Prevalence, chronicity, burden and borders of bipolar disorder

Bipolar Disorder: Role of Inflammation and the Development of Disease Biomarkers

Bipolar disorder is a severe and enduring psychiatric condition which in many cases starts during early adulthood and follows a relapsing and remitting course throughout life. In many patients the disease follows a progressive path with brief periods of inter-episode recovery, sub-threshold symptoms, treatment resistance and increasing functional impairment in the biopsychosocial domains. Knowledge about the neurobiology of bipolar disorder is increasing steadily and evidence from several lines of research implicates immuno-inflammatory mechanisms in the brain and periphery in the etiopathogenesis of this illness and its comorbidities. The main findings are an increase in the levels of proinflammatory cytokines during acute episodes with a decrease in neurotrophic support. Related to these factors are glial cell dysfunction, neuro-endocrine abnormalities and neurotransmitter aberrations which together cause plastic changes in the mood regulating areas of the brain and neuroprogression of the bipolar diathesis. Research in the above mentioned areas is providing an opportunity to discover novel biomarkers for the disease and the field is reaching a point where major breakthroughs can be expected in the not too distant future. It is hoped that with new discoveries fresh avenues will be found to better treat an otherwise recalcitrant disease.

Inflammation as a neurobiological substrate of cognitive impairment in bipolar disorder: Evidence, pathophysiology and treatment implications

BACKGROUND

Bipolar disorder (BD) has been associated with cognitive impairment during depressed, manic and euthymic periods. Inflammation has been shown to be involved in the pathophysiology of BD and cognitive impairment.

METHODS

For this systematic review, the MEDLINE/PubMed, Embase, Google Scholar and ClinicalTrials.gov databases were searched for relevant articles assessing the association between cognitive function and inflammatory markers in BD subjects. A discussion of potential mechanisms and therapeutic implications is also included to provide further context to the subject matter.

RESULTS

Eight studies, including a total of 555 BD subjects, assessing the association between cognitive function and inflammatory markers were identified. Cognitive dysfunction was associated with elevated levels of pro-inflammatory markers YKL40, IL-6, sCD40L, IL-1Ra, hsCRP and TNF-α. Mechanistically, elevation in inflammatory cytokines alters monoamine levels leading to cognitive and affective dysfunction. Neuro-inflammation, manifesting as microglial activation, leads to increased oxidative stress, pathologic synaptic pruning and impaired neuroplasticity in key brain regions sub-serving mood and cognition. Immune dysfunction also activates the hypothalamic-pituitary-adrenal (HPA) axis leading to hypercortisolemia and metabolic dysfunction, further promoting neuronal dysfunction. Anti-inflammatory agents are therefore currently being investigated in the treatment of BD and appear to exert an antidepressant effect; however, cognitive outcomes have yet to be reported.

CONCLUSION

Several studies suggest that immune dysfunction is associated with cognitive impairment in BD. Several neurobiological pathways have been identified whereby immune dysfunction may promote cognitive impairment in BD. Future investigations of anti-inflammatory agents targeting cognitive function as a treatment outcome are merited.

[Actigraphy in Bipolar Disorder and First Degree Relatives]

BACKGROUND

Bipolar disorder is a disabling disease that involves a significant economic costs to the health system, making it is essential to investigate possible early predictors such as changes in sleep-wake cycle in high-risk populations.

OBJECTIVE

To review the available literature on alterations in the sleep-wake cycle and circadian rhythm in patients with bipolar disorder and their first degree relatives.

METHODS

A literature search was performed in the data bases, Access Medicine, ClinicalKey, EMBASE, JAMA, Lilacs, OVID, Oxford Journals, ScienceDirect, SciELO, APA y PsycNET. Articles in both English and Spanish were reviewed, without limits by study type.

