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Bauer R, Conell J, Glenn T, Alda M, Ardau R, Baune BT, Berk M, Bersudsky Y, Bilderbeck A, Bocchetta A, Bossini L, Castro AMP, Cheung EYW, Chillotti C, Choppin S, Zompo MD, Dias R, Dodd S, Duffy A, Etain B, Fagiolini A, Hernandez MF, Garnham J, Geddes J, Gildebro J, Gonzalez-Pinto A, Goodwin GM, Grof P, Harima H, Hassel S, Henry C, Hidalgo-Mazzei D, Kapur V, Kunigiri G, Lafer B, Larsen ER, Lewitzka U, Licht RW, Hvenegaard Lund A, Misiak B, Piotrowski P, Monteith S, Munoz R, Nakanotani T, Nielsen RE, O'donovan C, Okamura Y, Osher Y, Reif A, Ritter P, Rybakowski JK, Sagduyu K, Sawchuk B, Schwartz E, Scippa ÂM, Slaney C, Sulaiman AH, Suominen K, Suwalska A, Tam P, Tatebayashi Y, Tondo L, Vieta E, Vinberg M, Viswanath B, Volkert J, Zetin M, Whybrow PC, Bauer M. International multi-site survey on the use of online support groups in bipolar disorder. Nord J Psychiatry 2017; 71:473-476. [PMID: 28696841 DOI: 10.1080/08039488.2017.1334819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Peer support is an established component of recovery from bipolar disorder, and online support groups may offer opportunities to expand the use of peer support at the patient's convenience. Prior research in bipolar disorder has reported value from online support groups. AIMS To understand the use of online support groups by patients with bipolar disorder as part of a larger project about information seeking. METHODS The results are based on a one-time, paper-based anonymous survey about information seeking by patients with bipolar disorder, which was translated into 12 languages. The survey was completed between March 2014 and January 2016 and included questions on the use of online support groups. All patients were diagnosed by a psychiatrist. Analysis included descriptive statistics and general estimating equations to account for correlated data. RESULTS AND CONCLUSIONS The survey was completed by 1222 patients in 17 countries. The patients used the Internet at a percentage similar to the general public. Of the Internet users who looked online for information about bipolar disorder, only 21.0% read or participated in support groups, chats, or forums for bipolar disorder (12.8% of the total sample). Given the benefits reported in prior research, clarification of the role of online support groups in bipolar disorder is needed. With only a minority of patients using online support groups, there are analytical challenges for future studies.
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Conell J, Bauer R, Glenn T, Alda M, Ardau R, Baune BT, Berk M, Bersudsky Y, Bilderbeck A, Bocchetta A, Bossini L, Paredes Castro AM, Cheung EYW, Chillotti C, Choppin S, Del Zompo M, Dias R, Dodd S, Duffy A, Etain B, Fagiolini A, Garnham J, Geddes J, Gildebro J, Gonzalez-Pinto A, Goodwin GM, Grof P, Harima H, Hassel S, Henry C, Hidalgo-Mazzei D, Kapur V, Kunigiri G, Lafer B, Lam C, Larsen ER, Lewitzka U, Licht RW, Lund AH, Misiak B, Piotrowski P, Monteith S, Munoz R, Nakanotani T, Nielsen RE, O'Donovan C, Okamura Y, Osher Y, Reif A, Ritter P, Rybakowski JK, Sagduyu K, Sawchuk B, Schwartz E, Scippa ÂM, Slaney C, Sulaiman AH, Suominen K, Suwalska A, Tam P, Tatebayashi Y, Tondo L, Vieta E, Vinberg M, Viswanath B, Volkert J, Zetin M, Zorrilla I, Whybrow PC, Bauer M. Erratum to: Online information seeking by patients with bipolar disorder: results from an international multisite survey. Int J Bipolar Disord 2017; 5:18. [PMID: 28364388 PMCID: PMC5376258 DOI: 10.1186/s40345-017-0082-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 02/24/2017] [Indexed: 11/29/2022] Open
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Goodday SM, Preisig M, Gholamrezaee M, Grof P, Angst J, Duffy A. The association between self-reported and clinically determined hypomanic symptoms and the onset of major mood disorders. BJPsych Open 2017; 3:71-77. [PMID: 28357133 PMCID: PMC5350540 DOI: 10.1192/bjpo.bp.116.004234] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/09/2017] [Accepted: 02/20/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Hypomanic symptoms may be a useful predictor of mood disorder among young people at high risk for bipolar disorder. AIMS To determine whether hypomanic symptoms differentiate offspring of parents with bipolar disorder (high risk) and offspring of well parents (control) and predict the development of mood episodes. METHOD High-risk and control offspring were prospectively assessed using semi-structured clinical interviews annually and completed the Hypomania Checklist-32 Revised (HCL-32). Clinically significant sub-threshold hypomanic symptoms (CSHS) were coded. RESULTS HCL-32 total and active or elated scores were higher in control compared with high-risk offspring, whereas 14% of high-risk and 0% of control offspring had CSHS. High-risk offspring with CSHS had a fivefold increased risk of developing recurrent major depression (P=0.0002). The median onset of CSHS in high-risk offspring was 16.4 (6-31) years and was before the onset of major mood episodes. CONCLUSIONS CSHS are precursors to major mood episodes in high-risk offspring and could identify individuals at ultra-high risk for developing bipolar disorder. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Duffy A, Malhi GS, Grof P. Do the Trajectories of Bipolar Disorder and Schizophrenia Follow a Universal Staging Model? CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:115-122. [PMID: 27310243 PMCID: PMC5298521 DOI: 10.1177/0706743716649189] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The purpose of this study is to address the question of whether a universal staging model of severe psychiatric disorders is a viable direction for future research by examining the extant literature. METHOD A narrative review was conducted of the relevant historical, conceptual, and empirical literature pertaining to the clinical trajectory of bipolar disorder and schizophrenia and issues relevant to staging. RESULTS There is substantive evidence that classic recurrent bipolar disorder is separable from schizophrenia on the basis of family history, developmental and clinical course, treatment response, and neurobiological findings. However, because of the intrinsic heterogeneity of diagnostic categories that has been amplified by recent changes in psychiatric taxonomy, key distinctions between the groups have become obfuscated. While mapping risk and illness markers to emerging psychopathology is a logical approach and may be of value for some psychiatric disorders and/or their clinical subtypes, robust evidence supporting identifiable stages per se is still lacking. Presently, even rudimentary stages such as prodromes cannot be meaningfully applied across different disorders and no commonalities can be found for the basis of universal staging. CONCLUSIONS Advances in the prediction of risk, accurate early illness detection, and tailored intervention will require mapping biomarkers and other risk indicators to reliable clinical phases of illness progression. Given the capricious nature of mood and psychotic disorders, this task is likely to yield success only if conducted in narrowly defined subgroups of individuals at high risk for specific illnesses. This approach is diametrically opposite to that being promulgated by proponents of a universal staging model.
