Exploratory study of ultraviolet B (UVB) radiation and age of onset of bipolar disorder

BACKGROUND

Sunlight contains ultraviolet B (UVB) radiation that triggers the production of vitamin D by skin. Vitamin D has widespread effects on brain function in both developing and adult brains. However, many people live at latitudes (about > 40 N or S) that do not receive enough UVB in winter to produce vitamin D. This exploratory study investigated the association between the age of onset of bipolar I disorder and the threshold for UVB sufficient for vitamin D production in a large global sample.

METHODS

Data for 6972 patients with bipolar I disorder were obtained at 75 collection sites in 41 countries in both hemispheres. The best model to assess the relation between the threshold for UVB sufficient for vitamin D production and age of onset included 1 or more months below the threshold, family history of mood disorders, and birth cohort. All coefficients estimated at P ≤ 0.001.

RESULTS

The 6972 patients had an onset in 582 locations in 70 countries, with a mean age of onset of 25.6 years. Of the onset locations, 34.0% had at least 1 month below the threshold for UVB sufficient for vitamin D production. The age of onset at locations with 1 or more months of less than or equal to the threshold for UVB was 1.66 years younger.

CONCLUSION

UVB and vitamin D may have an important influence on the development of bipolar disorder. Study limitations included a lack of data on patient vitamin D levels, lifestyles, or supplement use. More study of the impacts of UVB and vitamin D in bipolar disorder is needed to evaluate this supposition.

Behavioral self-regulation in pediatric bipolar disorder and healthy offspring of bipolar patients

OBJECTIVES

This study investigated behavioral self-regulation problems using the Children's Hostility Inventory (CHI) in pediatric bipolar disorder (PBD), healthy offspring of bipolar disorder patients (HOBD), and healthy controls (HC) without previous history of psychiatric disorders.

METHODS

The CHI was administered to 41 consecutive children and adolescents diagnosed with PBD, to 16 HOBD, and to 22 HC. The inventory assessed irritability, expression, hostility, and aggression and was completed by the children with the help of their mothers. Adolescents and their respective parents were interviewed separately using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL).

RESULTS

All subscales of the CHI presented statistically significant differences, except for the subscale assessing feelings of suspicion. Pairwise comparisons revealed consistently significant differences between the PBD group and controls, indicating more self-regulation difficulties in the PBD group, represented by high levels of hostility and aggressive behavior. There were no significant differences between the PBD and HOBD groups.

CONCLUSIONS

Future studies should further investigate if such behavior is state-dependent or a trait of bipolar juvenile expression. Expression of hostility and irritability should be considered relevant targets in psychosocial approaches addressing this population.

Structured physical exercise for bipolar depression: an open-label, proof-of concept study

BACKGROUND

Physical exercise (PE) is a recommended lifestyle intervention for different mental disorders and has shown specific positive therapeutic effects in unipolar depressive disorder. Considering the similar symptomatology of the depressive phase in patients with bipolar disorder (BD) and unipolar depressive disorder, it is reasonable to suggest that PE may also be beneficial for bipolar depression. However, there is an absence of studies evaluating the antidepressant effect of a structured PE intervention in BD.

METHODS

This is an open-label, single-arm study trial. Fifteen patients with a diagnosis of BD Type I or Type II, presenting a depressive episode were included in the study. After physical and functional evaluation, patients participated in supervised training sessions with aerobics followed by strength exercises, three times per week, for 12 weeks (36 training sessions). Depressive and manic symptoms were assessed at baseline and 2, 4, 8, and 12 weeks. Additionally, quality of Life and functioning were assessed at baseline and 4, 8, and 12 weeks). Finally, we tested cardiorespiratory fitness, muscle strength and body composition at baseline and week-12.

RESULTS

The mean (± SD) Montgomery Asberg Depression Rating Scale (MADRS) score at baseline was 23.6 ± 8.3 points and after 12 weeks of PE the mean score was 10.2 ± 4.8 points. Nine patients (82%) presented an antidepressant response defined as a reduction of more than 50% of depressive symptoms at week 12 with five of those patients (45%) presenting criteria for full remission. A large and significant Cohen's D Effect Size (pre-post) was verified for MADRS reduction [1.98 (95% Confidence interval = 0.88 to 3.08)]. We did not detect a significant change in manic symptoms, functioning, and quality of life during the 12-week follow-up. At week-12, all patients increased their muscular strength (one repetition maximal test - 1RM) and reduced the percentage of body fat (spectral bioelectrical impedance analysis).

