Untangling the complex relationship between bipolar disorder and anxiety: a comprehensive review of prevalence, prognosis, and therapy

Bipolar disorder (BD) frequently coexists with anxiety disorders, creating complex challenges in clinical therapy and management. This study investigates the prevalence, prognostic implications, and treatment strategies for comorbid BD and anxiety disorders. High comorbidity rates, particularly with generalized anxiety disorder, underscore the necessity of thorough clinical assessments to guide effective management. Our findings suggest that anxiety disorders may serve as precursors to BD, especially in high-risk populations, making early detection of anxiety symptoms crucial for timely intervention and prevention. We also found that comorbid anxiety can negatively affect the course of BD, increasing clinical severity, reducing treatment responsiveness, and worsening prognosis. These complexities highlight the need for caution in using antidepressants, which may destabilize mood. Alternatively, cognitive-behavioral therapy presents a promising, targeted approach for managing BD with comorbid anxiety. In summary, this study provides essential insights for clinicians and researchers, enhancing understanding of BD and anxiety comorbidity and guiding more precise diagnostics and tailored interventions to improve overall patient care.

Assessing acute effects of methylphenidate and modafinil on inhibitory capacity, time estimation, attentional lapses, and compulsive-like behavior in rats

Medications known as 'cognitive enhancers' are increasingly being consumed off-label by healthy people, raising concerns about their safety. The aim of our study was to profile behavioral performance upon oral administration of methylphenidate (2.5 mg/kg) and modafinil (64 mg/kg) - two popular cognitive enhancers - and upon their discontinuation. We modeled cognitively demanding challenges in neurotypical individuals using a behavioral task where Wistar - Lewis rats had to withhold responses for a specified time to obtain food rewards. This task allowed us to extract several measures of behavioral performance associated with clinically meaningful indices, such as compulsive-like responding, incapacity to wait (impulsivity), time estimation (precision and accuracy), and attentional lapses. Our study design involved examining these behavioral indices in subjects administered either methylphenidate, modafinil, or vehicle. We found that subjects administered modafinil obtained fewer rewards and were less efficient in reward pursuing than the vehicle group; this result was likely due to a drug-induced inability to wait. Upon modafinil discontinuation, subjects earned more rewards but did not entirely catch up with the vehicle group. As for methylphenidate, neither favorable nor unfavorable effects were found in our main analyses. However, an exploratory analysis of changes in behavioral performance within sessions suggested that methylphenidate fostered favorable, yet short-lived, effects. We discuss our results in terms of the risks and cost-benefits of doses above or below the effective dose of cognitive enhancement drugs.

The effectiveness of electroconvulsive therapy (ECT) for people with bipolar disorder: is there a specific role?

INTRODUCTION

Electroconvulsive therapy (ECT) has been used for over 80 years to treat various neuropsychiatric conditions, including mood and psychotic disorders. Despite its proven efficacy, ECT remains underutilized and underexplored in patients with bipolar disorder (BD).

AREAS COVERED

This perspective examines the role of ECT in BD, highlighting its effectiveness across depressive, manic, and mixed phases, including those characterized by catatonic or delirious features. Based on these findings, the authors propose a comprehensive transdiagnostic framework to conceptualize ECT-responsive syndromes based on psychomotor, psychotic, and cognitive disturbances. The potential long-term effectiveness of ECT as a mood stabilizer is also suggested, despite the limited amount of literature. Finally, safety issues and alternative options are discussed.

EXPERT OPINION

The shift in ECT usage, from being a first-line treatment for severe affective episodes to a 'last-resort' option for treatment-resistant depression, may have contributed to increased relapse rates and chronicity. Considering ECT at an early stage, potentially even before any medication trials, is recommended for specific clinical conditions associated with BD and marked by objective psychomotor disturbances, acute psychotic symptoms, and severe cognitive alterations.

A unified pathogenic hypothesis for mental disorders based on schismogenesis

Major Depressive Disorder, Bipolar Disorder, and Schizophrenia, share significant genetic, epigenetic, and phenotypic overlap, manifesting as dimensional psychopathology and convergent neuroimaging findings. These shared features have led to various models exploring common underlying pathophysiological mechanisms, including excitatory-inhibitory imbalance, the triple network model, network analysis, and social disconnection. While these models offer valuable insights, a unifying framework remains elusive. Schismogenesis, a transdisciplinary construct, is proposed to reconcile divergent perspectives on mental health conditions. Characterized by positive feedback loops leading to functional dissociation due to insufficient inhibitory control, complementary schismogenesis results in rigid hyperactivation and hypoactivation within neural, cognitive, and social networks, compromising system flexibility. This pathological process underlies the core features of Major Depressive Disorder, Bipolar Disorder, and Schizophrenia, depending on its location within networks. The schismogenesis hypothesis suggests that when individuals are overwhelmed by excessive stress or tension, they may experience a breakdown or disconnection to prevent irreversible damage, reflecting evolutionary adaptations. Importantly, the potential reversibility of schismogenesis, particularly through interventions that facilitate system reintegration, suggests promising therapeutic avenues for further exploration.

Shared Overall Topological Impairments of Functional Brain Networks Across Diverse State of Bipolar Disorder With Relevance to Cognitive Deficits and Genetic and Transcriptomic Variations

OBJECTIVES

Investigating brain network properties in BD patients across mood states can offer insights into the underlying mechanisms of the disorder. This study aimed to explore the topological architecture of functional brain networks in BD and its relationship with clinical variables and genetic/transcriptomic variations.

METHODS

The study involved 100 BD patients and 95 healthy controls. Researchers used graph theory-based methods to analyze whole-brain functional networks and explore their relationship with clinical variables. We also conducted a neuroimaging-transcription association analysis using the Allen Human Brain Atlas.

RESULTS

Depressive and manic BD patients exhibited increased local efficiency and decreased global efficiency at the global network level compared to healthy controls. Nodal-level analysis revealed disrupted nodal parameters within specific brain networks, including the fronto-parietal, default mode, and somatomotor networks. Significant correlations were found between nodal properties and cognitive function. All BD groups showed enhanced connectivity strength in rich-club and feeder connections compared to controls. Neuroimaging-transcription analysis identified potential genetic factors related to BD.

CONCLUSION

Our investigation unveiled shared impairments in the overall topological architecture of functional brain networks across depressive, manic, and euthymic BD. These observed abnormalities were associated with cognitive deficits in BD patients across three mood states. These common deficits, possibly stemming from the segregated changes in structural and functional rich-club connections, might represent trait-like pathophysiological mechanisms inherent to BD. Furthermore, our neuroimaging-transcription association analysis indicates the potential use of brain functional anomalies as endophenotypes in BD.

The trajectory of depressive symptoms and the association with quality of life and suicidal ideation in patients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is the most prevalent mental health disorder globally. However, the association between depressive symptom trajectories in the early period and subsequent mental health outcomes remains not fully elucidated. This study aimed to delineate the depressive symptom trajectories during the initial phase of treatment, identify baseline characteristics associated with these trajectories, and explore the association of trajectories with subsequent quality of life and suicidal ideation.

METHODS

Participants were from the Depression Cohort in China. The diagnosis of MDD was assessed using the Mini-International Neuropsychiatric Interview (M.I.N.I.). Information on depressive symptom severity, quality of life, suicidal ideation and other demographics were collected. Latent class trajectory modeling was used to identify distinct classes of depressive symptom trajectories.

RESULTS

A total of 566 patients with MDD were included, and we identified 3 categories with differential trajectories characterized by improving class (66.7%), moderate decreasing class (27.7%), and persistent high class (5.6%). Compared to the improving class, severer anxiety and depressive symptoms at baseline increased the odds of belonging to the moderate decreasing class and persistent high class. Both moderate decreasing class and persistent high class were associated with increased risks of subsequent diminished quality of life. Additionally, only persistent high class was associated with a higher risk of subsequent suicidal ideation.

CONCLUSION

Severe baseline anxiety and depressive symptoms identify a subpopulation of persons living with MDD who evince a greater likelihood of symptom worsening over time as well as greater decrements in quality of life and worsening measures of suicidality.

Exploring the predictive role of the first mood episode on the predominant polarity in bipolar disorder: insights from a path analysis

BACKGROUND

The predominant polarity in bipolar disorder (BD) is defined by the skewness of mood episodes towards either the manic or depressive pole. However, since the predominant polarity can only be established over the long term, it is crucial to identify predictors of illness trajectory. Among these factors, the polarity at onset has been suggested to hold important implications, even though research in this field is not entirely consistent so far. In this retrospective study, we thus explored whether the polarity of the first episode can predict the predominant polarity in BD.

METHODS

We included subjects with BD consecutively referred to two acute inpatient units in the Milan metropolitan area from May 2020 to January 2024. Following Barcelona criteria, a manic (mPP) and a depressive (dPP) predominant polarity were defined as having a ratio ≥ 2:1 of past manic/hypomanic or depressive episodes, respectively. The relationship between first episode polarity and either mPP or dPP was examined using multivariable logistic regression models. A path analysis was then performed to jointly test the associations between putative variables and the predominant polarity.

