International Society for Bipolar Disorders Task Force on Suicide: meta-analyses and meta-regression of correlates of suicide attempts and suicide deaths in bipolar disorder

Distinct patterns of altered quantitative T1ρ and functional BOLD response associated with history of suicide attempts in bipolar disorder

Despite the high risk for suicide, relatively few studies have explored the relationship between suicide and brain imaging measures in bipolar disorder. In addition, fewer studies have explored the possibility that altered brain metabolism may be associated with suicide attempt. To begin to fill in these gaps, we evaluated functional (task based fMRI) and metabolic (quantitative T1ρ) differences associated with suicide attempt in participants with bipolar disorder. Thirty-nine participants with bipolar disorder underwent fMRI during a flashing checkerboard task and 27 also underwent quantitative T1ρ. The relationship between neuroimaging and history of suicide attempt was tested using multiple regression while adjusting for age, sex, and current mood state. Differences between two measures of suicide attempt (binary: yes/no and continuous: number of attempts) were quantified using the corrected Akaike Information Criterion. Participants who had attempted suicide had greater fMRI task-related activation in visual areas and the cerebellum. The number of suicide attempts was associated with a difference in BOLD response in the amygdala, prefrontal cortex, and cerebellum. Increased quantitative T1ρ was associated with number of suicide attempts in limbic, basal ganglia, and prefrontal cortex regions. This study is a secondary analysis with a modest sample size. Differences between measures of suicide history may be due to differences in statistical power. History of suicide was associated with limbic, prefrontal, and cerebellar alterations. Results comparing those with and without suicide attempts differed from results using number of suicide attempts, suggesting that these variables have different neurobiological underpinnings.

Decreasing rate of inpatient pediatric bipolar disorder diagnosis in the US between 2004 and 2010

OBJECTIVES

Diagnosis of bipolar disorder (BD) increased substantially among youth between the mid-1990s and mid-2000s in the United States. This dramatic increase in diagnosis resulted in concern regarding the potential for misdiagnosis of BD among youth. However, the rate of BD diagnosis in the United States had not been evaluated nationally since the mid-2000s. It was unclear whether changes in diagnostic rates continued to occur. Therefore, the present study aimed to assess the pattern of longitudinal trends in the rate of national inpatient BD diagnosis subsequent to 2004.

METHODS

Data included a nationally representative dataset of inpatient hospitalizations between 1996 and 2010. De-identified data were obtained from the National Hospital Discharge Survey (NHDS) conducted annually by the National Center for Health Statistics.

RESULTS

The proportion of BD diagnoses relative to all psychiatric diagnoses increased between 1996 and 2004 among children and adolescents. The proportion of BD diagnoses then decreased between 2004 and 2010 among children but continued to increase for adolescents. However, population-adjusted rates of BD diagnosis per 10,000 individuals in the general population initially increased until the mid-2000s and then decreased until 2010 for both children and adolescents.

CONCLUSIONS

Rates of BD diagnosis substantially decreased for youth between the mid-2000s and 2010. This decline coincided with recommendations for more conservative diagnostic practices due to concerns about overdiagnosis and increasing awareness of the side effects of front-line medications used to treat BD in youth. Findings provide insight into changing trends in inpatient service utilization for BD in the United States.

Dissecting the genetic architecture of suicide attempt and repeated attempts in Korean patients with bipolar disorder using polygenic risk scores

BACKGROUND

Bipolar disorder (BD) has the greatest suicide risk among mental and physical disorders. A recent genome-wide association study (GWAS) of European ancestry (EUR) samples revealed that the genetic etiology of suicide attempt (SA) was not only polygenic but also, in part, diagnosis-specific. The authors aimed to examine whether the polygenic risk score (PRS) for SA derived from that study is associated with SA or repeated attempts in Korean patients with BD. This study also investigated the shared heritability of SA and mental disorders which showed an increased risk of SA and a high genetic correlation with BD.

METHODS

The study participants were 383 patients with BD. The history of SA was assessed on a lifetime basis. PRSs for reference disorders were calculated using the aforementioned GWAS data for SA and the Psychiatric Genomics Consortium data of BD, schizophrenia, major depressive disorder (MDD), and obsessive-compulsive disorder (OCD).

RESULTS

The PRS for SA was significantly associated with lifetime SA in the current subjects (Nagelkerke's R2 = 2.73%, odds ratio [OR] = 1.36, p = 0.007). Among other PRSs, only the PRS for OCD was significantly associated with lifetime SA (Nagelkerke's R2 = 2.72%, OR = 1.36, p = 0.007). The PRS for OCD was higher in multiple attempters than in single attempters (Nagelkerke's R2 = 4.91%, OR = 1.53, p = 0.043).

CONCLUSION

The PRS for SA derived from EUR data was generalized to SA in Korean patients with BD. The PRS for OCD seemed to affect repeated attempts. Genetic studies on suicide could benefit from focusing on specific psychiatric diagnoses and refined sub-phenotypes, as well as from utilizing multiple PRSs for related disorders.

Application of machine learning in diagnostic value of mRNAs for bipolar disorder

PURPOSE

Bipolar disorder (BD) is a type of severe mental illness with symptoms of mania or depression, it is necessary to find out effective diagnostic biomarkers for BD due to diagnosing BD is based on clinical interviews without objective indicators.

MATERIALS AND METHODS

The mRNA expression levels of genes included PIK3R1, FYN, TP53, PRKCZ, PRKCB, and YWHAB in the peripheral blood of 43 patients with bipolar disorder and 47 healthy controls were detected. Machine learning methods included Artificial Neural Networks, Extreme Gradient Boosting, Random Forest, and Support Vector Machine were adopted to fit different gene combinations to evaluate diagnostic value for bipolar disorder.

RESULTS

The combination 'PIK3R1 + FYN' in the SVM model showed the best diagnostic value, with AUC, sensitivity, and specificity values of 0.951, 0.928, and 0.937, respectively.

CONCLUSIONS

The diagnostic efficiency for bipolar disorder was significantly improved by fitting PIK3R1 and FYN through the Support Vector Machine model.

Auditory mismatch negativity in bipolar disorder: a focused review

The auditory mismatch negativity, a component of the event-related potential elicited by an unexpected stimulus in a sequence of acoustic stimuli, provides an objective measure of the accuracy of the echoic information processing of the human brain in vivo. Auditory mismatch negativity is also a useful probe of cortical glutamatergic N-methyl-d-aspartate receptor activity and disturbance. Notably, auditory mismatch negativity is consistently impaired in schizophrenia. Because of the wide spectrum extending from bipolar affective illness and schizoaffective psychosis to typical schizophrenia, we examined the literature on auditory mismatch negativity in bipolar disorder with the aim to find any neurophysiological dysfunction concerning pre-attentive information processing shared by these clinical conditions. This focused review includes 26 original articles published in peer-reviewed journals and indexed in the National Institutes of Health National Library of Medicine (PubMed) search system. Overall, evidence is consistent with the finding that auditory mismatch negativity is impaired in bipolar disorder with psychotic features, even though to a lesser extent than in schizophrenia. It must be acknowledged that, in a few twin and family studies, mismatch negativity abnormalities were not specifically associated with bipolar disorder. In conclusion, auditory mismatch negativity research supports the involvement of the N-methyl-d-aspartate system in the pathophysiology of bipolar disorder, as previously assessed for schizophrenia, thus creating an intriguing trait d'union between these two mental illnesses and stimulating the development of novel therapeutic agents. With additional replication and validation, auditory mismatch negativity may be further considered as a correlate of a common psychopathology of schizophrenia and bipolar spectrum illnesses.

Influence of childhood maltreatment on prevalence, onset and persistence of psychiatric comorbidities and suicide attempts in bipolar disorders

Background

Methods

Results

Conclusions

Suicide Attempts Among Racial and Ethnic Groups in a Nationally Representative Sample

OBJECTIVE

Evaluate suicide attempt prevalence and potentially related sociodemographic and psychiatric factors among racial and ethnic groups.

METHODS

Between 2012 and 2013, the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) conducted semi-structured interviews with 36,309 adults in the USA. We identified lifetime suicide attempt prevalence and significant predictors for each racial/ethnic group using stratified logistic regressions. Analyses were exploratory without a priori hypotheses.

RESULTS

Asian/Native Hawaiian/other Pacific Islander and Black individuals had the lowest prevalence of suicide attempts while Alaska Native/American Indian and White individuals had the highest prevalence. Identifying as female and meeting criteria for psychiatric diagnoses featuring mood regulation difficulties (depression, borderline personality disorder, bipolar I disorder) were consistently related to a suicide attempt history across racial and ethnic groups, whereas substance abuse disorders and other sociodemographic factors differed between racial and ethnic groups in their associations with suicide attempt history.

