risk Factors for Bipolar Disorder: Review of Prospective Studies

After participating in this activity, learners should be better able to:• Evaluate factors that have been identified in prospective studies as predicting the onset of bipolar disorder ABSTRACT: The prodromal phase of bipolar disorder (BD) remains incompletely characterized, limiting early detection of BD and delaying interventions that might limit future morbidity and disability. Retrospective and family-risk studies have consistently found evidence of prodromal psychopathology in subjects later diagnosed with BD. Here, we review prospective studies of clinical risk factors and exposures identified before diagnosis of BD: our findings are consistent with those from retrospective and family-risk studies. Affective psychopathology often precedes diagnosis to suggest a homotypic trajectory in developing BD. Early non-affective (heterotypic) psychopathological disturbances, including anxiety and disruptive behavior disorders, as well as environmental factors and exposures, have been found in prospective studies to increase the risk of BD, but tend to lack specificity in predicting BD. Findings from prospective studies are encouragingly similar to those of retrospective and family-risk studies.

Identifying and treating the prodromal phases of bipolar disorder and schizophrenia

Purpose of review

The goal of this paper is to review recent research on the identification and treatment of prodromal periods that precede bipolar and psychotic disorders. We also sought to provide information about current best clinical practices for prodromal youth.

Recent findings

Research in the areas of identifying prodromal periods has rapidly advanced. Calculators that can predict risk are now available for use during both bipolar and psychotic disorder prodromes. Cognitive behavior therapies have emerged as the gold standard psychosocial interventions for the psychosis prodrome, while several other types of therapies hold promise for treatment during the bipolar prodrome. Due to safety and efficacy concerns, pharmacologic treatments are not currently recommended during either prodromal period.

Summary

While additional research is needed to develop useful clinical tools to screen and diagnose during prodromal phases, existing literature has identified constellations of symptoms that can be reliably identified in research settings. Specialized psychotherapies are currently recommended to treat prodromal symptoms in clinical settings. They may also be useful to curtail future episodes, although further research is needed.

A Risk Calculator to Predict the Individual Risk of Conversion From Subthreshold Bipolar Symptoms to Bipolar Disorder I or II in Youth

OBJECTIVE

Youth with subthreshold mania are at increased risk of conversion to bipolar disorder (BP) I/II. Predictors for conversion have been published for the group as a whole. However, risk factors are heterogeneous, indicating the need for personalized risk assessment.

METHOD

One hundred forty youth with BP not otherwise specified (BP-NOS; 6-17 years old) followed through the Course and Outcome of Bipolar Youth (COBY) study with at least 1 follow-up assessment before conversion to BP-I/II were included. Youths were assessed on average every 7 months (median 11.5 years) using standard instruments. Risk predictors reported in the literature were used to build a 5-year risk calculator. Discrimination was measured using the time-dependent area under the curve after 1,000 bootstrap resamples. Calibration was evaluated by comparing observed with predicted probability of conversion. External validation was performed using an independent sample of 58 youths with BP-NOS recruited from the Pittsburgh Bipolar Offspring Study.

RESULTS

Seventy-five (53.6%) COBY youths with BP-NOS converted to BP-I/II, of which 57 (76.0%) converted within 5 years. Earlier-onset BP-NOS, familial hypomania/mania, and high mania, anxiety, and mood lability symptoms were important predictors of conversion. The calculator showed excellent consistency between the predicted and observed risks of conversion, good discrimination between converters and non-converters (area under the curve 0.71, CI 0.67-0.74), and a proportionally increasing rate of converters at each successive risk class. Discrimination in the external validation sample was good (area under the curve 0.75).

CONCLUSION

If replicated, the risk calculator would provide a useful tool to predict personalized risk of conversion from subsyndromal mania to BP-I/II and inform individualized interventions and research.