RESULTS

Actigraphy is a non-invasive, useful method for assessing sleep-wake cycle disturbances in the active phases of bipolar disorder, and during euthymia periods. Actigraphy showed good sensitivity to predict true sleep, but low specificity, compared with polysomnography. Although studies in bipolar offspring and relatives are scarce, they show sleep changes similar to bipolar patients.

CONCLUSIONS

Actigraphy may be a good screening tool of sleep/wake cycle in patients with bipolar disorders, because it is economic, non-invasive and sensitive. Longitudinal studies are required to evaluate its potential use as a risk marker.

Recovery in bipolar depression: Post-hoc analysis of a placebo-controlled lurasidone trial followed by a long-term continuation study

BACKGROUND

In this post-hoc analysis, rates of remission and recovery were evaluated in patients with bipolar depression treated with lurasidone.

METHODS

Outpatients meeting DSM-IV-TR criteria for bipolar I depression, were randomized to 6 weeks of once-daily, double-blind treatment with lurasidone 20-60mg, lurasidone 80-120mg or placebo, followed by a 6-month, open-label, flexible-dose, lurasidone continuation study. Recovery was defined as meeting criteria for combined symptomatic remission (Montgomery-Asberg Depression Rating Scale total score ≤12) and functional remission (all Sheehan Disability Scale domain scores ≤3) sustained for at least 3 months in the 6-month continuation study.

RESULTS

A significantly higher proportion of lurasidone-treated patients met criteria for combined symptomatic remission and functional remission (33.3%, 91/273) compared to the placebo group (21.0%, 30/143, p<0.05, NNT=9) at the 6-week study endpoint. In the 6-month continuation study, the proportion of lurasidone-treated patients achieving sustained recovery was 60.7% (85/140) and 44.9% (31/69), for patients who continued lurasidone treatment and who switched from placebo to lurasidone, respectively.

LIMITATIONS

The definition of recovery used has not been previously validated and the analysis was post hoc. Lack of a control group in the continuation study limits data interpretation.

CONCLUSIONS

Recovery in patients with bipolar depression was assessed based on rates of combined symptomatic and functional remission sustained over time. A majority of patients initially treated with lurasidone in the acute phase achieved recovery status in the continuation study. Treatment with lurasidone (vs. placebo) earlier in the course of the bipolar depressive episode increased the likelihood of subsequent recovery.

Diagnosis, Epidemiology and Management of Mixed States in Bipolar Disorder

Approximately 40% of patients with bipolar disorder experience mixed episodes, defined as a manic state with depressive features, or manic symptoms in a patient with bipolar depression. Compared with bipolar patients without mixed features, patients with bipolar mixed states generally have more severe symptomatology, more lifetime episodes of illness, worse clinical outcomes and higher rates of comorbidities, and thus present a significant clinical challenge. Most clinical trials have investigated second-generation neuroleptic monotherapy, monotherapy with anticonvulsants or lithium, combination therapy, and electroconvulsive therapy (ECT). Neuroleptic drugs are often used alone or in combination with anticonvulsants or lithium for preventive treatment, and ECT is an effective treatment for mixed manic episodes in situations where medication fails or cannot be used. Common antidepressants have been shown to worsen mania symptoms during mixed episodes without necessarily improving depressive symptoms; thus, they are not recommended during mixed episodes. A greater understanding of pathophysiological processes in bipolar disorder is now required to provide a more accurate diagnosis and new personalised treatment approaches. Targeted, specific treatments developed through a greater understanding of bipolar disorder pathophysiology, capable of affecting the underlying disease processes, could well prove to be more effective, faster acting, and better tolerated than existing therapies, therefore providing better outcomes for individuals affected by bipolar disorder. Until such time as targeted agents are available, second-generation neuroleptics are emerging as the treatment of choice in the management of mixed states in bipolar disorder.