CONCLUSIONS

Although several factors were consistently related to suicide risk across racial and ethnic groups, the prevalence of suicide attempts and overall pattern of related factors were not uniform between racial and ethnic groups.

POLICY IMPLICATIONS

Study findings highlight the importance of considering suicide risk within the context of race and ethnicity both regarding the overall prevalence of risk and in determining personal factors associated with elevated risk. A failure to appreciate experiences related to race and ethnicity may adversely impact suicide risk assessment and treatment, ultimately contributing to health disparities. Results suggest that additional research is warranted.

Ten-year course of treated bipolar I disorder: The role of polarity at onset

INTRODUCTION

Early-stage predictors of illness course are needed in bipolar disorder (BD). Differences among patients with a first depressive versus maniac/hypomanic episode have been stated, although in most studies, memory bias and time from onset to start of specialized treatment might interfere. The aim was to compare the first 10 years of illness course according to polarity at onset.

METHODS

49 type I BD patients admitted for treatment for a first-time affective episode and a following 10-year attendance to the institution were included. A retrospective year by year comparison according to polarity at onset (depressive (DPO) or maniac (MPO)) was performed. Cramer's V and Cohen d were computed to determine effect size.

RESULTS

59.2% (n = 29) started with MPO. Both groups were similar in demographic and social outcome characteristics, clinical features, and treatment variables. Patients with DPO reported more depressive episodes than MPO patients (U = 149.0 p < .001, Cohen's d = 0.87); both groups had a similar number of manic episodes. Only during the first year of follow-up, suicide attempts (SA) were more frequent in patients with DPO while the presence of a psychotic episode and psychiatric hospitalizations were more frequent in the MPO group.

CONCLUSION

According to these findings, it can be concluded that illness onset is only indicative of depressive predominant polarity but is not related to other poor prognostic variables after the first year of illness onset, in treated BD. SA in the first year of an affective disorder could represent a marker of BD.

Interactions and implications of Fuzzy-Trace theory for risk taking behaviors in bipolar disorder

BACKGROUND

According to Fuzzy-Trace Theory (FTT), qualitative, bottom-line, "gist" reasoning leads to less risk taking and more mature decision-making, less easily swayed by emotions than quantitative, detail-oriented, "verbatim" reasoning. In Bipolar disorder deleterious risky behaviors are common. Prior research confirmed the relationships posited between FTT and risk taking. We aim to understand whether FTT acts upon risk taking in the manner proposed in the FTT framework, namely, that (a) gist "values" mediate the role of "categorical gist". Furthermore, the roles of mania and impulsivity, cited as factors for risk-taking, remain to be clarified. In this study, we investigate if (b) manic symptoms and impulsivity moderate these relationships.

METHODS

Participants (N = 105) completed an online survey including demographics, clinical variables, symptomatology, FTT, risk taking and risk perception.

RESULTS

Mediational models indicated that (a) Gist Values mediated Categorical Gist's effect on risk taking, as expected by the FTT framework. (b) Impulsivity moderates risk taking, but manic-type symptomatology does not.

LIMITATIONS

Voluntary, self-report surveys may have low participant motivation and limit the diagnostic validity and the inpatient generalizability of the results.

CONCLUSIONS

The results move beyond a focus on mood-related aspects of Bipolar disorder and confirm the importance of understanding reasoning processes like FTT in combination with impulsivity, as potential behavioral factors of risk taking in Bipolar disorder. The clarifications on FTT's functioning as a mechanism prescribe possible openings for more efficacious reduction of risky behaviors through behavioral interventions focusing on value creation.

Comparison of Clinical Features of Bipolar Disorder Patients with and without Psychiatric Comorbidity

OBJECTIVE

Bipolar disorder (BPD) is a psychiatric condition that often manifests together with Axis-I comorbidity. Comorbidity of psychiatric disorders influences the recognition, prognosis, and treatment of the disorder, posing difficulties for the patient and physician. This study aims at identifying Axis-I comorbidities and their characteristics in patients with BPD.

MATERIALS AND METHODS

This retrospective study included 255 patients diagnosed with BPD according to the DSM-IV. Comorbidities were determined using the SCID-I, a semistructured sociodemographic data form developed by the authors, and a mood chart assessing clinical aspects. The patients were divided into 2 groups, those with and without comorbidity, and compared.

RESULTS

Out of these 255 patients, 35% was found to have a current and 84.3% a lifelong comorbid psychiatric disorder. About 33.1% of these patients had 1, 11.3% had 2, and 8.8% had more than 2 comorbid disorders. At least one comorbid anxiety disorder was found in 38.7% of the patients. Obsessive and compulsive disorder (OCD) being the most common comorbid psychiatric disorder, followed by social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), and generalized anxiety disorder (GAD). Comparing the clinical parameters between the 2 groups due to the presence of psychiatric comorbidity in the BD patients, there were statistically significant differences in terms of the number of depressive episodes (P = .041) and mania/hypomania (P = .048), and the need for antipsychotic monotherapy (P = .007) and antidepressants (P = .001) for prophylaxis between the 2 groups.

CONCLUSION

Axis-I psychiatric disorders and particularly OCD and anxiety disorders accompanying BPD prevail at a high rate. The presence of comorbid psychiatric disorder in BPD may negatively affect the clinical prognosis of the condition; therefore, this area requires more study and careful investigation.

Acute and Maintenance Treatment of Bipolar Depression

The World Health Organization reported a lifetime prevalence of 2.4% for BD-I, BD-II and sub-threshold types of bipolar disorder (BD). Depressive episodes are more common than manic episodes for many BD patients. Studies show that depressive mood persists in 2/3 of life, even if they are under treatment. It may be difficult to diagnose BD in the event of depression in the first episode. The correct diagnosis and the treatment can be delayed for 6-8 years, and even longer if disorder starts in adolescence. It is reported that 40% of the patients who were initially diagnosed as unipolar were later diagnosed as BD. The features that enable us to diagnose BD depressive episode: 1) family history of BD or psychosis 2) early onset with depression 3) cyclothymic temperament characteristics 4) four or more depressive episodes in 10 years 5) agitation, anger, insomnia, irritability, excessive talkativeness or other 'mixed' or hypomanic features or psychotic symptoms during depressive episode, 6) clinical 'worsening' caused by the appearance of mixed symptoms after AD treatment 7) suicidal thoughts and attempts 8) substance abuse 9) hypersomnia in the depressive episode or sleeping too much during the day, overeating, psychomotor agitation. The number of studies conducted on BD depressive treatment is limited, the information was obtained by excluding this group from the studies or by compiling the information obtained from the treatment of unipolar depression. In this review, acute and maintenance treatment of the depressive episodes of BD will be discussed according to the treatment algorithms.

Suicide prevention in psychiatric patients

An increased risk of suicide has been reported for psychiatric patients. In several world regions, an underlying psychiatric disorder is reported in up to 90% of people who die from suicide, though this rate seems to be considerably lower in low- and middle-income countries. Major psychiatric conditions associated with suicidality are mood disorders, alcohol and substance use disorders, borderline personality disorder, and schizophrenia. Comorbidity between different disorders is frequently associated with a higher suicide risk. A history of suicide attempts, feelings of hopelessness, impulsivity and aggression, adverse childhood experiences, severe psychopathology, and somatic disorders are common risk factors for suicide among psychiatric patients. Stressful life events and interpersonal problems, including interpersonal violence, are often triggers. A comprehensive and repeated suicide risk assessment represents the first step for effective suicide prevention. Particular attention should be paid during and after hospitalization, with the first days and weeks after discharge representing the most critical period. Pharmacological treatment of mood disorders and schizophrenia has been shown to have an anti-suicidal effect. A significant reduction of suicidal thoughts and behavior has been reported for cognitive behavioral therapy and dialectical behavior therapy. Brief interventions, including psychoeducation and follow-ups, are associated with a decrease in suicide deaths. Further development of suicide prevention in psychiatric patients will require a better understanding of additional risk and protective factors, such as the role of a person's decision-making capacity and social support, the role of spiritual and religious interventions, and the reduction of the treatment gap in mental health care.