RESULTS

This study included 128 participants. Regression models estimated an association between a manic onset and a mPP (β = 3.23, p < 0.001) as well as between a depressive onset and a dPP (β = 3.65, p < 0.001). Participants with a mPP showed a lower age at onset (β = - 0.13, p = 0.004), while subjects diagnosed with BD type I were less likely to show a dPP (β = - 2.09, p = 0.024). The path analysis highlighted an association between earlier onset and the likelihood of a first episode of manic polarity (coeff. = - 1.39, p = 0.021). A manic onset was associated with a higher likelihood of mPP (coeff. = 3.46, p < 0.001) and a lower likelihood of dPP (coeff. = - 3.71, p < 0.001). Consistently, participants with a manic onset were more likely to experience a lower number of depressive episodes (coeff. = - 1.36, p < 0.001). Finally, cannabis use disorder was associated with a lower number of depressive episodes (coeff. = - 0.57, p = 0.011).

CONCLUSIONS

These results provide important insights into the likely predictive value of first episode polarity in relation to the predominant polarity in BD. Though future studies validating these findings are needed, the polarity at onset may serve as an early marker for illness trajectory.

The potential of dibenzazepine carboxamides in cancer therapy

Cancer is a leading cause of mortality worldwide, with most conventional treatments lacking efficacy and having significant challenges like drug resistance. Finding new molecules is quite challenging in terms of cost, time and setbacks. Hence, drug repurposing is considered sensible for skipping the long process of drug development. Dibenzazepine carboxamides, as traditional anticonvulsants, primarily function by blocking voltage-gated sodium channels, which not only mitigate seizures but also influence mood disorders through modulation of serotonin and dopamine. Recent studies have uncovered their anticancer properties, demonstrated by both in vitro and in vivo experiments. This review comprehensively examines dibenzazepine's pharmacodynamics, pharmacokinetics, and clinical applications, focusing on their emerging role in oncology. By highlighting the anticancer mechanisms of action-including apoptosis induction, inhibition of HDAC, Wnt/β-Catenin signaling, and Voltage-gated sodium channels, we suggest further research to fully elucidate their therapeutic potential and application in cancer treatment.

Network analysis of central symptoms in Chinese young adults with subthreshold depression

Subthreshold depression (SD) is a prevalent condition among young adults, significantly increasing the risk of developing major depressive disorder (MDD). While the symptoms of MDD are well-documented, the network structure and key symptoms of SD, which forms a complex, interdependent system, have not been fully elucidated. This study sought to identify the central symptoms and their interconnections within the depressive symptom network in young adults with SD. A total of 834 Chinese young adults with SD completed the 21-item Beck Depression Inventory 2nd version (BDI-II) and were included in this study. Network analysis was employed to identify central symptoms (nodes) and associations between symptoms (edges) as assessed by the BDI-II. Additionally, centrality indicators for network robustness underwent assessment through stability and accuracy tests. The analysis revealed that Loss of interest was the most central node in the SD symptom network, with Tiredness/fatigue and Agitation following closely. Significant associations were observed between Loss of energy and Concentration difficulties, Agitation and Irritability, Guilty feelings and Self-dislike, as well as Tiredness and Loss of pleasure. The network demonstrated robustness across stability and accuracy assessments. Loss of interest, Tiredness/fatigue, and Agitation were pivotal symptoms within the depressive symptom network of SD in young adults. These symptoms may serve as critical targets for therapeutic interventions and should be prioritized in future psychological and neurobiological research to advance our understanding of SD.

Social functioning in bipolar disorder: investigating the role played by comorbid physical illnesses and cognition

Bipolar disorder (BD) is a psychiatric disorder associated with functioning and cognitive impairments, as well as a higher prevalence of physical disease comorbidities.

Objective

To determine the main predictors of functioning in patients with BD.

Methods

Thirty-five patients with BD type I in remission participated in this study. To better characterize the degree of impairment, 20 matched controls were also studied. Functioning was assessed through the Functioning Assessment Short Test (FAST) and the UCSD Performance-based Skills Assessment (UPSA), while cognition was assessed through the BAC-A. Current physical conditions were assessed and categorized according to the Cumulative Illness Rating Scale (CIRS). Regression analyses were performed to examine the relationship between functioning and clinical variables, global cognitive performance, and physical comorbidities in BD.

Results

UPSA correlated positively with the BAC-A total score (r=0.488; p=0.025), years of education (rho=0.41; p<0.01), and CIRS total score (rho=0.394; p<0.001). CIRS was the only predictor that remained negatively and significantly correlated with the UPSA total score (R2=0.446, F (1, 33)=8.198, p=0.007).

Conclusion

Patients with BD had poor functioning, with the primary determinant of poor functioning being the burden of physical illnesses. In addition, the low agreement between the FAST and UPSA scales suggests these tolls assess distinct constructs.

Axis I Psychiatric Disorders and Substance Abuse: A Systematic Review of Neuroimaging Findings

Background/Objectives: The present systematic review analyses the neuroradiological findings in subjects with axis I psychiatric disorders (i.e., bipolar, major depressive, schizophrenic, anxiety, and post-traumatic stress disorders) and comorbid substance use disorder in order to elucidate the organic changes that occur in the brains of people suffering from both conditions. Methods: We analysed and compared the different neuroimaging findings extracted from 93 studies and 10,823 patients; articles were obtained from three databases (Scopus, PubMed [Medline], and the Cochrane Controlled Register of Trials [Central]) and subjected to specific eligibility criteria. We selected articles that assessed patients with axis I psychiatric conditions and a comorbid substance abuse disorder; articles had to report relevant neuroimaging findings and bias was assessed via the Newcastle-Ottawa scale. Results: Significant findings were found on the structure or function of psychiatric patients' brains with comorbid substance abuse, with certain key areas that were further affected by substance use, especially in areas involved in reward processing, with reductions in volume and connectivity and the augmentation of stimuli-related activity. Conclusions: These results present important implications on the current understanding of psychiatric disorders and comorbid substance use, on the importance of neuroradiological tools in the diagnosis and treatment of these disorders, and on the search for potential new targets for the treatment of psychiatric disease and substance addiction.

Longitudinal bidirectional association between psychosocial function and depression in Chinese patients with clinically remitted depression: a cross-lagged panel model analysis

BACKGROUND

Major depressive disorder (MDD) imposes serious effect on patient's psychosocial function, which hinders the full recovery from the disease and increases the risk of recurrence, although the participants had achieved clinical remission. To understand the relationship between psychosocial function and depressive symptoms could facilitate recurrence prevention. Therefore, the purpose of this study was to analyze the relation among psychosocial function and BDI score in Chinese patients with clinically cured depression within 1 year follow-up.

METHODS

One hundred nineteen valid participants were assessed at baseline(t1), months 6(t2) and months 12(t3). Beck Depression Inventory-II (BDI-II) was used to assess depressive symptoms and indicate the possibility of depression level. Generic Quality of Life Inventory (GQOLI) was used to assessed the participants' psychosocial function(F), including body function (BF), psychological function (PF) and social function (SF). The application of a cross-lagged panel model (CLPM) approach revealed an association between BDI and psychosocial function.

RESULT

The CLPM results showed total average score of psychosocial function have reciprocal influence on BDI score. The model analyzed by structural equation modeling satisfied all indices of goodness-of-fit (chi-square = 10.306, TLI = 0.959, CFI = 0.988 RMSEA = 0.115). And body function, psychological function, social function and BDI score also affect each other. Depressive symptoms and psychosocial function could predict scores of each other 6 months later. By comparing standardized cross-lagged path, only social function has a more pronounced impact on depressive symptoms, since the absolute effect of SFt1 → BDIt2 is larger than that of BDIt1 → SFt2 (a1 vs. b1 = -.267, SE = .108, P < 0.05, 95%CI[-.485,-.063]) and the absolute effect of SFt2 → BDIt3 is larger than that of BDIt2 → SFt3 (a2 vs. b2 = -.317, SE = .096, P < 0.01,95%CI[-.508,-.129]).

CONCLUSION

The current study showed a significant bidirectional association between depressive level and psychosocial function, and the social function exerted more effect on the depression.