Predictors of switch from depression to mania in bipolar disorder

Manic switch is a relevant issue when treating bipolar depression. Some risk factors have been suggested, but unequivocal findings are lacking. We therefore investigated predictors of switch from depression to mania in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) sample. Manic switch was defined as a depressive episode followed by a (hypo)manic or mixed episode within the following 12 weeks. We assessed possible predictors of switch using generalized linear mixed models (GLMM). 8403 episodes without switch and 512 episodes with switch (1720 subjects) were included in the analysis. Several baseline variables were associated with a higher risk of switch. They were younger age, previous history of: rapid cycling, severe manic symptoms, suicide attempts, amphetamine use and some pharmacological and psychotherapeutic treatments. During the current depressive episode, the identified risk factors were: any possible mood elevation, multiple mania-associated symptoms with at least moderate severity, and comorbid panic attacks. In conclusion, our study suggests that both characteristics of the disease history and clinical features of the current depressive episode may be risk factors for manic switch.

Development of screening inventories for bipolar disorder at workplace: a diagnostic accuracy study

BACKGROUND

This study aimed to develop a new instrument for bipolar disorder screening, the Workplace Bipolar Inventory (WBI), and examine its efficiency as compared with Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) among workers on leave of the absence due to their mental health problems.

METHODS

Participants were recruited at a psychiatric outpatient clinic for return-to-work in Tokyo, Japan, during September to November 2009. 81 outpatients were recruited, 55 of whom (68%) agreed to participate in this study. Participants answered questionnaires including WBI, MDQ, BSDS, and demographic factors. Their diagnostic information according to the international statistical classification of diseases and related health problems 10th revision (ICD-10) was obtained from their attending psychiatrists. The WBI is a new self-rating 39-item questionnaire which developed with input from occupational mental health specialists and an analysis of WHO Composite International Diagnostic Interview (CIDI) items. The WBI contains 3 subtype scales: WBI-A (5 items), WBI-AB4 (9 items), and WBI-AB (39 items).

RESULTS

Reliability of these scales was moderate. In the AUC of these scales, BSDS was the best of them (0.83). In the optimal cut-off point of these scales, WBI-AB4 showed good efficiency of screening (sensitivity=0.78, specificity=0.75). Both MDQ and BSDS had high specificity, while low in sensitivity.

LIMITATIONS

The well validated diagnostic method (i.e., the structured clinical interview for DSM-IV [SCID] or CIDI) was not applied in this study.

CONCLUSIONS

The WBI, especially WBI-AB4 would be a useful workplace screening tool for workers with bipolar disorder.

An Integrated Risk Reduction Intervention can reduce body mass index in individuals being treated for bipolar I disorder: results from a randomized trial

OBJECTIVES

We conducted a randomized, controlled trial comparing the efficacy of an Integrated Risk Reduction Intervention (IRRI) to a control condition with the objective of improving mood stability and psychosocial functioning by reducing cardiometabolic risk factors in overweight/obese patients with bipolar I disorder.

METHODS

A total of 122 patients were recruited from our outpatient services and randomly allocated to IRRI (n = 61) or psychiatric care with medical monitoring (n = 61). Individuals allocated to IRRI received psychiatric treatment and assessment, medical monitoring by a nurse, and a healthy lifestyle program from a lifestyle coach. Those allocated to the control condition received psychiatric treatment and assessment and referral, if indicated, for medical problems. A mixed-effects model was used to examine the impact of the interventions on body mass index (BMI). Exploratory moderator analyses were used to characterize those individuals likely to benefit from each treatment approach.

RESULTS

Analyses were conducted on data for the IRRI (n = 58) and control (n = 56) participants with ≥ 1 study visit. IRRI was associated with a significantly greater rate of decrease in BMI (d = -0.51, 95% confidence interval: -0.91 to -0.14). Three variables (C-reactive protein, total cholesterol, and instability of total sleep time) contributed to a combined moderator of faster decrease in BMI with IRRI treatment.

