Impact of bipolar disorder: results from a screening study

Digital phenotyping in bipolar disorder: Using longitudinal Fitbit data and personalized machine learning to predict mood symptomatology

BACKGROUND

Effective treatment of bipolar disorder (BD) requires prompt response to mood episodes. Preliminary studies suggest that predictions based on passive sensor data from personal digital devices can accurately detect mood episodes (e.g., between routine care appointments), but studies to date do not use methods designed for broad application. This study evaluated whether a novel, personalized machine learning approach, trained entirely on passive Fitbit data, with limited data filtering could accurately detect mood symptomatology in BD patients.

METHODS

We analyzed data from 54 adults with BD, who wore Fitbits and completed bi-weekly self-report measures for 9 months. We applied machine learning (ML) models to Fitbit data aggregated over two-week observation windows to detect occurrences of depressive and (hypo)manic symptomatology, which were defined as two-week windows with scores above established clinical cutoffs for the Patient Health Questionnaire-8 (PHQ-8) and Altman Self-Rating Mania Scale (ASRM) respectively.

RESULTS

As hypothesized, among several ML algorithms, Binary Mixed Model (BiMM) forest achieved the highest area under the receiver operating curve (ROC-AUC) in the validation process. In the testing set, the ROC-AUC was 86.0% for depression and 85.2% for (hypo)mania. Using optimized thresholds calculated with Youden's J statistic, predictive accuracy was 80.1% for depression (sensitivity of 71.2% and specificity of 85.6%) and 89.1% for (hypo)mania (sensitivity of 80.0% and specificity of 90.1%).

CONCLUSION

We achieved sound performance in detecting mood symptomatology in BD patients using methods designed for broad application. Findings expand upon evidence that Fitbit data can produce accurate mood symptomatology predictions. Additionally, to the best of our knowledge, this represents the first application of BiMM forest for mood symptomatology prediction. Overall, results move the field a step toward personalized algorithms suitable for the full population of patients, rather than only those with high compliance, access to specialized devices, or willingness to share invasive data.

Elevated Cortisol Levels and Manic Symptoms in a 16-Year-Old Female: A Case Report

This case report presents the clinical presentation, diagnosis, and management of a 16-year-old female with elevated cortisol levels who was diagnosed with mania. The patient exhibited symptoms consistent with a manic episode, including extreme euphoria, decreased need for sleep, impulsivity, and heightened irritability. Laboratory investigations revealed an elevated morning cortisol level, prompting further psychiatric evaluation. A diagnosis of bipolar I disorder, manic episode, was made based on established criteria. The patient was initiated on mood stabilizers and antipsychotic medications alongside psychoeducation for the patient and her family. This case underscores the potential association between cortisol dysregulation and mood disorders, highlighting the importance of comprehensive assessment and personalized treatment approaches in adolescents with bipolar disorder. Further research is needed to elucidate the underlying mechanisms linking cortisol dysregulation and mood disturbances and explore novel therapeutic interventions targeting hypothalamic-pituitary-adrenal axis dysfunction.

The effect of comprehensive individual motivational-educational program on medication adherence in elderly patients with bipolar disorders: An experimental study

BACKGROUND

The number of older adults with bipolar disorder is increasing and medication non-adherence is a major problem that negatively impacts the course of bipolar disorder. This study aimed to determine the effect of a comprehensive individual motivational-educational program on medication adherence in elderly patients with bipolar disorder.

MATERIALS AND METHOD

An experimental study with pretest-posttest repeated measures with a control group was conducted on two groups of 62 elderly people with bipolar disorders hospitalized at Ibn Sina Hospital in Mashhad, Northeast Iran, 2019. For the elderly in the intervention group, a comprehensive motivational-educational program was administered for one month (four 30-45 minute sessions), and for the elderly in the control group, routine clinical care was performed. Medication adherence in both elderly groups was measured before, immediately after, one and two months after the intervention. Data were analyzed by SPSS statistical software (version 16) using descriptive statistics and independent t-test, Mann-Whitney, paired t-test, repeated measures analysis of variance (ANOVA), and Chi-square tests.