CONCLUSIONS

This study, using rigorous criteria and a structured intervention, provides valid pilot data, showing the feasibility of a structured PE intervention for the treatment of depressive symptoms in BD, and suggesting a potential adjunctive antidepressant effect. Moreover, PE showed a positive impact on muscle strength and body composition. This should be further verified by randomized controlled studies.

Association between polarity of first episode and solar insolation in bipolar I disorder

OBJECTIVE

Circadian rhythm disruption is commonly observed in bipolar disorder (BD). Daylight is the most powerful signal to entrain the human circadian clock system. This exploratory study investigated if solar insolation at the onset location was associated with the polarity of the first episode of BD I. Solar insolation is the amount of electromagnetic energy from the Sun striking a surface area of the Earth.

METHODS

Data from 7488 patients with BD I were collected at 75 sites in 42 countries. The first episode occurred at 591 onset locations in 67 countries at a wide range of latitudes in both hemispheres. Solar insolation values were obtained for every onset location, and the ratio of the minimum mean monthly insolation to the maximum mean monthly insolation was calculated. This ratio is largest near the equator (with little change in solar insolation over the year), and smallest near the poles (where winter insolation is very small compared to summer insolation). This ratio also applies to tropical locations which may have a cloudy wet and clear dry season, rather than winter and summer.

RESULTS

The larger the change in solar insolation throughout the year (smaller the ratio between the minimum monthly and maximum monthly values), the greater the likelihood the first episode polarity was depression. Other associated variables were being female and increasing percentage of gross domestic product spent on country health expenditures. (All coefficients: P ≤ 0.001).

CONCLUSION

Increased awareness and research into circadian dysfunction throughout the course of BD is warranted.

Variations in seasonal solar insolation are associated with a history of suicide attempts in bipolar I disorder

Background

Bipolar disorder is associated with circadian disruption and a high risk of suicidal behavior. In a previous exploratory study of patients with bipolar I disorder, we found that a history of suicide attempts was associated with differences between winter and summer levels of solar insolation. The purpose of this study was to confirm this finding using international data from 42% more collection sites and 25% more countries.

Methods

Data analyzed were from 71 prior and new collection sites in 40 countries at a wide range of latitudes. The analysis included 4876 patients with bipolar I disorder, 45% more data than previously analyzed. Of the patients, 1496 (30.7%) had a history of suicide attempt. Solar insolation data, the amount of the sun’s electromagnetic energy striking the surface of the earth, was obtained for each onset location (479 locations in 64 countries).

Results

This analysis confirmed the results of the exploratory study with the same best model and slightly better statistical significance. There was a significant inverse association between a history of suicide attempts and the ratio of mean winter insolation to mean summer insolation (mean winter insolation/mean summer insolation). This ratio is largest near the equator which has little change in solar insolation over the year, and smallest near the poles where the winter insolation is very small compared to the summer insolation. Other variables in the model associated with an increased risk of suicide attempts were a history of alcohol or substance abuse, female gender, and younger birth cohort. The winter/summer insolation ratio was also replaced with the ratio of minimum mean monthly insolation to the maximum mean monthly insolation to accommodate insolation patterns in the tropics, and nearly identical results were found. All estimated coefficients were significant at p < 0.01.

Conclusion

A large change in solar insolation, both between winter and summer and between the minimum and maximum monthly values, may increase the risk of suicide attempts in bipolar I disorder. With frequent circadian rhythm dysfunction and suicidal behavior in bipolar disorder, greater understanding of the optimal roles of daylight and electric lighting in circadian entrainment is needed.

Quality of life and clinical outcomes in bipolar disorder: An 8-year longitudinal study

OBJECTIVES

This longitudinal study examined the relationship of Quality of Life (QOL) throughout an 8-year follow-up period with baseline and longitudinal clinical variables indicative of outcome in patients with Bipolar Disorder (BD).