CONCLUSIONS

Overweight/obese patients with bipolar disorder can make modest improvements in BMI, even when taking medications with known potential for weight gain. Our finding that a combination of three baseline variables provides a profile of patients likely to benefit from IRRI will need to be tested further to evaluate its utility in clinical practice.

Bipolar disorder and antibodies against the N-methyl-d-aspartate receptor: A gate to the involvement of autoimmunity in the pathophysiology of bipolar illness

The high prevalence of comorbidity between bipolar disorder (BD) and other medical conditions, including autoimmune diseases, supports the hypothesis of the nature of BD as a biological illness category. Hence, an immune dysregulation process may play an important role in the development of at least certain subtypes of BD. Increasing evidence also suggests that the N-methyl-d-aspartate receptor (NMDAR) may be relevant in the pathophysiology of BD. A possible key mechanism underlying the physiopathology of certain autoimmune diseases that may present with affective symptoms might be the production of anti-NMDAR auto-antibodies (auto-Abs). The best characterized autoimmune anti-NMDAR disease is the anti-NMDAR encephalitis. It has been found that 4% of these patients present isolated, mostly affective, psychiatric manifestations during their illness. An interesting suggestion emerged from this overview is that the same mechanisms that trigger affective symptoms in patients with increased anti-NMDAR auto-Abs levels could be involved in the physiopathology of at least a subgroup of BD. Future studies are needed to characterize the relationship between anti-NMDAR auto-Abs and BD.

Association of the COMT synonymous polymorphism Leu136Leu and missense variant Val158Met with mood disorders

BACKGROUND

Major depressive disorder (MDD) and bipolar disorder (BD) are the two most common mood disorders. Given the recognized involvement of catecholamines in depression, genetic research focused on the evaluation of polymorphisms in genes coding for proteins that regulate neurotransmitter release, transport and degradation. Here we aimed at evaluating the distribution of two genetic variants of catechol-O-methyltransferase (COMT), namely the well characterized missense polymorphism G1947A (Val158Met) and the recently reported synonymous polymorphism C1886G (Leu136Leu), in MDD and BD patients compared with healthy subjects.

METHODS

Genotyping for COMT polymorphisms was carried out by DNA direct sequencing in 112 patients (54 MDD and 58 BD) and 58 healthy subjects.

RESULTS

We did not find significant differences in the Val158Met variant distribution between patients and controls. Instead, we found that the C1886 major allele and the CC1886 wild-type genotype frequencies were significantly higher in controls than in both groups of patients. On the contrary, the G1886 minor allele and the heterozygous CG1886 genotype were significantly more present in both MDD and BD patients than in healthy subjects. When looking at combined polymorphisms, we found a significantly higher frequency of the double heterozygous diplotype CG/GAVal/Met158 in both MDD and BD patients than in controls. Instead, the diplotype CC/GAVal/Met158 showed a significantly higher frequency in controls than in BD patients.

LIMITATIONS

The small size of our study cohort may limit the generalizability of the present findings.

CONCLUSIONS

This work first showed the association of combined Leu136Leu and Val158Met variants of COMT gene with MDD and BD.

Bipolar disorder prevalence: a systematic review and meta-analysis of the literature

OBJECTIVE

Bipolar disorder (BD) is common in clinical psychiatric practice, and several studies have estimated its prevalence to range from 0.5 to 5% in community-based samples. However, no systematic review and meta-analysis of the prevalence of BD type 1 and type 2 has been published in the literature. We carried out a systematic review and meta-analysis of the lifetime and 1-year prevalence of BD type 1 and type 2 and assessed whether the prevalence of BD changed according to the diagnostic criteria adopted (DSM-III, DSM-III-R vs. DSM-IV).

METHODS

We searched MEDLINE, Scopus, Web of Science, PsycINFO, and the reference lists of identified studies. The analyses included 25 population- or community-based studies and 276,221 participants.

