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Palau P, Solanes A, Madre M, Saez-Francas N, Sarró S, Moro N, Verdolini N, Sanchez M, Alonso-Lana S, Amann BL, Romaguera A, Martin-Subero M, Fortea L, Fuentes-Claramonte P, García-León MA, Munuera J, Canales-Rodríguez EJ, Fernández-Corcuera P, Brambilla P, Vieta E, Pomarol-Clotet E, Radua J. Improved estimation of the risk of manic relapse by combining clinical and brain scan data. Spanish Journal of Psychiatry and Mental Health 2023; 16:235-243. [PMID: 37839962 DOI: 10.1016/j.rpsm.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/22/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Estimating the risk of manic relapse could help the psychiatrist individually adjust the treatment to the risk. Some authors have attempted to estimate this risk from baseline clinical data. Still, no studies have assessed whether the estimation could improve by adding structural magnetic resonance imaging (MRI) data. We aimed to evaluate it. MATERIAL AND METHODS We followed a cohort of 78 patients with a manic episode without mixed symptoms (bipolar type I or schizoaffective disorder) at 2-4-6-9-12-15-18 months and up to 10 years. Within a cross-validation scheme, we created and evaluated a Cox lasso model to estimate the risk of manic relapse using both clinical and MRI data. RESULTS The model successfully estimated the risk of manic relapse (Cox regression of the time to relapse as a function of the estimated risk: hazard ratio (HR)=2.35, p=0.027; area under the curve (AUC)=0.65, expected calibration error (ECE)<0.2). The most relevant variables included in the model were the diagnosis of schizoaffective disorder, poor impulse control, unusual thought content, and cerebellum volume decrease. The estimations were poorer when we used clinical or MRI data separately. CONCLUSION Combining clinical and MRI data may improve the risk of manic relapse estimation after a manic episode. We provide a website that estimates the risk according to the model to facilitate replication by independent groups before translation to clinical settings.
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Affiliation(s)
- Pol Palau
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Benito Menni CASM - Hospital General de Granollers, Germanes Hospitalàries, Barcelona, Spain; Institute of Neurosciences, University of Barcelona, Barcelona, Spain
| | - Aleix Solanes
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Psychiatry and Forensic Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Merce Madre
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Hospital de la Santa Creu i Sant Pau, IIB SANT PAU, Barcelona, Spain
| | - Naia Saez-Francas
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Hospital Sant Rafael, Germanes Hospitalàries. Barcelona, Spain
| | - Salvador Sarró
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| | - Noemí Moro
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Benito Menni CASM - Hospital General de Granollers, Germanes Hospitalàries, Barcelona, Spain
| | - Norma Verdolini
- Institute of Neurosciences, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain; Barcelona Bipolar Disorders and Depressive Unit, Institute of Neurosciences, Hospital Clinic, Barcelona, Spain
| | - Manel Sanchez
- Department of Psychiatry and Forensic Medicine, Autonomous University of Barcelona, Barcelona, Spain; Department of Geriatric Psychiatry, Sagrat Cor Hospital, Martorell, Barcelona, Spain; Sociedad Española de Psicogeriatría (SEPG), Barcelona, Spain
| | - Sílvia Alonso-Lana
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Ace Alzheimer Center Barcelona - Universitat Internacional de Catalunya, Barcelona, Spain
| | - Benedikt L Amann
- Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain; Centre Fòrum Research Unit, Institute of Neuropsychiatry and Addiction, Parc de Salut Mar, Barcelona, Spain; Mental Health Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Pompeu Fabra University, Barcelona, Spain; Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Nussbaumstrasse 7, 80336 Munich, Germany
| | - Anna Romaguera
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Hospital Mare de Déu de la Mercè, Germanes Hospitalàries, Barcelona, Spain
| | - Marta Martin-Subero
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain; Centre Fòrum Research Unit, Institute of Neuropsychiatry and Addiction, Parc de Salut Mar, Barcelona, Spain; Mental Health Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Lydia Fortea
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Institute of Neurosciences, University of Barcelona, Barcelona, Spain
| | - Paola Fuentes-Claramonte
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| | - Maria A García-León
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| | - Josep Munuera
- Imatge Diagnòstica i Terapèutica, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950 Esplugues de Llobregat, Spain; Servei de Diagnòstic per la Imatge, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Spain
| | - Erick Jorge Canales-Rodríguez
- Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain; Signal Processing Laboratory (LTS5), École Polytechnique Fédérale de Lausanne (EPFL), EPFL-STI-IEL-LTS5, Station 11, CH-1015 Lausanne, Switzerland
| | - Paloma Fernández-Corcuera
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Psychiatry Department, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Paolo Brambilla
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Eduard Vieta
- Institute of Neurosciences, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain; Barcelona Bipolar Disorders and Depressive Unit, Institute of Neurosciences, Hospital Clinic, Barcelona, Spain
| | - Edith Pomarol-Clotet
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.