METHODS

36 participants, ages 18-70, were recruited from the Bipolar Disorder Research Program (PROMAN) outpatient clinic. Participants completed the WHOQOL-BREF questionnaire in 2009 (baseline), 2015 (6-years) and 2017 (8-years), with high scores being associated with better quality of life. Baseline clinical variables were collected through the Structured Clinical Interview for DSM-IV (SCID-IV) and a structured baseline interview for demographic and clinical assessment. Longitudinal clinical variables were collected through medical records, including mood charts and mood symptoms scales.

RESULTS

The results suggest that the QoL, as measured by the WHOQOL-BREF scale, is negatively affected by depressive episodes and is rather stable throughout the course of patients diagnosed with BD. In our study, all three scores were negatively correlated to depressive episodes, and one WHOQOL-BREF score was positively correlated to manic episodes, suggesting that higher scores, both at baseline and throughout the course of the disorder, may be associated to a higher occurrence of manic episodes, while lower QoL scores may be predictive of a higher occurrence of depressive episodes. Also, all three scores revealed significant positive correlations between themselves, suggesting QoL, as measured by the WHOQOL-BREF, remained constant throughout the 8-year observed period. Finally, patients presenting Obsessive Compulsive Disorder (OCD), Post-Traumatic Stress Disorder (PTSD) and substance abuse comorbidities revealed consistent lower WHOQOL-BREF scores, suggesting that these comorbidities may be an important predictor of QoL in BD patients.

Memory training combined with 3D visuospatial stimulus improves cognitive performance in the elderly: pilot study

Studies suggest that the engagement of aged participants in cognitive stimulation programs can reduce expected cognitive decline associated with age.

Objective

To evaluate the effects of memory training (MT) associated with three-dimensional multiple object tracking (3D-MOT) NeuroTracker (NT) in the elderly.

Methods

Forty-four participants (>60 years of age) were recruited and randomly distributed into two groups: experimental (EG; n=22) and comparative (CG; n=22). Both groups performed 12 one-hour MT sessions, twice a week, consisting of specific computerized stimuli associated with teaching of mnemonic strategies; 10 minutes of NT was part only of the EG's sessions. In pre- and post-training periods, both groups were evaluated using a sociodemographic questionnaire, neuropsychological assessment, as well as a specific measure offered by NT.

Results

Both groups benefited from the MT and reported more positive feelings regarding their memory and quality of life. However, the EG obtained better results in tests consistent with the strategies trained and which involved attentional resources, reaction time, visual processing speed, episodic, semantic, subjective and working memory as well as aspects of social cognition.

Conclusions

This study showed that the combination of MT and 3D-MOT contributed for a better cognitive performance in the EG. Thus, the results of the present study encourage further research and the development of combined cognitive interventions for the elderly population with and without cognitive deficits.

Impaired social cognition in bipolar disorder: A meta-analysis of Theory of Mind in euthymic patients

OBJECTIVE

To conduct a meta-analysis of Theory of Mind studies exclusively in euthymic patients with bipolar disorder.

METHOD

After the exclusion of studies evaluating symptomatic patients during acute episodes, we performed a meta-analysis including a total of 30 studies, comparing 1294 euthymic bipolar disorder patients and 1116 healthy controls.

RESULTS

Patients with bipolar disorder presented a significant impairment in Theory of Mind performance when compared to controls (Hedge's g = -0.589, 95% confidence interval: -0.764 to -0.414, Z = -6.594, p < 0.001). When compared to controls, Theory of Mind was impaired in patients with both bipolar disorder I (Hedge's g = -0.663, 95% confidence interval: -0.954 to -0.372, Z = -4.462, p < 0.001) and bipolar disorder II (Hedge's g = -1.165, 95% confidence interval: -1.915 to -0.415, Z = -3.044, p = 0.002). Theory of Mind impairments were also significantly more severe in verbal tasks (Hedge's g = -1.077, 95% confidence interval: -1.610 to -0.544, Z = -3.961 p < 0.001) than visual tasks (Hedge's g =-0.614, 95% confidence interval: -0.844 to -0.384, Z = -5.231, p < 0.001) when compared to controls.

