Obesity in bipolar disorder: an overview

Low-grade inflammation in first-episode psychosis is determined by increased waist circumference

Psychosis is associated with low-grade inflammation as measured by high-sensitivity C-reactive protein (hs-CRP), a risk factor for cardiovascular events and mortality in the general population. We investigated the relationship between hs-CRP and anthropometric and metabolic changes in first-episode psychosis (FEP) during the first treatment year. We recruited 95 FEP patients and 62 controls, and measured longitudinal changes in hs-CRP, weight, waist circumference, insulin resistance, and lipids. We used linear mixed models to analyze the longitudinal relationship between hs-CRP and clinical, anthropometric and metabolic measures. At baseline, patients with FEP had higher levels of insulin resistance, total and low-density lipoprotein cholesterol, apolipoprotein B, and triglycerides. Baseline weight, waist circumference, hs-CRP, fasting glucose, and high-density lipoprotein cholesterol were similar between patients and controls. Marked increases in anthropometric measures and hs-CRP were observed in FEP during the 12-month follow-up. However, glucose and lipid parameters did not change significantly. In the mixed models, waist circumference and female sex were significant predictors of hs-CRP levels in FEP. Prevention of the early development of abdominal obesity in FEP is crucial, as abdominal obesity is accompanied by chronic low-grade inflammation, which increases further the cardiovascular risk in this vulnerable population.

Association between binge eating disorder and psychiatric comorbidity profiles in patients with obesity seeking bariatric surgery

BACKGROUND

Eating disorders could be an important factor in the development of obesity, but psychiatric comorbidities are very heterogeneous in patients with obesity. Moreover, relationship between binge eating disorder and other psychiatric comorbidities is not clear. Our objective was to identify psychiatric comorbidity profiles of bariatric surgery candidates and to analyze the association between these profiles and binge-eating disorder.

METHODS

Our sample consisted of bariatric surgery candidates (n = 92) with mean Body Mass Index at 41.3 ± 0.6 kg/m². To construct profiles, we classified patients according to their psychiatric comorbidities using cluster analysis techniques. We used logistic regression modelling to analyze associations between the presence of binge-eating disorder and the psychiatric comorbidity profiles.

RESULTS

We identified four profiles of psychiatric phenotypes. One of these profiles was not associated with any psychiatric disorder. Binge eating disorder was significantly associated with two profiles (p < 0.05): a profile with bipolar and obsessive-compulsive disorder (OR = 7.7 [1.7; 35.1]), and a profile with bipolar and panic disorder (OR = 20.7 [3.1; 137.5]).

CONCLUSIONS

Our multidimensional approach identified certain profiles specifically associated with binge-eating disorder in patients with obesity seeking bariatric surgery. These results may lead to a better understanding of the relationship between obesity and psychiatric disorders.

Underdocumentation of Obesity by Medical Residents Highlights Challenges to Effective Obesity Care

OBJECTIVE

The goal of this study was to determine attitudes and practices of physicians in training with respect to the evaluation and treatment of obesity.

METHODS

Resident-generated admission and discharge notes of all 1,765 general medicine hospital admissions during 4 nonconsecutive months were analyzed, and any references to weight, obesity, BMI, adiposity, and body fat were identified. The full general resident cohort was then surveyed for perceptions and behaviors related to obesity.

RESULTS

Obesity was considered a highly important medical issue by 98.5% of residents; 90% correctly identified a class II obesity Stunkard phenotype, and 80% accurately calculated a BMI given height and weight in metric units. Residents overestimated inpatient obesity prevalence (estimate = 75%; actual = 35%) and the rate of obesity recording in the hospital admission note (estimate = 94%; actual = 49.5%). A BMI or current weight in the admission note or discharge summary was reported in none of the 1,765 patient records, and only 6% of the patients with obesity had obesity noted in either the inpatient admission or discharge assessment or plan.

CONCLUSIONS

Though residents recognize obesity and its clinical implications, it is underreported in the assessment of inpatients. This low level of documenting obesity and its impact on clinical care planning underscores a missed opportunity to establish appropriate referrals and initiate treatment at a clinically opportune time.

Early intervention for bipolar disorder in adolescents: A psychosocial perspective

AIM

Early intervention in bipolar disorder (BD) has received increasing attention in recent years. The identification of risk factors has improved, but researchers continue to struggle to find an effective treatment once the illness has become established. The aetiology of BD and feasibility of early intervention present a challenge, making it difficult to decide who to target, as well as how.

METHODS

This essay seeks to address the lack of guidance for managing patients with a possible emerging bipolar illness, by presenting a rough roadmap to psychological care. The psychological techniques currently showing the most potential for this challenging group are reviewed. Markers of risk and supplementary clinical targets, such as anxiety and sleep disruption, are also discussed.

RESULTS

While research in this group remains in its infancy, various avenues of enquiry show promise, such as family-based approaches, CBT that targets features beyond the core illness, psychoeducation, and interventions that consider physical health. However, clearer pathways for establishing the course and stage of the illness are required to inform the intensity and type of treatment.

CONCLUSION

It is argued that treating early, indistinct symptoms of psychological distress, that may or may not signify prodromal BD, is valuable beyond its utility as an early intervention tool, as it has the capacity to improve help-seeking behaviour, quality of life and the likelihood of functional recovery in those who go on to develop the illness as adults.