RESULTS

The pooled lifetime prevalence of BD type 1 was 1.06% (95% confidence interval [95%CI] 0.81-1.31) and that of BD type 2 was 1.57% (95%CI 1.15-1.99). The pooled 1-year prevalence was 0.71% (95%CI 0.56-0.86) for BD type 1 and 0.50% (95%CI 0.35-0.64) for BD type 2. Subgroup analysis showed a significantly higher lifetime prevalence of BD type 1 according to the DSM-IV criteria compared to the DSM-III and DSM-IIIR criteria (p < 0.001).

CONCLUSION

This meta-analysis confirms that estimates of BD type 1 and type 2 prevalence are low in the general population. The increase in prevalence from DSM-III and DSM-III-R to DSM-IV may reflect different factors, such as minor changes in diagnostic operationalization, use of different assessment instruments, or even a genuine increase in the prevalence of BD.

Pharmacotherapy of bipolar disorder with quetiapine: a recent literature review and an update

Bipolar disorder is a chronic, recurrent condition with the usual onset during adolescence or early adulthood. In the Diagnostic and Statistical Manual of Mental Disorders 5th edition, it is conceptualized as a spectrum disorder usually associated with such comorbidities as anxiety disorders and substance use disorders. It is a relatively prevalent condition often complicated by mixed episodes, rapid cycling, subsyndromal symptoms, and treatment refractoriness. In spite of carrying substantial morbidity and mortality, effective treatments are few and far between and conventional mood stabilizers are often unsuccessful in controlling the various manifestations of the disorder. In this scenario, second generation antipsychotics are emerging as treatments with valid efficacy in all phases of bipolar disorder. Quetiapine is a versatile atypical antipsychotic which was first approved for the treatment of schizophrenia, but latter on the basis of controlled studies earned United States Food and Drug Administration’s approval for acute as well as maintenance treatment of this difficult to treat condition. In this review, recently published studies in the last 10 years were examined to update the knowledge about the efficacy and safety of quetiapine in the treatment of bipolar disorder. The medication’s clinical pharmacology was first considered followed by a literature review summarizing its uses in bipolar disorder. The conclusion was that quetiapine was efficacious in manic, mixed and depressive episodes and as a maintenance agent with a good tolerability profile.

Internet-Based Cognitive Behavioral Therapy for Residual Symptoms in Bipolar Disorder Type II: A Single-Subject Design Pilot Study

Background

Bipolar disorder is a chronic condition with recurring episodes that often lead to suffering, decreased functioning, and sick leave. Pharmacotherapy in the form of mood stabilizers is widely available, but does not eliminate the risk of a new depressive or (hypo)manic episode. One way to reduce the risk of future episodes is to combine pharmacological treatment with individual or group psychological interventions. However, access to such interventions is often limited due to a shortage of trained therapists. In unipolar depression there is now robust evidence of the effectiveness of Internet-based psychological interventions, usually comprising psychoeducation and cognitive behavioral therapy (CBT). Internet-based interventions for persons suffering from bipolar disorder could increase access to psychological treatment.

Objective

The aim of this study was to investigate the feasibility of an Internet-based intervention, as well as its effect on residual depressive symptoms in persons diagnosed with bipolar disorder type II (BP-II). The most important outcomes were depressive symptoms, treatment adherence, and whether the patient perceived the intervention as helpful.

Methods

A total of 7 patients diagnosed with bipolar disorder type II at a Swedish psychiatric outpatient clinic were offered the opportunity to participate. Of the 7 patients, 3 (43%) dropped out before treatment began, and 4 (57%) were treated by means of an online, Internet-based intervention based on CBT (iCBT). The intervention was primarily aimed at psychoeducation, treatment of residual depressive symptoms, emotion regulation, and improved sleep. All patients had ongoing pharmacological treatment at recruitment and established contact with a psychiatrist. The duration of BP-II among the treated patients was between 6 and 31 years. A single-subject design was used and the results of the 4 participating patients were presented individually.