Efficacy and safety of each class of sleep medication for major depressive disorder with insomnia symptoms: A systematic review and meta-analysis of double-blind randomized controlled trials

Combination therapy with antidepressants and sleep medications is a promising candidate treatment for major depressive disorder (MDD) with insomnia. This systematic review and meta-analysis examined the efficacy and safety of combination therapy with antidepressants and sleep medication for treating MDD with insomnia compared to antidepressant monotherapy by sleep medication class (benzodiazepine, Z-drug, melatonin receptor agonist, and orexin receptor antagonist). This study was preregistered with PROSPERO (CRD42025636571). PubMed, CENTRAL, and Embase were searched for double-blind randomized controlled trials published until June 2024, resulting in eight eligible studies (1945 participants; eszopiclone = 4, zolpidem = 2, triazolam = 1, ramelteon = 1). Meta-analyses were performed based on six trials of Z-drugs. Compared with antidepressant monotherapy, combination therapy with antidepressants and Z-drugs resulted in higher remission rates from depressive symptoms (risk ratio: 1.25, 95% confidence interval [CI]: 1.08-1.45, P = 0.003), greater improvement in depressive symptoms (standardized mean difference [SMD]: 0.17, 95% CI: 0.01-0.33, P = 0.04) and insomnia symptoms (SMD: 0.43, 95% CI: 0.28-0.59, P < 0.001) in the short-term (within 12 weeks), with no difference in safety outcomes except for dizziness. Combination therapy with antidepressants and Z-drugs may be more useful for MDD with insomnia symptoms than antidepressant monotherapy in the short term. However, this study did not evaluate the benefits and harms of long-term adjunctive Z-drug therapy. Further long-term studies are needed to draw definitive conclusions regarding the efficacy and safety of combination therapy with antidepressants and Z-drugs. Moreover, further research is warranted to assess whether the findings of this study are applicable to other sleep medication classes.

Antidepressants in the treatment of bipolar depression: commentary

BACKGROUND

Depression is a therapeutic challenge with bipolar disorder (BD) patients and remains a major contributor to disability, comorbidity, and premature mortality. The efficacy and safety of antidepressants (ADs) for this indication remain particularly controversial, and optimally safe and effective treatment of bipolar (BP) depression remains uncertain.

METHOD

We summarized selected research findings on the treatment of depression in BD aimed at supporting practical guidelines for clinical treatment involving ADs.

RESULTS

Growing research evidence indicates that ADs are probably effective in BP depression and possibly not less than in major depressive disorder. Tolerability of antidepressant (AD) treatment is greater with type II BD (BD-2) than with type I (BD-1), particularly when ADs are combined with a mood stabilizer or antipsychotic. For BP depression, preferred ADs are serotonin-reuptake inhibitors and bupropion given in moderate doses for limited times.

CONCLUSIONS

Optimal treatment of depression requires further investigation, particularly for long-term maintenance. Nevertheless, treatment for acute depressive episodes can usefully and safely include some ADs in moderate doses for limited duration, best combined with lithium, some anticonvulsants, or certain atypical antipsychotics, and more safely with BD-2 than BD-1 with close clinical supervision.

Identifying depression with mixed features: the potential value of eye-tracking features

Objectives

To investigate the utility of eye-tracking features as a neurobiological marker for identifying depression with mixed features (DMF), a psychiatric disorder characterized by the presence of depressive symptoms alongside subsyndromal manic features, thereby complicating both diagnosis and therapeutic intervention.

Methods

A total of 93 participants were included, comprising 41 patients with major depressive disorder (MDD), of whom 20 were classified as DMF, and 52 healthy controls (HC). Eye-tracking features were collected using an infrared-based device, and participants were evaluated using clinical scales including the Montgomery-Åsberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS). Performance of extreme gradient boosting (XGBoost) model based on demographic and clinical characteristics was compared with that of the model created after adding ocular movement data.

Results

Significant differences were observed in certain eye-tracking features between DMF, MDD, and HC, particularly in orienting saccades and overlapping saccades. Incorporating eye-tracking features into the XGBoost model enhanced the predictive accuracy for DMF, as evidenced by an increase in the area under the curve (AUC) from 0.571 to 0.679 (p < 0.05), representing an 18.9% improvement. This suggests a notable enhancement in the model's ability to distinguish DMF from other groups. The velocity of overlapping saccades and task completion time during free viewing were identified as significant predictive factors.

Conclusion

Eye-tracking features, especially the velocity of overlapping saccades and free viewing task completion time, hold potential as non-invasive biomarkers for the identification of DMF. The integration of these parameters into the XGBoost machine learning model significantly improved the accuracy of DMF diagnosis, offering a promising approach for enhancing clinical decision-making in psychiatric settings.

Advances in neurofilament light chain analysis

This chapter provides a comprehensive summary of clinical laboratory testing for neurofilament light chain (NfL) in neurologic disease. A primer on the NfL structure and function is presented with its potential use as a biomarker. The most widely utilized methods for NfL in biologic samples are highlighted and examined. Limitations of current knowledge are considered, as are outstanding questions related to dissemination and standardization of testing. Herein we focus on methods available today and those in development for clinical use. In the final section, a broad vision is presented of how NfL may be utilized in the future to improve diagnosis and treatment of neurologic diseases as well as for maintaining health.

A systematic review of measures of mania and depression in older people with bipolar disorder

BACKGROUND

Previous research on bipolar disorder (BD) primarily focused on younger adults, with limited research on older adults. This systematic review is the first to investigate how mania and depression are measured in older adults with BD.

METHODS

The searches were completed in April 2024 using the databases PsycINFO, CINAHL Plus, MEDLINE, and Embase. Fifteen studies with a total of 1041 participants were included. These studies used quantitative measures to assess mania and depression in participants aged 50-98 with BD I or II. The studies' risk of bias was evaluated using the appropriate critical appraisal tools.

RESULTS

The Young Mania Rating Scale (YMRS) was the most commonly used measure of mania, while the Center for Epidemiologic Studies Depression Scale (CES-D) and the Hamilton Depression Rating Scale (HAM-D) were the most commonly used measures of depression. The pooled analysis revealed that older adult scores on the YMRS were relatively similar to younger cohorts in both euthymic and manic states. Variability in scores was seen across the depression scales.

LIMITATIONS

The review followed rigorous systematic processes. However, in some studies, the participant's mood state was unknown, possibly impacting their pooled scores on the measures.

CONCLUSIONS

The findings from the review add to our existing knowledge regarding the presentation of mania and depression in later life. There is still a great disparity in research developed for the older BD population. Large-scale studies are warranted to inform the development of tailored measures and interventions to improve the outcomes for this population.

Phosphorylated neurofilament heavy chain (pNfH) concentration in cerebrospinal fluid predicts overall disease aggressiveness (D50) in amyotrophic lateral sclerosis

Introduction

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder, characterized by tremendous clinical heterogeneity that necessitates reliable biomarkers for the trajectory of the disease. The potential of phosphorylated Neurofilament-Heavy-chain (pNfH) measured in cerebrospinal fluid (CSF) to mirror disease progressiveness has repeatedly been suggested but is not applicable as outcome on an individual patient-level. This potential was probably obfuscated before due to imprecise clinical measures of disease progression that assumed a linear decline of motoric function over time. The primary objective was therefore to study if disease aggressiveness, as quantified via the D50 model, would reveal more stable correlations with pNfH.

Methods

ELISA-quantified pNfH CSF levels of 108 patients with ALS were comparatively analyzed in relation to three different measures of disease progression speed via analyses of covariance, linear and non-linear regressions, respectively. These were (a) the D50, depicting a patient's overall disease aggressiveness, (b) cFL, the calculated functional loss-rate as locally derived parameter of progression speed, and (c) DPR, the disease progression-rate as more commonly used linear approximation of points lost per month in the ALS functional rating scale since symptom onset.

Results

All analyses of covariance showed a significant main impact of the respective disease progression-speed parameter on pNfH, independent of disease phase, presence of frontotemporal dementia, analyzing laboratory, sex or clinical onset type, while only age revealed borderline additional influence. Notably, CSF pNfH concentration was independent of how far the disease had progressed, as neither disease phase nor a direct regression with the quantified disease accumulation at the time of lumbar puncture revealed a significant correlation. However, the parameter D50 quantifying aggressiveness showed the most significant impact on pNfH-levels, as compared to the cFL and even more evident in contrast to the DPR. This superiority of D50 was confirmed in direct linear and most evident in non-linear regressions with pNfH.

Conclusion

Overall disease aggressiveness in ALS, as quantified by D50, most robustly correlated with CSF pNfH-levels, independent of the time of collection during symptomatic disease. This opens perspectives to use CSF pNfH as a prognostic outcome measure for future therapeutic interventions in the sense of precision medicine.

Comprehensive cross-sectional and longitudinal comparisons of plasma glial fibrillary acidic protein and neurofilament light across FTD spectrum disorders

BACKGROUND

Therapeutic development for frontotemporal dementia (FTD) is hindered by the lack of biomarkers that inform susceptibility/risk, prognosis, and the underlying causative pathology. Blood glial fibrillary acidic protein (GFAP) has garnered attention as a FTD biomarker. However, investigations of GFAP in FTD have been hampered by symptomatic and histopathologic heterogeneity and small cohort sizes contributing to inconsistent findings. Therefore, we evaluated plasma GFAP as a FTD biomarker and compared its performance to that of neurofilament light (NfL) protein, a leading FTD biomarker.