Dietary influences on cognition

Obesity is a world-wide crisis with profound healthcare and socio-economic implications and it is now clear that the central nervous system (CNS) is a target for the complications of metabolic disorders like obesity. In addition to decreases in physical activity and sedentary lifestyles, diet is proposed to be an important contributor to the etiology and progression of obesity. Unfortunately, there are gaps in our knowledge base related to how dietary choices impact the structural and functional integrity of the CNS. For example, while chronic consumption of hypercaloric diets (increased sugars and fat) contribute to increases in body weight and adiposity characteristic of metabolic disorders, the mechanistic basis for neurocognitive deficits in obesity remains to be determined. In addition, studies indicate that acute consumption of hypercaloric diets impairs performance in a wide variety of cognitive domains, even in normal non-obese control subjects. These results from the clinical and basic science literature indicate that diet can have rapid, as well as long lasting effects on cognitive function. This review summarizes our symposium at the 2017 Society for the Study of Ingestive Behavior (SSIB) meeting that discussed these effects of diet on cognition. Collectively, this review highlights the need for integrated and comprehensive approaches to more fully determine how diet impacts behavior and cognition under physiological conditions and in metabolic disorders like type 2 diabetes mellitus (T2DM) and obesity.

Impact of obesity and mood disorders on physical comorbidities, psychological well-being, health behaviours and use of health services

BACKGROUND

Albeit obesity and mood disorders frequently co-occur, few studies examined the impacts of this co-occurrence. The aim was to compare individuals with obesity and mood disorders (ObMD) to those with obesity without mood disorder in terms of physical comorbidities, psychological well-being, health behaviours and use of health services.

METHODS

Cross-sectional study using the Canadian Community Health Survey including a weighted sample of individuals with obesity (n = 1298) representing inhabitants from the province of Quebec (Canada).

RESULTS

Adjusted multivariate logistic regressions indicated that ObMD reported more physical conditions with odds ratio (OR) ranging from 1.8 [95%CI: 1.1 - 2.8] (hypertension) to 2.8 [95%CI: 1.3 - 6.0] (stomach ulcer). Also, ObMD reported poorer psychological well-being with OR ranging from 2.1 [95%CI: 1.4 - 3.3] (stress) to 25.6 [95%CI: 14.7 - 45.0] (poor perceived mental health). ObMD also reported more consultations with health professionals with OR ranging from 1.9 [95%CI: 1.0 - 3.5] (physicians) to 7.7 [95%CI: 4.2 - 14.3] (psychologists), and less healthy behaviours with OR ranging from 1.7 [95%CI: 1.1 - 2.6] (fruits and vegetables intake) to 2.1 [95%CI: 1.3 - 3.3] (tobacco).

LIMITATIONS

Self-reported data so we cannot discard the possibility of a bias in reporting. Also, given the cross-sectional design, no directional conclusion or causality about our results is possible.

DISCUSSION

The co-occurrence of mood disorder and obesity seems to be an aggravating factor of obesity-related factors because it is associated with poorer health in several areas. Interventions to prevent or manage obesity in mood disorders are necessary.

Precursors in adolescence of adult-onset bipolar disorder

BACKGROUND

Although the estimated contribution of genetic factors is high in bipolar disorder, environmental factors may also play a role. This Swedish register-based cohort study of men examined if physical and psychological characteristics in late adolescence, including factors previously linked with bipolar disorder (body mass index, asthma and allergy), are associated with subsequent bipolar disorder in adulthood. Unipolar depression and anxiety are analysed as additional outcomes to identify bipolar disorder-specific associations.

METHODS

A total of 213,693 men born between 1952 and 1956, who participated in compulsory military conscription assessments in late adolescence were followed up to 2009, excluding men with any psychiatric diagnoses at baseline. Cox regression estimated risk of bipolar disorder, depression and anxiety in adulthood associated with body mass index, asthma, allergy, muscular strength stress resilience and cognitive function in adolescence.

RESULTS

BMI, asthma and allergy were not associated with bipolar disorder. Higher grip strength, cognitive function and stress resilience were associated with a reduced risk of bipolar disorder and the other disease outcomes.

LIMITATIONS

The sample consisted only of men; even though the characteristics in adolescence pre-dated disease onset, they may have been the consequence of prodromal disease.

CONCLUSIONS

Associations with body mass index and asthma found by previous studies may be consequences of bipolar disorder or its treatment rather than risk factors. Inverse associations with all the outcome diagnoses for stress resilience, muscular strength and cognitive function may reflect general risks for these psychiatric disorders or intermediary factors.

Binge Eating Disorder and Bipolar Spectrum disorders in obesity: Psychopathological and eating behaviors differences according to comorbidities

BACKGROUND

Obesity is not a mental disorder, yet DSM-5 recognizes a strong association between obesity and psychiatric syndromes. Disorders within the Bipolar Spectrum (BSD) and Binge Eating Disorder (BED) are the most frequent psychiatric disorders among obese patients. The aim of this research is to investigate the psychopathological differences and the distinctive eating behaviors that accompany these comorbidities in obese patients.

METHODS

One hundred and nineteen obese patients (40 males; 79 females) underwent psychological evaluation and psychiatric interview, and a dietitian evaluated their eating habits. Patients were divided into four groups according to comorbidities, and comparisons were run accordingly.

RESULTS

Forty-one percent of participants presented BED+BSD comorbidity (Group 1), 21% BED (Group 2) and 8% BSD (Group 3); only 29% obese participants had no comorbidity (Group 4). Female gender was overrepresented among Groups 1 and 2. BSD diagnosis varied according to comorbidities: Type II Bipolar Disorder and Other Specified and Related Bipolar Disorder (OSR BD) were more frequent in Group 1 and Type I Bipolar Disorder in Group 3. A trend of decreasing severity in eating behaviors and psychopathology was evident according to comorbidities (Group 1=Group2>Group3>Group 4).

LIMITATIONS

Limitations include the small sample size and the cross-sectional design of the study.