RESULTS

The mean age of elderlies in the intervention and control groups were 69.03 ± 5.75 and 68.50 ± 6.73 years, respectively. Regardless of the groups to which the patients were assigned, a significant difference in medication adherence scores was observed during the study period (time effect; P < 0.001). Also, the medication adherence score was significantly lower in the intervention group, compared to the control group (group effect; P < 0.001). Also, there was a group time interaction between the medication adherence score and the time of evaluation (P < 0.001).

CONCLUSION

The results of the present study confirm the positive effect of a comprehensive educational-motivational program on improving medication adherence in elderly patients with bipolar disorder.

The impact of bipolar spectrum disorders on professional functioning: A systematic review

AIMS

The impact of bipolar spectrum (BS) disorders on professional functioning has not been systematically reviewed yet. Since even subsyndromal symptoms may disturb functioning, the determination of the prognostic value of the spectrum of bipolarity for employment seems extremely relevant. The aim of this study was to assess the impact of BS disorders on professional functioning.

MATERIALS AND METHODS

A systematic review of the literature (namely, cohort and cross-sectional studies) investigating a link between BS disorders and employment was performed in accordance with PRISMA guidelines. BS was defined based on the concept of two-dimensional BS by Angst. Occupational outcomes and factors affecting employment were evaluated as well.

RESULTS

Seventy-four studies were included. All disorders comprising BS had a negative impact on occupational status, work performance, work costs, and salary, with the greatest unfavorable effect reported by bipolar disorder (BD), followed by borderline personality disorder (BPD), major depressive disorder (MDD), and dysthymia. Employment rates ranged from 40 to 75% (BD), 33 to 67% (BPD), 61 to 88% (MDD), and 86% (dysthymia). The factors affecting employment most included: cognitive impairments, number/severity of symptoms, namely, subsyndromal symptoms (mainly depressive), older age, education, and comorbidity (substance abuse, personality disorders, anxiety, depression, ADHD, PTSD).

CONCLUSION

Bipolar spectrum symptoms exert a negative impact on professional functioning. Further evaluation of affecting factors is crucial for preventing occupational disability.

Re-work Program in Japan-Overview and Outcome of the Program

Background: The objective of this study was to examine the effect of the Japanese re-work program (RP) to aid in recurrent sick leave prevention. Methods: A multicenter retrospective cohort research was conducted for workers who returned to work (RTW) after sick leave due to mood disorder. Work continuation for subjects who RTW after RP participation and treatment as usual (TAU) and subjects who received TAU only were compared. The Kaplan-Meier method and Cox proportional hazard models were utilized. Additionally, propensity score matching was conducted to control for possible confounds. Results: Log-rank test of overall cohort (n = 323) showed that work continuation of RP + TAU subjects was significantly better compared to that of TAU-only subjects (p = 0.001). Multivariate analysis found a hazard rate of recurrent sick leave for TAU-only subjects of 2.121 (p = 0.001, 95% CI: 1.360-3.309). Additionally, the propensity score-matched cohort (n = 100) had similar differences (p = 0.008), with a hazard ratio of recurrent sick leave of 2.871 (p = 0.009, 95% CI: 1.302-6.331) for TAU-only subjects. Limitations: Only workers who RTW after sick leave were targeted, and no examination was made considering cases who dropped out from RP or TAU. Moreover, the sample was a non-randomized controlled trial, with propensity score matching performed. However, there was an inability to retrieve and adjust for working environment background factors after RTW. Conclusions: Work continuation of subjects with RP was observed to be significantly better, suggesting that the RP was effective for recurrent sick leave prevention.