Prevalence of psychopathology in bipolar high-risk offspring and siblings: a meta-analysis

This meta-analysis aimed to update existing data on the comparison of prevalence rates of psychopathology primarily among offspring with at least one parent with bipolar disorder (BD) and offspring of parents without psychiatric illness. Seventeen studies were derived from a systematic search of PsychInfo, Medline, Scopus and Embase. Inclusion criteria were use of a control offspring group, standardized diagnostic procedures and reporting of clear frequency data. Risk of psychopathology was estimated by aggregating frequency data from selected studies. Compared to control offspring, high-risk BD offspring are nine times more likely to have a bipolar-type disorder, almost two and a half times more likely to develop a non-BD affective disorder and over two times more likely to develop at least one anxiety disorder. High-risk offspring also showed a significant increased risk of other non-mood psychopathology such as attention deficit hyperactivity disorder (ADHD), any type of behavioral disorder and substance use disorder (SUDs). Risk of developing a broad range of affective and non-affective psychopathology is significantly higher in high-risk BD offspring. Identifying clinical presentations of this genetically high-risk cohort is important in establishing appropriate preventative treatment.

[Bipolar disorders and anorexia nervosa: A clinical study]

PURPOSE

Anorexia nervosa is often accompanied by comorbid mood disorders, in particular depression, but individual or family history of bipolar disorders has not frequently been explored in anorexia nervosa. The objectives of the present study were: (1) to assess the frequency of bipolar disorders in patients with anorexia nervosa hospitalized in adolescence and in their parents, (2) to determine whether the patients with a personal or family history of bipolar disorders present particular characteristics in the way in which anorexia nervosa manifests itself, in their medical history, in the secondary diagnoses established, and in the treatments prescribed.

METHOD

Overall, 97 female patients aged 13 to 20 hospitalized for anorexia nervosa and their parents were assessed. The diagnoses of anorexia nervosa and bipolar disorders were established on the basis of DSM-IV-TR criteria.

RESULTS

A high frequency of type II and type V bipolar disorders was observed. The patients with anorexia nervosa and presenting personal or family histories of bipolar disorder had an earlier onset of anorexia nervosa, more numerous hospitalizations, a longer time-lapse between anorexia nervosa onset and hospitalization, more suicide attempts and more psychiatric comorbidities.

CONCLUSION

The occurrence of anorexia nervosa-bipolar disorders comorbidity appears to be considerable and linked to the severity of anorexia nervosa, raising the issue of the relationship between anorexia nervosa and bipolar disorders.

Is recurrence in major depressive disorder related to bipolarity and mixed features? Results from the BRIDGE-II-Mix study

BACKGROUND

Current classifications separate Bipolar (BD) from Major Depressive Disorder (MDD) based on polarity rather than recurrence. We aimed to determine bipolar/mixed feature frequency in a large MDD multinational sample with (High-Rec) and without (Low-Rec) >3 recurrences, comparing the two subsamples.

METHODS

We measured frequency of bipolarity/hypomanic features during current depressive episodes (MDEs) in 2347 MDD patients from the BRIDGE-II-mix database, comparing High-Rec with Low-Rec. We used Bonferroni-corrected Student's t-test for continuous, and chi-squared test, for categorical variables. Logistic regression estimated the size of the association between clinical characteristics and High-Rec MDD.

RESULTS

Compared to Low-Rec (n = 1084, 46.2%), High-Rec patients (n = 1263, 53.8%) were older, with earlier depressive onset, had more family history of BD, more atypical features, suicide attempts, hospitalisations, and treatment resistance and (hypo)manic switches when treated with antidepressants, higher comorbidity with borderline personality disorder, and more hypomanic symptoms during current MDE, resulting in higher rates of mixed depression according to both DSM-5 and research-based diagnostic (RBDC) criteria. Logistic regression showed age at first symptoms < 30 years, current MDE duration ≤ 1 month, hypomania/mania among first-degree relatives, past suicide attempts, treatment-resistance, antidepressant-induced swings, and atypical, mixed, or psychotic features during MDE to associate with High-Rec.

LIMITATIONS

Number of MDEs for defining recurrence was arbitrary; cross-sectionality did not allow assessment of conversion from MDD to BD.