Results

Initiating treatment was perceived as too demanding under current life circumstances for 3 patients who consequently dropped out during baseline assessment. Self-ratings using the Montgomery-Åsberg Depression Rating Scale—Self-rated (MADRS-S) showed symptom reduction in 3 (75%) of the 4 treated cases during iCBT. In the evaluation of the treatment, 2 patients reported that they perceived that the treatment had reduced symptoms a little, 1 that it had reduced symptoms very much, and 1 not at all. Treatment adherence (ie, module completion) was fairly high in 3 cases. In general, the modules were perceived as fairly helpful or very helpful by the patients. In one case, there was a reliable change—according to the Reliable Change Index—in self-rated symptoms of depression and perseverative thinking.

Conclusions

The treatment seemed to have acceptable feasibility. The iCBT intervention could be an effective way to treat residual symptoms in some patients with bipolar disorder type II. This should be investigated in a larger study.

Trial Registration

ClinicalTrials.gov NCT01742351; https://clinicaltrials.gov/ct2/show/NCT01742351 (Archived by WebCite at http://www.webcitation.org/6XnVpv4C3).

Cost-of-illness studies for bipolar disorder: systematic review of international studies

BACKGROUND AND OBJECTIVES

Bipolar disorder (BD) may result in a greater burden than all forms of cancer, Alzheimer's disease and epilepsy. Cost-of-illness (COI) studies provide useful information on the economic burden that BD imposes on a society. Furthermore, COI studies are pivotal sources of evidence used in economic evaluations. This study aims to give a general overview of COI studies for BD and to discuss methodological issues that might potentially influence results. This study also aims to provide recommendations to improve practice in this area, based on the review.

METHODS

A search was performed to identify COI studies of BD. The following electronic databases were searched: MEDLINE, EMBASE, PsycInfo, Cochrane Database of Systematic Reviews, HMIC and openSIGLE. The primary outcome of this review was the annual cost per BD patient. A narrative assessment of key methodological issues was also included. Based on these findings, recommendations for good practice were drafted.

RESULTS

Fifty-four studies were included in this review. Because of the widespread methodological heterogeneity among included studies, no attempt has been made to pool results of different studies. Potential areas for methodological improvement were identified. These were: description of the disease and population, the approach to deal with comorbidities, reporting the rationale and impact for choosing different cost perspectives, and ways in which uncertainty is addressed.

CONCLUSIONS

This review showed that numerous COI studies have been conducted for BD since 1995. However, these studies employed varying methods, which limit the comparability of findings. The recommendations provided by this review can be used by those conducting COI studies and those critiquing them, to increase the credibility and reporting of study results.

Co-morbidity of bipolar disorder and borderline personality disorder: findings from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVES

Clinical studies suggest a high co-morbidity rate of borderline personality disorder (BPD) with bipolar disorder (BD). This study examines the prevalence and correlates of BPD in BD (I and II) in a longitudinal population-based survey.

METHODS

Data came from waves 1 and 2 (wave 2: N=34,653, 70.2% cumulative response rate; age ≥ 20 years) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Lay interviewers conducted in person interviews using the Alcohol Use Disorders and Associated Disabilities Interview (AUDADIS-IV), a reliable diagnostic tool of psychiatric disorders based on DSM-IV criteria. Subjects with BD I (n=812), BD I/BPD (n=360), BD II (n=327) and BD II/BPD (n=101) were examined in terms of sociodemographics, mood, anxiety, substance use and personality disorder co-morbidities and history of childhood traumatic experiences.

RESULTS

Lifetime prevalence of BPD was 29.0% in BD I and 24.0% in BD II. Significant differences were observed between co-morbid BD I/II and BPD versus BD I/II without BPD in terms of number of depressive episodes and age of onset, co-morbidity, and childhood trauma. BPD was strongly and positively associated with incident BD I (AOR=16.9; 95% CI: 13.88-20.55) and BD II (AOR=9.5; 95% CI: 6.44-13.97).

