The pharmacotherapeutic management of comorbid bipolar disorder and alcohol use disorder

INTRODUCTION

Comorbidity of bipolar disorder (BD) and alcohol use disorder (AUD) is very frequent resulting in detrimental outcomes, including increased mortality. Diagnosis of AUD in BD and vice versa is often delayed as symptoms of one disorder mimic and obscure the other one. Evidence for pharmacotherapies for people with comorbid BD and AUD remains limited, and further proof-of-concept studies are urgently needed.

AREAS COVERED

This paper explores the currently available pharmacotherapies for AUD, BD and their usefulness for comorbid BD and AUD. It also covers to some degree the epidemiology, diagnosis, and potential common neurobiological traits of comorbid BD and AUD.

EXPERT OPINION

The authors conclude that more controlled studies are needed before evidence-based guidance can be drawn up for clinician's use. Since there are no relevant pharmacological interactions, approved medications for AUD can also be used safely in BD. For mood stabilization, lithium should be considered first in adherent persons with BD and comorbid AUD. Alternatives include valproate, lamotrigine, and some atypical antipsychotics, with partial D2/D3 receptor agonism possibly being beneficial in AUD, too.

Are personality disorders in bipolar patients more frequent in the US than Europe?

OBJECTIVE

Bipolar patients in the United States (US) compared to those from the Netherlands and Germany (here abbrev. as "Europe") have more Axis I comorbidities and more poor prognosis factors such as early onset and psychosocial adversity in childhood. We wished to examine whether these differences also extended to Axis II personality disorders (PDs).

METHODS

793 outpatients with bipolar disorder diagnosed by SCID gave informed consent for participating in a prospective longitudinal follow up study with clinician ratings at each visit. They completed detailed patient questionnaires and a 99 item personality disorder inventory (PDQ-4). US versus European differences in PDs were examined in univariate analyses and then logistic regressions, controlling for severity of depression, age, gender, and other poor prognosis factors.

RESULTS

In the univariate analysis, 7 PDs were more prevalent in the US than in Europe, including antisocial, avoidant, borderline, depressive, histrionic, obsessive compulsive, and schizoid PDs. In the multivariate analysis, the last 4 of these PDs remained independently greater in the US than Europe.

CONCLUSIONS

Although limited by use of self report and other potentially confounding factors, multiple PDs were more prevalent in the US than in Europe, but these preliminary findings need to be confirmed using other methodologies. Other poor prognosis factors are prevalent in the US, including early age of onset, more childhood adversity, anxiety and substance abuse comorbidity, and more episodes and rapid cycling. The interactions among these variables in relationship to the more adverse course of illness in the US than in Europe require further study.

The detrimental effects of smoking on the course and outcome in adults with bipolar disorder-A narrative review

BACKGROUND

Smoking is a substantial and avoidable risk for physical disability and premature death. Despite a declining tobacco use in the community of developed countries, smoking remains abundant in people with mental disorders. This narrative review highlights the epidemiology, consequences and treatment options of tobacco use disorder (TUD) and nicotine dependence (ND) in people with bipolar disorder (BD).

METHODS

The authors conducted a Medline literature search from 1970 to November 2022 using MeSH terms "bipolar disorder" x "smoking" or "nicotine" or "tobacco" that retrieved 770 results. Search results were complemented by additional literature retrieved from examining cross references and by hand search in text books. Finally, 92 references were considered as essential and selected for the educational purpose of this review.

SUMMARY OF FINDINGS

Lifetime and point prevalence of smoking in people with BD is in the range of 45-70% and thus about 2-3 times more frequent in BD than in community samples. Smoking, TUD and ND have a detrimental impact both on mental and physical health as well as mortality in people with BD. In the absence of large controlled studies in comorbid BD and TUD or ND, pharmacological treatment follows the individual guidance for each disorder. Community-based psychosocial interventions for TUD and ND appear to be suitable in people with BD, too, as well as Cognitive Behavioral (CBT) or Acceptance and Commitment (ACT) based psychotherapies.