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Doucette S, Levy A, Flowerdew G, Horrocks J, Grof P, Ellenbogen M, Duffy A. Early parent-child relationships and risk of mood disorder in a Canadian sample of offspring of a parent with bipolar disorder: findings from a 16-year prospective cohort study. Early Interv Psychiatry 2016; 10:381-9. [PMID: 25356767 DOI: 10.1111/eip.12195] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 09/16/2014] [Indexed: 01/14/2023]
Abstract
AIM Exposure to parental bipolar disorder (BD) early in life may increase the risk of developing a mood disorder. However, the impact of early parent-child relationships when a parent is affected and how this impacts an offspring's risk remains unclear. The primary objective of this study was to determine the association between parent-child relationships and risk of mood disorder in offspring of parents with BD and, secondly, to determine the interaction of temperament and life stress on this association. METHODS Two hundred and thirty-three offspring completed annual clinical assessments following Kiddie Schedule for Affective Disorders (KSADS) format interviews as part of an ongoing Canadian prospective cohort study conducted from 1996 to 2013. Offspring completed measures of early adversity, life stress and temperament. Clinical data from the affected parents were prospectively collected over the first decade of their offspring's life using SADS format interviews. RESULTS Higher perceived neglect from mother and offspring emotionality were significantly associated with the hazard of mood disorder (hazard ratio (HR): 1.1, 95% confidence interval (CI): 1.0-1.2 and HR: 1.7, 95% CI: 1.0-3.1, respectively). Duration of exposure to parental BD significantly interacted with offspring emotionality to predict mood disorder (P = 0.01). Further, perceived neglect from mother was associated with offspring high emotionality (P = 0.02). CONCLUSIONS Neglect from mother is a significant early predictor of mood disorder in offspring at familial risk for BD and may increase emotional sensitivity. Psychosocial support and interventions for high-risk families could be beneficial in reducing early adversity, maternal neglect and the risk of subsequent mood disorders in offspring.
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Bauer R, Conell J, Glenn T, Alda M, Ardau R, Baune BT, Berk M, Bersudsky Y, Bilderbeck A, Bocchetta A, Bossini L, Castro AMP, Cheung EY, Chillotti C, Choppin S, Del Zompo M, Dias R, Dodd S, Duffy A, Etain B, Fagiolini A, Hernandez MF, Garnham J, Geddes J, Gildebro J, Gonzalez-Pinto A, Goodwin GM, Grof P, Harima H, Hassel S, Henry C, Hidalgo-Mazzei D, Kapur V, Kunigiri G, Lafer B, Larsen ER, Lewitzka U, Licht RW, Lund AH, Misiak B, Monteith S, Munoz R, Nakanotani T, Nielsen RE, O'Donovan C, Okamura Y, Osher Y, Piotrowski P, Reif A, Ritter P, Rybakowski JK, Sagduyu K, Sawchuk B, Schwartz E, Scippa ÂM, Slaney C, Sulaiman AH, Suominen K, Suwalska A, Tam P, Tatebayashi Y, Tondo L, Vieta E, Vinberg M, Viswanath B, Volkert J, Zetin M, Whybrow PC, Bauer M. Internet use by patients with bipolar disorder: Results from an international multisite survey. Psychiatry Res 2016; 242:388-394. [PMID: 27391371 DOI: 10.1016/j.psychres.2016.05.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/30/2016] [Accepted: 05/30/2016] [Indexed: 02/03/2023]
Abstract
There is considerable international interest in online education of patients with bipolar disorder, yet little understanding of how patients use the Internet and other sources to seek information. 1171 patients with a diagnosis of bipolar disorder in 17 countries completed a paper-based, anonymous survey. 81% of the patients used the Internet, a percentage similar to the general public. Older age, less education, and challenges in country telecommunications infrastructure and demographics decreased the odds of using the Internet. About 78% of the Internet users looked online for information on bipolar disorder or 63% of the total sample. More years of education in relation to the country mean, and feeling very confident about managing life decreased the odds of seeking information on bipolar disorder online, while having attended support groups increased the odds. Patients who looked online for information on bipolar disorder consulted medical professionals plus a mean of 2.3 other information sources such as books, physician handouts, and others with bipolar disorder. Patients not using the Internet consulted medical professionals plus a mean of 1.6 other information sources. The percentage of patients with bipolar disorder who use the Internet is about the same as the general public. Other information sources remain important.