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

Background

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

Methods

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

Results

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

Conclusion

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

A Systematic Review of the Clinical Use of Gabapentin and Pregabalin in Bipolar Disorder

Despite its prevalence and disease burden, several chasms still exist with regard to the pharmacotherapy of bipolar disorder (BD). Polypharmacy is commonly encountered as a significant proportion of patients remain symptomatic, and the management of the depressive phase of the illness is a particular challenge. Gabapentin and pregabalin have often been prescribed off-label in spite of a paucity of evidence and clinical practice guidelines to support its use. This systematic review aimed to synthesize the available human clinical trials and inform evidence-based pharmacological approaches to BD management. A total of six randomized, controlled trials (RCTs) and 13 open-label trials involving the use of gabapentin and pregabalin in BD patients were reviewed. Overall, the studies show that gabapentin and its related drug pregabalin do not have significant clinical efficacy as either monotherapy or adjunctive therapy for BD. Gabapentin and pregabalin are probably ineffective for acute mania based on the findings of RCT, with only small open-label trials to support its potential adjunctive role. However, its effects on the long-term outcomes of BD remain to be elucidated. The evidence base was significantly limited by the generally small sample sizes and the trials also had heterogeneous designs and generally high risk of bias.

Older Age Bipolar Disorder

Further understanding of older age bipolar disorder (OABD) may lead to more specific recommendations for treatment adjusted to the specific characteristics and needs caused by age-related somatic and cognitive changes. Late-onset mania has a broad differential diagnosis and requires full psychiatric and somatic work-up, including brain imaging. Research on pharmacotherapy in OABD is limited. First-line treatment of OABD is similar to that for adult bipolar disorder (BD), with specific attention to vulnerability to side effects and somatic comorbidity. Because findings in younger adults with BD cannot be extrapolated to OABD, more research in OABD is warranted.

Clozapine for Treatment-Refractory Aggressive Behavior

Emergency psychiatry has the main role of resolving suicidal behavior and aggression. These severe psychiatric symptoms can be found in many psychiatric disorders such as schizophrenia, bipolar disorder, major depression, personality disorders, cognitive disorders, intellectual disability and substance abuse. Although indications for the use of antipsychotics are limited to a specific group of diseases, they are frequently used as rescue medication in high-risk or nonresponsive cases. Clozapine, the gold standard for TRS (treatment resistant schizophrenia) is effective in controlling aggression. The aim of the research was to identify the use of clozapine for treatment-refractory aggressive behavior in psychiatric emergency. A retrospective study based on the paper files of patients admitted between 2010 and 2019 in the Clinical Hospital of Psychiatry and Neurology of Brasov, Romania. Were included all the patients admitted as a psychiatric emergency and treated with clozapine for aggressive behavior. The hospital is an academic institution with 150 beds for acute patients, serving an area of over 600,000 inhabitants. It is the main public institution where patients with psychiatric emergencies are hospitalized. Off 19,000 patients admitted during the study period, 504 patients (2,4%) with a diagnosis other than schizophrenia or schizoaffective disorder received clozapine for aggressiveness (89.5%). The first four diagnoses identified were bipolar disorder (n = 172), intellectual disability (n = 128), cognitive impairment (n = 112), and personality disorder (n = 92). Other disorders identified but with a smaller number of cases were major depressive disorder (n = 3), adjustment disorders (n = 2), delusional disorder (n = 2), obsessive compulsive disorder (n = 2) and postpartum psychosis (n = 1). Clozapine was used as 3rd or 4th choice. The dose was greater for manic patients (350.29 ± 98.01 mg/day) compared with all the other diagnoses. Clozapine was effective and safe in cases of patients with treatment-refractory aggressive behavior.

History of suicide attempts in patients with bipolar disorder type I: socio-demographic and clinical factors, quality of life and functioning

INTRODUCTION

This study aims to evaluate sociodemographic and clinical factors, quality of life (QoL) and functioning associated with history of suicide attempts (SA) in a sample of bipolar disorder (BD) type I patients.

METHODS

A total of 417 BD type I patients, with and without history of SA were recruited from two Brazilian specialized Mood Disorder Centers. They were assessed with a sociodemographic and clinical questionnaire, the Young Mania Rating Scale, the Hamilton Depression Rating Scale, the Structured Clinical Interviews for DSM-IV Axis I Disorders, the World Health Organization Quality of Life-BREF, and the Sheehan Disability Scale.

RESULTS

One hundred and seventy-nine (42.9%) patients had a history of SA. There were no statistically significant sociodemographic differences between BD patients with and without a history of SA. Logistic regression found that lifetime hospitalization, comorbid anxiety disorders, depressive polarity in the first episode, current intensity of depressive symptoms, history of rapid cycling, family history of suicide and age at onset were significantly associated with SA in BD. Multiple linear regression showed that SA had no effect on QoL and functioning, which were affected mainly by comorbid anxiety disorders and current intensity of depressive symptoms, even in patients considered euthymic.

CONCLUSION

Suicidal behavior in patients with BD is a complex phenomenon and reflects a more severe course of illness. Patients with history of SA may have worse QoL and functional impairment not because of its direct effect, but because of the greater association with clinical factors related to poor prognosis.

Preventive effect of morning light exposure on relapse into depressive episode in bipolar disorder

OBJECTIVE

Light therapy has been suggested to have a curative effect on bipolar depression; however, preventive effects of light exposure on depressive episodes remain unclear. This study evaluated whether daytime light exposure in real-life situations was associated with a preventive effect on relapse into depressive episodes in patients with bipolar disorder.

METHODS

This prospective, naturalistic, observational study was conducted in Japan between August 2017 and June 2020. Outpatients with bipolar disorder were objectively evaluated for daytime light exposure over 7 consecutive days using an actigraph that could measure ambient light at baseline assessment and then assessed at 12-month follow-up for relapse into mood episodes.

RESULTS

Of 202 participants, 198 (98%) completed follow-up at 12 months and 78 (38%) experienced relapse into depressive episodes during follow-up. In a Cox proportional hazards model adjusting for potential confounders, a longer time above 1000 lux at daytime was significantly associated with decrease in relapse into depressive episodes (per log min; hazard ratio, 0.66; 95% confidence interval, 0.50-0.91). In addition, a higher average illuminance and longer time above 1000 lux in the morning exhibited a significant decrease in relapse into depressive episodes (per log lux and per log min; hazard ratio, 0.65 and 0.61; 95% confidence interval, 0.49-0.86 and 0.47-0.78, respectively). The association between daytime light exposure and relapse into manic/hypomanic/mixed episodes was not significantly different.

CONCLUSION

A significant association was observed between increased daytime light exposure, mainly in the morning, and decreased relapse into depressive episodes.

Clinical Differences between Bipolar Disorder and Borderline Personality Disorder: A Case Report

The clinical difference between bipolar disorder and borderline personality disorder has always been a diagnostic challenge, especially with type II bipolar disorder and subthreshold symptoms, opening a diagnostic bias with the consequent repercussions of inappropriate treatment. Both pathologies are often misdiagnosed initially. The objective of this article is to emphasise the main clinical differences between the two pathologies. We present the case of a patient with a long history of psychiatric symptoms that started in childhood, with considerable functional impairment, who met the criteria for both disorders, pointing to comorbidity. During follow-up, she responded favourably to psychotropic drugs, pushing the diagnosis towards the bipolar spectrum, due to the notable improvement. However, comorbidity should not be neglected due to its high presentation.

Temporal dynamics alterations of spontaneous neuronal activity in anterior cingulate cortex predict suicidal risk in bipolar II patients

Bipolar disorder type II (BD-II) is linked to an increased suicidal risk. Since a prior suicide attempt (SA) is the single most important risk factor for sequent suicide, the elucidation of involved neural substrates is critical for its prevention. Therefore, we examined the spontaneous brain activity and its temporal variabilities in suicide attempters with bipolar II during a major depressive episode. In this cross-sectional study, 101 patients with BD-II, including 44 suicidal attempters and 57 non-attempters, and 60 non-psychiatric controls underwent a resting-state functional magnetic resonance imaging (fMRI). Participants were assessed with Hamilton Rating Scale for Depression (HAMD) and Nurses^, Global Assessment of Suicide Risk (NGASR). The dynamics of low-frequency fluctuation (dALFF) was measured using sliding-window analysis and its correlation with suicidal risk was conducted using Pearson correlation. Compared to non-attempters, suicidal attempters showed an increase in brain activity and temporal dynamics in the anterior cingulate cortex (ACC). In addition, the temporal variabilities of ACC activity positively correlated with suicidal risk (R = 0.45, p = 0.004), while static ACC activity failed to (R = 0.08, p > 0.05). Our findings showed that an aberrant static ALFF and temporal variability could affect suicidal behavior in BD-II patients. However, temporal variability of neuronal activity was more sensitive than static amplitude in reflecting diathesis for suicide in BD-II. Dynamics of brain activity could be considered in developing neuromarkers for suicide prevention.