CONCLUSIONS

Smoking is a modifiable risk factor causing increased risks both for mental and physical health in BD, and deserves more attention in treatment. More treatment research into pharmacological and psychosocial interventions in comorbid BD and TUD or ND are still needed to deliver evidence-based recommendations to physicians.

Bipolar Disorder and Comorbid Use of Illicit Substances

Substance use disorders (SUD) are highly prevalent in bipolar disorder (BD) and significantly affect clinical outcomes. Incidence and management of illicit drug use differ from alcohol use disorders, nicotine use of behavioral addictions. It is not yet clear why people with bipolar disorder are at higher risk of addictive disorders, but recent data suggest common neurobiological and genetic underpinnings and epigenetic alterations. In the absence of specific diagnostic instruments, the clinical interview is conducive for the diagnosis. Treating SUD in bipolar disorder requires a comprehensive and multidisciplinary approach. Most treatment trials focus on single drugs, such as cannabis alone or in combination with alcohol, cocaine, or amphetamines. Synopsis of data provides limited evidence that lithium and valproate are effective for the treatment of mood symptoms in cannabis users and may reduce substance use. Furthermore, the neuroprotective agent citicoline may reduce cocaine consumption in BD subjects. However, many of the available studies had an open-label design and were of modest to small sample size. The very few available psychotherapeutic trials indicate no significant differences in outcomes between BD with or without SUD. Although SUD is one of the most important comorbidities in BD with a significant influence on clinical outcome, there is still a lack both of basic research and clinical trials, allowing for evidence-based and specific best practices.

Mania and bipolar depression: complementing not opposing poles-a post-hoc analysis of mixed features in manic and hypomanic episodes

BACKGROUND

Depending on the classification system used, 5-40% of manic subjects present with concomitant depressive symptoms. This post-hoc analysis evaluates the hypothesis that (hypo)manic subjects have a higher burden of depression than non-(hypo)manic subjects.

METHODS

Data from 806 Bipolar I or II participants of the Stanley Foundation Bipolar Network (SFBN) were analyzed, comprising 17,937 visits. A split data approach was used to separate evaluation and verification in independent samples. For verification of our hypotheses, we compared mean IDS-C scores ratings of non-manic, hypomanic and manic patients. Data were stored on an SQL-server and extracted using standard SQL functions. Linear correlation coefficients and pivotal tables were used to characterize patient groups.

RESULTS

Mean age of participants was 40 ± 12 years (range 18-81). 460 patients (57.1%) were female and 624 were diagnosed as having bipolar I disorder (77.4%) and 182 with bipolar II (22.6%). Data of 17,937 visits were available for analyses, split into odd and even patient numbers and stratified into three groups by YMRS-scores: not manic < 12, hypomanic < 21, manic < 30. Average IDS-C sum scores in manic or hypomanic states were significantly higher (p < .001) than for non-manic states. (Hypo)manic female patients were likely to show more depressive symptoms than males (p < .001). Similar results were obtained when only the core items of the YMRS or only the number of depressive symptoms were considered. Analyzing the frequency of (hypo)manic mixed states applying a proxy of the DSM-5 mixed features specifier extracted from the IDS-C, we found that almost 50% of the (hypo)manic group visits fulfilled DSM-5 mixed features specifier criteria.

CONCLUSION

Subjects with a higher manic symptom load are also significantly more likely to experience a higher number of depressive symptoms. Mania and depression are not opposing poles of bipolarity but complement each other.

Life Course of Physical Activity and Risk and Prognosis of Amyotrophic Lateral Sclerosis in a German ALS Registry

BACKGROUND AND OBJECTIVES

Whether physical activity (PA) is a risk factor for amyotrophic lateral sclerosis (ALS) is controversial because data on lifelong PA are rare. The main objective of this study is to provide insight into PA as a potential risk factor for ALS, reporting data on cumulative PA, leisure-time PA, and occupational PA. This study also aims to gather evidence on the role of PA as a prognostic factor in disease course.