METHODS

We availed ARTFL LEFFTDS Longitudinal Frontotemporal Lobar Degeneration (ALLFTD) study resources to conduct a comprehensive cross-sectional and longitudinal examination of the susceptibility/risk, prognostic, and predictive performance of GFAP and NfL in the largest series of well-characterized presymptomatic FTD mutation carriers and participants with sporadic or familial FTD syndromes. Utilizing single molecule array technology, we measured GFAP and NfL in plasma from 161 controls, 127 presymptomatic mutation carriers, 702 participants with a FTD syndrome, and 67 participants with mild behavioral and/or cognitive changes. We used multivariable linear regression and Cox proportional hazard models adjusted for co-variates to examine the biomarker utility of baseline GFAP and NfL concentrations or their rates of change.

RESULTS

Compared to controls, GFAP and NfL were elevated in each FTD syndrome but GFAP, unlike NfL, poorly discriminated controls from participants with mild symptoms. Similarly, both baseline GFAP and NfL were higher in presymptomatic mutation carriers who later phenoconverted, but NfL better distinguished non-converters from phenoconverters. We additionally observed that GFAP and NfL were associated with disease severity indicators and survival, but NfL far outperformed GFAP. Nevertheless, we validated findings that the GFAP/NfL ratio may discriminate frontotemporal lobar degeneration with tau versus TDP-43 pathology.

CONCLUSIONS

Our head-to-head comparison of plasma GFAP and NfL as biomarkers for FTD indicate that NfL consistently outmatched GFAP as a prognostic and predictive biomarker for participants with a FTD syndrome, and as a susceptibility/risk biomarker for people at genetic risk of FTD. Our findings underscore the need to include leading biomarkers in investigations evaluating new biomarkers if the field is to fully ascertain their performance and clinical value.

Investigating the Relationship Between Anti-seizure Medications and Bleeding Disorders: A Comprehensive Review of the Current Literature

Anti-seizure medications (ASMs) are specific types of anticonvulsants used to treat epileptic seizures. However, several studies have shown an association between ASMs and an increased risk of hematological disorders, such as thrombocytopenia, aplastic anemia, and platelet function disorders leading to prolonged bleeding times. This review explores the existing literature on this topic, investigating a wide variety of ASMs, ranging from first-generation medications to newer ones. A comprehensive search was conducted on all the currently approved ASMs using PubMed and Google Scholar: review articles, clinical trials, meta-analysis, observational studies, case reports, and relevant animal studies were identified. We extracted 15 ASMs including valproic acid (VPA), carbamazepine, phenytoin, phenobarbital, diazepam, clonazepam, lamotrigine, levetiracetam, oxcarbazepine, felbamate, topiramate, pregabalin, lacosamide, cannabidiol (CBD), and perampanel that contain considerable literature regarding different coagulopathies. An in-depth review of over 140 studies revealed a robust association between ASM-induced changes and the onset of bleeding disorders via several different mechanisms. Polytherapy, the use of multiple ASMs, also emerged as a significant risk factor for the development of coagulopathies. This review highlights the potential link between ASMs and bleeding disorders, emphasizing the importance of considering this risk during treatment planning. By understanding these associations, healthcare providers can optimize patient outcomes and minimize bleeding risks. Additionally, this review identifies the need for further research to bridge current knowledge gaps in clinical pharmacology related to ASMs and bleeding disorders.

Prospective, comparative, pilot study of maintenance treatment in comorbid bipolar disorders with post-traumatic stress disorder

There is limited real-world evidence that evaluates the impact of monotherapy vs. combination therapy as a maintenance treatment in comorbid post-traumatic stress disorder (PTSD) in bipolar disorder (BD). Our aim was to compare lithium vs. lithium plus quetiapine in maintenance treatment in a sample of comorbid BD with PTSD. An exploratory, comparative pilot study over a 28-week period in 34 comorbid BD with PTSD patients was performed to compare monotherapy (n = 18) vs. combination therapy (n = 16) during maintenance treatment. The primary outcome was the time to event of recurrence of any mood episode. The secondary outcomes were regarding change from the baseline to endpoint in the Montgomery-Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS). A Cox regression, Kaplan-Meir survival, and mixed-effects model for repeated measures analyses were performed. Lithium plus quetiapine reduces the risk of recurrence of any mood episode. There are significant differences between baseline and endpoint for YMRS, MADRS, and CGI-BP scales in the sample. In this pilot, exploratory analysis, combination therapy during maintenance treatment for comorbid BD with PTSD may be effective in preventing recurrences of any type of mood episode.

Left Ventrolateral Prefrontal Cortical Activity During Reward Expectancy and Mania Risk

Importance

Mania/hypomania is the pathognomonic feature of bipolar disorder (BD). As BD is often misdiagnosed as major depressive disorder (MDD), replicable neural markers of mania/hypomania risk are needed for earlier BD diagnosis and pathophysiological treatment development.

Objective

To replicate the previously reported positive association between left ventrolateral prefrontal cortex (vlPFC) activity during reward expectancy (RE) and mania/hypomania risk, to explore the effect of MDD history on this association, and to compare RE-related left vlPFC activity in individuals with and at risk of BD.

Design, Setting, and Participants

This cross-sectional study was conducted from July 2014 to December 2023 at the University of Pittsburgh, Pittsburgh, Pennsylvania. Three samples were formed comprising young adults (aged 18 to 30 years) without BD and with a range of subsyndromal-syndromal affective and anxiety psychopathologies, including a new sample and 2 test samples from our previous research; a sample of individuals aged 18 to 30 years with euthymic BD was also included. All participants were recruited from the community through advertising.

Exposures

Functional magnetic resonance imaging during an RE task.

Main Outcomes and Measures

New sample: whole-brain activity during RE regressed to the Mood Spectrum Self-Report Lifetime Questionnaire (MOODS-SR-L) manic domain score in all participants and in those without history of MDD and RE-related whole-brain activity regressed to the MOODS-SR-L depressive domain score to determine specificity to mania/hypomania risk. Test samples: these associations were examined using parameter estimates of activity extracted from respective masks created from activity in the new sample. A tertile split of MOODS-SR-L manic domain score divided the new sample into 3 mania/hypomania risk groups. Comparison of RE-related activity (extracted parameter estimates) was performed in risk groups and individuals with BD.

Results

Among the 113 individuals in the new sample, 73 were female, and the mean (SD) age was 23.88 (3.32) years. In each of the test samples, there were 52 individuals (39 female; mean [SD] age, 21.94 [2.12] years) and 65 individuals (47 female; mean [SD] age, 21.39 [2.11] years). The euthymic BD group had 37 individuals (30 female; mean [SD] age, 25.12 [3.81] years). In the new sample, 8 clusters of RE-related activity, including left vlPFC activity, showed a positive association with mania/hypomania risk, which remained after excluding individuals with MDD history and was specific to mania/hypomania risk. In the test samples, this association was shown in test sample 1 only (β, 0.21; 95% CI, 0.08-0.35; P = .002; q(false discovery rate [FDR]), 0.006; R2, 0.04). Test sample 2 had a higher proportion with MDD history (49 of 65 [75.3%] compared to 31 of 52 [59.6%] in sample 1). Combining individuals without history of MDD in both test samples replicated the association (β, 0.32; 95% CI, 0.08-0.58; P = .01; q[FDR], 0.023; R2, 0.02). RE-related left vlPFC activity was significantly greater in individuals at highest risk vs lowest (Cohen d, 1.01; 95% CI, 0.29-0.79; P < .001) and medium (Cohen d, 0.59; 95% CI, 0.12-0.63; P = .004) risk, as well as the euthymic BD group (Cohen d, 0.54; 95% CI, 0.07-0.58; P = .01), potentially due to medication effects.

Conclusion and Relevance

Elevated RE-related left vlPFC activity was associated with mania/hypomania risk and attenuated by MDD history. These findings provide a neural target to help develop pathophysiological interventions for individuals with or at risk of mania/hypomania.

Psilocybin-Assisted Psychotherapy for Treatment-Resistant Depression in Bipolar II Disorder

Background

Bipolar II disorder (BD-II) is often associated with chronic and treatment resistant major depressive episodes. Psilocybin has shown promise for its rapid-acting antidepressant effects, though its impact on bipolar depression remains unexplored. In the present subgroup analysis of an already published trial on treatment-resistant depression (TRD), we aimed to preliminarily evaluate the safety and efficacy of psilocybin in patients with BD-II.

Methods

Adults with TRD associated with BD-II, excluding those with psychosis were included. Participants underwent one or two psilocybin sessions, each with a dose of 25 mg, along with preparatory and integrative psychotherapy sessions.

Results

A total of four participants with a mean age of 37.5  ±  4.15 years were included. At baseline, the mean Montgomery-Åsberg Depression Rating Scale (MADRS) score was 32.5 (95% CI: 26.3-38.7, SD = 3.87). By week 2 post-dose, mean MADRS decreased to 20.3, and 2 weeks after dose 2, it further dropped to 19. At the end of the 6-month study, the mean MADRS score was 21.3. Young Mania Rating Scale scores remained stable at a mean of one throughout the study with no evidence of treatment emergent mania, hypomania or psychosis observed in any participants.