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Goodday SM, Horrocks J, Keown-Stoneman C, Grof P, Duffy A. Repeated salivary daytime cortisol and onset of mood episodes in offspring of bipolar parents. Int J Bipolar Disord 2016; 4:12. [PMID: 27230036 PMCID: PMC4882311 DOI: 10.1186/s40345-016-0053-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/12/2016] [Indexed: 12/04/2022] Open
Abstract
Background Differences in cortisol secretion may differentiate individuals at high compared to low genetic risk for bipolar disorder (BD) and predict the onset or recurrence of mood episodes. The objectives of this study were to determine if salivary cortisol measures are: (1) different in high-risk offspring of parents with BD (HR) compared to control offspring of unaffected parents (C), (2) stable over time, (3) associated with the development of mood episode onset/recurrence, and (4) influenced by comorbid complications. Methods Fifty-three HR and 22 C completed salivary cortisol sampling annually for up to 4 years in conjunction with semi-structured clinical interviews. The cortisol awakening response (CAR), daytime cortisol [area under the curve (AUC)], and evening cortisol (8:00 p.m.) were calculated. Results There were no differences in baseline CAR, AUC and evening cortisol between HR and C (p = 0.38, p = 0.30 and p = 0.84), respectively. CAR, AUC and evening cortisol were stable over yearly assessments in HR, while in Cs, evening cortisol increased over time (p = 0.008), and CAR and AUC remained stable. In HR, AUC and evening cortisol increased the hazard of a new onset mood disorder/recurrence by 2.7 times (p = 0.01), and 3.5 times (p = 0.01), respectively, but this was no longer significant after accounting for multiple comparisons. Conclusions Salivary cortisol is stable over time within HR offspring. However, between individuals, basal salivary cortisol is highly variable. More research is needed, with larger samples of prospectively studied HR youth using a more reliable method of cortisol measurement, to determine the potential role of cortisol in the development of mood disorders. Electronic supplementary material The online version of this article (doi:10.1186/s40345-016-0053-5) contains supplementary material, which is available to authorized users.
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Hou L, Heilbronner U, Degenhardt F, Adli M, Akiyama K, Akula N, Ardau R, Arias B, Backlund L, Banzato CEM, Benabarre A, Bengesser S, Bhattacharjee AK, Biernacka JM, Birner A, Brichant-Petitjean C, Bui ET, Cervantes P, Chen GB, Chen HC, Chillotti C, Cichon S, Clark SR, Colom F, Cousins DA, Cruceanu C, Czerski PM, Dantas CR, Dayer A, Étain B, Falkai P, Forstner AJ, Frisén L, Fullerton JM, Gard S, Garnham JS, Goes FS, Grof P, Gruber O, Hashimoto R, Hauser J, Herms S, Hoffmann P, Hofmann A, Jamain S, Jiménez E, Kahn JP, Kassem L, Kittel-Schneider S, Kliwicki S, König B, Kusumi I, Lackner N, Laje G, Landén M, Lavebratt C, Leboyer M, Leckband SG, Jaramillo CAL, MacQueen G, Manchia M, Martinsson L, Mattheisen M, McCarthy MJ, McElroy SL, Mitjans M, Mondimore FM, Monteleone P, Nievergelt CM, Nöthen MM, Ösby U, Ozaki N, Perlis RH, Pfennig A, Reich-Erkelenz D, Rouleau GA, Schofield PR, Schubert KO, Schweizer BW, Seemüller F, Severino G, Shekhtman T, Shilling PD, Shimoda K, Simhandl C, Slaney CM, Smoller JW, Squassina A, Stamm T, Stopkova P, Tighe SK, Tortorella A, Turecki G, Volkert J, Witt S, Wright A, Young LT, Zandi PP, Potash JB, DePaulo JR, Bauer M, Reininghaus EZ, Novák T, Aubry JM, Maj M, Baune BT, Mitchell PB, Vieta E, Frye MA, Rybakowski JK, Kuo PH, Kato T, Grigoroiu-Serbanescu M, Reif A, Del Zompo M, Bellivier F, Schalling M, Wray NR, Kelsoe JR, Alda M, Rietschel M, McMahon FJ, Schulze TG. Genetic variants associated with response to lithium treatment in bipolar disorder: a genome-wide association study. Lancet 2016; 387:1085-1093. [PMID: 26806518 PMCID: PMC4814312 DOI: 10.1016/s0140-6736(16)00143-4] [Citation(s) in RCA: 221] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lithium is a first-line treatment in bipolar disorder, but individual response is variable. Previous studies have suggested that lithium response is a heritable trait. However, no genetic markers of treatment response have been reproducibly identified. METHODS Here, we report the results of a genome-wide association study of lithium response in 2563 patients collected by 22 participating sites from the International Consortium on Lithium Genetics (ConLiGen). Data from common single nucleotide polymorphisms (SNPs) were tested for association with categorical and continuous ratings of lithium response. Lithium response was measured using a well established scale (Alda scale). Genotyped SNPs were used to generate data at more than 6 million sites, using standard genomic imputation methods. Traits were regressed against genotype dosage. Results were combined across two batches by meta-analysis. FINDINGS A single locus of four linked SNPs on chromosome 21 met genome-wide significance criteria for association with lithium response (rs79663003, p=1·37 × 10(-8); rs78015114, p=1·31 × 10(-8); rs74795342, p=3·31 × 10(-9); and rs75222709, p=3·50 × 10(-9)). In an independent, prospective study of 73 patients treated with lithium monotherapy for a period of up to 2 years, carriers of the response-associated alleles had a significantly lower rate of relapse than carriers of the alternate alleles (p=0·03268, hazard ratio 3·8, 95% CI 1·1-13·0). INTERPRETATION The response-associated region contains two genes for long, non-coding RNAs (lncRNAs), AL157359.3 and AL157359.4. LncRNAs are increasingly appreciated as important regulators of gene expression, particularly in the CNS. Confirmed biomarkers of lithium response would constitute an important step forward in the clinical management of bipolar disorder. Further studies are needed to establish the biological context and potential clinical utility of these findings. FUNDING Deutsche Forschungsgemeinschaft, National Institute of Mental Health Intramural Research Program.