CONCLUSION

The results obtained confirm that Theory of Mind is impaired in remitted bipolar disorder patients, being a potential endophenotype for bipolar disorder. Moreover, we found higher deficits in verbal Theory of Mind, compared with visual Theory of Mind. Since most studies were cross-sectional, there is a need for longitudinal studies to evaluate whether the deficits detected in Theory of Mind are progressive over the course of the illness.

Psychological evaluation of children victims of sexual abuse: development of a protocol

Sexual abuse (SA) is associated with significant psychological problems in childhood, making it increasingly important to develop evaluation protocols. This study examined clinical aspects and cognitive measures of 49 children (24 with SA history and 25 controls). It employed a SA assessment questionnaire, clinical evaluations of posttraumatic stress disorder, risk indicators and neuropsychological tests in order to elaborate a specific forensic psychological evaluation protocol for this population. Conflicting couples (80%), separated parents (68%) and parents' alcohol/drug abuse (76%) were revealed as major risk factors. Fathers represented the primary perpetrator (24%). The main cognitive complaint was difficulty concentrating. Regarding the association between clinical and cognitive variables, it was observed that children who were anxious or referred to having fear, difficulties with operational memory and difficulty sleeping, had more trouble performing tasks that required attention and memory (operational, immediate and late). Children with SA history demonstrated inferior performance in visual attention/task switching and memory; with an emphasis in the loss of set in the Wisconsin test. The findings suggest the possibility of a primary attention deficit in children with SA history, possibly influencing the performance of other cognitive functions.

Personality traits and risky behavior among motorcyclists: An exploratory study

BACKGROUND

Personality traits have been associated with a series of dysfunctional behaviors, ranging from violence to drug abuse and other risky behaviors. However, few studies have investigated motorcycle riders' personality traits, and no research using the psychobiological model of personality was found. Thus, we investigated the association between temperament and character traits and the occurrence of Motorcycle Accidents (MAs).

METHODS

This cross-sectional study was conducted with a randomly selected of 153 Brazilian motorcycle riders (116 male and 37 female) with a mean age of 31.8randomly selected from the driver's license register, between 2015 and 2018. A sociodemographic questionnaire and the Temperament and Character Inventory (TCI) were used.

RESULTS

Of the 153 participants, 146 (95.4%) reported having been involved in previous accidents, with the main causes as follows: "other drivers' careless behavior" (34.9%); "personal disrespect of traffic rules" (18.5%) and "personal careless behavior" (20.6%). Motorcyclists exhibited higher scores for the temperament factors of novelty seeking and persistence and lower scores for harm avoidance and reward dependence in comparison to the Brazilian population). Considering the reason for motorcycle use, the group of riders that used their motorcycles for work exhibited more temperament factors associated with risk behaviors than those who did not. It was observed that 68.9% of them had low Harm Avoidance (HA) factor scores, whereas 72.1% had high Novelty Seeking (NS) factor scores.

DISCUSSION

The present study highlighted the influences of different personality traits on behaviors, decision-making and risk attitudes that can be potentially harmful to an individual and others. The results provided evidence that a lack of knowledge and experience in riding a motorcycle or any other vehicle, combined with personality traits, contribute to the adoption of risky behaviors that may act as triggers for most causes of Motorcycle Accidents.

Indicadores emocionais de Koppitz no desenho da figura humana: comparação entre uma amostra clínica e escolares

Uno de los instrumentos más empleados en la evaluación psicológica infantil es el dibujo de la figura humana (dfh), que posee diversos sistemas de puntuación, uno de los más utilizados internacionalmente es el de Koppitz, en el cual es verificada la presencia de indicadores de maduración para la evaluación del desarrollo del niño, y de indicadores emocionales para determinar compromisos en esa área. Una revisión de la literatura indicó que aunque muchos estudios se han hecho con el dfh, hay controversia sobre estos indicadores. El uso de esta técnica justifica la relevancia de esta investigación. El presente estudio investigó los ítems propuestos por Koppitz para la evaluación de dificultades emocionales comparando una muestra de 74 niños en el rango de edad de 6 a 11 años, que buscaron atención psicológica con quejas diversas, con un grupo de control de 74 escolares emparejados por edad, sexo y tipo de escuela, sin quejas emocionales. La aplicación fue individual y ocurrió en las clínicas de atendimiento para el primer grupo y en las escuelas para el grupo control. Los resultados mostraron que los indicadores emocionales diferenciaron a los niños con dificultades emocionales, que en general tienen sus dibujos afectados por ellas, lo que contribuyó en la confirmación de la validez del dfh para evaluación emocional en Brasil.Palabras clave: evaluación psicológica, dibujo de figuras humanas, indicadores de maduración de Koppitz, indicadores emocionales de Koppitz.