CONCLUSIONS

BED and BSD are frequent comorbidities in obesity. Type II Bipolar Disorder and OSR BD are more frequent in the group with double comorbidity. The double comorbidity seems associated to more severe eating behaviors and psychopathology. Distinctive pathological eating behaviors could be considered as warning signals, symptomatic of psychiatric comorbidities in Obesity.

Correlates of Overweight and Obesity Among Adolescents With Bipolar Disorder in the National Comorbidity Survey-Adolescent Supplement (NCS-A)

OBJECTIVE

Despite substantial evidence on the prevalence and correlates of overweight and obesity (OW/OB) in adults with bipolar disorder (BD), little is known about this topic in adolescents with BD.

METHOD

The method consisted of the National Comorbidity Survey-Adolescent Supplement, a face-to-face survey of mental disorders from 2001 through 2004, using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview. Participants were adolescents 13 to 17 years of age, with bipolar disorder I or II (n = 295), major depressive disorder (n = 1,112), or controls with neither mood disorder (n = 8,716). Analyses examined for group differences in the prevalence of OW/OB and for correlates of OW/OB in the group with BD.

RESULTS

There were no significant differences in weight categories across groups. OW and OB in adolescents with BD were associated with significantly higher lifetime rates of suicide attempt (odds ratio 3.02, 95% CI 1.11-8.24), physical or sexual abuse (2.82, 1.20-6.60), binge eating or bulimia (2.66, 1.13-6.26), and conduct disorder (2.60, 1.10-6.13) in covariate-adjusted analyses. OW and OB also were significantly associated with seeing a professional for depression, being hospitalized overnight for depression, and receiving general medical treatment.

CONCLUSION

The similar prevalence of OW/OB in adolescents with and without BD suggests that this potent association in adults likely comprises a consequence of BD or its correlates. In contrast, the strong association of OW/OB with proxies for depression severity, including suicide attempts and hospitalization, is already evident even in this young, nonclinical sample. Studies are warranted to determine whether early intervention of OW/OB in BD might optimize physical and mental health.

Adverse Events in Childhood as a Risk Factor for Elevated BMI among People with Schizophrenia and Bipolar Disorder

Diseases of obesity have become a major cause of morbidity and mortality among people with schizophrenia and bipolar disorder. Childhood adversity has been associated with adult obesity in the general public, but has not been examined among people with mental illness. This study used a secondary analysis to examine childhood adversity and body mass index in people with schizophrenia and bipolar disorder. Among females, a history of physical abuse from parents or paternal emotional neglect was associated with an increased risk for obesity (OR = 3.34 and 2.44, respectively).

Abdominal obesity is associated with impaired cognitive function in euthymic bipolar individuals

OBJECTIVES

Overweight/obesity has been implicated to play a role in cognitive deficits in bipolar disorder (BD). This study aims to identify the relationship between body fat distribution and different domains of cognition in BD during euthymia.

METHODS

A sample of 100 euthymic individuals with BD was measured with a cognitive test battery (i.e., Trail Making Test-A-B/TM-A/B, d2 Test of Attention, Stroop test, California Verbal Learning Test/CVLT) and an anthropometric measures set (body mass index, waist circumference, hip circumference, waist-to-hip-ratio, waist-to-height-ratio, and lipometry). Patient data were compared with a healthy control group (n = 64).

RESULTS

Results show that overweight patients with BD exhibit lower performance in the TMT-A/B as well as in the free recall performance of the CVLT compared to normal-weight patients with BD and controls. In bipolar individuals, (abdominal) obesity was significantly associated with a poor cognitive performance. In bipolar females, associations with measures of verbal learning and memory were found; in bipolar males, associations with poor performance in the TMT-A/B and in the Stroop interference task were demonstrated. In controls, no associations were found.

CONCLUSIONS

There are several possible pathways moderating the association between obesity and cognition in BD. Anthropometric and lipometry data underline the substantial mediating impact of body fat distribution on cognition in BD.

The potential association between obesity and bipolar disorder: A meta-analysis

BACKGROUND

Several epidemiological studies have found that the prevalence of bipolar disorder (BD) is significantly higher in obese population than non-obese population. However, no meta-analysis has been published to quantitatively summarize the related literature.

METHODS

In this study, we conducted a meta-analysis to explore the association between obesity and BD by combining 9 cross-sectional studies with a total of 12,259 BD cases and 615,490 non-BD controls. The meta-analysis was performed using the effect estimates and 95% confidence intervals (CIs) to calculate the pooled odds ratio (OR), while the heterogeneity was assessed using I(2) and Q statistic.

RESULTS

Our meta-analysis suggests that obesity is associated with increased prevalence of BD by a random-effect model (OR=1.77, 95% CI: 1.40-2.23; Q=44.62, P<0.001, I(2)=82.1%).

LIMITATION

Without prospective studies, we cannot determine whether obesity increased the risk of developing BD or vice-versa.

CONCLUSION

Obesity is positively associated with BD.

Body mass index and psychiatric disorders: a Mendelian randomization study

Obesity is a highly prevalent risk factor for cardiometabolic diseases. Observational studies suggest that obesity is associated with psychiatric traits, but causal inference from such studies has several limitations. We used two-sample Mendelian randomization methods (inverse variance weighting, weighted median and MR-Egger regression) to evaluate the association of body mass index (BMI) with three psychiatric traits using data from the Genetic Investigation of Anthropometric Traits and Psychiatric Genomics consortia. Causal odds ratio estimates per 1-standard deviation increment in BMI ranged from 0.88 (95% CI: 0.62; 1.25) to 1.23 (95% CI: 0.65; 2.31) for bipolar disorder; 0.93 (0.78; 1.11) to 1.41 (0.87; 2.27) for schizophrenia; and 1.15 (95% CI: 0.92; 1.44) to 1.40 (95% CI: 1.03; 1.90) for major depressive disorder. Analyses removing potentially influential SNPs suggested that the effect estimates for depression might be underestimated. Our findings do not support the notion that higher BMI increases risk of bipolar disorder and schizophrenia. Although the point estimates for depression were consistent in all sensitivity analyses, the overall statistical evidence was weak. However, the fact that SNP-depression associations were estimated in relatively small samples reduced power to detect causal effects. This should be re-addressed when SNP-depression associations from larger studies become available.