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Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. Int J Bipolar Disord 2015; 3:23. [PMID: 26493348 PMCID: PMC4615994 DOI: 10.1186/s40345-015-0040-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 09/24/2015] [Indexed: 12/03/2022] Open
Abstract
Lithium has been used as the gold standard in the treatment of major depressive and bipolar disorders for decades. Due to its narrow therapeutic index, lithium toxicity is a common clinical problem. Although risk factors for lithium intoxication seem to be well-described, lacking patient education and inexperience of treatment are assumed to contribute to the probability of lithium intoxication. A review of literature shows that the treatment of lithium intoxication has not been adequately studied or standardized. The aim of this literature review is to compile and present current evidence on the treatment of lithium intoxication and contribute to a standardization regarding general treatment recommendations as well as evidence on indication for extracorporeal methods. Against the background of this common and potentially life-threatening condition, the standardization of the treatment of lithium intoxication is definitely a task for the future.
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Grof E, Brown GM, Grof P, Finkelberg F. Depression and Hormones. An Outline and Some Perspectives. INTERNATIONAL JOURNAL OF MENTAL HEALTH 2015. [DOI: 10.1080/00207411.1980.11448863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Keown-Stoneman CD, Horrocks J, Darlington GA, Goodday S, Grof P, Duffy A. Multi-state models for investigating possible stages leading to bipolar disorder. Int J Bipolar Disord 2015; 3:5. [PMID: 25713772 PMCID: PMC4338115 DOI: 10.1186/s40345-014-0019-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 12/30/2014] [Indexed: 11/17/2022] Open
Abstract
Background It has been proposed that bipolar disorder onsets in a predictable progressive sequence of clinical stages. However, there is some debate in regard to a statistical approach to test this hypothesis. The objective of this paper is to investigate two different analysis strategies to determine the best suited model to assess the longitudinal progression of clinical stages in the development of bipolar disorder. Methods Data previously collected on 229 subjects at high risk of developing bipolar disorder were used for the statistical analysis. We investigate two statistical approaches for analyzing the relationship between the proposed stages of bipolar disorder: 1) the early stages are considered as time-varying covariates affecting the hazard of bipolar disorder in a Cox proportional hazards model, 2) the early stages are explicitly modelled as states in a non-parametric multi-state model. Results We found from the Cox model thatthere was evidence that the hazard of bipolar disorder is increased by the onset of major depressive disorder. From the multi-state model, in high-risk offspring the probability of bipolar disorder by age 29 was estimated as 0.2321. Cumulative incidence functions representing the probability of bipolar disorder given major depressive disorder at or before age 18 were estimated using both approaches and found to be similar. Conclusions Both the Cox model and multi-state model are useful approaches to the modelling of antecedent risk syndromes. They lead to similar cumulative incidence functions but otherwise each method offers a different advantage.
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Duffy A, Horrocks J, Keown-Stoneman C, Doucette S, Grof P. Authors' reply. Br J Psychiatry 2014; 205:159. [PMID: 25252323 DOI: 10.1192/bjp.205.2.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Duffy A, Horrocks J, Doucette S, Keown-Stoneman C, Grof P, Andreazza A, Young LT. Immunological and neurotrophic markers of risk status and illness development in high-risk youth: understanding the neurobiological underpinnings of bipolar disorder. Int J Bipolar Disord 2014; 2:29. [PMID: 26092400 PMCID: PMC4447739 DOI: 10.1186/2194-7511-2-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/14/2014] [Indexed: 12/17/2022] Open
Abstract
Bipolar disorder is a highly heritable illness that onsets in adolescence and young adulthood. We examined gene expression (mRNA) and protein levels of candidate immune and neurotrophic markers in well-characterized offspring of bipolar parents in order to identify reliable indicators of illness risk status and the early clinical stages of illness development. We measured mRNA expression and protein levels in candidate immune (TNF-α, IL-1β, IL-10, IFN-δ) and neurotrophic (brain-derived neurotrophic factor (BDNF)) markers from plasma. High-risk offspring were identified from families in which one parent had confirmed bipolar disorder. Control offspring were identified from families in which neither parent met lifetime criteria for a major psychiatric disorder. All parental Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses were based on Schedule for Affective Disorders - Lifetime Version (SADS-L) interviews and blind consensus review. As part of an ongoing study, all offspring were prospectively assessed using KSADS-PL format interviews and diagnoses confirmed on blind consensus review. High-risk offspring had significantly increased IL-6 (p = 0.050) and BDNF (p = 0.006) protein levels compared to controls. Those high-risk offspring in earlier compared to later clinical stages of illness development had higher IL-6 (p = 0.050) and BDNF (p = 0.045) protein levels. After adjustments, only differences in BDNF protein levels remained significant. There was a moderating effect of the BDNF genotype on both gene expression and protein levels in high-risk compared to control offspring. The BDNF genotype also moderated the association between clinical stage and gene expression levels in high-risk offspring. These findings provide support for detectable differences in candidate immune and neurotrophic markers in individuals at high risk of developing bipolar disorder and for detectable changes over the clinical stages of illness development. These associations appear to be moderated by genetic variants.