The Effect of Family-Centered Psycho-Education on Mental Health and Quality of Life of Families of Adolescents with Bipolar Mood Disorder: A Randomized Controlled Clinical Trial

BACKGROUND

Bipolar Mood Disorder (BMD) is a type of mood disorder which is associated with various disabilities. The family members of the patients with BMD experience many difficulties and pressures during the periods of treatment, rehabilitation and recovery and their quality of life (QOL) is threatened. In the present study, we aimed to evaluate the effect of family-centered education on mental health and QOL of families with adolescents suffering from BMD.

METHODS

In this randomized controlled clinical trial performed on 40 families which were mostly mothers of the adolescents with BMD referred to the psychiatric clinics affiliated to Shiraz University of Medical Sciences during 2012-13. They were randomly assigned to intervention and control groups.

RESULTS

The results of single factor multivariate ANOVA/single-factor multivariate analysis of variance and Bonferroni post hoc tests showed that the interaction between the variables of group and time was significant (P<0.001). The mean of QOL and mental health scores increased in the intervention group, but it decreased in the control group at three measurement time points.

CONCLUSION

The study findings confirmed the effectiveness of family-centered psychoeducation program on Mental Health and Quality of life of the families of adolescents with Bipolar Mood Disorder.

TRIAL REGISTRATION NUMBER

IRCT201304202812N15.

Development of screening inventories for bipolar disorder at workplace: a diagnostic accuracy study

BACKGROUND

This study aimed to develop a new instrument for bipolar disorder screening, the Workplace Bipolar Inventory (WBI), and examine its efficiency as compared with Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) among workers on leave of the absence due to their mental health problems.

METHODS

Participants were recruited at a psychiatric outpatient clinic for return-to-work in Tokyo, Japan, during September to November 2009. 81 outpatients were recruited, 55 of whom (68%) agreed to participate in this study. Participants answered questionnaires including WBI, MDQ, BSDS, and demographic factors. Their diagnostic information according to the international statistical classification of diseases and related health problems 10th revision (ICD-10) was obtained from their attending psychiatrists. The WBI is a new self-rating 39-item questionnaire which developed with input from occupational mental health specialists and an analysis of WHO Composite International Diagnostic Interview (CIDI) items. The WBI contains 3 subtype scales: WBI-A (5 items), WBI-AB4 (9 items), and WBI-AB (39 items).

RESULTS

Reliability of these scales was moderate. In the AUC of these scales, BSDS was the best of them (0.83). In the optimal cut-off point of these scales, WBI-AB4 showed good efficiency of screening (sensitivity=0.78, specificity=0.75). Both MDQ and BSDS had high specificity, while low in sensitivity.

LIMITATIONS

The well validated diagnostic method (i.e., the structured clinical interview for DSM-IV [SCID] or CIDI) was not applied in this study.

CONCLUSIONS

The WBI, especially WBI-AB4 would be a useful workplace screening tool for workers with bipolar disorder.

Family Care giving in Bipolar disorder: Experiences of Stigma

BACKGROUND

Stigma is a serious impediment to the well-being of those who experience it. Many family- caregivers are challenged by the stereotypes and prejudice that result from misconceptions about bipolar disorder.

OBJECTIVE

The purpose of this study was to explore the stigma experienced by family caregivers of patients with bipolar disorder.

METHODS

This was a qualitative and phenomenological study. In this study, we selected the family caregivers of patients with bipolar disorder in a psychiatric hospital (Iran) using purposive sampling in 2011. By reaching data saturation, the number of participant was 12. Data were gathered through in-depth interviews and analyzed by the "Collaizi" method.

RESULT

Stigma was a pervasive concern to almost all participants. Family caregivers of patients with Bipolar disorders reported feelings and experiences of stigma and were most affected by them. Analysis of the interviews revealed 3 themes: Negative judgment, Shame, Stigmatization and Social Isolation.

CONCLUSION

For a person with bipolar disorder, this illness is associated with the following problems: worse recovery, difficulty accessing health services, receiving poor treatment and support, and difficulty gaining community acceptance. Rejection of people with mental illness might also affect their family caregivers at various levels.