Conclusions

These findings suggest potential improvement in depressive symptoms with psilocybin administration in BD-II. Future studies with larger sample size are required to replicate our results and further evaluate antidepressant effects of psilocybin in bipolar depression.

Medication Adherence and Its Relationship With Quality of Life and Functionality in Individuals With Bipolar Disorder: A Cross-Sectional Correlational Study

PURPOSE

The current cross-sectional correlational study aimed to determine the relationship of medication adherence with functionality and quality of life in individuals with bipolar disorder (BD).

METHOD

The research was conducted with 141 individuals with BD followed as outpatients. Data were collected using an information form, Morisky Medication Adherence Scale (MMAS), Quality of Life in Bipolar Disorder Scale (QoL.BD), and Bipolar Disorder Functioning Questionnaire (BDFQ).

RESULTS

A significant positive correlation was found between participants' MMAS total score and QoL.BD (p < 0.001) and BDFQ (p < 0.05) scores. A significant positive correlation was also found between QoL.BD and BDFQ scores (p < 0.001).

CONCLUSION

Medication compliance positively affects quality of life and social functionality in individuals with BD. Thus, interventions to increase medication adherence are recommended. [Journal of Psychosocial Nursing and Mental Health Services, 63(3), 27-35.].

Contrasting genetic burden for bipolar disorder: Early onset versus late onset in an older adult bipolar disorder sample

Older Adults with Bipolar Disorder (OABD) represent a heterogeneous group, including those with early and late onset of the disorder. Recent evidence shows both groups have distinct clinical, cognitive, and medical features, tied to different neurobiological profiles. This study explored the link between polygenic risk scores (PRS) for bipolar disorder (PRS-BD), schizophrenia (PRS-SCZ), and major depressive disorder (PRS-MDD) with age of onset in OABD. PRS-SCZ, PRS-BD, and PRS-MDD among early vs late onset were calculated. PRS was used to infer posterior SNP effect sizes using a fully Bayesian approach. Demographic, clinical, and cognitive variables were also analyzed. Logistic regression analysis was used to estimate the amount of variation of each group explained by standardized PRS-SCZ, PRS-MDD, and PRS-BD. A total of 207 OABD subjects were included (144 EOBD; 63 LOBD). EOBD showed higher PRS-BD compared to LOBD (p = 0.005), while no association was found between age of onset and PRS-SCZ or PRS-MDD. Compared to LOBD, EOBD individuals also showed a higher likelihood for suicide attempts (p = 0.01), higher presence of psychotic symptoms (p = 0.003), higher prevalence of BD-I (p = 0.002), higher rates of familiarity for any psychiatric disorder (p = 0.004), and lower processing speed measured with Trail-Making Test part A (p = 0.03). OABD subjects with an early onset showed a greater genetic burden for BD compared to subjects with a late onset. These findings contribute to the notion that EOBD and LOBD may represent different forms of OABD, particularly regarding the genetic predisposition to BD.

[Second-step strategies in antidepressant pharmacotherapy : Results of current meta-analyses]

BACKGROUND

Antidepressant pharmacotherapy often does not result in the desired effect despite adequate duration and dose. Better evidence on second-step strategies is needed.

OBJECTIVE

Overview of the current evidence for various pharmacological second-step strategies after nonresponse to antidepressant monotherapy.

MATERIAL AND METHODS

Summary of recent systematic reviews with meta-analyses of the group of authors on pharmacological second-step treatment.

RESULTS

A meta-analysis showed no advantage of switching to a second antidepressant compared with continuing the previously ineffective monotherapy. Another two meta-analyses showed no benefit of increasing the dose of selective serotonin reuptake inhibitors (SSRI). For serotonin and noradrenaline reuptake inhibitors (SNRI) and tricyclic antidepressants (TCA) in each case a meta-analysis showed no clear advantage of increasing the dose. Another two meta-analyses showed a superiority of a combination therapy consisting of a reuptake inhibitor (SSRI, SNRI, TCA) with a presynaptic alpha‑2 autoreceptor antagonist (e.g., mirtazapine) compared with an antidepressant monotherapy.

CONCLUSION

In accordance with the recommendations of the German national treatment guideline, in the event of nonresponse to antidepressant monotherapy, the combination of two antidepressants is preferable to repeated switching of the antidepressant.

Child maltreatment and psycho-social impairments among child laborers in rural Bangladesh

PURPOSE

The current study focused on exploring the impact of maltreatment of child laborers on their psychosocial health condition from the views of their parents.

METHODS

A total of 100 parents of child laborers were recruited using snowball sampling. The structured questionnaire comprised two validated scales including ISPCAN Child Abuse Screening Tool (ICAST-P), and Paediatric Symptom Checklist (PSC) were used for the survey. Factor analysis and multivariable linear regression analysis were performed to examine the data using SPSS version 26, and Stata version 16.1.

RESULTS

A three-factor model consisting of internalizing, externalizing, and attention associated psycho-social impairments of child laborers were derived from the 35-item scale of PSC tool and represented a good fit to the data. A mean estimate of maltreatment indicates that a majority of child laborers are maltreated psychologically, followed by physical maltreatment and neglect. The factor analysis resulted that maltreated child laborers are highly prone to exhibit internalized psycho-social difficulties, followed by externalized and attention-associated emotional and behavioral difficulties among child laborers. The regression model further depicts that child laborers, who had been physically and psychologically maltreated, are significantly more likely to be affected by internalized and attention-related psycho-social impairments.

CONCLUSIONS

The study concluded that victimized child laborers exhibited significant internalized, as well as attention-related problems. These findings may be useful for future studies that examine emotional and behavioral problems among maltreated child laborers and, therefore, for developing prevention strategies.

Therapeutic Potential of Saffron Extract in Mild Depression: A Study of Its Role on Anhedonia in Rats and Humans

Drugs generally used in major depressive disorder are considered inappropriate for the more common milder forms. The efficacy of saffron extracts has been demonstrated in mild to moderate depression and in preclinical models of depression. However, evidence of saffron activity on reduced hedonic responsiveness and motivational anhedonia is limited. Since dopamine transmission dysfunctions are crucially involved in anhedonia and saffron seems to positively modulate dopamine release, we studied the potential antidepressant and anti-anhedonic effects of a standardized formulation of saffron extract in preclinical models of anhedonia-like behaviors, and patients diagnosed with unipolar or bipolar depression. We tested saffron activity in a rat model of stress-induced motivational anhedonia using sucrose self-administration protocols and investigated the molecular underpinnings of this effect focusing on DARPP-32 phosphorylation pattern in response to a reinforcer and BDNF-TrkB signaling, in the nucleus accumbens and medial prefrontal cortex. In parallel, with a pilot double-blind placebo-controlled study we investigated whether saffron add-on therapy reduced symptoms of depression and anhedonia, measured by the Montgomery-Åsberg Depression Rating Scale. Repeated saffron administration restored motivation and reactivity to reward-associated cues in anhedonic rats, likely modulating dopaminergic transmission and BDNF-TrkB signaling. In depressed patients, an 8-week saffron add-on therapy induced a global improvement in depressive symptoms and a significant reduction in anhedonia. The study supports a pro-motivational effect of saffron and suggests a potentially useful saffron-based augmentation strategy in anhedonic patients, albeit with limitations due to small sample size and short trial duration.

Aggressive Behavior in Children and Adolescents With Bipolar Spectrum Disorder: A Systematic Review of the Prevalence, Associated Factors, and Treatment

Objective

Bipolar disorder (BD) in childhood and adolescence is associated with aggressive behaviors, which might be common and in turn associated with poor clinical outcomes. This is the first systematic review to provide a comprehensive view of the current status of the knowledge about aggressive behaviors in youth with BD.

Method

We conducted a PRISMA-compliant systematic review of studies investigating aggressive behaviors in children and adolescents with BD (PROSPERO: CRD42023431674). A systematic multi-step literature search was performed on PubMed and the Web of Science. Literature search and data extraction were carried out independently. We provided a systematic synthesis of the findings from the included studies We assessed risk of bias using a modified version of the Newcastle-Ottawa Scale for cross-sectional and cohort studies.

Results

Of the 2,277 identified records 35 were included; mean age was 12.4 years, and 57.1% were male individuals. 7 studies reported on the prevalence of aggressive behavior among BD children and adolescent population, with 5 of them reporting a prevalence of over 69.0%. Aggressive behaviors were more common in children and adolescents with BD than in those with ADHD or depression. Aggressive behaviors were associated with borderline personality disorder features and poor family functioning. Valproic acid received empirical support for its efficacy in reducing aggressive behavior in BD.

Conclusion

Aggressive behaviors are prevalent among youth with BD and warrant clinical attention and specific evidence-based management. Further research on prognostic factors and psychosocial interventions evaluated prospectively is required.