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Mühleisen TW, Leber M, Schulze TG, Strohmaier J, Degenhardt F, Treutlein J, Mattheisen M, Forstner AJ, Schumacher J, Breuer R, Meier S, Herms S, Hoffmann P, Lacour A, Witt SH, Reif A, Müller-Myhsok B, Lucae S, Maier W, Schwarz M, Vedder H, Kammerer-Ciernioch J, Pfennig A, Bauer M, Hautzinger M, Moebus S, Priebe L, Czerski PM, Hauser J, Lissowska J, Szeszenia-Dabrowska N, Brennan P, McKay JD, Wright A, Mitchell PB, Fullerton JM, Schofield PR, Montgomery GW, Medland SE, Gordon SD, Martin NG, Krasnow V, Chuchalin A, Babadjanova G, Pantelejeva G, Abramova LI, Tiganov AS, Polonikov A, Khusnutdinova E, Alda M, Grof P, Rouleau GA, Turecki G, Laprise C, Rivas F, Mayoral F, Kogevinas M, Grigoroiu-Serbanescu M, Propping P, Becker T, Rietschel M, Nöthen MM, Cichon S. Genome-wide association study reveals two new risk loci for bipolar disorder. Nat Commun 2014; 5:3339. [PMID: 24618891 DOI: 10.1038/ncomms4339] [Citation(s) in RCA: 263] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 01/29/2014] [Indexed: 12/24/2022] Open
Abstract
Bipolar disorder (BD) is a common and highly heritable mental illness and genome-wide association studies (GWAS) have robustly identified the first common genetic variants involved in disease aetiology. The data also provide strong evidence for the presence of multiple additional risk loci, each contributing a relatively small effect to BD susceptibility. Large samples are necessary to detect these risk loci. Here we present results from the largest BD GWAS to date by investigating 2.3 million single-nucleotide polymorphisms (SNPs) in a sample of 24,025 patients and controls. We detect 56 genome-wide significant SNPs in five chromosomal regions including previously reported risk loci ANK3, ODZ4 and TRANK1, as well as the risk locus ADCY2 (5p15.31) and a region between MIR2113 and POU3F2 (6q16.1). ADCY2 is a key enzyme in cAMP signalling and our finding provides new insights into the biological mechanisms involved in the development of BD.
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Duffy A, Horrocks J, Doucette S, Keown-Stoneman C, McCloskey S, Grof P. The developmental trajectory of bipolar disorder. Br J Psychiatry 2014; 204:122-8. [PMID: 24262817 DOI: 10.1192/bjp.bp.113.126706] [Citation(s) in RCA: 186] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Bipolar disorder is highly heritable and therefore longitudinal observation of children of affected parents is important to mapping the early natural history. AIMS To model the developmental trajectory of bipolar disorder based on the latest findings from an ongoing prospective study of the offspring of parents with well-characterised bipolar disorder. METHOD A total of 229 offspring from families in which 1 parent had confirmed bipolar disorder and 86 control offspring were prospectively studied for up to 16 years. High-risk offspring were divided into subgroups based on the parental long-term response to lithium. Offspring were clinically assessed and DSM-IV diagnoses determined on masked consensus review using best estimate procedure. Adjusted survival analysis and generalised estimating equations were used to calculate differences in lifetime psychopathology. Multistate models were used to examine the progression through proposed clinical stages. RESULTS High-risk offspring had an increased lifetime risk of a broad spectrum of disorders including bipolar disorder (hazard ratio (HR) = 20.89; P = 0.04), major depressive disorder (HR = 17.16; P = 0.004), anxiety (HR = 2.20; P = 0.03), sleep (HR = 28.21; P = 0.02) and substance use disorders (HR = 2.60; P = 0.05) compared with controls. However, only offspring from lithium non-responsive parents developed psychotic disorders. Childhood anxiety disorder predicted an increased risk of major mood disorder and evidence supported a progressive transition through clinical stages, from non-specific psychopathology to depressive and then manic or psychotic episodes. CONCLUSIONS Findings underscore the importance of a developmental approach in conjunction with an appreciation of familial risk to facilitate earlier accurate diagnosis in symptomatic youth.
