Non-alcoholic fatty liver disease in a sample of individuals with bipolar disorders: results from the FACE-BD cohort

OBJECTIVE

Non-Alcoholic fatty liver disease (NAFLD) is becoming the most common liver disease in Western populations. While obesity and metabolic abnormalities are highly frequent in bipolar disorders (BD), no studies have been performed to estimate the prevalence of NALFD in individuals with BD. The aim of our study is to estimate the prevalence of NAFLD and to identify the potential associated risk factors in a large sample of BD individuals.

METHODS

Between 2009 and 2019, 1969 BD individuals from the FACE-BD cohort were included. Individuals with liver diseases, Hepatitis B or C, and current alcohol use disorders were excluded from the analyses. A blood sample was drawn from participants. Screening of NAFLD was determined using fatty liver index (FLI). Individuals with FLI> 60 were considered as having NAFLD.

RESULTS

The prevalence of NAFDL in this sample was estimated at 28.4%. NAFLD was observed in 40% of men and 21% of women. NAFLD was independently associated with older age, male gender, sleep disturbances, and current use of atypical antipsychotics or anxiolytics. As expected, the prevalence of NALFD was also higher in individuals with overweight and in those with metabolic syndrome.

CONCLUSIONS

This study reinforces the view that individuals with BD are highly vulnerable to metabolic and cardiovascular diseases. The prevalence of NAFLD in individuals with BD was two times higher than the prevalence reported in the general population. The regular screening of the MetS in individuals with BD should be therefore complemented by the additional screening of NAFLD among these vulnerable individuals.

Trajectories of functioning in bipolar disorders: A longitudinal study in the FondaMental Advanced Centers of Expertise in Bipolar Disorders cohort

OBJECTIVE

We aimed at identifying distinct trajectories of functioning and at describing their respective clinical characteristics in a cohort of individuals with bipolar disorders.

METHODS

We included a sample of 2351 individuals with bipolar disorders who have been followed-up to 3 years as part as the FondaMental Advanced Centers of Expertise in Bipolar Disorders cohort. Global functioning was measured using the Functioning Assessment Short Test. We used latent class mixed models to identify distinct longitudinal trajectories of functioning over 3 years. Multivariable logistic regression models were used to identify the baseline factors that were associated with the membership to each trajectory of functioning.

RESULTS

Three distinct trajectories of functioning were identified: (1) a majority of individuals (72%) had a stable trajectory of mild functional impairment, (2) 20% of individuals had a stable trajectory of severe functional impairment and (3) 8% of individuals had a trajectory of moderate functional impairment that improved over time. The membership to a trajectory of stable severe versus stable mild functional impairment was associated with unemployment, a higher number of previous hospitalizations, childhood maltreatment, a higher level of residual depressive symptoms, higher sleep disturbances, a higher body mass index and a higher number of psychotropic medications being prescribed at baseline. The model that included these seven factors led to an area under the curve of 0.85.

CONCLUSION

This study enabled to stratify individuals with bipolar disorders according to three distinct trajectories of functioning. The results regarding the potential determinants of the trajectory of severe functional impairment needs to be replicated in independent samples. Nevertheless, these potential determinants may represent possible therapeutic targets to improve the prognosis of those patients at risk of persistent poor functioning.

[Can we assess the efficacy of psychotherapies in a clinical trial?]

Extensive evidence demonstrates that psychotherapy can be an efficacious and effective health care service for a wide range of mental health and health conditions. Recently, an important distinction between efficacy research and effectiveness research has been made within research focused on the outcome of psychotherapy. Data from both efficacy and effectiveness studies are fundamental to a complete understanding of the potential impact of a psychotherapy and the way to carry successful psychotherapeutics interventions to routine clinical practice. Efficacy studies, using randomized controlled trials, maximize the internal validity of a study by the use of design features, such as random assignment to a psychotherapeutic intervention and control conditions, training of therapists to a specified level of competence in providing the treatment, and ensuring that all participants have the condition that the treatment was designed to address. The randomized controlled trials allowed to objectify the efficacy of the psychotherapies in multiple pathological contexts, as we will see with the example of bipolar disorders. On the other hand, effectiveness studies strive to maximize external validity (while maintaining an adequate level of internal validity) by locating the study within clinical service sites that provide ongoing health services, using clinicians who are routinely providing psychological services and patients who have been referred to the clinical settings. These studies do not allow understanding changes and psychotherapeutic processes in real practice. A solution might be found in using pragmatic case studies in a systematic manner to constitute ecologically valid samples and measure change and psychotherapeutic processes during clinically significant periods of time.

Quels sont les facteurs sociodémographiques, cliniques et neuropsychologiques associés à l’observance médicamenteuse ?