Longitudinal Neuropsychological Assessment in Two Elderly Adults With Attention-Deficit/Hyperactivity Disorder: Case Report

The neuropsychological deficits in attention-deficit/hyperactivity disorder (ADHD) may present clinical features similar to mild and/or major neurocognitive disorder and may act as a confounding factor, making it difficult to detect cognitive decline. In this paper, we present the results of longitudinal neuropsychological evaluations in two elderly women with ADHD. Three neuropsychological assessments were performed in two women with ADHD (60 and 77 years old) between 2010 and 2013 at intervals varying from 12 to 15 months. We used structural magnetic resonance imaging to rule out significant abnormalities that could account for cognitive impairment. The results showed two different cognitive profiles with fluctuations in performance over these 2 years, sometimes with improvement and sometimes with decline of some functions such as attention, memory, inhibitory control, and reaction time. To minimize confounding aspects of these fluctuations in clinical practice, we used a longer follow-up with the application of a reliable change index and a minimum of three spaced assessments to provide a more consistent baseline cognitive profile. Our findings did not indicate a consistent cognitive decline, suggesting a less pessimistic perspective about cognitive impairments that could be a prodrome of ADHD-related dementia.

Predominant polarity classification and associated clinical variables in bipolar disorder: A machine learning approach

BACKGROUND

Bipolar disorder (BD) is a severe psychiatric disorder characterized by periodic episodes of manic and depressive symptomatology. Predominant polarity (PP) appears to be an important specifier of BD. The present study employed machine learning (ML) algorithms to accurately determine a patient´s PP without the inclusion of number and polarity of past episodes, while exploring associations between PP and demographic and clinical variables.

METHODS

From a cohort of 148 BD patients, demographic and clinical variables were collected using a customized questionnaire and the SCID-CV. The algorithm employed was the Random-Forest method. The algorithm was programed to classify patients into either depressive or manic predominant polarities and to reveal which variables were associated to the specifier.

RESULTS

The algorithm attained an AUC ROC of 74.72% (95% CI = 72.29-77.15%) in classifying patients into either manic or depressive PP. The variables selected by the algorithm were: (1) age at first depressive episode; (2) number of hospitalizations; (3) BD Type II; (4) manic onset; (5) delusions; (6) psychotic features at onset; (7) tobacco addiction; (8) family history of BD; (9) hallucinations; and (10) comorbid anxiety disorders, (11) alcohol dependence, (12) eating disorders and (13) substance dependence.

LIMITATIONS

The study is limited due to the small sample size, the inclusion of only self-reported and clinician-observed clinical variables and its cross-sectional design.

DISCUSSION

The results suggest that the ML approach could be effective in determining a patient´s PP. Furthermore, although not previously reported, some variables, such as tobacco use and comorbid eating disorders, appear to be closely associated with PP.

Impact of predominant polarity on long-term outcome in bipolar disorder: A 7-year longitudinal cohort study

INTRODUCTION

Recent studies suggest that Predominant Polarity (PP) may be an important specifier of Bipolar Disorder (BD), establishing distinct groups of patients and providing a potential tool for tailored treatment. PP has been associated to various clinical variables present in the course of the disorder, including deficits in cognitive functioning, suicide attempts, hospitalizations and response to pharmacological treatment. However, most published studies are retrospective and cross-sectional, frequently relying on patients´ ability to recall past information, which may often be inaccurate.

METHODS

Participants were recruited from the outpatient clinic of the Bipolar Disorder Research Program at the Institute of Psychiatry of the University of São Paulo. Baseline clinical and demographic variables were collected using a semi-structured questionnaire and the SCID-CV. Longitudinal data were collected through medical records, mood charts, and mood symptom scales conducted throughout a 7-year follow-up period.