CONCLUSIONS

High-Rec MDD differed from Low-Rec group for several clinical/epidemiological variables, including bipolar/mixed features. Bipolarity specifier and RBDC were more sensitive than DSM-5 criteria in detecting bipolar and mixed features in MDD.

From the Psychiatrist's Couch to Induced Pluripotent Stem Cells: Bipolar Disease in a Dish

Bipolar disease (BD) is one of the major public health burdens worldwide and more people are affected every year. Comprehensive genetic studies have associated thousands of single nucleotide polymorphisms (SNPs) with BD risk; yet, very little is known about their functional roles. Induced pluripotent stem cells (iPSCs) are powerful tools for investigating the relationship between genotype and phenotype in disease-relevant tissues and cell types. Neural cells generated from BD-specific iPSCs are thought to capture associated genetic risk factors, known and unknown, and to allow the analysis of their effects on cellular and molecular phenotypes. Interestingly, an increasing number of studies on BD-derived iPSCs report distinct alterations in neural patterning, postmitotic calcium signaling, and neuronal excitability. Importantly, these alterations are partly normalized by lithium, a first line treatment in BD. In light of these exciting findings, we discuss current challenges to the field of iPSC-based disease modelling and future steps to be taken in order to fully exploit the potential of this approach for the investigation of BD and the development of new therapies.

Parental Reports of Prodromal Psychopathology in Pediatric Bipolar Disorder

Abstract: Objectives: Early psychopathology in children diagnosed with Bipolar Disorder (BD) remains poorly characterized. Parental retrospective reports provide helpful details on the earliest manifestations and their evolution over time. These symptoms occur early in the course of BD, often before a formal diagnosis is made and/or treatment is implemented, and are of great importance to early recognition and prevention.

Methods: Parents of pre-pubertal children and adolescents with DSM-IV diagnoses of BD attending an outpatient mood disorders clinic provided retrospective ratings of 37 symptoms of child psychopathology. Stability and comorbidity of diagnoses were evaluated, and severity of symptoms for each subject was assessed by identifying the earliest occurrence of the reported symptoms causing impairment.

Results: Severe mood instability, temper tantrums, anxiety symptoms, sleep disturbances and aggression were among the most common signs of psychopathology reported in children diagnosed with BD before puberty. Symptoms were already apparent in the first three years in 28%, and formal diagnoses were made before the age of 8 y in the majority of cases.

Conclusions: Retrospective parental reports of early symptoms of psychopathology in pre-pubertal children with BD revealed a very early occurrence of affective precursors (irritability and mood dysregulation) and clinical risk factors like impulsive aggression and anxiety that can precede the syndromal onset of mania by several years. These findings support previous reports suggesting a progression of symptoms from abnormal, non-specific presentations to sub-threshold and finally syndromal BD. The importance of early identification and intervention is discussed.

Pediatric Mania: The Controversy between Euphoria and Irritability

Abstract: Pediatric Bipolar Disorder (BD) is a highly morbid pediatric psychiatric disease, consistently associated with family psychiatric history of mood disorders and associated with high levels of morbidity and disability and with a great risk of suicide. While there is a general consensus on the symptomatology of depression in childhood, the phenomenology of pediatric mania is still highly debated and the course and long-term outcome of pediatric BD still need to be clarified. We reviewed the available studies on the phenomenology of pediatric mania with the aim of summarizing the prevalence, demographics, clinical correlates and course of these two types of pediatric mania. Eighteen studies reported the number of subjects presenting with either irritable or elated mood during mania. Irritability has been reported to be the most frequent clinical feature of pediatric mania reaching a sensitivity of 95–100% in several samples. Only half the studies reviewed reported on number of episodes or cycling patterns and the described course was mostly chronic and ultra-rapid whereas the classical episodic presentation was less common.