Screening for bipolar disorders in patients with alcohol or substance use disorders: performance of the mood disorder questionnaire

BACKGROUND

Screening properties of the mood disorder questionnaire (MDQ) to detect bipolar disorder (BD) in patients with substance use disorders are unknown.

METHODS

403 treatment seeking patients with a substance use disorder completed the MDQ and subsequently 111 MDQ positives and 59 MDQ negatives were assessed with the Structured Clinical Interview for DSM-IV to diagnose BD. In addition, given the overlap with BD symptoms, the presence of borderline personality disorder (BPD), antisocial personality disorder (APD) and attention deficit/hyperactivity disorder (ADHD), were assessed using the Diagnostic Interview Schedule and the Structured Interview for DSM-IV Personality.

RESULTS

Of the 170 patients with a SCID interview, 35 patients (20.6%) met criteria for a lifetime diagnosis of BD. Twenty-three patients (62.8%) with BD had a positive MDQ score and 47 of the 135 patients (34.8%) without BD had a negative MDQ score resulting in a weighted sensitivity of .43, a weighted specificity of .57, a positive predictive value of .21, a negative predictive value (NPV) of .80 and an area under the curve of .50. The area under the curve of the MDQ to detect BPD, APD, ADHD and any externalizing disorder ranged from .55 (APD) to .63 (ADHD).

CONCLUSIONS

The MDQ is not a suitable screening instrument for the detection of BD or other externalizing disorders but it could be used for ruling out the presence of BD in treatment seeking substance use disorder patients.

Screening for bipolar disorder with the Mood Disorders Questionnaire: a review

BACKGROUND

Several research reports have suggested that bipolar disorder is underrecognized. Recommendations for improving the detection of bipolar disorder include the use of screening questionnaires. The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening instrument for bipolar disorder, with nearly two dozen published reports on its performance. We reviewed the literature on the MDQ's performance to assess its utility as a screening instrument.

METHODS

We conducted a Medline search on the terms Mood Disorders Questionnaire, MDQ, screening AND bipolar disorder, and recognition AND bipolar disorder. Only studies of adults were included.

RESULTS

Across all studies the sensitivity of the MDQ was 61.3%; specificity, 87.5%; positive predictive value, 58.0%; and negative predictive value, 88.9%. Compared to the studies using the MDQ for psychiatric outpatients, studies using it in the general population found it to have much lower sensitivity and positive predictive value, and higher specificity and negative predictive value. The MDQ's sensitivity was higher in detecting bipolar I disorder than bipolar II disorder (66.3% vs. 38.6%). Lowering the threshold to identify cases markedly improved the MDQ's sensitivity, with only a modest reduction in specificity. Studies of the best symptom cutoff to identify cases have produced inconsistent findings.

CONCLUSIONS

The MDQ's performance depends upon the setting in which it is used, the threshold to identify caseness, and the subtype of bipolar disorder examined. Conceptual issues in the use of a bipolar disorder screening questionnaire are discussed, and questions are raised about the clinical value of a self-report screening scale for bipolar disorder. Based on current available evidence, routine clinical use of the MDQ cannot be recommended because of the absence of studies simultaneously examining both the potential benefits (e.g., improved detection) and costs (e.g., overdiagnosis) of screening.

Tools to improve differential diagnosis of bipolar disorder in primary care

Among patients seen in a primary care setting for depressive and/or anxiety symptoms, 20% to 30% are estimated to have bipolar disorder. Although relatively common in primary care settings, bipolar disorder is still underrecognized, primarily due to misdiagnosis as unipolar depression. Patients often seek treatment when they are depressed but uncommonly present with mania or hypomania, the specific markers of bipolar spectrum disorders. An awareness of the prevalence, characteristics, and predictors of bipolar disorder can help the primary care physician to properly differentiate between bipolar depression and unipolar depression. Completing a differential diagnosis of bipolar disorder requires obtaining a comprehensive patient history that investigates symptom phenomenology and associated features, family history, longitudinal course of illness, and prior treatment response. In addition to the clinical interview, the Mood Disorder Questionnaire and the World Health Organization Composite International Diagnostic Interview 3.0 can be useful tools for evaluating patients for bipolar disorder. Screening patients at risk for bipolar disorder will help to avoid the use of unproductive or possibly even harmful treatments.