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Bauer R, Glenn T, Alda M, Sagduyu K, Marsh W, Grof P, Munoz R, Murray G, Ritter P, Lewitzka U, Severus E, Whybrow PC, Bauer M. Antidepressant dosage taken by patients with bipolar disorder: factors associated with irregularity. Int J Bipolar Disord 2013; 1:26. [PMID: 25505689 PMCID: PMC4215816 DOI: 10.1186/2194-7511-1-26] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 11/15/2013] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND This study analyzed regularity in the daily dosage of antidepressants taken by patients with bipolar disorder and identified the factors associated with irregularity. METHODS Daily self-reported medication dosage taken and mood ratings were available from 144 patients who received treatment as usual. All 144 patients took the same antidepressant for at least 100 days. One hundred eleven of these patients were also taking a mood stabilizer. Approximate entropy (ApEn) was used to measure serial regularity in daily dosage. Regularity is the tendency that values within a time series remain the same on incremental comparisons. Drug holidays (missing three or more consecutive days) were also determined. Generalized estimating equations (GEE) were used to estimate if any demographic or clinical variables were associated with regularity. RESULTS Although the mean percent of days missing doses was only 18.6%, there was a wide range of regularity in the daily antidepressant dosage. Drug holidays were common, occurring in 41% of the analyses. Factors significantly associated with irregularity were as follows: total number of psychotropic medications (p = 0.005), pill burden (p = 0.005), and depression (p = 0.015). Neither the percent of days missing doses nor the drug holidays were associated with any demographic or clinical factors. For patients taking both antidepressants and mood stabilizers, there was no significant difference in regularity in daily dosage between these drugs. DISCUSSION There can be considerable irregularity in daily dosage despite a low percent of days missing doses. Medication regimen complexity and depressed mood are associated with increased irregularity. Daily regularity in drug dosage may be more dependent on the individual than on the specific drug. Research on the clinical impact of irregularity in daily dosage of antidepressants is needed.
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Alda M, Shao L, Wang JF, Lopez de Lara C, Jaitovich-Groisman I, Lebel V, Sun X, Duffy A, Grof P, Rouleau GA, Turecki G, Young LT. Alterations in phosphorylated cAMP response element-binding protein (pCREB) signaling: an endophenotype of lithium-responsive bipolar disorder? Bipolar Disord 2013; 15:824-31. [PMID: 24238631 DOI: 10.1111/bdi.12131] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 08/26/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Abnormalities of signal transduction are considered among the susceptibility factors for bipolar disorder (BD). These include changes in G-protein-mediated signaling and subsequent modification of gene expression via transcription factors such as cAMP response element-binding protein (CREB). METHODS We investigated levels of CREB in lymphoblasts from patients with BD, all responders to lithium prophylaxis (n = 13), and healthy control subjects (n = 15). Phosphorylated CREB (pCREB) was measured by immunoblotting in subjects with BD (n = 15) as well as in their affected (n = 17) and unaffected (n = 18) relatives, and healthy controls (n = 16). RESULTS Basal CREB levels were comparable in patients and control subjects and were not changed by lithium treatment. pCREB levels were increased in both patients and their relatives compared to controls (p = 0.003). Forskolin stimulation led to a 24% increase in pCREB levels in cells from healthy subjects (p = 0.002) but not in the other three groups. When using basal and stimulated pCREB levels as a biochemical phenotype in a preliminary linkage study, we found the strongest support for linkage in regions largely overlapping with those showing linkage with the clinical phenotype (3p, 6p, 16p, 17q, 19q, and 21q). CONCLUSIONS Abnormal pCREB signaling could be considered a biochemical phenotype for lithium-responsive BD.
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Doucette S, Horrocks J, Grof P, Keown-Stoneman C, Duffy A. Attachment and temperament profiles among the offspring of a parent with bipolar disorder. J Affect Disord 2013; 150:522-6. [PMID: 23453672 DOI: 10.1016/j.jad.2013.01.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 01/29/2013] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Attachment is associated both with the risk of developing a mood disorder and temperamental profile. Relatively little is known about these associations in children of a parent with bipolar disorder (BD). The present study is a preliminary analysis of the association between attachment, temperament and psychopathology among high-risk offspring. METHODS As part of an ongoing prospective cohort study, offspring from families with one parent with BD (HR) and offspring from families with unaffected parents (C) were clinically assessed using KSADS-PL format interviews annually. Validated self-report measures of perceived attachment and temperament were completed. RESULTS Perceived attachment did not differentiate HR from C offspring and did not predict psychopathology or mood disorder in particular. However, high emotionality significantly predicted the risk of psychopathology in HR offspring, where 1 standard deviation increase in emotionality significantly increased the hazard of psychopathology by a factor of 1.36 (p=0.0009) and mood disorder by a factor of 1.24 (p=0.02). LIMITATIONS Use of retrospective measures and low sample size for some models. CONCLUSIONS There may be no gross abnormalities in attachment among HR compared to C offspring. It remains unclear if emotionality is a barometer of illness or a true risk factor in this population. More longitudinal research is needed to advance understanding of the influential pathways by which psychosocial risk factors impact the development of BD. This research has implications for targeted early interventions in HR youth.