Differentiating between bipolar and unipolar depression using prefrontal activation patterns: Promising results from functional near infrared spectroscopy (fNIRS) findings

BACKGROUND

Bipolar depression (BD) is a unique, severe and prevalent mental illness that shares many similarities in symptoms with unipolar depression (UD). Improving precision of their diagnoses would enhance treatment outcome and prognosis for both conditions. This study aims to provide evidence from functional Near-Infrared Spectroscopy (fNIRS) as a potential tool to differentiate UD and BD based on their differences in hemodynamic change in the prefrontal cortex during verbal fluency tasks (VFT).

METHODS

We enrolled 179 participants with clinically confirmed diagnoses, including 69 UD patients, 68 BD patients and 42 healthy controls(HC). Every participant was assessed using a 45-channel fNIRS and various clinical scales.

FINDINGS

Compared with HC, region-specific fNIR leads show UD patients had significant lower hemodynamic activation in 4 particular pre-frontal regions: 1) the left dorsolateral prefrontal cortex (DLPFC), 2) orbitofrontal cortex (OFC), 3) bilateral ventrolateral prefrontal cortex (VLPFC) and 4) left inferior frontal gyrus (IFG). In contrast, BD vs. HC comparisons showed only significant lower hemodynamic activation in the LIFG area. Furthermore, compared to BD patients, UD patients showed decreased hemodynamic activation changes in the VLPFC region.

CONCLUSION

Our results show significant frontal lobe activation pattern differences between UD and BD groups. fNIRS can be a potential tool to increase diagnostic precision for these conditions. In particular, the VLPFC area holds promise to be a useful site for such differentiation for further investigations.

Prevention of suicidal behavior in bipolar disorder

BACKGROUND

Excess mortality is a critical hallmark of bipolar disorder (BD) due to co-occurring general medical disorders and especially from suicide. It is timely to review of the status of suicide in BD and to consider the possibility of limiting suicidal risk.

METHODS

We carried out a semi-systematic review of recent research reports pertaining to suicide in BD.

FINDINGS

Suicide risk in BD is greater than with most other psychiatric disorders. Suicide rates (per 100,000/year) are approximately 11 and 4 in the adult and juvenile general populations, but over 200 in adults, and 100 among juveniles diagnosed with BD. Suicide attempt rates with BD are at least 20 times higher than in the adult general population, and over 50 times higher among juveniles. Notable suicidal risk factors in BD include: previous suicidal acts, depression, mixed-agitated-dysphoric moods, rapid mood-shifts, impulsivity, and co-occurring substance abuse. Suicide-preventing therapeutics for BD remain severely underdeveloped. Evidence favoring lithium treatment is stronger than for other measures, although encouraging findings are emerging for other treatments.

CONCLUSIONS

Suicide is a leading clinical challenge for those caring for BD patients. Improved understanding of risk and protective factors combined with knowledge and close follow-up of BD patients should limit suicidal risk. Ethically appropriate and scientifically sound studies of plausible medicinal, physical, and psychosocial treatments aimed at suicide prevention specifically for BD patients are urgently needed.

Comparisons between suicide in persons with serious mental illness, other mental disorders, or no known mental illness: Results from 37 U.S. states, 2003-2017

BACKGROUND

Suicide is a leading cause of death in persons with schizophrenia and other serious mental illnesses (SMI), however, little is known about the characteristics and circumstances of suicide decedents with SMI in the US compared to those with other or no known mental illness.

METHODS

This study was a retrospective analysis of suicide deaths in individuals aged ≥18 years from the National Violent Death Reporting System, 2003-2017. Odds ratios compared sociodemographic and clinical characteristics, cause of death, precipitating circumstances, and post-mortem toxicology results. All analyses were stratified by gender.

RESULTS

Of the 174,001 suicide decedents, 8.7% had a known SMI, 33.0% had other mental disorders, and 58.2% had no known mental illness. Relative to persons with other mental disorders, SMI decedents were younger and more likely to have previous suicide attempts and co-occurring drug use. Problems with intimate partners, poor physical health, and recent institutional release were the most common precipitating circumstances for SMI decedents. Firearms were the most common suicide method for males with SMI. Although 67.0% male and 76.0% of female SMI decedents were currently in treatment, toxicology results suggest many were not taking antipsychotic or antidepressant medications at the time of death.

CONCLUSIONS

Persons with SMI are over-represented in suicide deaths. Efforts to improve treatment of co-occurring substance use disorders, continuity of care following hospitalization, medication adherence, and to reduce access to firearms are important suicide prevention strategies.

Effects of psychological and pharmacological interventions on anxiety symptoms in patients with bipolar disorder in full or partial remission: A systematic review

BACKGROUND

Anxiety symptoms are prevalent in bipolar disorder (BD) even during periods of remission and impede treatment efficacy, prognosis and functional capacity. This highlights a pressing clinical need to identify novel effective anxiety treatments. This systematic review aimed to evaluate the evidence within the field.

METHODS

Following PRISMA guidelines, we conducted a systematic search on PubMed, PsycInfo, EMBASE and Cochrane Library for randomised controlled trials (RCTs) targeting anxiety in remitted BD patients.

RESULTS

We identified 10 RCTs investigating the effects of psychological or pharmacological treatments on anxiety in remitted BD patients. Two studies of transdiagnostic personalised cognitive behavioural therapy (CBT) found a treatment-related reduction in anxiety. This evidence was preliminary given small sample size and use of self-report measures in a single-blind trial design, respectively. The remaining six psychological intervention trials provided more preliminary evidence due to several methodological challenges. The two pharmacological studies found anxiolytic effects of add-on olanzapine or methylene blue to lithium treatment, respectively. Nevertheless, this evidence should be interpreted with caution given high drop-out rates and substantial side-effects that may have impeded blinding.

LIMITATIONS

We did not conduct a quantitative meta-analysis.

CONCLUSIONS

There is preliminary evidence for beneficial effects of modified CBT and add-on pharmacotherapy on residual anxiety in BD. Future trials should pre-screen participants for anxiety, define one clinician-rated anxiety measurement as a primary outcome, and employ intention-to-treat analysis to assess treatment effect. This will advance treatment development and enable personalised approaches to address residual anxiety in BD, which has great clinical relevance.

Non-pharmacological strategies for self-directed and interpersonal violence in people with severe mental illness: a rapid overview of systematic reviews

INTRODUCTION

Self-directed and interpersonal violence among people with severe mental illness has become a health priority. Though non-pharmacological interventions have been investigated, to our knowledge, no summary of all systematic reviews on this topic has been reported. We will conduct a rapid overview of reviews to synthesise evidence available by identifying systematic reviews on non-pharmacological interventions for self-directed or interpersonal violence in people with severe mental illness.

METHODS AND ANALYSIS

This is a protocol for a rapid overview of reviews. The overview will include any systematic reviews (with or without meta-analyses) of randomised controlled trials (RCTs) or cluster RCTs that examine the effect of non-pharmacological interventions on self-directed or interpersonal violence in people with severe mental illness. This protocol applies the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols, the criteria for conducting overviews of reviews in the Cochrane Handbook of Systematic Reviews of Interventions and the criteria for the Cochrane Rapid Reviews. To identify studies, a search will be performed in the following databases: PubMed, EMBASE, PsycINFO, CINAHL, LILACS, SciELO, Web of Science, Scopus, ProQuest, the Cochrane Database of Systematic Reviews through the Cochrane Library and the Epistemonikos database of systematic reviews. The searches date from inception to September 2020. The study selection process will be described using a PRISMA flow diagram, we will assess the quality of evidence in systematic reviews included and the quality of the systematic reviews themselves and the main results will be summarised in categories to provide a map of the evidence available.

ETHICS AND DISSEMINATION

No patients or other participants will be involved in this study. The results will be presented at mental health conferences and for publication in a peer-reviewed journal.

REGISTRATION DETAILS

The protocol was registered on the Open Science Framework (https://osf.io/myzd9/).

Bipolar disorder: An evolutionary psychoneuroimmunological approach

Bipolar disorder is a mental health disorder characterized by extreme shifts in mood, high suicide rate, sleep problems, and dysfunction of psychological traits like self-esteem (feeling inferior when depressed and superior when manic). Bipolar disorder is rare among populations that have not adopted contemporary Western lifestyles, which supports the hypothesis that bipolar disorder results from a mismatch between Homo sapiens's evolutionary and current environments. Recent studies have connected bipolar disorder with low-grade inflammation, the malfunctioning of the internal clock, and the resulting sleep disturbances. Stress is often a triggering factor for mania and sleep problems, but stress also causes low-grade inflammation. Since inflammation desynchronizes the internal clock, chronic stress and inflammation are the primary biological mechanisms behind bipolar disorder. Chronic stress and inflammation are driven by contemporary Western lifestyles, including stressful social environments, unhealthy dietary patterns, limited physical activity, and obesity. The treatment of bipolar disorder should focus on reducing stress, stress sensitivity, and inflammation by lifestyle changes rather than just temporarily alleviating symptoms with psychopharmacological interventions.