Diversity & Inclusion Statement

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. One or more of the authors of this paper self-identifies as living with a disability. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group.

Exploring the interplay between mitochondrial dysfunction, early life adversity and bipolar disorder

OBJECTIVE

Mitochondria are essential for energy production and reactive oxygen species (ROS) generation, with changes in ROS levels or energy demands affecting mitochondrial DNA (mtDNA) copy numbers, indicating mitochondrial function. Early life adversity (ELA) affects mitochondrial dynamics, influencing long-term health. Both ELA and mitochondrial abnormalities have been independently associated with bipolar disorder (BD). This study aims to explore the complex interplay between mitochondrial dysfunction, ELA, and BD.

METHODS

The study included 60 participants diagnosed with BD and 66 healthy controls (HCs). Data were collected using the Childhood Trauma Questionnaire (CTQ), and leukocyte mtDNA copy number (MCN) was determined from blood samples.

RESULTS

The results indicated the CTQ sum scores were significantly higher in the BD group, reflecting greater exposure to ELA. In HCs, a marginally significant nonlinear relationship between the square of the CTQ sum score and MCN was found. Further analysis demonstrated a significant interaction between ELA and BD on MCN (p = 0.023), highlighting a critical connection between ELA and mitochondrial dysfunction in BD and reinforcing its biological underpinnings.

CONCLUSIONS

Future treatments for BD might target mitochondrial dysfunctions related to chronic stress, with potential pharmaceuticals designed to address these issues and mitigate the negative effects of chronic stress.

Mood, Activity, and Instability in Bipolar Disorder and Unipolar Disorder-An Exploratory Post Hoc Study Using Digital Data

BACKGROUND

Mood, activity, and instability in symptomatology hold significant roles in bipolar disorder (BD) and unipolar disorder (UD). The objectives were to examine disparities in these symptoms among patients with BD and UD.

METHODS

Data from two studies including patients with BD and UD, respectively, were combined for exploratory analyses. Patients provided daily smartphone-based evaluations of mood and activity/energy for a 6-month period. A total of 47 patients with BD and 59 patients with UD were included in the analyses. The dataset contains more than 13,000 patient-reported evaluations of mood and activity. Daily mood and activity instability measures were calculated using the root squared successive difference method.

RESULTS

In linear mixed effect regression models adjusted for age, sex, and work status, there were statistically significant lower levels of activity in patients with BD as compared with patients with UD overall, during euthymic states and during depressive states (B: -0.61, 95% CI: -0.98; -0.24, p = 0.001). There were no statistically significant differences in mood instability and activity instability between patients with BD and patients with UD overall, during euthymic states and during depressive states, when accounting for multiple testing (p > 0.012).

LIMITATIONS

Analyses were exploratory and post hoc. Findings should be interpreted with caution. The sample size was modest.

CONCLUSION

Patients with BD presented with lower level of activity as compared with patients with UD. There were no differences in mood and activity instability between these groups. Future studies including larger sample sizes should investigate differences between BD and UD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03033420.

Pediatric Bipolar Disorder: Challenges in Diagnosis and Treatment

Despite an opportunity to prevent adult psychopathology associated with bipolar disorder through early diagnosis in children, there is insufficient information and awareness among healthcare providers about the unique features and treatment of mania and its comorbid conditions in children. Converging evidence from disparate sites describe a developmentally distinct presentation of bipolar disorder in youth that is highly morbid, persistent and responds to treatment with the mood stabilizer medications used in the treatment of adult bipolar disorder, such as divalproex sodium and carbamazepine. Some are additionally approved for use in pediatric populations including, for manic or mixed states, risperidone, aripiprazole, and asenapine for those aged 10-17 years and also including lithium and olanzapine for ages 13-17 years. Quetiapine is approved as monotherapy or as adjunct to lithium or divalproex sodium for manic states in those aged 10-17 years. Delayed or missed diagnosis, inappropriate treatment, worsening course, and treatment resistance unfortunately still occur. While an array of mood-stabilizing medications is available for treatment, such as second-generation antipsychotics, lithium, and anticonvulsants, these can be only partially effective and fraught with annoying and serious side effects. This article will review current practice in the diagnosis and treatment of pediatric bipolar disorder and its comorbid conditions, highlighting areas of need for future research.

Cross-sectional and longitudinal analysis of high-sensitivity C-reactive protein as a biomarker for suicidal behavior in depressive patients undergoing pharmacotherapy

This study investigated the role of serum high-sensitivity C-reactive protein (hsCRP) as a biomarker for suicidal behavior (SB) in both cross-sectional and longitudinal contexts, driven by emerging evidence that systemic inflammation, marked by elevated hsCRP levels, may be linked to increased suicidality in individuals with depressive disorders. Serum hsCRP levels were measured at baseline in 1,094 patients with depressive disorders. Of these, 884 were followed during a 12-month period of stepwise pharmacotherapy. SB assessments included previous suicide attempts and baseline suicidal severity at baseline, and increased suicidal severity and fatal/non-fatal suicide attempts at follow-up. We analyzed the associations between hsCRP levels (and elevated levels ≥1.0 mg/L) with these SB categories using logistic regression, adjusting for relevant covariates. Higher or elevated serum hsCRP levels were significantly associated with SB at baseline in cross-sectional analyses. However, these associations did not persist in the 12-month longitudinal analyses after adjustments. While hsCRP serves as a concurrent biomarker for SB, it does not act as a predictive marker for future suicidal behaviors. Future research should include repeated measures of hsCRP in a controlled setting to confirm these findings.

Esketamine Treatment for Depression in Adults: A PRISMA Systematic Review and Meta-Analysis

OBJECTIVE

Intranasal esketamine has been approved as an adjunctive therapy for treatment-resistant major depressive disorder with acute suicidal ideation and behavior. The authors conducted a systematic review and meta-analysis of the available data on its efficacy against depression and suicidality as well as its side effects.

METHODS

MEDLINE was searched with the keyword "esketamine" on March 24, 2024, using the PRISMA method. Data processing and statistical analysis were performed with R, version 4.3.3, and the meta-analysis was performed with the METAFOR package.

RESULTS

Of 1,115 articles initially identified, 87 were included for analysis and discussion. At weeks 2-4, randomized controlled trials were mostly negative or failed; however, the meta-analysis returned a weak but significant positive effect for depression (effect size range, 0.15-0.23 at weeks 2-4), similar to augmentation strategies with atypical antipsychotics for treatment-resistant depression. The effect size concerning suicidality was not significant at any time point. The sensitivity analysis produced the same results.

CONCLUSIONS

The study findings suggest that esketamine's efficacy as an add-on to antidepressants is modest in treatment-resistant depression (similar to augmentation strategies with atypical antipsychotics) and is absent against suicidality itself. These findings need to be considered in light of esketamine's abuse potential and the fact that long-term effects are still not fully known. Some alarming signs concerning deaths and emerging suicidality during the testing phase are discussed, along with other regulatory issues.

Pharmacotherapy in Comorbid Bipolar Disorder and Post-Traumatic Stress Disorder From the STEP-BD Cohort

INTRODUCTION

Post-traumatic stress disorder (PTSD) is more prevalent in those with bipolar disorder (BD) than in the general population, with rates of PTSD as high as 55% in some BD cohorts. Despite this, little research explores the effects of pharmacotherapy treatments in those with comorbid BD and PTSD. This study aims to explore patterns of pharmacotherapy use at baseline and their impact on symptoms in individuals with BD alone and comorbid BD and PTSD.

METHODS

The Systematic Treatment Enhancement Program for BD (STEP-BD) cohort was utilised to examine and compare BD symptoms and pharmacotherapy treatments between those with BD alone (n = 3393) and those with comorbid BD and PTSD (n = 304). We conducted regression models to compare those with and without comorbid PTSD. Models included measures of depression, mania, functioning and quality of life over 24 months of the STEP-BD study. We included baseline pharmacotherapies (lithium, valproate, antidepressants, antipsychotics and benzodiazepines) as predictor outcome variables in all models.

RESULTS

At baseline, reported use of lithium was lower in the comorbid BD and PTSD group, while the use of antidepressants, antipsychotics and benzodiazepines was significantly higher in the comorbid BD and PTSD than in the BD alone group. Benzodiazepine use was associated with a small improvement in depression symptom scores and poorer quality of life in those with comorbid BD and PTSD. Lastly, those with comorbid PTSD experienced higher levels of mania and depression symptoms and lower functioning and quality of life compared to BD alone, irrespective of pharmacotherapy treatment.

CONCLUSION

Clinical trial participants with BD and PTSD reported worse symptoms and outcomes across 24 months of the STEP-BD study compared to those without comorbid PTSD, regardless of baseline medication use. These results highlight the importance of considering comorbidity in the treatment of mental health conditions, specifically BD, and the need for further exploration of effective treatment options.