METHODS

Lifetime PA values collected by questionnaires addressing work and leisure time were quantified into metabolic equivalents (METs). A population-based case-control study embedded in the ALS Registry Swabia served to calculate the odds ratio (OR) of ALS by PA in different time intervals and prognosis.

RESULTS

In ALS cases (393 cases, 791 age- and sex-matched controls), we observed reduced total PA at interview and up to 5 years before interview compared to controls. Total PA was not associated with ALS risk 5 to 55 years before interview. Heavy occupational work intensity was associated with increased ALS risk (OR 1.97, 95% confidence interval 1.34, 2.89). Total PA levels were associated with survival in a nonlinear manner: inactive patients and highest activity levels (25 MET-h/wk) revealed the worst survival time of 15.4 and 19.3 months, respectively. Best median survival with 29.8 months was seen at 10.5 MET-h/wk after adjustment for other prognostic factors.

DISCUSSION

Lifetime combined PA decreased sharply several years before disease onset compared to controls. The risk of developing ALS was not associated with former total PA levels 5 to 55 years before interview in contrast to occupational PA, probably reflecting work-associated exposures. We found a strong nonlinear association of current and prediagnostic PA level and survival in ALS cases with the best survival with moderate PA. PA intensity may be a disease-modifying factor with an unfavorable outcome in sedentary and hyperactive behavior.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that PA was not associated with the development of ALS.

Treatment of bipolar disorders in older adults: a review

BACKGROUND

Old age bipolar disorder has been an orphan of psychiatric research for a long time despite the fact that bipolar disorder (BD)-I and II together may affect 0.5-1.0% of the elderly. It is also unclear whether aetiology, course of illness and treatment should differ in patients with a first manifestation in older age and patients suffering from a recurrence of a BD known for decades. This narrative review will summarize the current state of knowledge about the epidemiology, clinical features, and treatment of BD in the elderly.

METHODS

We conducted a Medline literature search from 1970 to 2021 using MeSH terms "Bipolar Disorder" × "Aged" or "Geriatric" or "Elderly". Search results were complemented by additional literature retrieved from examining cross references and by hand search in text books. Varying cut-off ages have been applied to differentiate old age from adult age BD. Within old age BD, there is a reasonable agreement of distinct entities, early and late-onset BD. They differ to some extent in clinical symptoms, course of illness, and some co-morbidities. Point prevalence of BD in older adults appears slightly lower than in working-age adults, with polarity of episodes shifting towards depression. Psychopharmacological treatment needs to take into account the special aspects of somatic gerontology and the age-related change of pharmacokinetic and pharmacodynamic characteristics. The evidence for commonly used treatments such as lithium, mood-stabilizing antiepileptics, antipsychotics, and antidepressants remains sparse. Preliminary results support a role of ECT as well as psychotherapy and psychosocial interventions in old age BD.

CONCLUSIONS

There is an obvious need of further research for all treatment modalities of BD in old age. The focus should be pharmacological and psychosocial approaches, as well as their combination, and the role of physical treatment modalities such as ECT.

"Apples and pears are similar, but still different things." Bipolar disorder and schizophrenia- discrete disorders or just dimensions ?

Starting with the dichotomous view of Kraepelin, schizophrenia and bipolar disorder have traditionally been considered as separate entities. More recent, this taxonomic view of illnesses has been challenged and a continuum psychosis has been postulated based on genetic and neurobiological findings suggestive of a large overlap between disorders. In this paper we will review clinical and experimental data from genetics, morphology, phenomenology and illness progression demonstrating what makes schizophrenia and bipolar disorder different conditions, challenging the idea of the obsolescence of the categorical approach. However, perhaps it is also time to move beyond DSM and search for more refined clinical descriptions that could uncover clinical invariants matching better with molecular data. In the future, computational psychiatry employing artificial intelligence and machine learning might provide us a tool to overcome the gap between clinical descriptions (phenomenology) and neurobiology.