Few long-term outcome studies have reported a diagnostic stability of mania from childhood to young adult age. Future research should focus on the heterogeneity of irritability aiming at differentiating distinct subtypes of pediatric psychiatric disorders with distinct phenomenology, course, outcome and biomarkers. Longitudinal studies of samples attending to mood presentation, irritable versus elated, and course, chronic versus episodic, may help clarify whether these are meaningful distinctions in the course, treatment and outcome of pediatric onset bipolar disorder.

BDNF and BMI effects on brain structures of bipolar offspring: results from the global mood and brain science initiative

OBJECTIVE

To compare brain-derived neurotrophic factor (BDNF) levels between offspring of individuals with bipolar disorders (BD) and healthy controls (HCs) and investigate the effects of BDNF levels and body mass index (BMI) on brain structures.

METHOD

Sixty-seven bipolar offspring and 45 HCs were included (ages 8-28). Structural images were acquired using 3.0 Tesla magnetic resonance imaging. Serum BDNF levels were measured using enzyme-linked immunosorbent assay. Multivariate and univariate analyses of covariance were conducted.

RESULTS

Significantly higher BDNF levels were observed among bipolar offspring, relative to HCs (P > 0.025). Offspring status moderated the association between BDNF and BMI (F₁ =4.636, P = 0.034). After adjustment for relevant covariates, there was a trend for a significant interaction of group and BDNF on neuroimaging parameters (Wilks'λ F_56,94 =1.463, P = 0.052), with significant effects on cerebellar white matter and superior and middle frontal regions. Brain volume and BDNF were positively correlated among HCs and negatively correlated among bipolar offspring. Interactions between BDNF and BMI on brain volumes were non-significant among HCs (Wilks'λ F_28,2 =2.229, P = 0.357), but significant among bipolar offspring (Wilks'λ F_28,12 =2.899, P = 0.028).

CONCLUSION

Offspring status and BMI moderate the association between BDNF levels and brain structures among bipolar offspring, underscoring BDNF regulation and overweight/obesity as key moderators of BD pathogenesis.

Borderline personality and attention-deficit hyperactivity traits in childhood are associated with hypomanic features in early adulthood

BACKGROUND

There is limited understanding of the symptomatic development of bipolar disorder from childhood to early adulthood.

AIMS

We assessed whether borderline personality disorder traits, ADHD, and emotional, behavioural and social difficulties during childhood were associated with hypomania assessed in young adulthood.

METHOD

We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC), to examine associations between measures of childhood psychopathology and lifetime hypomanic features assessed at age 22-23 years using the Hypomania Checklist-32 (HCL-32; n = 3372). We also conducted a factor analysis of the HCL to identify latent constructs underlying hypomania, and the extent to which childhood psychopathology was associated with these.

RESULTS

We identified two factors of the HCL corresponding to energy/mood and risk-taking/irritability. There was evidence of association between childhood borderline personality disorder traits and both hypomania factors, with evidence that the association was stronger with the risk-taking/irritability factor. All individual borderline traits, with the exception of fear of abandonment, were associated with hypomania. There was also evidence of association between most other measures of childhood psychopathology (ADHD, hyperactivity, conduct problems, peer relationship problems and reduced prosocial behaviour) and the risk-taking/irritability factor, but much less consistent evidence of association with the energy/mood factor.

LIMITATIONS

The HCL cannot diagnose bipolar disorder and may be subject to reporting bias.

CONCLUSIONS

A broad range of childhood psychopathologies may represent early markers of risk for hypomania. Further studies are required to understand the mechanisms underlying these associations, and to inform earlier detection of bipolar disorder.

Suicide Attempts in Juvenile Bipolar Versus Major Depressive Disorders: Systematic Review and Meta-Analysis

OBJECTIVE

Suicide attempts are prevalent in association with major mood disorders, and risk is greater with bipolar disorder (BD) than major depressive disorder (MDD) in adults. There may be similar relationships in juvenile mood disorders, but the evidence has not been compiled systematically and quantitatively.

METHOD

We searched for reports of studies comparing rates of suicide attempts in children or adolescents diagnosed with BD or MDD, and applied random-effects meta-analysis.