Sex Differences in Weight Loss among Veterans with Serious Mental Illness: Observational Study of a National Weight Management Program

PURPOSE

Obesity disproportionately burdens individuals with serious mental illness (SMI), especially women. This observational study investigated whether there were sex differences in weight loss and program participation among veterans with SMI enrolled in the Veterans Health Administration's (VHA) MOVE! weight management program.

PROCEDURES

Participants were identified from a national cohort of 148,254 veterans enrolled in MOVE! during fiscal years 2008 through 2012 who attended two or more sessions within 12 months of enrollment. The cohort included those with International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) diagnoses for SMI, age less than 70 years, and weight data at baseline and one or more follow-up timepoints within approximately 1 year of enrollment (n = 8,943 men; n = 2,245 women). Linear mixed models assessed associations of sex with 6- and 12-month weight change from baseline, adjusting for demographic- and site-level variables.

FINDINGS

Both sexes averaged 6.4 (standard deviation, 4.6) sessions within 12 months; however, women with and without SMI participated at rates double their respective proportion rates among all VHA users. Participants averaged statistically significant weight loss at 6 months (men, -2.5 lb [95% CI, -2.8 to -2.1]; women, -2.4 lb [95% CI, -3.1 to -1.7]) and 12 months (men, -2.5 lb [95% CI, -2.8 to -2.2]; women, -2.9 lb [95% CI, -3.6 to -2.2]), but no sex-based difference in absolute weight loss at either timepoint. Slightly more women achieved 5% or greater (clinically significant) weight loss at the 12-month follow-up than did men (25.7% vs. 23.0%; p < .05).

CONCLUSIONS

Women with SMI participated in MOVE! at rates equivalent to or greater than men with SMI, with comparable weight loss. More women were Black, single, had bipolar and posttraumatic stress disorder, and higher service-connected disability, suggesting areas for program customization.

Bipolar Depression and Cognitive Impairment: Shared Mechanisms and New Treatment Avenues

Depression and cognitive impairment are pervasive and highly disabling aspects of bipolar disorder. Although cognitive impairment is partially independent from mood episodes, depressive symptoms may increase the risk of cognitive impairment in bipolar disorder through inflammatory processes as well as health risks such as obesity and sedentary behavior. Novel treatment avenues at the intersection of bipolar depression and cognitive impairment target inflammation directly or indirectly health behaviors such as diet, physical activity, and sleep hygiene.

Obesity, but not metabolic syndrome, negatively affects outcome in bipolar disorder

OBJECTIVE

Examine the effects of obesity and metabolic syndrome on outcome in bipolar disorder.

METHOD

The Comparative Effectiveness of a Second Generation Antipsychotic Mood Stabilizer and a Classic Mood Stabilizer for Bipolar Disorder (Bipolar CHOICE) study randomized 482 participants with bipolar disorder in a 6-month trial comparing lithium- and quetiapine-based treatment. Baseline variables were compared between groups with and without obesity, with and without abdominal obesity, and with and without metabolic syndrome respectively. The effects of baseline obesity, abdominal obesity, and metabolic syndrome on outcomes were examined using mixed effects linear regression models.

RESULTS

At baseline, 44.4% of participants had obesity, 48.0% had abdominal obesity, and 27.3% had metabolic syndrome; neither obesity, nor abdominal obesity, nor metabolic syndrome were associated with increased global severity, mood symptoms, or suicidality, or with poorer functioning or life satisfaction. Treatment groups did not differ on prevalence of obesity, abdominal obesity, or metabolic syndrome. By contrast, among the entire cohort, obesity was associated with less global improvement and less improvement in total mood and depressive symptoms, suicidality, functioning, and life satisfaction after 6 months of treatment. Abdominal obesity was associated with similar findings. Metabolic syndrome had no effect on outcome.

CONCLUSION

Obesity and abdominal obesity, but not metabolic syndrome, were associated with less improvement after 6 months of lithium- or quetiapine-based treatment.

Elevated C-reactive protein and late-onset bipolar disorder in 78 809 individuals from the general population

BACKGROUND

No prospective studies have examined the role of C-reactive protein (CRP) in late-onset bipolar disorder.

AIMS

We tested the hypothesis that elevated levels of CRP are associated cross-sectionally and prospectively with late-onset bipolar disorder, and that such an association possibly is causal.

METHOD

We performed cross-sectional and prospective analyses with a median follow-up time of 5.9 years (interquartile range: 4.4-7.6) in 78 809 individuals from the general population, and used genetic variants influencing CRP levels to perform a Mendelian randomisation study.

RESULTS

Elevated levels of CRP were associated both cross-sectionally and prospectively with late-onset bipolar disorder. When CRP was on a continuous scale, a doubling in CRP yielded an observational odds ratio for late-onset bipolar disorder of 1.28 (1.08-1.52) with a corresponding causal odds ratio of 4.66 (0.89-24.3).

CONCLUSION

Elevated CRP is associated with increased risk of late-onset bipolar disorder in the general population which was supported by the genetic analysis.