Fibromyalgia and bipolar disorder: a potential problem?

OBJECTIVE

To screen patients with fibromyalgia for bipolar disorder and to determine if there were any clinical clues, other than the Mood Disorders Questionnaire (MDQ), which might suggest a diagnosis of comorbid bipolar disorder.

METHODS

A total of 128 consecutive new fibromyalgia patients referred to a tertiary care center rheumatology practice were enrolled and assessed using a standard clinical protocol that included the completion of four screening questionnaires: (i) MDQ for bipolar disorder, (ii) Beck Depression Inventory (BDI) for depression, (iii) Epworth Sleepiness Scale (ESS) for daytime sleepiness, and (iv) Fibromyalgia Impact Questionnaire Disability Index (FIQ-DI) to assess for functional capacity.

RESULTS

A quarter of the fibromyalgia subjects, 25.19%, had a positive screen for bipolar disorder (MDQ >or= 7); 78.12% were clinically depressed (BDI >or= 10); and 52.13% reported daytime sleepiness (ESS >or= 10). Fibromyalgia subjects who screened positive for bipolar disorder had more severe depression than those with a negative screen [median BDI: 26.0 (19.0, 32.0) versus 15.0 (9.0, 24.0), p < 0.001].

CONCLUSIONS

We report a high prevalence of positive testing for bipolar disorder in this fibromyalgia cohort. Clinical data and questionnaire instruments other than nonspecific high depression severity failed to identify these patients. Since the norepinephrine serotonin reuptake inhibitors duloxetine and milnacipran have been recently approved by the U.S. Food and Drug Administration for the treatment of fibromyalgia, and because patients with bipolar disorder may experience destabilization of mood when treated with such agents, patients with fibromyalgia should be systematically screened for bipolar disorder prior to treatment.

Screening for bipolar disorder during pregnancy and the postpartum period

Bipolar disorder is a significant mental health problem among perinatal women; however, little attention has been devoted to methods of screening for bipolar disorder during this phase of women's life cycle. There is a need for reliable and valid screening instruments for perinatal women. This paper presents a review of 11 self-report measures used to screen bipolar disorder in the general population and discusses their applicability to screening among perinatal women. Published psychometric data, including reliability, sensitivity, specificity, and positive predictive value of each self-report instrument, is presented and critiqued. We make recommendations for screening in clinical practice and highlights priorities for future research. The need for more research in this area is emphasized.

Reliability of the Mood Disorder Questionnaire: comparison with the Structured Clinical Interview for the DSM-IV-TR in a population sample

OBJECTIVE

The Mood Disorder Questionnaire (MDQ) is a widely used self-report screening instrument for the detection of bipolar disorder in clinical populations. The aim of the present study was therefore to investigate the reliability of this instrument.

METHODS

Screening results using the MDQ were compared with results obtained using the Structured Clinical Interview for DSM-IV-TR Research Version, Non-patient edition (SCID) in a community-based sample of 1066 women. Trained personnel, who were blind to the results of the MDQ screen, conducted clinical interviews.

RESULTS

Using the MDQ, 21 women screened positive for bipolar disorder, and using the SCID diagnoses, 24 women were confirmed with a diagnosis of bipolar disorder. Six women were detected on both instruments. Compared to the SCID, the sensitivity for the MDQ was 25%, specificity 99%, positive predictive value 28%, negative predictive value 98%, and a demonstrated kappa of 0.25. The MDQ failed to detect any of the 11 participants in the study with bipolar II disorder and missed seven of 13 participants with bipolar I disorder or bipolar not otherwise specified. Of the 21 women who screened positive using the MDQ, 19 had current or past psychopathologies other than bipolar disorder.