RESULTS

In 6 reports from 1995 to 2017, with 2,303 participants diagnosed with mood disorder from the United States and South Korea, aged 3 to 18 years, rates of suicide attempts differed significantly by diagnosis: BD (31.5%) > MDD (20.5%) > hypomania or mania-only (8.49%). Risk of suicide attempts differed (BD > MDD) highly significantly by meta-analysis (odds ratio [OR] = 1.71, CI = 1.33-2.20, p < .0001), and was very similar if a study with attempts and suicidal ideation was excluded (OR = 1.64, CI = 1.26-2.15, p < .0001).

CONCLUSION

Risk of suicide attempts in juvenile mood disorder patients ranked: BD > MDD >> hypomania or mania-only >> juvenile general population.

Clinical stabilisation with lacosamide of mood disorder comorbid with PTSD and fronto-temporal epilepsy

Background and aim of the work:

Mood disorders are often complicated by comorbidity with epilepsy. Anxiety and personality disorders may worsen prognosis and treatment outcome. Lacosamide has been recently introduced as adjunctive treatment for partial epilepsy. Its mechanism consists of selective slow inactivation of voltage-gated sodium channels, thus promoting an extended stabilisation of cell membranes. Antiepileptic drugs have been largely used since the 1950s in psychiatry as mood stabilisers due to their membrane stabilising and anti-kindling effects. Like lithium, antiepileptic drugs are first choice treatment for Bipolar and Cyclothymic Disorders.

Methods:

We tested the efficacy of the most recent antiepileptic medication, lacosamide, in a patient with simultaneously occurring cyclothymic disorder, severe post-traumatic stress disorder, and fronto-temporal epilepsy. Lacosamide was titrated up to 200 mg/day, added to ongoing 750 mg/day lithium, 15 mg/day oral aripiprazole then switched to 400 mg/month long-acting aripiprazole, and 2 mg/day A-desmethyldiazepam.

Results:

We observed EEG normalisation one month later, along with reduced anxiety and an additive effect to lithium-induced stabilisation of mood fluctuations since the second week of lacosamide addition.

Conclusions:

Further studies with this drug in the bipolar spectrum are warranted. (www.actabiomedica.it)

Precursors in adolescence of adult-onset bipolar disorder

BACKGROUND

Although the estimated contribution of genetic factors is high in bipolar disorder, environmental factors may also play a role. This Swedish register-based cohort study of men examined if physical and psychological characteristics in late adolescence, including factors previously linked with bipolar disorder (body mass index, asthma and allergy), are associated with subsequent bipolar disorder in adulthood. Unipolar depression and anxiety are analysed as additional outcomes to identify bipolar disorder-specific associations.

METHODS

A total of 213,693 men born between 1952 and 1956, who participated in compulsory military conscription assessments in late adolescence were followed up to 2009, excluding men with any psychiatric diagnoses at baseline. Cox regression estimated risk of bipolar disorder, depression and anxiety in adulthood associated with body mass index, asthma, allergy, muscular strength stress resilience and cognitive function in adolescence.

RESULTS

BMI, asthma and allergy were not associated with bipolar disorder. Higher grip strength, cognitive function and stress resilience were associated with a reduced risk of bipolar disorder and the other disease outcomes.

LIMITATIONS

The sample consisted only of men; even though the characteristics in adolescence pre-dated disease onset, they may have been the consequence of prodromal disease.

CONCLUSIONS

Associations with body mass index and asthma found by previous studies may be consequences of bipolar disorder or its treatment rather than risk factors. Inverse associations with all the outcome diagnoses for stress resilience, muscular strength and cognitive function may reflect general risks for these psychiatric disorders or intermediary factors.

Baseline dimensional psychopathology and future mood disorder onset: findings from the Dutch Bipolar Offspring Study

OBJECTIVE

To identify the early signs of mood disorder development, specifically bipolar disorder (BD), in a population at familial risk for BD.