White Matter Correlates of Suicidality in Adults With Bipolar Disorder Who Have Been Prospectively Characterized Since Childhood

BACKGROUND

Prevention of suicide in individuals with early-onset bipolar disorder (BD) remains a challenge. Diffusion magnetic resonance imaging studies in BD have identified neural correlates of emotional dysregulation implicated in BD and suicide. Using diffusion magnetic resonance imaging, we sought to identify neural signatures of suicide attempts in adults with childhood-onset BD who have been clinically followed for up to 19 years as part of the COBY (Course and Outcome of Bipolar Youth) study.

METHODS

Diffusion magnetic resonance imaging data were collected in 68 adults with BD: 20 in the suicide attempter (SA+) group and 48 in the non-suicide attempter (SA-) group. Multivariate analysis of covariance was used to identify the effect of group (SA+, SA-) on mean fractional anisotropy (indirect index of fiber collinearity) in key white matter tracts of emotional regulation. The effect of suicidal ideation and other clinical factors was further explored. False discovery rate was used to account for multiple comparison. Forty healthy control subjects were included.

RESULTS

Analyses revealed a main effect of group on fractional anisotropy (F5,59 = 3.0, p = .017). Specifically, the SA+ group showed lower fractional anisotropy than the SA- and healthy control groups in the middle portion of the forceps minor (FMIN) (F1,63 = 8.5, p = .010) and in the anterior (F1,63 = 7.8, p = .010) and posterior (F1,63 = 8.7, p = .006) portion of the right cingulum bundle (CB). Abnormalities in the FMIN, but not CB, were also associated with suicidal ideation (F1,64 = 10.6, p = .002) and levels of emotional distress at scan.

CONCLUSIONS

FMIN and CB abnormalities have been associated with emotional dysregulation in BD. Our findings suggest that the FMIN may represent a generic marker of suicidal ideation and, more broadly, emotional distress, while CB may represent a specific marker of attempted suicide.

Brain Functional and Structural Alterations in Women With Bipolar Disorder and Suicidality

Objective: Suicide is the leading cause of death from bipolar disorder (BD). At least 25-50% of the patients with BD will attempt suicide, with suicide rates much higher in women patients than in men. It is crucial to explore the potential neural mechanism underlying suicidality in women with BD, which will lead to understanding and detection of suicidality and prevent death and injury from suicide. Methods: Brain function and structure were measured by amplitude of low-frequency fluctuation (ALFF) and gray matter volume (GMV) in 155 women [30 women with BD and a history of suicidality, 50 women with BD without suicidality, and 75 healthy controls (HC)]. The differences in ALFF and GMV across the BD with suicidality, BD without suicidality, and HC groups were investigated. Results: BD with suicidality showed significantly increased ALFF in the left and right cuneus compared with BD without suicidality and HC groups. Moreover, the GMV in the left lateral prefrontal cortex and left cuneus in BD with suicidality were significantly lower than those in BD without suicidality and HC groups, while the GMV of the right ventral prefrontal cortex was significantly decreased in both BD with and without suicidality groups. Conclusions: This study, combining functional and structural neuroimaging techniques, may help to identify specific pathophysiological changes in women with BD and suicidality. Increased ALFF and less GMV in cuneus might represent the neuroimaging features of suicidality in women with BD. Investigating this potential neuromarker for suicidality in women with BD may lead to the ability to prevent suicidality.

Higher prevalence of intentional self-harm in bipolar disorder with evening chronotype: A finding from the APPLE cohort study

BACKGROUND

Patients with bipolar disorder (BD) frequently self-harm, and this is strongly associated with subsequent suicide. This study investigated the association between chronotype and intentional self-harm in patients with BD.

METHODS

Two-hundred and five outpatients with BD participated in this cross-sectional study. Each participant's chronotype was evaluated using the Morningness-Eveningness Questionnaire, dividing the scores into three types: evening, 16-41 points; intermediate, 42-58 points; and morning, 59-86 points. Intentional self-harm over the past year were self-reported by questionnaire. Propensity score for evening chronotype was estimated from age, sex, socioeconomic factors, mood symptoms, total sleep time, age at the onset of BD, psychiatric inpatient history, family history of suicide, psychiatric comorbidity, and use of lithium.

RESULTS

Thirty-six (18%) of the 205 participants reported self-harm. A substantially higher proportion of the evening chronotype group self-harmed compared to the other groups (evening, 37%; intermediate, 13%; morning 10%). In multivariable analysis adjusted for propensity score, the odds ratio (OR) for self-harming significantly increased from morning to intermediate to evening chronotype (ORs: morning, 1.00; intermediate, 1.56; evening, 3.61; P for trend = 0.038).

LIMITATIONS

This study was a cross-sectional and small sample size.

CONCLUSIONS

Although a third factors, such as personality disorder or disrupted circadian rhythm, may have influenced, these findings suggest association between chronotype and intentional self-harm in BD patients.

Factors associated with single versus multiple suicide attempts in depressive disorders

BACKGROUND

Many risk factors for suicidal behavior have been identified. Much less has been done to associate risk factors with recurrence of suicidal behavior.

METHODS

We compared prevalence of 30 potential risk factors among 8496 depressive patient-subjects from the BRIDGE consortium with no (NSA, n = 6267), one (1SA, n = 1123), or repeated (≥2) suicide attempts (RSA, n = 1106).

RESULTS

Prevalence of most factors ranked: RSA ≥ 1SA > NSA, with a notable opposite trend for the diagnosis of type II bipolar disorder (BD). Factors independently and significantly more present among RSA than 1SA subjects were: borderline personality, substance abuse, mood-switching with antidepressant treatment, female sex, and unsatisfactory response to antidepressant treatment. There also were notably strong associations of RSA with type I or probable BD and associated factors, including family history of BD, young onset, mixed and psychotic features.

LIMITATIONS

Potential effects of treatment on risk of suicidal acts could not be evaluated adequately, as well as associations between levels of suicidal behavior and eventual death by suicide.

CONCLUSIONS

In a large cohort of depressive patients, there were significant associations not only with suicidal behavior generally, but also with the intensity of suicide attempts.

Altered Functional Connectivity Differences in Salience Network as a Neuromarker of Suicide Risk in Euthymic Bipolar Disorder Patients

Objective

The occurrence of death by suicide in patients diagnosed with bipolar disorder is as much as 60 times greater than in the general population. Even during the state of euthymia patients are characterized by suicide risk. The aim of the study is to investigate the baseline brain activity in euthymic bipolar disorder patients in regard to suicide risk. We hypothesized that patients compared to healthy control group will demonstrate altered functional connectivity among resting state networks which will be directly related to current suicide risk.

Method

41 subjects were enrolled in the study consisting control group (n = 21) and euthymic bipolar disorder patients group (n = 20). Functional magnetic resonance imaging was used to evaluate resting state brain activity and ROI-ROI functional connectivity analysis was performed. Suicidal risk was estimated using The Suicide Behaviors Questionnaire-Revised.

Results

A two sample t-test revealed decreased functional connectivity between regions involved in the salience network in patients compared to the control group. This decrease was negatively correlated with current suicide risk.

Conclusion

Obtained results suggest the association between risk of suicide and activity of regions responsible for functions such as learning from mistakes, prospective thinking, and sensory integration.

Suicidal Ideation and Insomnia in Bipolar Disorders: Idéation suicidaire et insomnie dans les troubles bipolaires

OBJECTIVE

Bipolar disorder (BD) confers elevated suicide risk and associates with misaligned circadian rhythm. Real-time monitoring of objectively measured sleep is a novel approach to detect and prevent suicidal behavior. We aimed at understanding associations between subjective insomnia and actigraphy data with severity of suicidal ideation in BDs.

METHODS

This prospective cohort study comprised 76 outpatients with a BD aged 18 to 65 inclusively. Main measures included 10 consecutive days of wrist actigraphy; the Athens Insomnia Scale (AIS); the Montgomery-Åsberg Depression Rating Scale (MADRS); the Quick Inventory of Depressive Symptoms-16, self-rating (QIDS-SR-16); and the Columbia Suicide Severity Rating Scale. Diagnoses, medications, and suicide attempts were obtained from chart review.