CONCLUSION

The MDQ has substantial limitations for detection of bipolar disorder, in particular bipolar II disorder, in non-clinical populations.

Clinical features, response to treatment and functional outcome of bipolar disorder patients with and without co-occurring substance use disorder: 1-year follow-up

INTRODUCTION

Bipolar disorder patients (BP) with comorbid Substance Use Disorder (SUD) may present clinical features that could compromise adherence and response to pharmacological treatment. The purpose of this study was to examine clinical and psychopathological features of BP with and without comorbid SUD in a real-world setting.

METHODS

The sample was composed by 131 affective patients. Sixty-five patients were affected by Bipolar Disorder I (BP-I, 49.2%), 29 by Bipolar Disorder II (BP-II, 22.3%) and 37 by Cyclothymic Disorder (CtD, 28.5%), according to DSM-IV. Sixty-six patients were diagnosed for a comorbid SUD. All patients have been submitted to psychometric assessment with Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Young Mania Rating Scale (YMRS), Global Assessment Scale (GAS), Social Adjustment Self-reported Scale (SASS), Quality of Life Scale (QoL), at baseline and repeated follow-up periods (1, 3, 6, 12 months).

RESULTS

BP comorbid for SUD were more likely diagnosed as BP-II and CtD and were less likely to present a moderate-severe manic symptomatology. Furthermore, personality disorders were more frequent in SUD patients than in non-comorbid BP. BP with SUD were not different for primary outcome measure (HDRS, HARS, YMRS, GAS) from non-comorbid BP; however, BP with SUD were significantly more impaired in social functioning (SASS) at any stage of the follow-up and poor functioning increased the risk of relapse in substance use during treatment. Finally, SUD comorbidity did not represent a risk factor for treatment drop-out, while in our sample young age, low treatment dosage and BP-I diagnosis were significantly associated with drop-out.

DISCUSSION

The primary finding of this work is that BP with comorbid SUD are significantly more compromised in social functioning. Second, these patients were less likely to be diagnosed for BP-I and to present a severe manic symptomatology. Finally, we found that the diagnosis of SUD, but young age, low treatment dosage and BP-I diagnosis to be risk factors for treatment drop-out. Physicians should be alert to these differences in their clinical practice.

Risk of rehospitalization among bipolar disorder patients who are nonadherent to antipsychotic therapy after hospital discharge

PURPOSE

The relationship between nonadherence to antipsychotic medication after hospital discharge and risk of rehospitalization in patients who were previously hospitalized for treatment of bipolar disorder was studied.

METHODS

Administrative claims data from 2000 through 2006 were obtained from commercial insurance plans. Patients age 18-64 years who were discharged from a hospital with a diagnosis of bipolar disorder and given a prescription for an antipsychotic 0-14 days after discharge comprised the study sample. Adherence to antipsychotic medication was determined by measuring the number of unique days during which medication was supplied during the treatment period, a calculation known as the medication possession ratio (MPR). Rehospitalization was considered to be an indicator of relapse. A multivariate, stepwise logistic regression, which controlled for patient characteristics, type of bipolar disorder, general health status, and comorbid conditions, was used to assess the relationship between medication non-adherence and rehospitalization.

RESULTS

A total of 1973 individuals were included in the analyses. The mean +/- S.D. MPR for this patient population was 0.46 +/- 0.32. Patients whose MPR was 0.75 or greater had a lower risk of all-cause rehospitalization (odds ratio [OR], 0.730; 95% confidence interval [CI], 0.580-0.919) and a lower risk of a mental-health-related rehospitalization (OR, 0.759; 95% CI, 0.603-0.955). As medication adherence increased above the MPR of 0.75, the risk of rehospitalization significantly decreased.

CONCLUSION

Among patients who were previously hospitalized for treatment of bipolar disorder, those who were adherent to their antipsychotic medication at least 75% of the time had lower risks of all-cause rehospitalization and mental-health-related rehospitalization.