METHOD

The sample included 107 Dutch adolescent bipolar offspring (age 12-21) followed into adulthood (age 22-32). Lifetime DSM-IV axis I diagnoses were examined at baseline, 1-, 5-, and 12- year follow-up. Symptoms were assessed at baseline on a 3-point Likert scale at baseline with the K-SADS-PL and were analyzed using symptom and sum scores. As observed in previous studies, BD typically starts with other mood disorders. Therefore, the sample was stratified in offspring with a mood diagnosis (n = 29) and without (n = 78) at baseline.

RESULTS

Subthreshold manic experiences proved the strongest predictor of BD conversion (n = 10; HR2.16, CI95% 1.23-3.78). At symptom level, elated mood, decreased need of sleep, racing thoughts, suicidal ideation, and middle insomnia were significantly associated with BD conversion. Depressive symptoms proved the strongest predictor for first mood episode onset (n = 28; HR1.27, CI95% 1.02-1.58).

CONCLUSION

This study extends our knowledge of prodromal manifestations of BD in a high-risk population. Although preliminary, findings of this study provide potential targets for early identification and underscore the importance of detailed assessment of manic symptomatology in bipolar offspring.

Assessment of a Person-Level Risk Calculator to Predict New-Onset Bipolar Spectrum Disorder in Youth at Familial Risk

IMPORTANCE

Early identification of individuals at high risk for the onset of bipolar spectrum disorder (BPSD) is key from both a clinical and research perspective. While previous work has identified the presence of a bipolar prodrome, the predictive implications for the individual have not been assessed, to date.

OBJECTIVE

To build a risk calculator to predict the 5-year onset of BPSD in youth at familial risk for BPSD.

DESIGN, SETTING, AND PARTICIPANTS

The Pittsburgh Bipolar Offspring Study is an ongoing community-based longitudinal cohort investigation of offspring of parents with bipolar I or II (and community controls), recruited between November 2001 and July 2007, with a median follow-up period of more than 9 years. Recruitment has ended, but follow-up is ongoing. The present analysis included offspring of parents with bipolar I or II (aged 6-17 years) who had not yet developed BPSD at baseline.

MAIN OUTCOMES AND MEASURES

This study tested the degree to which a time-to-event model, including measures of mood and anxiety, general psychosocial functioning, age at mood disorder onset in the bipolar parent, and age at each visit, predicted new-onset BPSD. To fully use longitudinal data, the study assessed each visit separately, clustering within individuals. Discrimination was measured using the time-dependent area under the curve (AUC), predicting 5-year risk; internal validation was performed using 1000 bootstrapped resamples. Calibration was assessed by comparing observed vs predicted probability of new-onset BPSD.

RESULTS

There were 412 at-risk offspring (202 [49.0%] female), with a mean (SD) visit age of 12.0 (3.5) years and a mean (SD) age at new-onset BPSD of 14.2 (4.5) years. Among them, 54 (13.1%) developed BPSD during follow-up (18 with BD I or II); these participants contributed a total of 1058 visits, 67 (6.3%) of which preceded new-onset BPSD within the next 5 years. Using internal validation to account for overfitting, the model provided good discrimination between converting vs nonconverting visits (AUC, 0.76; bootstrapped 95% CI, 0.71-0.82). Important univariate predictors of outcome (AUC range, 0.66-0.70) were dimensional measures of mania, depression, anxiety, and mood lability; psychosocial functioning; and parental age at mood disorder.

CONCLUSIONS AND RELEVANCE

This risk calculator provides a practical tool for assessing the probability that a youth at familial risk for BPSD will develop new-onset BPSD within the next 5 years. Such a tool may be used by clinicians to inform frequency of monitoring and treatment options and for research studies to better identify potential participants at ultra high risk of conversion.