RESULTS

Suicidal ideation correlated moderately with subjective insomnia (AIS with QIDS-SR-16 item 12 ρ =0.26, P = 0.03; MADRS item 10 ρ = 0.33, P = 0.003). Graphical sleep patterns showed that suicidal patients were enriched among the most fragmented sleep patterns, and this was confirmed by correlations of suicidal ideation with actigraphy data at 2 visits. Patients with lifetime suicide attempts (n = 8) had more varied objective sleep (a higher standard deviation of center of daily inactivity [0.64 vs. 0.26, P = 0.01], consolidation of daily inactivity [0.18 vs. 0.10, P = <0.001], sleep offset [3.02 hours vs. 1.90 hours, P = <0.001], and total sleep [105 vs. 69 minutes, P = 0.02], and a lower consolidation of daily inactivity [0.65 vs. 0.79, P = 0.03]).

CONCLUSIONS

Subjective insomnia, a nonstigmatized symptom, can complement suicidality screens. Longer follow-ups and larger samples are warranted to understand whether real-time sleep monitoring predicts suicidal ideation in patient subgroups or individually.

Prevalence and clinical correlates of substance use amongst acute psychiatric inpatients in Gauteng, South Africa

Background

Mental disorders and substance use disorders (SUD) commonly occur together, impacting healthcare outcomes. The diagnosis of substance use is often inadequate when comorbidity is present. It is vital to understand the prevalence of substance use amongst psychiatric patients to inform both clinical practice and service development in South Africa.

Aim

To ascertain the prevalence and clinical correlates of SUD amongst acute psychiatric inpatients.

Setting

The setting for this study was Helen Joseph Hospital acute psychiatric ward.

Methods

A cross-sectional study was conducted whereby consecutively admitted patients were invited to participate in a structured clinical interview utilising the alcohol use disorders identification test (AUDIT) and drug use disorders identification test (DUDIT) questionnaires. Statistical comparisons were made between those with and without SUD.

Results

Of 150 participants, 100 (67%) were identified with a SUD. Those with SUD were younger (p = 0.0010), more often male (p = 0.012), less likely to have a disability grant (p = 0.015) and more likely to be brought to hospital by police, ambulance or self than by a family member (p = 0.025). Almost half of people with bipolar disorder (47.3%) and schizophrenia (41.4%) had comorbid SUD. Twenty-three (15%) participants identified with SUD on questionnaire had been missed clinically. Only two participants were referred for inpatient substance rehabilitation on discharge.

Conclusion

Substance use disorders are highly prevalent amongst psychiatric inpatients. The AUDIT and DUDIT are potentially useful screening tools in routine clinical practice. Greater collaboration between psychiatric and substance rehabilitation services is recommended.

Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 1. Risk factors, protective factors, and assessment

Suicide is a global public health problem that causes the loss of more than 800,000 lives each year, principally among young people. In Brazil, the average mortality rate attributable to suicide is approximately 5.23 per 100,000 population. Although many guidelines have been published for the management of suicidal behavior, to date, there are no recent guidelines based on the principles of evidence-based medicine that apply to the reality of suicide in Brazil. The objective of this work is to provide key guidelines for managing patients with suicidal behavior in Brazil. This project involved 11 Brazilian psychiatry professionals selected by the Psychiatric Emergencies Committee (Comissão de Emergências Psiquiátricas) of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. For the development of these guidelines, 79 articles were reviewed (from 5,362 initially collected and 755 abstracts). In this review, we present definitions, risk and protective factors, assessments, and an introduction to the Safety Plan.

Systematic review registry number: CRD42020206517

[What are the characteristics of patients with bipolar disorder type I who attempt suicide?]

Suicide is a public health problem affecting majority of patients with psychiatric diseases, including bipolar disorder (BD). The purpose of this study was to estimate the prevalence of suicide attempts (SAs) and to identify different factors associated with it in a population of patients with bipolar disorder type I (BD I). We conducted a cross-sectional and descriptive study of 150 patients. We used a fact sheet, questionnaires assessing affective temperaments, alcohol addiction and drug addiction. A comparison between suicidal (23,3%, n = 35) and non-suicidal (76,7%, n = 115) subjects enabled the identification of the following risk factors for suicide: cannabis addiction, addiction to psychotropic drugs, advanced age, a family history of BD, depression, SA and suicide deaths, a personal somatic history, a personality disorder associated, in particular, with histrionic personality, depressive temperament, a first thymic depressive episode, recurrent thymic episodes and long-term disease progression. Two protective factors were also identified: valproic acid and a higher number of siblings. In a multivariate study risk factors included: age, a family history of BD, a family history of SA and cannabis addiction. Particular attention should be given to determinants associated with suicidal behavior in BD I patients in order to adopt effective preventive and therapeutic strategies.

Aberrant functional connectivity and graph properties in bipolar II disorder with suicide attempts

OBJECTIVE

The physiological mechanism of suicide attempt (SA) in bipolar II disorder (BD-II) remains only partially understood. The study seeks to identify the dysfunction pattern in suicide brain for BD-II patients.

METHODS

Graph theory was utilized to explore topological properties at whole-brain, module and region levels based on resting-state functional MRI (rs-fMRI) data, which acquired from 38 un-medicated BD-II patients with at least one SA, 60 none SA (NSA) patients and 69 healthy controls (HCs). Finally, the correlation relationship between graph metrics and clinical variables were estimated.

RESULTS

Compared with NSA patients and HCs, the functional connectivity strength between limbic/sub-cortical (LIMB/SubC) and frontoparietal network (FPN) were significantly weakened. Nodal strength in left head of caudate nucleus (HCN), raphe nucleus (RN), right nucleus accumbens (NAcc), right subgenual anterior cingulate cortex (sgACC) and nodal efficiency in right sgACC, right HCN for SA patients were significantly reduced relative to NSA and HCs. In particular, nodal strength in RN and nodal efficiency in right sgACC showed a significant negative correlation with Nurses' Global Assessment of Suicide Risk (NGASR) scores.

LIMITATIONS

This is a single-mode cross-sectional study, the results were not verified by multi-center data.

CONCLUSIONS

The abnormal disrupted FC between LIMB/SubC and FPN is associated with SA in BD-II patients, which increased the susceptibility of suicide. Especially, the dysfunction in RN and right sgACC predict a higher suicide risk in BD-II patients.The results can help us to understand the suicide mechanism and early judgment of suicidal behaviors for BD-II patients.

Serum oxytocin concentrations in current and recent suicide survivors are lower than in healthy controls

BACKGROUND

Suicide and suicide attempts are dramatic events both for the individuals concerned and for their social circles. From a psychopathological perspective, suicidal behavior could be understood as a severe breakdown in relations with their social worlds. Oxytocin is a neuropeptide highly involved in the perception of facets of social relationship such as their quality feelings of belongingness, and mutual trust. Given this, we expected that serum oxytocin concentrations would be lower in current and recent suicide survivors than in healthy controls.

METHODS

A total of 48 participants (mean age: 27 years; 62.5% females) took part in the study. Of these, 16 (62.5% females) survived a suicide attempt 12-24 h ago; 16 (62.5% females) had made a suicide attempt about 12 weeks ago, and 16 (62.5% females) were healthy age- and gender-matched controls. Blood samples were taken in the morning to assess serum oxytocin concentrations. Participants also completed questionnaires covering sociodemographic information and a scale assessing suicidal ideation.

RESULTS

Compared to healthy controls, suicide survivors had significantly lower serum oxytocin concentrations, but these levels did not differ between current and recent suicide survivors. Compared to healthy controls and recent suicide attempters, current suicide attempters recorded significantly higher scores on the Beck scale for suicidal ideation. Across the sample as a whole, higher scores for suicidal ideation were associated with lower serum oxytocin concentrations. Serum oxytocin concentrations and scores on the Beck scale for suicidal ideation did not differ between females and males.

CONCLUSIONS

Given that oxytocin is a neurobiological correlate of subjectively perceived quality of social interaction and social relationships, the results support the notion that suicide attempts are closely linked to suicide survivors' perceptions of the quality of their social lives. Speculatively, and based on the serum oxytocin concentrations, it also appears that 12 weeks after a suicide attempt, the survivor's perceived quality of social life has not significantly improved.