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Berghöfer A, Alda M, Adli M, Baethge C, Bauer M, Bschor T, Grof P, Müller-Oerlinghausen B, Rybakowski JK, Suwalska A, Pfennig A. Stability of lithium treatment in bipolar disorder - long-term follow-up of 346 patients. Int J Bipolar Disord 2013; 1:11. [PMID: 25505678 PMCID: PMC4230691 DOI: 10.1186/2194-7511-1-11] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/19/2013] [Indexed: 11/23/2022] Open
Abstract
Background The purpose of this study was to investigate the effectiveness and stability of long-term lithium treatment in a prospective, international, multicenter cohort of bipolar patients in a naturalistic setting. Methods Patients were selected according to DSM IV criteria for bipolar disorder and required long-term treatment. They were prospectively followed and documented in five centers belonging to the International Group for the Study of Lithium-Treated Patients. This was a prospective cohort study without a comparison group. Lithium treatment was administered in a naturalistic and specialized outpatient setting. All patients underwent a comprehensive psychiatric examination, which included the use of standard rating scales, as well as an evaluation of clinical course based on the morbidity index (MI). Wald tests were used to assess the significance of fixed effects and covariates when analyzing the relationship between depressive, manic, and total morbidity index and several characteristics of illness course. Results and discussion A total of 346 patients with bipolar disorder I or II were followed for a mean period of 10.0 years (standard deviation (SD) 6.2, range 1 to 20). The morbidity index remained stable over time: the mean MI was 0.125 (SD 0.299) in year 1 and 0.110 (SD 0.267) in year 20. The MI was not associated with the duration of lithium treatment, the number or frequency of episodes prior to treatment, or latency from the onset of bipolar disorder to the start of lithium treatment. The drop-out rate was high over the study period. Our findings suggest that long-term response to lithium maintenance treatment remains stable over time.
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Grof P, Müller-Oerlinghausen B. [S3 guidelines on bipolar disorders are contemporary and important instruments for clinical practice. Against]. DER NERVENARZT 2013; 84:876-878. [PMID: 23709049 DOI: 10.1007/s00115-013-3797-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Bauer M, Glenn T, Alda M, Sagduyu K, Marsh W, Grof P, Munoz R, Baethge C, Lewitzka U, Pilhatsch M, Bauer R, Whybrow PC. Regularity in daily mood stabilizer dosage taken by patients with bipolar disorder. PHARMACOPSYCHIATRY 2013; 46:163-8. [PMID: 23797414 DOI: 10.1055/s-0033-1343398] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of this study was to investigate regularity in the daily mood stabilizer dosage taken by patients with bipolar disorder, and identify factors associated with irregularity. METHODS Self-reported daily mood and medication data were available from 206 patients who took the same mood stabilizer for ≥100 days. Approximate entropy (ApEn) was used to measure serial regularity in daily mood stabilizer dosage. Generalized estimating equations (GEE) were used to estimate if demographic or clinical variables were associated with ApEn. RESULTS There was a wide range of regularity in the daily mood stabilizer dosage. The mean percent of days of missing doses was 13.6%. The number of psychotropic medications (p=0.007), pill burden (p=0.004) and percent of days with depressed mood (p=0.013) were associated with more irregularity, while the percent of days euthymic (p=0.014) was associated with less irregularity. The percent of days missing doses was not associated with the number of medications, pill burden or mood ratings. DISCUSSION Patients may have irregularity in daily dosage in spite of a low percent of days missing doses. Psychotropic medication regimen complexity and depression are associated with increased dosage irregularity. Research is needed on how irregularity in daily dosage impacts the continuity of drug action of mood stabilizers.
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Eid L, Heim K, Doucette S, McCloskey S, Duffy A, Grof P. Bipolar disorder and socioeconomic status: what is the nature of this relationship? Int J Bipolar Disord 2013; 1:9. [PMID: 25505676 PMCID: PMC4230315 DOI: 10.1186/2194-7511-1-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 05/31/2013] [Indexed: 11/10/2022] Open
Abstract
Background In psychiatric literature stretching over a century, there have been glaring discrepancies in the findings describing the relationship between bipolar disorder (BD) and socioeconomic status (SES). Early studies indicated an overall association between manic-depressive illness and higher social class. However, recent epidemiologic studies have failed to find an association between BD and SES. Instead, they report a similar distribution of BD among social classes and educational levels, and in one particular study, a lower family income was reported. The determinants of SES are complex, and the early findings are now interpreted as having been incorrect and stemming from past methodological weaknesses. Methods For this analysis we explored the relationship between SES and BD in a sample of patients who had participated in prior clinical and therapeutic studies. These patients met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BD, required long-term stabilizing treatment, and were assessed in terms of their response to lithium stabilization and a number of other clinical characteristics in accordance with research protocol. Good response to lithium stabilization (LiR) served as a proxy for identifying a subtype of manic-depressive illness, the classical form of BD. Non-responders to stabilizing lithium (LiNR) were considered belonging to other subtypes of bipolar spectrum disorder. The SES of the parents was measured upon entry into treatment using the Hollingshead SES scale, which despite its limitations has been used in psychiatry most widely to determine SES. The groups of LiR and LiNR were compared statistically in terms of SES. The influence of bipolar subtype and gender on SES was investigated. Results and discussion A significantly higher SES was associated with the lithium-responsive form (LiR) of BD when compared with patients continuing to relapse despite adequate lithium treatment (representing other types of bipolar spectrum). Our observation suggests that the discrepant literature findings about SES and BD may be better explained by the change in diagnostic practices: early studies describing a positive relationship included mostly classical manic-depressive disorder, while the patients in recent studies have been diagnosed according to much broader criteria, reflecting the era of bipolar spectrum disorder.