Innovative approaches to bipolar disorder and its treatment

All psychiatric disorders have suffered from a dearth of truly novel pharmacological interventions. In bipolar disorder, lithium remains a mainstay of treatment, six decades since its effects were serendipitously discovered. The lack of progress reflects several factors, including ignorance of the disorder's pathophysiology and the complexities of the clinical phenotype. After reviewing the current status, we discuss some ways forward. First, we highlight the need for a richer characterization of the clinical profile, facilitated by novel devices and new forms of data capture and analysis; such data are already promoting a reevaluation of the phenotype, with an emphasis on mood instability rather than on discrete clinical episodes. Second, experimental medicine can provide early indications of target engagement and therapeutic response, reducing the time, cost, and risk involved in evaluating potential mood stabilizers. Third, genomic data can inform target identification and validation, such as the increasing evidence for involvement of calcium channel genes in bipolar disorder. Finally, new methods and models relevant to bipolar disorder, including stem cells and genetically modified mice, are being used to study key pathways and drug effects. A combination of these approaches has real potential to break the impasse and deliver genuinely new treatments.

Child and Adolescent Clinical Features Preceding Adult Suicide Attempts

The objective of this study was to identify the predictive value of juvenile factors for adult suicidal behavior. We reviewed clinical records to compare factors identified in childhood and adolescence between adult suicidal versus nonsuicidal major affective disorder subjects. Suicide attempts occurred in 23.1% of subjects. Age-at-first-symptom was 14.2 vs. 20.2 years among suicidal versus nonsuicidal subjects (p < 0.0001). More prevalent in suicidal versus non-suicidal subjects by multivariate analysis were: depressive symptoms, hyper-emotionality, younger-at-first-affective-episode, family suicide history, childhood mood-swings, and adolescence low self-esteem. Presence of one factor yielded a Bayesian sensitivity of 64%, specificity of 50%, and negative predictive power of 86%. Several juvenile factors were associated with adult suicidal behavior; their absence was strongly associated with a lack of adult suicidal behavior.

A 10-year evaluation on adolescents with anxiety disorders: are they at risk of bipolarity?

OBJECTIVE

Anxiety disorders are the most frequent disorders comorbid with bipolar disorder (BD) often preceding the BD onset. The presence of comorbid anxiety in patients diagnosed with BD is associated with worsening of their BD symptoms, increased risky behaviour, decreased response to pharmacological treatment and deterioration in their quality of life and global functioning. The aim of this study was to investigate if anxiety disorders in adolescence could be considered as predictors of BD.

METHODS

Adolescents with a primary anxiety disorder were recruited consecutively from the Mood and Anxiety Disorders Unit, Department of Neuroscience, University of Turin. Subjects were evaluated for Axis I psychiatric disorders, family history and global functioning, and followed up on average 10 years later.

RESULTS

A total of 29 patients (59.2%) were male and the mean age at the onset of anxiety disorder was 16.3 (±0.8). Ten years following recruitment, 11 (22.4%) patients fulfilled the criteria for BD. Of them, 10 (90.9%) had a family history of BD and four (36.4%) presented a comorbid substance use disorder.

CONCLUSIONS

Our study shows that both family history of BD and substance use disorder, in adolescent patients with a primary anxiety disorder, should be considered as potential predictors of BD onset.

Prodrome or risk syndrome: what's in a name?

Background

In the last decade, an increasing number of publications have examined the precursors of bipolar disorders (BD) and attempted to clarify the early origins and illness trajectory. This is a complex task as the evolution of BD often shows greater heterogeneity than psychosis, and the first onset episode of BD may be dominated by depressive or manic features or both. To date, most of the published reviews have not clarified whether they are focused on prodromes, risk syndromes or addressing both phenomena. To assist in the interpretation of the findings from previous reviews and independent studies, this paper examines two concepts deemed critical to understanding the pre-onset phase of any mental disorder: prodromes and risk syndromes. The utility of these concepts to studies of the evolution of bipolar disorder (BD) is explored.