Bipolar disorder symptoms in patients seeking bariatric surgery

BACKGROUND

Mood disorders are common among patients seeking bariatric surgery although little data exist regarding the prevalence of bipolar symptoms in this population and how they influence surgical outcomes. Our aim was to describe baseline rates of bipolar symptoms and their relationship to psychological factors and completing surgery in a sample of adults seeking bariatric surgery at an academic medical center.

METHODS

We retrospectively reviewed the relationship of bipolar symptoms to demographic characteristics, baseline weight, psychological factors, and bariatric surgery completion.

RESULTS

Nine hundred thirty-five patients completed the preoperative psychological evaluation. Six percent of the preoperative sample screened positive for symptoms of bipolar disorder. Patients with bipolar symptoms endorsed more robust psychopathology, trauma history, and problematic eating behaviors than patients without bipolar symptoms. Twenty-two percent of the patients with bipolar symptoms underwent bariatric surgery (n = 12), yet only 13 % were denied bariatric surgery for psychiatric reasons, suggesting that other variables may influence the completion of bariatric surgery for these patients.

CONCLUSION

Prevalence rates of bipolar symptoms may be greater in patients seeking bariatric surgery compared with the general population, and few patients with bipolar symptoms actually undergo bariatric surgery. Psychological factors differentiate patients with bipolar symptoms who undergo bariatric surgery vs those who do not.

Atypical features in depression: Association with obesity and bipolar disorder

OBJECTIVES

Depression with atypical features amounts to a significant proportion of depressed patients. Studies have shown its association with bipolarity and, recently, with obesity. In this study, we investigated atypical features of depression in relation to overweight/obesity in three diagnostic categories: unipolar depression, bipolar depression and dysthymia.

METHODS

Out of 512 depressed patients screened, we recruited 182 research subjects, consisting of 91 pairs, matched by age, gender and diagnosis, in which one member of the pair was within the normal weight range (BMI≤25) and the other was either overweight or obese (BMI>25). There were 35 pairs with unipolar depression, 27 with bipolar depression and 29 with dysthymia. Symptoms of atypical depression, such as increased appetite, hypersomnia, leaden paralysis, longstanding pattern of interpersonal rejection sensitivity, and, a significant weight gain in the past 3 months, were assessed.

RESULTS

All the symptoms of atypical depression were significantly more pronounced in those depressed patients with a BMI>25, compared with depressed subjects with a normal weight. Except for hypersomnia, these symptoms scored significantly higher in women compared to men. Among the diagnostic categories, symptoms of atypical depression were significantly higher in patients with bipolar disorder compared with both major depressive disorder and dysthymia.

LIMITATIONS

The preponderance of women, the assessment of atypical depression by adaptation of the DSM criteria, entirely Polish population, specificity of selection criteria.

CONCLUSIONS

The results demonstrated a higher intensity of atypical depression's symptoms in overweight/obese depressed patients. They also confirm the association between obesity and bipolarity.

Are medical comorbid conditions of bipolar disorder due to immune dysfunction?

OBJECTIVE

Epidemiological data have shown a clear association between bipolar disorder (BD) and medical comorbidities. The aim of this article was to assess the evidence of immune dysfunction as a key mediator of this observed association.

METHOD

For this narrative clinical overview, the MEDLINE/PubMed, EMBASE, Google Scholar, and ClinicalTrials.gov databases were searched for relevant articles.

RESULTS

Bipolar disorder has been shown to have an increased prevalence in patients with autoimmune disorders, cardiovascular disease, and metabolic dysfunction. Further, an elevation in proinflammatory cytokines in BD has been repeatedly demonstrated. Several mechanisms have been proposed to explain the effect of immune dysfunction on mood and cognition. Anti-inflammatory agents including TNF-α inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs), minocycline and omega-3 polyunsaturated fatty acids (O3PUFA) are being investigated for their use as novel treatment of BD in patients with immune dysfunction.

CONCLUSION

Immune dysfunction appears to be an important mediator of the association observed between BD and medical comorbidities. It therefore serves as a potential novel target for treatment of BD. Further, the observed bidirectional interaction merits screening for psychiatric disorders in patients with immune dysfunction and vice versa to allow for early detection and treatment of this at risk population.

Eating behavior and obesity in bipolar disorder

OBJECTIVES

Individuals with bipolar disorder are more frequently overweight or obese than the general population, but the reasons for this association are unknown. The aim of this study is to further understand the etiology of overweight and obesity in bipolar disorder.

METHODS

We invited patients in a specialty outpatient bipolar clinic to complete the Eating Inventory. Patients provided self-reported restraint, disinhibition, and perceived hunger as well as general perceptions of dietary intake.

RESULTS

Sixty-two individuals (37 female) between the ages of 18 and 67 (M = 41.5, SD = 13.38) and with an average body mass index (BMI) of 27.18 (SD = 5.71) completed the survey. Disinhibition and perceived hunger were positively correlated with BMI and self-reported difficulty eating healthy foods. Restraint was positively correlated with healthy eating (ps < .05). Stepwise linear regressions revealed that hunger was the most significant predictor of BMI (F(1) = 8.134, p = .006). Those participants with bipolar I or II disorder reported greater hunger scores (p < .01) and difficulty eating healthily (p < .05) than those without a full diagnosis.

CONCLUSIONS

These results suggest that disinhibition and perception of hunger may be linked to the disproportionately high rate of obesity in bipolar disorder.

Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder

People with severe mental illness have a considerably shorter lifespan than the general population. This excess mortality is mainly due to physical illness. Next to mental illness-related factors, unhealthy lifestyle, and disparities in health care access and utilization, psychotropic medications can contribute to the risk of physical morbidity and mortality. We systematically reviewed the effects of antipsychotics, antidepressants and mood stabilizers on physical health outcomes in people with schizophrenia, depression and bipolar disorder. Updating and expanding our prior systematic review published in this journal, we searched MEDLINE (November 2009 - November 2014), combining the MeSH terms of major physical disease categories (and/or relevant diseases within these categories) with schizophrenia, major depressive disorder and bipolar disorder, and the three major psychotropic classes which received regulatory approval for these disorders, i.e., antipsychotics, antidepressants and mood stabilizers. We gave precedence to results from (systematic) reviews and meta-analyses wherever possible. Antipsychotics, and to a more restricted degree antidepressants and mood stabilizers, are associated with an increased risk for several physical diseases, including obesity, dyslipidemia, diabetes mellitus, thyroid disorders, hyponatremia; cardiovascular, respiratory tract, gastrointestinal, haematological, musculoskeletal and renal diseases, as well as movement and seizure disorders. Higher dosages, polypharmacy, and treatment of vulnerable (e.g., old or young) individuals are associated with greater absolute (elderly) and relative (youth) risk for most of these physical diseases. To what degree medication-specific and patient-specific risk factors interact, and how adverse outcomes can be minimized, allowing patients to derive maximum benefits from these medications, requires adequate clinical attention and further research.

Managing the side effects associated with commonly used treatments for bipolar depression

BACKGROUND

The most commonly used pharmacologic therapies for bipolar depression are mood stabilizers, atypical antipsychotics, and antidepressants. This paper reviews common side effects associated with these medications and provides recommendations for managing adverse medication effects in clinical practice.

METHODS

Narrative review based on literature searches of Medline and evidence-based treatment guidelines for agents that have been approved by the US Food and Drug Administration and/or are commonly used to treat bipolar depression.

RESULTS

Side effects of bipolar depression pharmacotherapies are common and vary by medication, with weight gain, metabolic dysregulation, sedation/somnolence, and akathisia among those observed most frequently. These adverse events (weight gain and sedation/somnolence, in particular) negatively affect treatment adherence in patients with bipolar disorder. Furthermore, endocrine and metabolic comorbidities, weight gain, and obesity may reduce the likelihood of positive clinical responses to pharmacologic therapies. Clinicians may consider switching patients to bipolar depression medication(s) with a lower propensity for sedation or adverse metabolic effects. Lifestyle modification (e.g., dietary changes, exercise) is an important component in the treatment of weight gain/obesity, dyslipidemia, hypertension, and hyperglycemia; in addition, a wide range of medications are available as therapeutic options for patients in whom non-pharmacologic management strategies are insufficient. The use of adjunctive medication may also reduce treatment-related sedation and somnolence.

LIMITATIONS

The selection of relevant studies from the literature search relied primarily on the author's expertise in the area of bipolar depression and knowledge of the issues addressed.

CONCLUSION

Successful treatment of bipolar depression extends beyond managing mood symptoms to also monitoring adverse medication events and managing associated medical disorders.

Genome-wide association study of bipolar disorder accounting for effect of body mass index identifies a new risk allele in TCF7L2

Bipolar disorder (BD) is associated with higher body mass index (BMI) and increased metabolic comorbidity. Considering the associated phenotypic traits in genetic studies of complex diseases, either by adjusting for covariates or by investigating interactions between genetic variants and covariates, may help to uncover the missing heritability. However, obesity-related traits have not been incorporated in prior genome-wide analyses of BD as covariates or potential interacting factors. To investigate the genetic factors underlying BD while considering BMI, we conducted genome-wide analyses using data from the Genetic Association Information Network BD study. We analyzed 729,454 genotyped single-nucleotide polymorphism (SNP) markers on 388 European-American BD cases and 1020 healthy controls with available data for maximum BMI. We performed genome-wide association analyses of the genetic effects while accounting for the effect of maximum BMI, and also evaluated SNP-BMI interactions. A joint test of main and interaction effects demonstrated significant evidence of association at the genome-wide level with rs12772424 in an intron of TCF7L2 (P=2.85E-8). This SNP exhibited interaction effects, indicating that the bipolar susceptibility risk of this SNP is dependent on BMI. TCF7L2 codes for the transcription factor TCF/LF, part of the Wnt canonical pathway, and is one of the strongest genetic risk variants for type 2 diabetes (T2D). This is consistent with BD pathophysiology, as the Wnt pathway has crucial implications in neurodevelopment, neurogenesis and neuroplasticity, and is involved in the mechanisms of action of BD and depression treatments. We hypothesize that genetic risk for BD is BMI dependent, possibly related to common genetic risk with T2D.

Inflamed moods: a review of the interactions between inflammation and mood disorders

Mood disorders have been recognized by the World Health Organization (WHO) as the leading cause of disability worldwide. Notwithstanding the established efficacy of conventional mood agents, many treated individuals continue to remain treatment refractory and/or exhibit clinically significant residual symptoms, cognitive dysfunction, and psychosocial impairment. Therefore, a priority research and clinical agenda is to identify pathophysiological mechanisms subserving mood disorders to improve therapeutic efficacy. During the past decade, inflammation has been revisited as an important etiologic factor of mood disorders. Therefore, the purpose of this synthetic review is threefold: 1) to review the evidence for an association between inflammation and mood disorders, 2) to discuss potential pathophysiologic mechanisms that may explain this association and 3) to present novel therapeutic options currently being investigated that target the inflammatory-mood pathway. Accumulating evidence implicates inflammation as a critical mediator in the pathophysiology of mood disorders. Indeed, elevated levels of pro-inflammatory cytokines have been repeatedly demonstrated in both major depressive disorder (MDD) and bipolar disorder (BD) patients. Further, the induction of a pro-inflammatory state in healthy or medically ill subjects induces 'sickness behavior' resembling depressive symptomatology. Potential mechanisms involved include, but are not limited to, direct effects of pro-inflammatory cytokines on monoamine levels, dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, pathologic microglial cell activation, impaired neuroplasticity and structural and functional brain changes. Anti-inflammatory agents, such as acetyl-salicylic acid (ASA), celecoxib, anti-TNF-α agents, minocycline, curcumin and omega-3 fatty acids, are being investigated for use in mood disorders. Current evidence shows improved outcomes in mood disorder patients when anti-inflammatory agents are used as an adjunct to conventional therapy; however, further research is needed to establish the therapeutic benefit and appropriate dosage.