Suicide mortality after discharge from inpatient care for bipolar disorder: A 14-year Swedish national registry study

Bipolar disorder has long been associated with increased risks for suicidality; though factors associated with dying by suicide remain obscure. Here, we retrospectively examine the associations between the different phases of bipolar illness and other common comorbidities with death by suicide in the 120 days following each discharge for Swedes first admitted as inpatients for bipolar disorder during the years 2000-2014. Data on admissions and suicide deaths were extracted from the Swedish National Patient Register and the Cause of Death Register, respectively. ICD-10 diagnostic codes were used to define the phases: depressive, manic, mixed, and other; and the comorbidities: specific substance use disorders, attention deficit hyperactivity disorder, and personality disorders. Extended Cox regressions were employed to model the time to death by suicide as a function of the bipolar phases, comorbidities, and other important control variables. Our analysis included 60,643 admissions by 22,402 patients over an observation time of 15,187 person-years. Overall, 213 (35.7%) of all suicides occurred within 120 days of discharge. Upon adjustment and compared to the depressive phases, manic phases were significantly associated with a far lower hazard of dying by suicide (HR 0.34, 95% CI: 0.21-0.56, p < 0.001), though mixed phases were not (HR 0.92, 95% CI: 0.48-1.73, p = 0.957). With regard to comorbidity, only sedative use disorder remained significantly associated with dying by suicide upon adjustment (HR 2.08, 95% CI: 1.41-3.06, p = 0.001). Vigilant monitoring of patients post discharge and of prescription practices are recommended.

Suicides in Mood Disorders in Psychiatric Settings in Nordic National Register-Based Studies

OBJECTIVE

Although risk factors for nonfatal suicidal behavior in mood disorders have been vastly investigated, rate and risk factors of suicide deaths are less well known. Extensive health care and other population registers in the Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) allow national-level studies of suicide rates and risk factors. This systematic review examined Nordic studies of suicide in mood disorders.

METHODS

National Nordic studies published after 1.1.2000 reporting on suicide mortality or relative risk in diagnosed unipolar depression or bipolar disorder treated in psychiatric settings; temporal variations in suicide risk after discharge, or risk factors for suicide were systematically reviewed.

RESULTS

Altogether 16 longitudinal studies reported on rate and risk of suicide in depression. They found 2%-8% of psychiatric inpatients with depression to have died by suicide. However, in Finland suicide risk among depressive inpatients halved since the early 1990s. Nine studies investigated suicide risk in bipolar disorder, finding 4-8% of patients having died by suicide in long term. The relative risk of suicide was consistently found extremely high (SMR > 100) during the first weeks postdischarge, declining steeply over time to approximately SMR of five after five years. Male gender, preceding suicide attempts, high severity of depression and substance abuse were found risk factors for suicide in depression, with only minor gender differences in risk factors, but major differences in lethal methods. Three studies investigated risk factors for suicide in bipolar disorder, finding male gender, preceding suicide attempts, and depressive episodes and psychiatric comorbidity to be associated with risk.

CONCLUSIONS

Overall, of psychiatric inpatients with depressive of bipolar disorders in the Nordic countries, 2%-8% have died by suicide in the last few decades, but current rates may be lower. Suicide risk is approximately similar or somewhat higher among patients with bipolar disorder, risk factor studies of whom are fewer. Risk of suicide is remarkably high immediately after discharge, and higher among males than females, those with preceding suicide attempts, high severity of depression, or concurrent substance abuse. Generalizability of findings from these Nordic studies to other countries need to be investigated, and their methodological limitations understood.

Cortical Volumetric Correlates of Childhood Trauma, Anxiety, and Impulsivity in Bipolar Disorder

OBJECTIVE

More recently, attention has turned to the linkage between childhood trauma and emotional dysregulation, but the evidence in bipolar disorder (BD) is limited. To determine neurobiological relationships between childhood trauma, current anxiety, and impulsivity, we investigated cortical volumetric correlates of these clinical factors in BD.

METHODS

We studied 36 patients with DSM-5 BD and 29 healthy controls. Childhood trauma, coexisting anxiety, and impulsivity were evaluated with the Korean version-Childhood Trauma Questionnaire (CTQ), the Korean version-Beck Anxiety Inventory (BAI), and the Korean version-Barratt Impulsiveness Scale (BIS). Voxel-based morphometry (VBM) was used to assess gray matter volume (GMV) alterations on the brain magnetic resonance imaging (MRI). Partial correlation analyses were conducted to examine associations between the GMV and each scale in the BD group.

RESULTS

Childhood trauma, anxiety, and impulsivity were interrelated in BD. BD patients revealed significant inverse correlations between the GMV in the right precentral gyrus and CTQ scores (r=-0.609, p<0.0003); between the GMV in the left middle frontal gyrus and BAI scores (r=-0.363, p=0.044). Moreover, patients showed similar tendency of negative correlations between the GMV in the right precentral gyrus and BIS scores; between the GMV in the left middle frontal gyrus and CTQ scores.

CONCLUSION

The present study provides evidence for a neural basis between childhood trauma and affect regulations in BD. The GMV alterations in multiple frontal lobe areas may represent neurobiological markers for anticipating the course of BD.

Suicidal Risks in 12 DSM-5 Psychiatric Disorders

OBJECTIVE

As modern studies evaluating suicidal behaviors in large samples of major psychiatric disorder patients are rare, we compared suicidal risks associated with a variety of psychiatric diagnoses.

METHODS

We quantified rates of intake suicidal ideation and lifetime attempts, suicides, and violent acts (attempts + suicides) in 6050 adult patients in a European psychiatric center, diagnosed with 12 prevalent, DSM-5 psychiatric disorders.

RESULTS

Ideation ranged from 53.9% of subjects with bipolar disorder (BD) with mixed features, to 8.70% in anxiety disorders. Subjects making at least one suicide attempt were most prevalent in BD with mixed or psychotic features. Suicide rates ranked: substance abuse > BD with psychotic features > psychotic disorders ≥ BD-I > major depressive disorder (MDD). Suicidal intensity (acts/100 PEY) was highest with BD, psychotic disorders, and MDD; lethality (lower attempt/suicide ratio) was greatest with substance abuse, psychotic disorders, and BD with psychotic features. Rates of suicidal acts in BD vs. MDD were similarly high among ever-hospitalized subjects but much lower in never-hospitalized MDD subjects. Women had higher overall risks of ideation and attempts, but violent acts and suicide were more likely among men, whereas SMR for suicide was greater among women, presumably reflecting very low risks among women in the regional general population.

CONCLUSIONS

Suicidal risks were particularly high in BD with psychotic or mixed features as well as with substance abuse and in severe MDD with hospitalization.

Sex difference in glia gene expression in the dorsolateral prefrontal cortex in bipolar disorder: Relation to psychotic features

BACKGROUND

Suicide, psychotic features and gender influence the epidemiology and clinical prognosis of bipolar disorder (BD). Differences in glial function between the genders might contribute to these clinical variables. Here we studied expression of glial genes in human post-mortem prefrontal cortex of BD and control subjects in relation to suicide, psychotic features and sex.

METHODS

Real time PCR was used to detect transcriptional alterations of 16 glia-related genes in two brain areas, the dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC), from 30 patients with BD subdivided by suicide and psychotic features, and from 34 well-matched control cases.

RESULTS

We found no evidence of immune activation in BD. Instead, we found three microglial genes to be downregulated in the DLPFC of non-suicidal individuals with BD, i.e. CD68, triggering receptor expressed on myeloid cells 2 (TREM2) and purinergic receptor 12 (P2RY12). A remarkable sex difference was observed in the DLPFC of patients with BD: 14 glia-related genes were expressed at significantly higher levels in males, including all three glial cell types. A subset analysis showed that the sex differences were closely associated with the presence of psychotic features.

CONCLUSIONS

No evidence of immune activation was found in these two brain regions in BD. The sex-specific differences in glial gene expression in BD, found particularly in patients with psychotic features, may be associated with the potential co-existence of mania and psychotic features and could potentially contribute to the gender-biased characteristics in BD.

ENIGMA MDD: seven years of global neuroimaging studies of major depression through worldwide data sharing

A key objective in the field of translational psychiatry over the past few decades has been to identify the brain correlates of major depressive disorder (MDD). Identifying measurable indicators of brain processes associated with MDD could facilitate the detection of individuals at risk, and the development of novel treatments, the monitoring of treatment effects, and predicting who might benefit most from treatments that target specific brain mechanisms. However, despite intensive neuroimaging research towards this effort, underpowered studies and a lack of reproducible findings have hindered progress. Here, we discuss the work of the ENIGMA Major Depressive Disorder (MDD) Consortium, which was established to address issues of poor replication, unreliable results, and overestimation of effect sizes in previous studies. The ENIGMA MDD Consortium currently includes data from 45 MDD study cohorts from 14 countries across six continents. The primary aim of ENIGMA MDD is to identify structural and functional brain alterations associated with MDD that can be reliably detected and replicated across cohorts worldwide. A secondary goal is to investigate how demographic, genetic, clinical, psychological, and environmental factors affect these associations. In this review, we summarize findings of the ENIGMA MDD disease working group to date and discuss future directions. We also highlight the challenges and benefits of large-scale data sharing for mental health research.