| | - Joaquim Radua
- Institute of Neurosciences, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain; Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom; Centre for Psychiatric Research and Education, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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Pomarol-Clotet E, Alonso-Lana S, Moro N, Sarró S, Bonnin MC, Goikolea JM, Fernández-Corcuera P, Amann BL, Romaguera A, Vieta E, Blanch J, McKenna PJ, Salvador R. Brain functional changes across the different phases of bipolar disorder. Br J Psychiatry 2015; 206:136-44. [PMID: 25497296 DOI: 10.1192/bjp.bp.114.152033] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Little is known about how functional imaging changes in bipolar disorder relate to different phases of the illness. AIMS To compare cognitive task activation in participants with bipolar disorder examined in different phases of illness. METHOD Participants with bipolar disorder in mania (n = 38), depression (n = 38) and euthymia (n = 38), as well as healthy controls (n = 38), underwent functional magnetic resonance imaging during performance of the n-back working memory task. Activations and de-activations were compared between the bipolar subgroups and the controls, and among the bipolar subgroups. All participants were also entered into a linear mixed-effects model. RESULTS Compared with the controls, the mania and depression subgroups, but not the euthymia subgroup, showed reduced activation in the dorsolateral prefrontal cortex, the parietal cortex and other areas. Compared with the euthymia subgroup, the mania and depression subgroups showed hypoactivation in the parietal cortex. All three bipolar subgroups showed failure of de-activation in the ventromedial frontal cortex. Linear mixed-effects modelling revealed a further cluster of reduced activation in the left dorsolateral prefrontal cortex in the patients; this was significantly more marked in the mania than in the euthymia subgroup. CONCLUSIONS Bipolar disorder is characterised by mood state-dependent hypoactivation in the parietal cortex. Reduced dorsolateral prefrontal activation is a further feature of mania and depression, which may improve partially in euthymia. Failure of de-activation in the medial frontal cortex shows trait-like characteristics.
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Affiliation(s)
- Edith Pomarol-Clotet
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Silvia Alonso-Lana
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Noemi Moro
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Salvador Sarró
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Mar C Bonnin
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - José M Goikolea
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Paloma Fernández-Corcuera
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Benedikt L Amann
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Anna Romaguera
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Eduard Vieta
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Josep Blanch
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Peter J McKenna
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Raymond Salvador
- Edith Pomarol-Clotet, MD, PhD, Silvia Alonso-Lana, BSc, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Noemi Moro, MD, FIDMAG, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Salvador Sarró, MD, FIDMAG, Germanes Hospitalàries, Barcelona and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Mar C. Bonnin, BSc, José M. Goikolea, MD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Paloma Fernandez-Corcuera, MD, Germanes Hospitalàries and Benito Menni Complex Assistencial en Salut Mental, Barcelona, Spain; Benedikt L. Amann, MD, PhD, Anna Romaguera, MD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain; Eduard Vieta, MD, PhD, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and Bipolar Disorder Program, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain; Josep Blanch, MD, Hospital Sant Joan de Déu Infantil, Barcelona, Spain; Peter J. McKenna, MRCPsych, Raymond Salvador, PhD, FIDMAG, Germanes Hospitalàries, Barcelona, Spain and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
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