Electroconvulsive Therapy (ECT) in Bipolar Disorder Patients with Ultra-Rapid Cycling and Unstable Mixed States

Background and Objectives: Unstable mixed episodes or rapid switching between opposite affective poles within the scope of short cycles was first characterized in 1967 by S. Mentzos as complex polymorphous states with chaotic overlap of manic and depressive symptoms. Well-known examples include antidepressant-induced mania/hypomania and rapid/ultra-rapid/ultradian cycling, when clinicians observe an almost continuous mixed state with a constant change of preponderance of manic or depressive symptoms. Achieving stable remission in these cases is challenging with almost no data on evidence-based treatment. When mood stabilizers are ineffective, electroconvulsive therapy (ECT) has been suggested. Objectives: After reviewing the evidence from available literature, this article presents our own clinical experience of ECT efficacy and tolerability in patients with ultra-rapid cycling bipolar disorder (BD) and unstable mixed states. Materials and Methods: We conducted an open, one-year observational prospective study with a "mirror image" design, including 30 patients with rapid and ultra-rapid cycling BD on long-term mood stabilizer treatment (18 received lithium carbonate, 6 on valproate and 6 on carbamazepine) with limited effectiveness. A bilateral ECT course (5-10 sessions) was prescribed for regaining mood stability. Results: ECT was very effective in 12 patients (40%) with a history of ineffective mood stabilizer treatment who achieved and maintained remission; all of them received lithium except for 1 patient who received carbamazepine and 2 with valproate. Nine patients (30%) showed partial response (one on carbamazepine and two on valproate) and nine patients (30%) had no improvement at all (four on carbamazepine and two on valproate). For the whole sample, the duration of affective episodes was significantly reduced from 36.05 ± 4.32 weeks in the year prior to ECT to 21.74 ± 12.14 weeks in the year post-ECT (p < 0.001). Depressive episodes with mixed and/or catatonic features according to DSM-5 specifiers were associated with a better acute ECT response and/or long-term mood stabilizer treatment outcome after ECT. Conclusions: ECT could be considered as a useful option for getting mood instability under control in rapid and ultra-rapid cycling bipolar patients. Further randomized trials are needed to confirm these results.

The Challenges of Children with Bipolar Disorder

Childhood onset bipolar disorder (CO-BD) presents a panoply of difficulties associated with early recognition and treatment. CO-BD is associated with a variety of precursors and comorbidities that have been inadequately studied, so treatment remains obscure. The earlier the onset, the longer is the delay to first treatment, and both early onset and treatment delay are associated with more depressive episodes and a poor prognosis in adulthood. Ultra-rapid and ultradian cycling, consistent with a diagnosis of BP-NOS, are highly prevalent in the youngest children and take long periods of time and complex treatment regimens to achieve euthymia. Lithium and atypical antipsychotics are effective in mania, but treatment of depression remains obscure, with the exception of lurasidone, for children ages 10-17. Treatment of the common comorbid anxiety disorders, oppositional defiant disorders, pathological habits, and substance abuse are all poorly studied and are off-label. Cognitive dysfunction after a first manic hospitalization improves over the next year only on the condition that no further episodes occur. Yet comprehensive expert treatment after an initial manic hospitalization results in many fewer relapses than traditional treatment as usual, emphasizing the need for combined pharmacological, psychosocial, and psycho-educational approaches to this difficult and highly recurrent illness.

Long-term treatment of bipolar disorder type I: A systematic and critical review of clinical guidelines with derived practice algorithms

OBJECTIVES

This systematic review aimed at providing a critical, comprehensive synthesis of international guidelines' recommendations on the long-term treatment of bipolar disorder type I (BD-I).