Findings

The term “prodrome” is commonly used to describe the symptoms and signs that precede episode onset. If strictly defined, the term should only be applied retrospectively as it refers to cohorts of cases that all progress to meet diagnostic criteria for a specific disorder and gives insights into equifinality. Whilst prodromes may reliably predict individual relapses, the findings cannot necessarily be extrapolated to identify prospectively who will develop a first episode of a specific disorder from within a given population. In contrast, ‘risk syndrome’ is a term that encompasses sub-threshold symptom clusters, but has often been extended to include other putative risk factors such as family history, or other variables expressed continuously in the population, such as personality traits. Only a minority of individuals ‘at risk’ make the transition to a specific mental disorder. By prospectively observing those cases where the risk syndrome does not progress to severe disorder or progress to a non-BD condition, we gain insights into the discriminant validity of different pre-BD characteristics, pluripotentiality of outcomes, and protective factors and resilience.

Conclusion

We emphasize the clinical and research utility of prodromes and risk syndromes, examine examples of the conflation of the concepts, and highlight the rationale for regarding them as discrete entities.

The predictive value of childhood subthreshold manic symptoms for adolescent and adult psychiatric outcomes

BACKGROUND

Childhood subthreshold manic symptoms may represent a state of developmental vulnerability to Bipolar Disorder (BD) and may also be associated with other adverse psychiatric outcomes. To test this hypothesis we examined the structure and predictive value of childhood subthreshold manic symptoms for common psychiatric disorders presenting by early adulthood.

METHODS

Subthreshold manic symptoms at age 11 years and lifetime clinical outcomes by age 19 years were ascertained in the TRacking Adolescents' Individual Lives Survey (TRAILS), a prospective Dutch community cohort. We used latent class analysis to identify subthreshold manic symptom profiles at baseline. The association between class membership and subsequent clinical diagnoses of BD (comprising BD-I, BD-II, mania and hypomania), depressive, anxiety and substance abuse disorders was determined using Cox proportional-hazard ratio (HR) models.

RESULTS

At age 11 years, we identified a normative (n=916; 47%), a mildly symptomatic (n=843; 43%) and a highly symptomatic class (n=198; 10%). Referenced to the normative class, the sex- and age-adjusted risk of new-onset BD by the age of 19 years was significantly increased in the mildly (HR=2.01, 95%CI 1.13-3.59) and highly symptomatic classes (HR=5.02, 95%CI 2.48-10.16). These estimates remained significant after further adjustments for cognitive and family function, parental socioeconomic status, parental psychiatric morbidity, and comorbid disorders at baseline (p-value for linear trend across classes<0.01). Class membership did not show significant associations with incident depressive, anxiety and substance abuse disorders in the fully adjusted regression models.

LIMITATIONS

The period of risk for adult-onset BD extends beyond the observational period of the study.

CONCLUSIONS

Elevated childhood subthreshold manic symptoms are associated with increased risk of BD by early adulthood and are therefore a potentially useful phenotype for the early identification of at-risk individuals.

What is the role of conventional antidepressants in the treatment of major depressive episodes with Mixed Features Specifier?

The newly introduced Mixed Features Specifier of Major Depressive Episode and Disorder (MDE/MDD) is especially challenging in terms of pharmacological management. Prior to the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the symptoms of the mixed features specifier were intradepressive hypomanic symptoms, always and only associated with bipolar disorder (BD). Intradepressive hypomanic symptoms, mostly referred to as depressive mixed states (DMX), have been poorly characterized, and their treatment offers significant challenges. To understand the diagnostic context of DMX, we trace the nosological changes and collocation of intradepressive hypomanic symptoms, and examine diagnostic and prognostic implications of such mixed features. One of the reasons so little is known about the treatment of DMX is that depressed patients with rapid cycling, substance abuse disorder, and suicidal ideation/attempts are routinely excluded from clinical trials of antidepressants. The exclusion of DMX patients from clinical trials has prevented an assessment of the safety and tolerability of short- and long-term use of antidepressants. Therefore, the generalization of data obtained in clinical trials for unipolar depression to patients with intradepressive hypomanic features is inappropriate and methodologically flawed. A selective review of the literature shows that antidepressants alone have limited efficacy in DMX, but they have the potential to induce, maintain, or worsen mixed features during depressive episodes in BD. On the other hand, preliminary evidence supports the effective use of some atypical antipsychotics in the treatment of DMX.