Digital phenotyping in bipolar disorder: Using longitudinal Fitbit data and personalized machine learning to predict mood symptomatology

BACKGROUND

Effective treatment of bipolar disorder (BD) requires prompt response to mood episodes. Preliminary studies suggest that predictions based on passive sensor data from personal digital devices can accurately detect mood episodes (e.g., between routine care appointments), but studies to date do not use methods designed for broad application. This study evaluated whether a novel, personalized machine learning approach, trained entirely on passive Fitbit data, with limited data filtering could accurately detect mood symptomatology in BD patients.

METHODS

We analyzed data from 54 adults with BD, who wore Fitbits and completed bi-weekly self-report measures for 9 months. We applied machine learning (ML) models to Fitbit data aggregated over two-week observation windows to detect occurrences of depressive and (hypo)manic symptomatology, which were defined as two-week windows with scores above established clinical cutoffs for the Patient Health Questionnaire-8 (PHQ-8) and Altman Self-Rating Mania Scale (ASRM) respectively.

RESULTS

As hypothesized, among several ML algorithms, Binary Mixed Model (BiMM) forest achieved the highest area under the receiver operating curve (ROC-AUC) in the validation process. In the testing set, the ROC-AUC was 86.0% for depression and 85.2% for (hypo)mania. Using optimized thresholds calculated with Youden's J statistic, predictive accuracy was 80.1% for depression (sensitivity of 71.2% and specificity of 85.6%) and 89.1% for (hypo)mania (sensitivity of 80.0% and specificity of 90.1%).

CONCLUSION

We achieved sound performance in detecting mood symptomatology in BD patients using methods designed for broad application. Findings expand upon evidence that Fitbit data can produce accurate mood symptomatology predictions. Additionally, to the best of our knowledge, this represents the first application of BiMM forest for mood symptomatology prediction. Overall, results move the field a step toward personalized algorithms suitable for the full population of patients, rather than only those with high compliance, access to specialized devices, or willingness to share invasive data.

Comparative efficacy, safety, and tolerability of pharmacotherapies for acute mania in adults: a systematic review and network meta-analysis of randomized controlled trials

The aim of this study was to provide evidence-based recommendations regarding the efficacy, safety, and tolerability of currently used pharmacological treatments for adults with acute bipolar mania. To achieve this, we conducted a systematic review and network meta-analysis (NMA) using R software and related packages. We searched primary clinical databases until February 2023 for reports of randomized controlled trials of drug treatments and adjunctive therapies for adults with acute bipolar mania, with outcomes including efficacy (mean change from baseline to endpoint in mania rating scores), safety (clinically significant adverse events from baseline to end of treatment), and tolerability (the proportion of patients who completed the whole trial to the planned endpoint). A total of 113 studies were included in our analysis, in which 23,491 participants (50.38% males; mean age = 38.6 years; mean study duration = 3.39 weeks; mean manic baseline score = 29.37) were randomly allocated to one of 51 monotherapies, adjunctive treatments, or placebo. Our results showed that tamoxifen (mean difference, -22.31 [-25.97, -18.63], N = 2, n1 = 43, n2 = 39) and tamoxifen+ lithium or valproate (LIT/VAL) (-16.37 [-22.55, -10.25], N = 1, n1 = 20, n2 = 20) had the best and second-best clinical efficacy in adults with acute bipolar mania over the placebo. Furthermore, olanzapine, paliperidone, quetiapine, ziprasidone, risperidone, divalproex, and haloperidol were significantly better tolerated than placebo. Combination therapies of antipsychotics and LIT/VAL appeared to be more effective than their corresponding monotherapies. While pharmacotherapies were associated with specific common adverse events, we found no evidence of increased incidence of headache or depression events compared to the placebo. Overall, our NMAs provided important insights into the effectiveness, safety, and tolerability of pharmacological treatments for acute bipolar mania and can help guide treatment decisions for clinicians.

Linking Mitochondrial Dysfunction, Neurotransmitter, and Neural Network Abnormalities and Mania: Elucidating Neurobiological Mechanisms of the Therapeutic Effect of the Ketogenic Diet in Bipolar Disorder

There is growing interest in the ketogenic diet as a treatment for bipolar disorder (BD), and there are promising anecdotal and small case study reports of efficacy. However, the neurobiological mechanisms by which diet-induced ketosis might ameliorate BD symptoms remain to be determined, particularly in manic and hypomanic states-defining features of BD. Identifying these mechanisms will provide new markers to guide personalized interventions and provide targets for novel treatment developments for individuals with BD. In this critical review, we describe recent findings highlighting 2 types of neurobiological abnormalities in BD: 1) mitochondrial dysfunction and 2) neurotransmitter and neural network functional abnormalities. We link these abnormalities to mania/hypomania and depression in BD and then describe the biological underpinnings by which the ketogenic diet may have a beneficial effect in individuals with BD. We end the review by describing approaches that can be employed in future studies to elucidate the neurobiology that underlies the therapeutic effect of the ketogenic diet in BD. Doing this may provide marker predictors to identify individuals who will respond well to the ketogenic diet, as well as offer neural targets for novel treatment developments for BD.

Ten Years of Bipolar Telehealth: Program Evaluation of a Team-Based Telemental Health Clinic

Objectives: Telemental health via videoconferencing (TMH-V) can overcome many of the barriers to accessing quality mental health care. Toward this end, in 2011, the U.S. Department of Veterans Affairs (VA) established the National Bipolar Disorders TeleHealth (BDTH) Program to provide expert mental health consultation and treatment to Veterans with bipolar spectrum disorders. Methods: Initial analyses of BDTH services suggested that participants had positive changes in quality-of-care indices and clinical outcomes; however, that evaluation was based on a limited sample of both participants and VA medical centers. We were able to confirm and expand upon those early results by using nearly eight times the number of participants and more than twice as many medical centers. Results: For the 2,456 Veterans who completed the intake to our program, there were significant improvements in some of the quality metrics (e.g., lithium use) and a 54% reduction in positive suicide screens (p < 0.05). The Veterans who completed the initial and postprogram assessments (n = 815) reported a 16.6% reduction in manic symptoms (p < 0.001), a 29.3% reduction in depressive symptoms (p < 0.001), and a 21.2% reduction in mood episodes (p < 0.001). Additionally, these Veterans demonstrated significant improvements (p < 0.001) in mental health-related quality of life between the two assessments. Conclusions: These analyses provide further support for the general effectiveness and safety of telemental health via videoconferencing. Future research should examine the generalizability of these findings across various subgroups (e.g., minority patients, patients in rural areas), populations, and health care systems.

Extended course accelerated intermittent theta burst stimulation as a substitute for depressed patients needing electroconvulsive therapy

In response to restrictions on electroconvulsive therapy (ECT) access during COVID-19, we designed a trial to assess the clinical outcomes service impacts, employing an extended course of accelerated intermittent theta burst stimulation (aiTBS), in patients with moderate to severe depression in need of ECT. This open label clinical trial was comprised of 3 phases: (i) an acute phase, where iTBS treatments were administered 8 times daily, for up to 10 days; (ii) a tapering phase of 2 treatment days per week for 2 weeks, followed by 1 treatment day per week for 2 weeks; and (iii) a symptom-based relapse prevention phase, whereby treatments were scheduled based on symptom re-emergence, for up to 6 months. Of the 155 patients who completed the acute phase of the study, the remission rate was 16.1%. The mean reduction from baseline on the HRSD-24 was 29.4% (p < 0.001) and the response rate was 25.2%. Of the 110 patients who completed the tapering phase, the mean reduction from baseline was 42.6% (p < 0.001) and response and remission rates were 49.6% and 34.8%, respectively. Of the 61 patients who were eligible for the relapse prevention phase, 43 completed, with a mean reduction from baseline of 60.1% (p < 0.001); 7 patients relapsed during this phase. This study demonstrated that an extended aiTBS protocol safely led to meaningful clinical outcomes in patients with severe depression, who otherwise would have received ECT, and thus reduced pressure on ECT services during the pandemic. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04384965 ( https://clinicaltrials.gov/study/NCT04384965?term=NCT04384965&rank=1 ).

Hormone circuit explains why most HPA drugs fail for mood disorders and predicts the few that work

Elevated cortisol in chronic stress and mood disorders causes morbidity including metabolic and cardiovascular diseases. There is therefore interest in developing drugs that lower cortisol by targeting its endocrine pathway, the hypothalamic-pituitary-adrenal (HPA) axis. However, several promising HPA-modulating drugs have failed to reduce long-term cortisol in mood disorders, despite effectiveness in other hypercortisolism conditions such as Cushing's syndrome. The reasons for these failures remain unclear. Here, we use a mathematical model of the HPA axis to demonstrate that the pituitary and adrenal glands compensate for drug effects by adjusting their functional mass, a feedback mechanism absent in Cushing tumors. Our systematic in silico analysis identifies two interventions targeting corticotropin-releasing hormone (CRH) as effective for lowering long-term cortisol. Other targets either fail due to gland mass compensation or harm other aspects of the HPA axis. We propose CRH-neutralizing antibodies and CRH-synthesis inhibitors as potential targets for reducing long-term cortisol in mood disorders and chronic stress. More generally, this study indicates that understanding the slow compensatory mechanisms in endocrine axes can be crucial to prioritize drug targets.