METHODS

MEDLINE/PubMed and EMBASE databases were searched from inception to January 15th, 2019 following PRISMA and PICAR rules. International guidelines providing recommendations for the long-term treatment of BD-I were included. A methodological quality assessment was conducted with the Appraisal of Guidelines for Research and Evaluation-AGREE II.

RESULTS

The final selection yielded five international guidelines, with overall good quality. The evaluation of applicability was the weakest aspect across the guidelines. Differences in their updating strategies and the rating of the evidence, particularly for meta-analyses, randomized clinical trials (RCTs) and observational studies, could be responsible of some level of heterogeneity among recommendations. Nonetheless, the guidelines recommended lithium as the 'gold standard' in the long-term treatment of BD-I. Quetiapine was another possible first-line option as well as aripiprazole (for the prevention of mania). Long-term treatment should contemplate monotherapy, at least initially. Clinicians should check regularly for efficacy and side effects and if necessary, switch to first-line alternatives (i.e. Valproate), combine first-line compounds with different mechanisms of action or switch to second-line options or combinations.

CONCLUSIONS

The possibility to monitor improvements in long-term outcomes, namely relapse prevention and inter-episode subthreshold depressive symptoms, based on the application of their recommendations is an unmet need of clinical guidelines. In terms of evidence of clinical guidelines, there is a need for more efficacious treatment strategies for the prevention of bipolar depression.

Efficacy of Carbamazepine and Its Derivatives in the Treatment of Bipolar Disorder

Background and Objectives: This review is dedicated to the use of carbamazepine and its derivatives oxcarbazepine and eslicarbazepine in bipolar disorder and their relative strengths in treating and preventing new depressive or manic episodes. This paper will discuss the evidence of their efficacy relative to the polarity of relapse from controlled acute and maintenance/relapse prevention studies in bipolar patients. Materials and Methods: A Medline search was conducted for controlled acute and maintenance studies with carbamazepine, oxcarbazepine, and eslicarbazepine in bipolar disorder. In addition, abstracts reporting on controlled studies with these medications from key conferences were taken into consideration. Results: Information was extracted from 84 articles on the acute and prophylactic efficacy of the medications under consideration. They all appear to have stronger efficacy in treating acute mania than depression, which also translates to better protection against manic than depressive relapses for carbamazepine. Still, there is a paucity of controlled acute studies on bipolar depression for all and, with the exception of carbamazepine, a lack of long-term monotherapy maintenance data. For eslicarbazepine, the efficacy in bipolar disorder remains largely unknown. Especially with carbamazepine, tolerability issues and drug-drug interactions need to be kept in mind. Conclusions: Two of the medications discussed in this review, carbamazepine and oxcarbazepine, match Class A criteria according to the criteria proposed by Ketter and Calabrese, meaning acute antimanic efficacy, prevention of manic relapses, and not causing or worsening depression.

25 Years of the International Bipolar Collaborative Network (BCN)

BACKGROUND

The Stanley Foundation Bipolar Treatment Outcome Network (SFBN) recruited more than 900 outpatients from 1995 to 2002 from 4 sites in the United States (US) and 3 in the Netherlands and Germany (abbreviated as Europe). When funding was discontinued, the international group of investigators continued to work together as the Bipolar Collaborative Network (BCN), publishing so far 87 peer-reviewed manuscripts. On the 25th year anniversary of its founding, publication of a brief summary of some of the major findings appeared appropriate. Important insights into the course and treatment of adult outpatients with bipolar disorder were revealed and some methodological issues and lessons learned will be discussed.

RESULTS

The illness is recurrent and pernicious and difficult to bring to a long-term remission. Virtually all aspects of the illness were more prevalent in the US compared to Europe. This included vastly more patients with early onset illness and those with more psychosocial adversity in childhood; more genetic vulnerability; more anxiety and substance abuse comorbidity; more episodes and rapid cycling; and more treatment non-responsiveness.