RESULTS

Manic Predominant Polarity (MPP) was associated with a significantly higher number of hospitalizations, suicide attempts, and episodes with psychotic symptoms throughout the 7-year observed period in comparison to Depressive Predominant Polarity (DPP) and Indefinite Predominant Polarity (IPP) patients. Moreover, baseline PP was significantly associated with 7-year PP, with 67% of patients maintaining their PP both at baseline and after the 7-year follow-up period.

LIMITATIONS

The present study is limited due to the statistically small sample size, although, to our knowledge, it is the largest longitudinal study conducted in this topic, and the unequally distributed frequency of patients´ visitations, which may have created intervals of unobserved periods within the follow-up period.

DISCUSSION

The results revealed PP to be an important specifier for predicting the course of the disorder. Overall, MPP was significantly associated with variables indicative of a worse outcome, suggesting that greater attention to preventive treatment should be addressed to this subgroup. Lastly, baseline PP was significantly associated with 7-year observed PP, suggesting that patients tend to remain within the same PP throughout the course of the disorder.

Cognitive impairments and predominant polarity in bipolar disorder: a cross-sectional study

Background

Bipolar disorder (BD) patients exhibit cognitive impairments during euthymic states. Studies suggest that manic episodes may be correlated to cognitive impairments. The present study investigated the relationship between predominant polarity and the cognitive deficits frequently detected in bipolar patients. We hypothesize that mania predominant polarity (MPP) patients should exhibit greater cognitive impairments in comparison to depressive (DPP) and indefinite predominant polarity (IPP) patients and healthy control (HC) individuals.

Methods

The study evaluated 55 euthymic BD patients, type I and II, and 31 HCs. Patients were divided into 3 groups: MPP (n = 17), DPP (n = 22), and IPP (n = 16), and compared regarding demographic and clinical variables, and performance on a 7-test neuropsychological battery.

Results

MPP patients demonstrated greater cognitive impairments in alternating attention, verbal fluency, and delayed memory in comparison to DPP, IPP, and HC. Compared to HC, IPP patients exhibit cognitive deficits in verbal fluency and alternating attention and DPP patients solely in verbal fluency. Furthermore, DPP patients did not exhibit, in none of the seven neuropsychological tests, significant poorer performances than MPP or IPP patients, although having significant more episodes than MPP patients.

Conclusion

MPP patients exhibit increased cognitive impairments in comparison to DPP, IPP, and HC subjects. Manic episodes may play an important role in the development of cognitive deficits and thus, in potential neuroprogression. Predominant polarity may be an important specifier for predicting future cognitive impairments.

Cognitive-behavioral rehabilitation vs. treatment as usual for bipolar patients: study protocol for a randomized controlled trial

BACKGROUND

Bipolar disorder (BD) is commonly associated with cognitive and functional impairments even during remission periods, and although a growing number of studies have demonstrated the benefits of psychotherapy as an add-on to pharmacological treatment, its effectiveness appears to be less compelling in severe presentations of the disorder. New interventions have attempted to improve cognitive functioning in BD patients, but results have been mixed.

METHODS

The study consists of a clinical trial comparing a new structured group intervention, called "Cognitive-Behavioral Rehabilitation," with treatment as usual (TAU) for bipolar patients. The new approach is a combination of cognitive behavioral strategies and cognitive remediation exercises, consisting of 12 weekly group sessions of 90 min each. To be included in the study, patients must be diagnosed with BD type I or II, aged 18-55 years, in full or partial remission, and have an IQ of at least 80. A comprehensive neuropsychological battery, followed by mood, social functioning, and quality of life assessments will occur in three moments: pre and post intervention and 12 months later. The primary outcome of the study is to compare the time, in weeks, that the first full mood episode appears in patients who participated in either group of the study. Secondary outcome will include improvement in cognitive functions.

DISCUSSION

This is the first controlled trial assessing the validity and effectiveness of the new "Cognitive-Behavioral Rehabilitation" intervention in preventing new mood episodes and improving cognitive and functional impairments.

TRIAL REGISTRATION

Clinicaltrial.gov, NCT02766361 . Registered on 2 May 2016.