Long-Acting Injectable Antipsychotics in Adolescents with Bipolar Disorder

Background: Bipolar disorder often begins in adolescence or early adulthood, characterized by recurrent manic episodes that can lead to neurodegenerative brain changes and functional decline. While several oral second-generation antipsychotics are Food and Drug Administration (FDA)-approved for mania, adherence to maintenance treatment is frequently poor due to factors such as anosognosia, cognitive dysfunction, impulsivity, side effects aversion, and substance use. Long-acting injectable (LAI) antipsychotics, approved for adults with bipolar mania or schizoaffective disorder (bipolar type), offer a potential solution for adolescents with similar conditions. This study reports on the efficacy of LAI antipsychotics in managing bipolar mania in adolescents, tracking outcomes over up to a year with baseline and follow-up Young Mania Rating Scale (YMRS) assessments. Methods: The study included 116 adolescents with a mean age of 16.17 years (66% male, 48% white, 23% black). Of these, 73% were diagnosed with bipolar mania and 22% with schizoaffective disorder, bipolar type. The mean illness duration was 1.9 years, with a baseline YMRS score of 33.8 and a body mass index (BMI) of 23.4 kg/m². LAI antipsychotics administered included aripiprazole, paliperidone, and risperidone, given at intervals of 1, 2, or 3 months. Results: YMRS scores showed substantial improvement, declining to 21.7 at 1 month, 12.3 at 2 months, 4.9 at 6 months, and 3.0 at 1 year. Common side effects were increased appetite and weight gain (mean BMI rose to 26.3 kg/m²). There were no dropouts, although 12% of participants switched formulations due to side effects. Notably, 86.2% of adolescents improved sufficiently to return to school or work. While 28.4% experienced depressive episodes, there were no suicide attempts or deaths during the 4- to 14-month follow-up. Discussion: This study demonstrates that LAI antipsychotics can effectively stabilize adolescents with bipolar mania or schizoaffective disorder, bipolar type, showing a marked decline in YMRS scores and high rates of remission and functional recovery. Despite the lack of FDA approval for LAI antipsychotics in those younger than 18, our results from off-label use suggest significant efficacy and tolerability. Further FDA clinical trials are needed to explore LAI antipsychotic formulations in adolescents to address the needs of this high-risk, nonadherent population.

Opioid use and abuse in adolescents and young adults; dealing with science, laws and ethics: Charming the COBRAS

The subject of substance use disorders in the pediatric population remains a disturbing conundrum for clinicians, researchers and society in general. Many of our youth are at risk of being damaged and even killed by drug addictions that result from the collision of rapidly developing as well as vulnerable central nervous systems encountering the current global drug addiction crisis. A major motif of this chemical calamity is opioid use disorder in adolescents and young adults that was stimulated by the 19th century identification of such highly addictive drugs as morphine, heroin and a non-opiate, cocaine. This analysis focuses on the pervasive presence of opioid drugs such as heroin and fentanyl that has become a major tragedy in the 21st century arising from an overall substance use and misuse phenomenon rampant in global society. Themes covered in this article include the history of addictive drugs in humans, diagnostic terms in use, the role of neurobiology in drug addiction, and current psychopharmacologic approaches to opioid overdose as well as addiction. Our youth are continuously confronted by dangers of high-risk behaviors including death and injury from opioid use disorders due to their central nervous system neuroplasticity as well as the widespread availability of these harmful chemicals. Healthcare professionals should actively assist our youth who unknowingly and even innocently encounter this deadly menace in the 21st century.

Next-Generation Cognitive-Behavioral Therapy for Depression: Integrating Digital Tools, Teletherapy, and Personalization for Enhanced Mental Health Outcomes

Background and Objectives: This systematic review aims to present the latest developments in next-generation CBT interventions of digital support tools, teletherapies, and personalized treatment modules in enhancing accessibility, improving treatment adherence, and optimizing therapeutic outcomes for depression. Materials and Methods: This review analyzed 81 PRISMA-guided studies on the efficacy, feasibility, and applicability of NG-CBT approaches. Other important innovations include web-based interventions, AI-operated chatbots, and teletherapy platforms, each of which serves as a critical challenge in delivering mental health care. Key messages have emerged regarding technological readiness, patient engagement, and the changing role of therapists within the digital context of care. Results: Findings indicate that NG-CBT interventions improve treatment accessibility and engagement while maintaining clinical effectiveness. Personalized digital tools enhance adherence, and teletherapy platforms provide scalable and cost-effective alternatives to traditional therapy. Conclusions: Such developments promise great avenues for decreasing the global burden of depression and enhancing the quality of life through novel, accessible, and high-quality therapeutic approaches.

Understanding Relapse in Bipolar Disorder at a Tertiary Mental Health Facility in Uganda

Background

Bipolar disorder (BD) is a chronic psychiatric condition characterized by recurrent episodes of mania, hypomania, and depression, affecting approximately 1 in 150 adults globally. BD contributes significantly to disability and years of life lost, with a notable prevalence in Africa. The high relapse rates in BD, exacerbated by limited mental health resources and underdiagnosis, highlight the need for targeted interventions. This study explores the factors contributing to relapse among BD patients at Butabika National Referral Mental Hospital, Uganda, a crucial mental health facility in the region.

Methods

This cross-sectional qualitative study was conducted at Butabika National Referral Mental Hospital. Adult patients aged 18-65, diagnosed with BD and experiencing relapse after treatment, were included. Data were collected through purposive sampling, focusing on obtaining detailed personal accounts from approximately 15 participants until data saturation was achieved. Thematic analysis identified key themes and subthemes related to relapse factors.

Results

Five major themes emerged: treatment adherence, psychosocial factors, cultural beliefs, economic challenges, and coping mechanisms. Non-adherence to medication, driven by side effects, forgetfulness, and financial constraints, was a significant relapse factor. Psychosocial stressors, such as life events and social isolation, alongside stigma and cultural beliefs in traditional healing, further complicated relapse patterns. Economic hardships affected medication access and treatment consistency. Supportive social networks and psychoeducation emerged as crucial for effective management and relapse prevention.

Conclusion

Addressing medication adherence, psychosocial stressors, cultural beliefs, and economic barriers through a holistic approach integrating medical treatment with psychoeducation and support systems is essential for improving patient outcomes and reducing relapse rates in this setting. Therefore, the effective management of bipolar disorder at Butabika National Referral Mental Hospital requires a complex interplay between biological, psychological, and social factors.

The relationship of body image with sexual dysfunction and dyadic adjustment in individuals diagnosed with bipolar disorder in Türkiye

Introduction

The objective of this study is to evaluate the relationship of body image (BI) with sexual dysfunction (SD) and dyadic adjustment (DA) in individuals diagnosed with Bipolar Disorder (BD). Dyadic adjustment has been defined as a dynamic process determined by variables such as relationship differences, interpersonal tensions and personal concerns, relationship satisfaction, and couple consensus. In this context, it was specifically aimed to determine the link between these factors and quality of life (QoL) in individuals with BD based on the effects of BI on sexual function and marital adjustment.

Methods

This study was conducted in a psychiatric hospital in Turkiye. The population of this cross-sectional, single-center study consisted of 110 individuals who applied to the outpatient clinics of Istanbul Erenköy Mental Health and Neurological Diseases Training and Research Hospital between March 2020 and August 2020. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)Disorders-Clinician Version (SCID-5-CV), sociodemographic and clinical data form, Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAM-D), Golombok-Rust Inventory of Sexual Satisfaction (GRISS), Dyadic Adjustment Scale (DAS), Body Image Scale (BIS) and the Brief Quality of Life in Bipolar Disorder (Brief QoL.BD) Questionnaire were used to collect the research data.

Results

The study sample consisted of 80 individuals, 50 females and 30 males, who were diagnosed with BD and were in remission. The rate of SD in individuals with BD was found to be 55%. The most common SD was vaginismus in female individuals with BD and premature ejaculation in male individuals with BD. It has been observed that SD negatively affected DA in individuals with BD. On the other hand, no significant relationship was found between body mass index (BMI) and BI or between BI and SD in individuals with BD. However, increased satisfaction with BI positively affected DA and QoL.

Discussion

The study's findings indicated a significant relationship between sexual satisfaction, marital adjustment, BI, and QoL in individuals with BD. While no significant change was observed in DA in male individuals with BD, it was found that sexual satisfaction decreased as DA deteriorated in female individuals with BD. Additionally, it was found that BI affected DA in individuals with BD but not sexual satisfaction. Lastly, no significant relationship was observed between BMI and BI, DA, or QoL.