CONCLUSIONS

The findings provide a road map for a new round of much needed clinical treatment research studies. They also emphasize the need for the formation of a new network focusing on child and youth onset of mood disorders with a goal to achieve early precision diagnostics for intervention and prevention in attempting to make the course of bipolar illness more benign.

Comorbid Bipolar and Alcohol Use Disorder-A Therapeutic Challenge

Comorbidity rates in Bipolar disorder rank highest among major mental disorders, especially comorbid substance use. Besides cannabis, alcohol is the most frequent substance of abuse as it is societally accepted and can be purchased and consumed legally. Estimates for lifetime comorbidity of bipolar disorder and alcohol use disorder are substantial and in the range of 40-70%, both for Bipolar I and II disorder, and with male preponderance. Alcohol use disorder and bipolarity significantly influence each other's severity and prognosis with a more complicated course of both disorders. Modern treatment concepts acknowledge the interplay between these disorders using an integrated therapy approach where both disorders are tackled in the same setting by a multi-professional team. Motivational interviewing, cognitive behavioral and socio- therapies incorporating the family and social environment are cornerstones in psychotherapy whereas the accompanying pharmacological treatment aims to reduce craving and to optimize mood stability. Adding valproate to lithium may reduce alcohol consumption whereas studies with antipsychotics or naltrexone and acamprosate did not affect mood fluctuations or drinking patterns. In summary, there is a continuous need for more research in order to develop evidence-based approaches for integrated treatment of this frequent comorbidity.

Reducing Addiction in Bipolar Disorder via Hacking the Dopaminergic System

The dopaminergic system plays a central and decisive role in substance use disorder (SUD), bipolar disorder (BD), and possibly in a subgroup of patients with refractory depression. Common genetic markers and underlying cellular processes, such as kindling, support the close link between these disorders, which is also expressed by the high rate of comorbidity. Although partial dopamine agonists/antagonists acting on D₂ and D₃ receptors have an established role in treating BD, their usefulness in SUD is less clear. However, dopamine D₃ receptors were shown to play a central role in SUD and BD, making D₂/D₃ partial agonists/antagonists a potential target for both disorders. This narrative review examines whether these substances bear the promise of a future therapeutic approach especially in patients with comorbid BD and SUD.

How Does Adding the DSM-5 Criterion Increased Energy/Activity for Mania Change the Bipolar Landscape?

According to DSM-IV, the criterion (A) for diagnosing hypomanic/manic episodes is mood change (i.e., elevated, expansive or irritable mood). Criterion (A) was redefined in DSM-5 in 2013, adding increased energy/activity in addition to mood change. This paper examines a potential change of prevalence data for bipolar I or II when adding increased energy/activity to the criterion (A) for the diagnosis of hypomania/mania. Own research suggests that the prevalence of manic/hypomanic episodes drops by at least one third when using DSM-5 criteria. Whether this has positive or negative impact on clinical practice and research still needs further evaluation.

Does a Lack of Awareness of Cycloid Psychosis Hamper Adequate Treatment for Patients Suffering From This Disorder? A Case Report