Study of Risk Factors Associated with Suicide Attempt in Patients with Bipolar Disorder Type I

Background  Suicide is the leading contributor to mortality in bipolar disorder (BD). A history of suicidal attempt is a robust predictive marker for future suicide attempts. Personality profiles and coping strategies are the areas of contemporary research in bipolar suicides apart from clinical and demographic risk factors. However, similar research in developing countries is rarer.

Objectives  The present study aimed to identify the risk factors associated with suicidal attempts in BD type I (BD-I).

Materials and Methods  Patients with BD-I currently in clinical remission ( N = 102) were recruited. Sociodemographic details and the clinical data were collected using a semistructured pro forma. The psychiatric diagnoses were confirmed using the Mini-International Neuropsychiatric Interview 5.0. The National Institute of Mental Health–Life Chart Methodology Clinician Retrospective Chart was used to chart the illness course. Presumptive Stressful Life Events Scale, Coping Strategies Inventory Short Form, Buss–Perry aggression questionnaire, Past Feelings and Acts of Violence, and Barratt Impulsivity scale were used to assess the patient’s stress scores, coping skills, aggression, violence, and impulsivity, respectively.

Statistical Analysis  Descriptive statistics were used for demographic details and characteristics of the illness course. Binary logistic regression analyses were performed to identify the predictors for lifetime suicide attempt in BD-I.

Results  A total of 102 patients (males = 49 and females = 53) with BD-I were included. Thirty-seven subjects (36.3%) had a history of suicide attempt. The illness course in suicide attempters more frequently had an index episode of depression, was encumbered with frequent mood episodes, especially in depression, and had a higher propensity for psychiatric comorbidities. On binary logistic regression analysis, the odds ratios (ORs) for predicting a suicide attempt were highest for positive family history of suicide (OR: 13.65, 95% confidence interval [CI]: 1.28–145.38, p = 0.030), followed by the presence of an index depressive episode (OR: 6.88, 95% CI: 1.70–27.91, p = 0.007), and lower scores on problem-focused disengagement (OR: 0.72, 95% CI: 0.56–0.92, p = 0.009).

Conclusion  BD-I patients with lifetime suicide attempt differ from non-attempters on various course-related and temperamental factors. However, an index episode depression, family history of suicide, and lower problem-focused engagement can predict lifetime suicide attempt in patients with BD-I.

Remission and recurrence in bipolar disorder: The data from health outcomes and patient evaluations in bipolar disorder (HOPE-BD) study

BACKGROUND

The HOPE-BD was a naturalistic study established to follow individuals in Canada seeking treatment for bipolar disorder (BD). The study aimed to examine the course of BD and describe how clinical and sociodemographic factors are associated with outcomes.

METHODS

Individuals with BD had their clinical data recorded at enrolment and were naturalistically treated. Participant were followed for up to four years, and visits occurred at least once every three months. We investigated the longitudinal outcomes with logistic, Cox, and quantile regressions.

RESULTS

Among the 354 participants, 57.3% had BD type I. Depression as first episode, younger ages at onset and older ages of the first professional help predicted longer delays in correct diagnosis. Among the symptomatic patients at baseline, the median time to remission was 10.9 months. Comorbid alcohol use disorder and the severity of baseline depressive symptoms predicted longer times to remission. Among the euthymic participants, the median time to recurrence was 14.5 months. History of anxiety disorder and younger ages at onset predicted shorter times to recurrence. Baseline depression scores predicted recurrence in euthymic patients.

LIMITATIONS

We did not investigate the predictors of each polarity. Our findings may not apply to individuals followed in non-specialised outpatient services.

CONCLUSION

Our study reinforces the necessity of early diagnosis and interventions, as well as the importance of treating depressive symptoms and comorbidities.

Effect of the Type and Number of Adverse Childhood Experiences and the Timing of Adverse Experiences on Clinical Outcomes in Individuals with Bipolar Disorder

Studies have reported an association between adverse childhood experiences (ACEs) and the clinical outcomes of bipolar disorder (BD). However, these studies have several limitations; therefore, we aimed to clarify the effect of the type and number of ACEs and the timing of adverse experiences on clinical outcomes in patients with BD. We analyzed the data of patients with BD (N = 2675) obtained from the National Institute of Mental Health: Bipolar Disorder Genetic Association Information Network, Translational Genomic Institute-I, and Translational Genomic Institute-II. All patients had been diagnosed using the Diagnostic Interview for Genetic Studies. ACEs were evaluated using the Childhood Life Events Scale (CLES). We analyzed the relationship between childhood trauma and clinical outcome in patients with and without exposure to ACEs. We found that ACEs had a robust negative effect on clinical outcomes, including earlier age at onset, presence of psychotic episodes, suicide attempts, mixed symptoms or episodes, substance misuse comorbidity, and worse life functioning. Specifically, the number of ACEs had the most significant effect on clinical outcomes; however, specific ACEs, such as physical abuse, had a considerable influence. Moreover, post-childhood adverse experiences had a weaker effect on clinical outcomes than ACEs did. There was an association of ACEs with negative clinical outcomes in patients with BD. This indicates the importance of basic and clinical research on ACEs in patients with BD.

Psychiatric comorbidities in bipolar disorders: An examination of the prevalence and chronology of onset according to sex and bipolar subtype

OBJECTIVES

Bipolar Disorder (BD) is frequently comorbid with other psychiatric disorders. However, few studies systematically examine which disorders are more likely to occur pre- or post-BD onset. We examine the prevalence and Age At Onset (AAO) of psychiatric conditions in adults with BD.

METHODS

A structured clinical interview was used to assess lifetime history and AAO of alcohol and cannabis misuse, suicide attempts, anxiety and eating disorders in a French sample of euthymic patients with BD (n = 739). Regression analyses were used to test for statistically significant associations between rates and AAO of comorbidities in BD groups stratified by sex or subtype.

RESULTS

Prevalence of alcohol and cannabis misuse was associated with male sex and BD-I subtype; whilst most anxiety and eating disorders were associated with female sex. The AAO of most comorbid conditions preceded that of BD, except for panic disorder, agoraphobia and alcohol misuse. Few variations were observed in AAO of comorbidities according to groups.

LIMITATIONS

All assessments were retrospective, so estimates of prevalence rates and especially exact AAO of some comorbidities are at risk of recall bias.

CONCLUSIONS

Sex and BD subtype are associated with different rates of comorbid disorders. However, there were minimal between group differences in median AAO of comorbidities. By describing the chronological sequence of comorbidities in BD we were able to demonstrate that a minority of comorbidities typically occurred post-onset of BD. This is noteworthy as these disorders might be amenable to interventions aimed at early secondary prevention.

Evening chronotype as a discrete clinical subphenotype in bipolar disorder

OBJECTIVE

Our aim was to investigate evening chronotype, a proxy marker of circadian system dysfunction, as a clinical subphenotype in bipolar disorder (BD).

METHODS

In this cross-sectional study, 773 BD participants and 146 control subjects were evaluated using the Structured Clinical Interview for DSM-IV and a set of questionnaires. Chronotype was determined using item-5 from the reduced Morningness-Eveningness Questionnaire. Univariate analyses and regression models were used to compare evening and non-evening chronotype in BD and chronotype association with clinical variables.

RESULTS

Overall, 205 (27%) of BD patients reported an evening chronotype. Evening chronotype was higher in a matched sub-sample of BD patients (n = 150) than in controls (24% and 5% respectively, OR=5.4, p<0.01). Compared to those with non-evening chronotypes, BD patients with an evening chronotype were younger, had an earlier age of onset of BD, and had more prior depressive and manic episodes, higher rates of rapid cycling, past suicide attempts, more comorbid anxiety and substance use disorders. Multivariate regression showed age, prior suicide attempts, and co-occurring substance use disorder were associated with evening chronotype (OR range of 0.97 to1.59). Hypertension, migraine, asthma, and obstructive sleep apnea were significantly associated with evening chronotype (OR range of 1.56 to 2.0).

LIMITATION

Limitations include a cross-sectional study design that precludes establishing causality. Analyses did not control for medication use. Younger participant age may prevent evaluation of associations with late-life illnesses.

CONCLUSIONS

Evening chronotype may be a discrete clinical subphenotype in BD and circadian dysfunction a shared pathophysiological mechanism between psychopathology and medical morbidity.