Body mass index-related regional gray and white matter volume reductions in first-episode mania patients

BACKGROUND

We previously reported that overweight/obese first-episode mania patients had reduced white matter (WM) and temporal lobe volumes compared with normal-weight patients. WM reductions are characteristic of early-stage bipolar disorder (BD), whereas temporal lobe reductions are frequently reported later in the illness. These findings thus suggested a testable hypothesis: that the neuropathology of BD is exacerbated with elevated body mass index (BMI).

METHODS

We used voxel-based morphometry to examine the relationship between BMI and regional gray matter (GM) and WM volumes in our sample of 57 euthymic first-episode mania patients and 55 healthy subjects. We hypothesized that elevated BMI in patients, but not healthy subjects, would be associated with volume reductions in frontal, temporal, and subcortical limbic brain regions implicated in the pathophysiology of BD.

RESULTS

At recovery from their first manic episode, patients with higher BMI had GM and WM reductions in the predicted emotion-generating and -regulating regions. In contrast, healthy subjects with higher BMI had reduced occipital lobe GM only. Factorial analyses confirmed significant BMI × diagnosis interactions for the WM reductions. Approximately three-quarters of patients with elevated BMI were overweight rather than obese; thus, weight-related volume reductions were detectable in patients with modestly elevated BMI.

CONCLUSIONS

This is the first hypothesis-driven test of, and supporting evidence for, our theory that elevated BMI is associated with unique brain changes in BD that have a negative impact on regions believed to be vulnerable in the illness. Our results suggest a neurobiological mechanism to explain the well-validated link between obesity and illness severity in BD.

Association of obesity and treated hypertension and diabetes with cognitive ability in bipolar disorder and schizophrenia

OBJECTIVES

People with bipolar disorder or schizophrenia are at greater risk for obesity and other cardio-metabolic risk factors, and several prior studies have linked these risk factors to poorer cognitive ability. In a large ethnically homogenous outpatient sample, we examined associations among variables related to obesity, treated hypertension and/or diabetes and cognitive abilities in these two patient populations.

METHODS

In a study cohort of outpatients with either bipolar disorder (n = 341) or schizophrenia (n = 417), we investigated the association of self-reported body mass index and current use of medications for hypertension or diabetes with performance on a comprehensive neurocognitive battery. We examined sociodemographic and clinical factors as potential covariates.

RESULTS

Patients with bipolar disorder were less likely to be overweight or obese than patients with schizophrenia, and also less likely to be prescribed medication for hypertension or diabetes. However, obesity and treated hypertension were associated with worse global cognitive ability in bipolar disorder (as well as with poorer performance on individual tests of processing speed, reasoning/problem-solving, and sustained attention), with no such relationships observed in schizophrenia. Obesity was not associated with symptom severity in either group.

CONCLUSIONS

Although less prevalent in bipolar disorder compared to schizophrenia, obesity was associated with substantially worse cognitive performance in bipolar disorder. This association was independent of symptom severity and not present in schizophrenia. Better understanding of the mechanisms and management of obesity may aid in efforts to preserve cognitive health in bipolar disorder.

The presentation, recognition and management of bipolar depression in primary care

Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.

Primary prevention of cardiovascular events in patients with major mental illness: a possible role for statins

OBJECTIVES

To examine the need for and the possible benefits and risks of statin therapy in patients with major mental illness.

METHODS

Patients with psychiatric conditions, especially those with major mental illnesses such as schizophrenia and bipolar disorder, are at increased risk of overweight, obesity, dyslipidemia, diabetes mellitus, and the metabolic syndrome, all of which increase the risk of cardiovascular disease, cerebrovascular disease, and mortality. The literature on the subject was qualitatively reviewed.

RESULTS

Primary prevention benefits with statins are well known in the general population of high-risk patients; recent evidence suggests that statins also carry primary prevention benefits in low-risk subjects. Regrettably, the primary prevention of cardiovascular and cerebrovascular events in psychiatry is a neglected area in clinical practice as well as in interventional research, whether in high- or in low-risk patients. Initial concerns notwithstanding, psychiatric complications do not appear to be important among the adverse effects of statins. Although statins are associated with an increased risk of incident diabetes mellitus, myopathy, and other untoward consequences, the risk-benefit ratio appears to favor statin use. The advisability of using statins in low-risk or medically healthy subjects remains debatable.

CONCLUSIONS

Overweight, obesity, dyslipidemia, diabetes mellitus, and the metabolic syndrome are common in patients with major mental illness, and these increase the risk of medical morbidity and mortality. Statin use should therefore be considered for the primary prevention of cardiovascular and cerebrovascular events in psychiatric patients, especially in those at high risk.

Obesity and bipolar disorder: synergistic neurotoxic effects?