Categorial systems of nosology are based on a cross-sectional enumeration of symptoms with a predefined cut-off, but hardly capture rapid fluctuations of manifestation nor longitudinal characteristics, e.g., cyclicity. Especially with disorders presenting with an admixture or frequent change of psychotic and affective symptoms, diagnostic specifity of the DSM and ICD diminishes. In those instances, alternative concepts as cycloid psychosis might display more accurately the very characteristics and course of a mental disorder and help to tailor individualized treatments. Karl Leonhard described three major subtypes of cycloid psychosis: anxiety-happiness psychosis, confusion psychosis, and motility psychosis, all showing a pleiomorphic symptom profile resembling intraphasic switching of poles. Here we present the case of a 59-year-old woman suffering from cycloid psychosis as defined by the criteria of Perris. Between 2013 and June 2019, the patient was admitted 35 times for compulsory treatment. A frequent change of diagnoses, ranging from adjustment disorder to complex PTSD, and from unipolar depression to "pseudoneurotic schizophrenia," resembles the puzzling manifestations. Most of the time the patient was labeled as schizoaffective disorder despite never displaying clear psychotic core symptoms. Despite treatment with different antipsychotics including LAI the cumulative length of hospitalization increased steadily from 74 days in 2014 to 292 days in 2017. When reviewing the case in 2017 the longitudinal pattern of her disorder and the diverse acute manifestations were finally conceptualized as a cyclic on-off of an atypical psychosis. After starting lithium to pre-existing LAI antipsychotics and valproic acid, the number of days per year spent in inpatient care sharply dropped to 136 in 2018. We propose to reconsider cycloid psychosis as a useful clinical concept whose descriptive value, validity and utility for treatment decisions should be further evaluated. Lithium alone or in addition to valproic acid may act on cyclicity as a core symptom of cycloid psychosis as well as of bipolar disorder, even in the absence of major affective symptoms.

Relationship of comorbid personality disorders to prospective outcome in bipolar disorder

Introduction There is a high incidence of Axis II personality disorders (PDs) in patients with bipolar illness, but their influence on the prospectively measured course of bipolar disorder has been less well explicated. Methods 392 outpatients with bipolar disorder gave informed consent, completed the PDQ4 99 item personality disorder rating, and where clinically rated during at least one year of prospective naturalistic treatment. They were classified as Well on admission (N = 64) or Responders (N = 146) or Non-responders (N = 182) to treatment for at least six months. Results Patients who were positive for PDs were very infrequently represented in the category of Well on admission. In addition, patients with borderline, depressive, and schizoid PDs were significantly more likely to be Non-responders compared to Responders upon prospective naturalistic treatment in the network. Conclusions Patients with bipolar disorder and comorbid PDs were in general less likely to be Well from treatment in the community at network entry or to be a Responder to prospective treatment in the network. Therapeutic approaches to patients with PDs deserve specific study in an attempt to achieve a better long-term course of bipolar disorder.

Double jeopardy in the United States: Early onset bipolar disorder and treatment delay

BACKGROUND

Evidence is emerging that early onset bipolar disorder and the duration of the delay to first treatment are both risk factors for poor treatment outcome. We report on the incidence and implications of these two risk factors in patients from the United States (US) versus Europe.

METHODS

Age of onset and age at first treatment for depression or mania was assessed in 967 outpatients with bipolar disorder who gave informed consent for participation and filling out a detailed questionnaire. Age at onset and treatment delay were compared in the 675 patients from the US and 292 from the Netherlands and Germany (abbreviated as Europe). Both were then graphed and analyzed.

RESULTS

Age of onset of bipolar disorder was earlier in the US than in Europeans by an average of 6-7 years with similar results in those with first onsets of depression or of mania. Delay to first treatment was strongly inversely related to age of onset and was twice as long in the US than in Europe, and especially different for mania in adolescents. The longer delay to treatment in the US was not solely due to earlier age of onset.

CONCLUSIONS

Treatment delay is a remedial risk factor and could be shortened with better recognition of the higher incidence of early onset bipolar disorder in the US, which also associated with more genetic and environmental vulnerability factors compared to Europe. New treatment and research initiatives are needed to address these liabilities so that children with bipolar achieve more positive long-term outcomes.

The CINP Guidelines on the Definition and Evidence-Based Interventions for Treatment-Resistant Bipolar Disorder

BACKGROUND

Resistant bipolar disorder is a major mental health problem related to significant disability and overall cost. The aim of the current study was to perform a systematic review of the literature concerning (1) the definition of treatment resistance in bipolar disorder, (2) its clinical and (3) neurobiological correlates, and (4) the evidence-based treatment options for treatment-resistant bipolar disorder and for eventually developing guidelines for the treatment of this condition.