L’observance médicamenteuse est un des facteurs majeur du pronostic des troubles bipolaires, alors que l’on considère que plus de 50 % des patients ont des difficultés à prendre régulièrement leur traitement (Lingam et Scott, 2002). Plusieurs facteurs cliniques semblent être associés au problème d’inobservance tels que les troubles addictifs (Leclerc et al., 2013), la symptomatologie dépressive résiduelle (Belzeaux et al., 2013) ou encore le niveau d’impulsivité de non-planification (Belzeaux et al., 2015). Pourtant, l’observance est un phénomène encore mal compris et une meilleure identification des facteurs pouvant l’influencer permettrait d’améliorer le pronostic de la maladie et de dépister les patients à risque. L’observance médicamenteuse a été évaluée de façon catégorielle à partir de la Medication Adherence Rating Scale. Des données socio-démographiques ont été recueillies ainsi que des données cliniques à l’aide d’échelles psychométriques et d’entretiens semi-directifs (SCID). Par ailleurs, un bilan neuropsychologique standardisé a permis d’évaluer le fonctionnement cognitif des patients. Au total, les analyses ont porté sur les données de 713 patients bipolaires euthymiques recrutés dans les différents centres experts de France. Les analyses univariées montrent que le degré d’observance est influencé par l’âge et par le genre mais également par la présence de certaines comorbidités psychiatriques telles que les troubles addictifs ou les troubles du comportement alimentaire. La symptomatologie dépressive résiduelle, le niveau d’anxiété et de tolérance du traitement sont également associés à l’observance. En revanche, aucun lien n’a été montré entre le degré d’observance et les performances cognitives. Dans cette étude, plusieurs facteurs socio-démographiques et cliniques, dont la présence de certaines comorbidités, sont associés à l’observance médicamenteuse alors que le fonctionnement cognitif ne semble pas participer au phénomène. Toutefois, des analyses multi-variées seront réalisées afin de mettre à jour d’éventuelles interactions entre les facteurs pouvant influencer le degré d’observance.

[Psychotherapeutic and psychosocial interventions and endophenotypes in bipolar disorders]

Diseases with complex determinism, bipolar disorders, involve at the same time environmental and genetic factors of vulnerability. The characterization of these vulnerabilities would allow a better knowledge of their etiology and envisage the development of therapeutics, more specialized, even preventive. The research in genetic psychiatry allowed to highlight endophenotype candidates associated to bipolar disorders. They are endogenous clinical or biological features, biologically more elementary than phenotypes and more directly bound to the physiological consequences of genes and their polymorphisms. Targeting some of them with specific psychotherapy and psychosocial interventions could reduce the consequences of their expression and so have an action on the course of the disease and also preventive.

[What perspectives for cognitive remediation in schizophrenia?]

Cognitive deficits are routinely evident in schizophrenia, and are of sufficient magnitude to influence functional outcomes in work, social functioning and illness management. Cognitive remediation is an evidenced-based non-pharmacological treatment for the neurocognitive deficits seen in schizophrenia. Narrowly defined, cognitive remediation is a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning, but from the vantage of the psychiatric rehabilitation field, cognitive remediation is a therapy which engages the patient in learning activities that enhance the neurocognitive skills relevant to their chosen recovery goals. Cognitive remediation programs vary in the extent to which they reflect these narrow or broader perspectives but a metaanalytic study reports moderate range effect sizes on cognitive test performance, and daily functioning. Reciprocal interactions between baseline ability level, the type of instructional techniques used, and motivation provide some explanatory power for the heterogeneity in patient response to cognitive remediation. Recent studies indicate that intrinsic motivation mediates the relationship between neurocognition and functional outcomes. Results of these studies suggest that intrinsic motivation should be a viable treatment target in cognitive remediation intervention. In this perspective, NEAR (Neuropsychological Educational Approach to Remediation) program was created to enhance intrinsic motivation by employing more engaging and interesting software packages for cognitive practice, involving consumers in choosing the focus of training and having the NEAR leader serve as a coach to engage the consumers in active guidance of their own treatment program.

[Schizophrenia, executive control and memory]

Schizophrenia affects 1% of the general population. In addition to disabling clinical symptoms, cognitive deficits have also been updated. It has further been proposed that the well-known diversity of schizophrenia in terms of functional outcome and recovery from acute episode is best characterized by cognitive deficits, but not by its classical symptoms. DSM-V acknowledges the importance of cognition in schizophrenia, and could recommend a formal neuropsychological assessment in individuals with psychosis. Schizophrenic patient's cognitive functioning has been studied extensively in the domain of memory and executive control. To date, the studies highlight important deficits in both of these domains. However, within the memory systems, some of them remain unaffected. Altogether, the data invalidate the hypothesis of a global damage and are in favor of specific cognitive deficits. The observed deficits would depend on the dominant symptoms and pre-morbid functioning. The interest of these results was to give impulse to the development of comprehensive assessment battery designed to evaluate the cognitive profiles of each patient and develop a personalized program of cognitive remediation.