Bipolar disorder (BD) is a disabling and chronic neuropsychiatric disorder that is typified by a complex illness presentation, episode recurrence and by its frequent association with psychiatric and medical comorbidities. Over the past decade, obesity has emerged as one of many comorbidities generating substantial concern in the BD population due to important prognostic implications. This comprehensive review details the bidirectional relationship between obesity and BD as evidenced by alterations in the structure and function of the central nervous system, in addition to greater depressive recurrence, cognitive dysfunction and risk of suicidality. Drawing on current research results, this article presents several putative mechanisms underlying the synergistic toxic effects and provides a framework for future treatment options for the obesity-BD comorbidity. There is a need for more large-scale prospective studies to investigate the bidirectional relationships between obesity and BD.

Clinical phenotype of bipolar disorder with comorbid binge eating disorder

BACKGROUND

To explore the relationship between binge eating disorder (BED) and obesity in patients with bipolar disorder (BP).

METHODS

717 patients participating in the Mayo Clinic Bipolar Biobank completed structured diagnostic interviews and questionnaires for demographic and illness-related variables. They also had weight and height measured to determine body mass index (BMI). The effects of BED and obesity (BMI≥30 kg/m(2)), as well as their interaction, were assessed on one measure of general medical burden and six proxies of psychiatric illness burden.

RESULTS

9.5% of patients received a clinical diagnosis of BED and 42.8% were obese. BED was associated with a significantly elevated BMI. Both BED and obesity were associated with greater psychiatric and general illness burden, but illness burden profiles differed. After controlling for obesity, BED was associated with suicidality, psychosis, mood instability, anxiety disorder comorbidity, and substance abuse comorbidity. After controlling for BED status, obesity was associated with greater general medical comorbidity, but lower substance abuse comorbidity. There were no significant interaction effects between obesity and BED, or BMI and BED, on any illness burden outcome.

LIMITATIONS

There may have been insufficient power to detect interactions between BED and obesity.

CONCLUSIONS

Among patients with BP, BED and obesity are highly prevalent and correlated, but associated with different profiles of enhanced illness burden. As the association of BED with greater psychiatric illness burden remained significant even after accounting for the effect of obesity, BP with BED may represent a clinically important sub-phenotype.

Selfish brain and neuroprogression in bipolar disorder

Bipolar disorder is associated with increases in mortality rates due to metabolic complications when compared to the general population. The "selfish brain" theory postulates that the CNS modulates energy metabolism in the periphery in order to prioritize its own demand and offers an heurist value framework to understand how and why metabolic abnormalities develop in the course of BD. Mood episodes, especially those of manic polarity are neurotoxic, because of the acute release of the neurotransmitters dopamine and glutamate, oxidative species, inflammatory cytokines and the deprivation of neuroprotective factors, such as neurotrophins. The cell loss and malfunctioning require from the brain an extra effort to repair itself, which will demand energetic supplies. Application of "selfish brain" theory in BD can potentially offer new insights about how to prevent and treat metabolic complications in BD.

Development of the International Classification of Functioning, Disability and Health core sets for bipolar disorders: results of an international consensus process

PURPOSE

The International Classification of Functioning, Disability and Health (ICF) is a tool of the World Health Organization (WHO) designed to be a guide to identify and classify relevant domains of human experience affected by health conditions. The purpose of this article is to describe the process for the development of two Core Sets for bipolar disorder (BD) in the framework of the ICF. The Comprehensive ICF Core Set for BD intends to be a guide for multidisciplinary assessment of patients diagnosed with this condition, while the Brief ICF Core Set for BD will be useful when rating aspects of patient's experience for clinical practice or epidemiological studies.

METHODS

An international consensus conference involving a sample of experts with different professional backgrounds was performed using the nominal group technique. Various preparatory studies identified a set of 743 potential ICF categories to be included in the Core Sets.

RESULTS

A total of 38 ICF categories were selected to be included in the Comprehensive Core Set for BD. A total of 19 ICF categories from the Comprehensive Core Set were chosen as the most significant to constitute the Brief Core Set for BD.

CONCLUSIONS

The formal consensus process integrating evidence and expert opinion on the ICF led to the formal adoption of the ICF Core Sets for BD. The most important categories included are representative of the characteristics usually associated with BD. The next phase of this ICF project is to conduct a formal validation process to establish its applicability in clinical settings. Implications for Rehabilitation Bipolar disorder (BD) is a prevalent condition that has a great impact on people who suffer it, not only in health but also in daily functioning and quality of life. No standard has been defined so far regarding the problems in functioning of persons with BDs. The process described in this article defines the set of areas of functioning to be addressed in clinical assessments of persons with BD and establish the starting point for the development of condition-specific outcome measures.

Psychiatric disorders of patients seeking obesity treatment

BACKGROUND

Obese and overweight people have a higher risk of both chronic physical illness and mental illness. Obesity is reported to be positively associated with psychiatric disorders, especially in people who seek obesity treatment. At the same time, obesity treatment may be influenced by psychological factors or personality characteristics. This study aimed to understand the prevalence of mental disorders among ethnic Chinese who sought obesity treatment.

METHODS

Subjects were retrospectively recruited from an obesity treatment center in Taiwan. The obesity treatments included bariatric surgery and non-surgery treatment. All subjects underwent a standardized clinical evaluation with two questionnaires and a psychiatric referral when needed. The psychiatric diagnosis was made thorough psychiatric clinic interviews using the SCID. A total of 841 patients were recruited. We compared the difference in psychiatric disorder prevalence between patients with surgical and non-surgical treatment.

RESULTS

Of the 841 patients, 42% had at least one psychiatric disorder. Mood disorders, anxiety disorders and eating disorders were the most prevalent categories of psychiatric disorders. Females had more mood disorders and eating disorders than males. The surgical group had more binge-eating disorder, adjustment disorder, and sleep disorders than the non-surgical group.

CONCLUSION

A high prevalence of psychiatric disorders was found among ethnic Chinese seeking obesity treatment. This is consistent with study results in the US and Europe.