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Manchia M, Adli M, Akula N, Ardau R, Aubry JM, Backlund L, Banzato CEM, Baune BT, Bellivier F, Bengesser S, Biernacka JM, Brichant-Petitjean C, Bui E, Calkin CV, Cheng ATA, Chillotti C, Cichon S, Clark S, Czerski PM, Dantas C, Zompo MD, DePaulo JR, Detera-Wadleigh SD, Etain B, Falkai P, Frisén L, Frye MA, Fullerton J, Gard S, Garnham J, Goes FS, Grof P, Gruber O, Hashimoto R, Hauser J, Heilbronner U, Hoban R, Hou L, Jamain S, Kahn JP, Kassem L, Kato T, Kelsoe JR, Kittel-Schneider S, Kliwicki S, Kuo PH, Kusumi I, Laje G, Lavebratt C, Leboyer M, Leckband SG, López Jaramillo CA, Maj M, Malafosse A, Martinsson L, Masui T, Mitchell PB, Mondimore F, Monteleone P, Nallet A, Neuner M, Novák T, O’Donovan C, Ösby U, Ozaki N, Perlis RH, Pfennig A, Potash JB, Reich-Erkelenz D, Reif A, Reininghaus E, Richardson S, Rouleau GA, Rybakowski JK, Schalling M, Schofield PR, Schubert OK, Schweizer B, Seemüller F, Grigoroiu-Serbanescu M, Severino G, Seymour LR, Slaney C, Smoller JW, Squassina A, Stamm T, Steele J, Stopkova P, Tighe SK, Tortorella A, Turecki G, Wray NR, Wright A, Zandi PP, Zilles D, Bauer M, Rietschel M, McMahon FJ, Schulze TG, Alda M. Assessment of Response to Lithium Maintenance Treatment in Bipolar Disorder: A Consortium on Lithium Genetics (ConLiGen) Report. PLoS One 2013; 8:e65636. [PMID: 23840348 PMCID: PMC3686769 DOI: 10.1371/journal.pone.0065636] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 04/26/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The assessment of response to lithium maintenance treatment in bipolar disorder (BD) is complicated by variable length of treatment, unpredictable clinical course, and often inconsistent compliance. Prospective and retrospective methods of assessment of lithium response have been proposed in the literature. In this study we report the key phenotypic measures of the "Retrospective Criteria of Long-Term Treatment Response in Research Subjects with Bipolar Disorder" scale currently used in the Consortium on Lithium Genetics (ConLiGen) study. MATERIALS AND METHODS Twenty-nine ConLiGen sites took part in a two-stage case-vignette rating procedure to examine inter-rater agreement [Kappa (κ)] and reliability [intra-class correlation coefficient (ICC)] of lithium response. Annotated first-round vignettes and rating guidelines were circulated to expert research clinicians for training purposes between the two stages. Further, we analyzed the distributional properties of the treatment response scores available for 1,308 patients using mixture modeling. RESULTS Substantial and moderate agreement was shown across sites in the first and second sets of vignettes (κ = 0.66 and κ = 0.54, respectively), without significant improvement from training. However, definition of response using the A score as a quantitative trait and selecting cases with B criteria of 4 or less showed an improvement between the two stages (ICC1 = 0.71 and ICC2 = 0.75, respectively). Mixture modeling of score distribution indicated three subpopulations (full responders, partial responders, non responders). CONCLUSIONS We identified two definitions of lithium response, one dichotomous and the other continuous, with moderate to substantial inter-rater agreement and reliability. Accurate phenotypic measurement of lithium response is crucial for the ongoing ConLiGen pharmacogenomic study.
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Bauer M, Glenn T, Alda M, Sagduyu K, Marsh W, Grof P, Munoz R, Severus E, Ritter P, Whybrow PC. Drug treatment patterns in bipolar disorder: analysis of long-term self-reported data. Int J Bipolar Disord 2013; 1:5. [PMID: 25505672 PMCID: PMC4230449 DOI: 10.1186/2194-7511-1-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 01/25/2013] [Indexed: 12/28/2022] Open
Abstract
Background The objective of this study is to investigate drug treatment patterns in bipolar disorder using daily data from patients who received treatment as usual. Methods Patients self-reported the drugs taken daily for about 6 months. Daily drug use and drug combinations were determined for each patient, both by the specific drugs and by medication class. The drug load was calculated for all drugs taken within a medication class. Results and discussion Four hundred fifty patients returned a total of 99,895 days of data (mean 222.0 days). The most frequently taken drugs were mood stabilizers. Of the 450 patients, 353 (78.4%) took a stable drug combination for ≥50% of days. The majority of patients were taking polypharmacy, including 75% of those with a stable combination. Only a small number of drugs were commonly taken within each medication class, but there were a large number of unique drug combinations: 52 by medication class and 231 by specific drugs. Eighty percent of patients with a stable combination were taking three or less drugs daily. Patients without a stable combination took drugs but made frequent changes. Taking more than one drug within a medication class greatly increased the drug load. To summarize, (1) patients were more likely to take a mood stabilizer than any other drug; (2) although most patients were taking polypharmacy, there were no predominant drug regimens even among those taking a stable combination; and (3) most patients with a stable combination take a relatively small number of drugs daily. The wide variation in drug regimens and numerous possible drug combinations suggest that more evidence is needed to optimize treatment of bipolar disorder.
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Grof P. Melancholia: a distinct entity? CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:181-2. [PMID: 23547639 DOI: 10.1177/070674371305800401] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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