MATERIALS AND METHODS

The PRISMA method was used to identify all published papers relevant to the definition of treatment resistance in bipolar disorder and the associated evidence-based treatment options. The MEDLINE was searched to April 22, 2018.

RESULTS

Criteria were developed for the identification of resistance in bipolar disorder concerning all phases. The search of the literature identified all published studies concerning treatment options. The data were classified according to strength, and separate guidelines regarding resistant acute mania, acute bipolar depression, and the maintenance phase were developed.

DISCUSSION

The definition of resistance in bipolar disorder is by itself difficult due to the complexity of the clinical picture, course, and treatment options. The current guidelines are the first, to our knowledge, developed specifically for the treatment of resistant bipolar disorder patients, and they also include an operationalized definition of treatment resistance. They were based on a thorough and deep search of the literature and utilize as much as possible an evidence-based approach.

[German S3 guidelines on bipolar disorders-first update 2019 : What is new in pharmacotherapy?]

BACKGROUND

German S3 guidelines are subject to the highest methodological standards. This includes that they are only valid for a certain time period. Following the first edition in 2012 the first update of the S3 guidelines on bipolar disorder has now been published (2019).

OBJECTIVE

What has changed in the field of pharmacological recommendations comparing the first edition with the update in 2019?

MATERIAL AND METHODS

Comparison of the 1st edition from 2012 with the update from 2019 of the S3 guidelines for the diagnostics and treatment of bipolar disorders.

RESULTS

The three principle treatment targets of acute treatment of bipolar depression, acute treatment of mania and phase prophylaxis (maintenance treatment) can be distinguished. For acute treatment of bipolar depression, for the first time a medication has received a level A recommendation: quetiapine. For the acute treatment of mania, several drugs are still recommended with the same level of recommendation (B). Asenapine has been added as the tenth substance. Lithium is still the only drug with a level A recommendation for maintenance and prophylactic treatment and is also the only drug approved for this indication without restrictions. A new recommendation is that in the absence of contraindications, phase prophylaxis with a serum level of at least 0.6 mmol/l should be carried out. With a B recommendation, quetiapine has been added to the drugs for phase prophylactic treatment.

CONCLUSION

The S3 guidelines make recommendations at the highest scientific level. In view of these findings, lithium is clearly underutilized for maintenance therapy. In the absence of clear contraindications (advanced renal insufficiency), every patient with bipolar disease should be given the chance of lithium prophylaxis for an adequately long period.

More assortative mating in US compared to European parents and spouses of patients with bipolar disorder: implications for psychiatric illness in the offspring

The effect of assortative mating on offspring is often not considered. Here, we present data on illness in the spouse and the parents of patients with bipolar disorder as they affect illness in the offspring. A history of psychiatric illness (depression, bipolar disorder, suicide attempt, alcohol abuse, drug abuse, and "other" illness) was elicited for the parents, spouse, and the offspring of 968 patients with bipolar disorder (540 of whom had children) who gave informed consent for participation in a treatment outcome network. Assortative mating for a mood disorder in the spouse and parents in those from the United States (US) was compared to those from the Netherlands and Germany and related to illnesses in the offspring. There was more illness and assortative mating for a mood disorder in both the spouse and patient's parents from the US compared to Europe. In the parents of the US patients, assortative mating for a mood disorder was associated with more depression, bipolar disorder, alcohol, and "other" illness in the offspring. Compared to the Europeans, there was more assortative mating for mood and other disorders in two generations of those from the US. This bilineal positivity for a parental mood disorder was related to more depression a second generation later in the patients' offspring. In clinical assessment of risk of illness in the offspring, the history of psychiatric illness in the spouse and patient's parents might provide additional information.

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

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