CONCLUSIONS

BD with BPD has a more severe presentation of illness than BD alone. The results suggest that BPD is highly predictive of a future diagnosis of BD. Childhood traumatic experiences may have a role in understanding this relationship.

Designing a patient monitoring system for bipolar disorder using Semantic Web technologies

The new movement to personalize treatment plans and improve prediction capabilities is greatly facilitated by intelligent remote patient monitoring and risk prevention. This paper focuses on patients suffering from bipolar disorder, a mental illness characterized by severe mood swings. We exploit the advantages of Semantic Web and Electronic Health Record Technologies to develop a patient monitoring platform to support clinicians. Relying on intelligently filtering of clinical evidence-based information and individual-specific knowledge, we aim to provide recommendations for treatment and monitoring at appropriate time or concluding into alerts for serious shifts in mood and patients' non response to treatment.

Evaluating depressive symptoms in mania: a naturalistic study of patients with bipolar disorder

OBJECTIVE

This study aimed to evaluate patients with bipolar I disorder (BD-I) who have mania with depressive symptoms and who meet the new "with mixed features" specifier of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

METHOD

This prospective, multinational, naturalistic study surveyed psychiatrists and their patients with BD-I from October 2013 to March 2014. Eligible patients had BD-I, had a (current) manic episode, and had experienced onset of a manic episode within the previous 3 months. Psychiatrists provided patient information on depressive symptoms (DSM-5 criteria); symptoms of anxiety, irritability, and agitation; suicide attempts; and physician satisfaction with treatment response. Data were stratified according to whether patients met the criteria for the BD-I "with mixed features" specifier of DSM-5 (≥3 depressive symptoms) or not, and characteristics were compared between the two subgroups. Patients also self-reported on depressive symptoms using the Mini-International Neuropsychiatric Interview module questionnaire.

RESULTS

Overall, 34% of 1,035 patients met the criteria for BD-I "with mixed features," exhibiting ≥3 depressive symptoms during their current manic episode. This correlated with the matched patient self-reports of depressive symptoms. During their current manic episode, BD-I patients "with mixed features" had more severe symptoms of anxiety, irritability, and agitation (average composite severity score of 4.1 vs 3.4), a higher incidence of suicide attempts (38% vs 9%), and more physician dissatisfaction with treatment response (22% vs 14%), compared to patients with 0-2 depressive symptoms (all P<0.05).

CONCLUSION

This study found that patients with BD-I "with mixed features" (ie, ≥3 depressive symptoms during a manic episode), suffered, on average, from a greater burden of disease than patients with pure mania. Improved identification of these patients may help to optimize treatment outcomes.

Cost-effectiveness of asenapine in the treatment of patients with bipolar I disorder with mixed episodes in an Italian context

INTRODUCTION

Bipolar disorder is a chronic disease characterized by periods of mania or hypomania, depression, or a combination of both (mixed state). Because bipolar disorder is one of the leading causes of disability, it represents an important economic burden on society. Asenapine (ASE) is a new second-generation antipsychotic developed and approved for the treatment of manic or mixed episodes associated with bipolar disorder. The objective of the present study was to assess the cost-effectiveness of ASE compared to olanzapine (OLA) in the treatment of patients experiencing mixed episodes associated with bipolar I disorder in the context of the Italian National Health Service (NHS).

METHODS

A pharmacoeconomic model was developed to simulate the management of Italian bipolar I patients with mixed episodes over a 5-year time horizon by combining clinical parameters with resource utilization. An expert panel of Italian psychiatrists and health economists was responsible for adapting a UK model to the Italian context. The primary outcome measure of the economic evaluation was the incremental cost effectiveness ratio, where effectiveness is measured in terms of quality adjusted life-years gained. Scenario analyses, sensitivity analyses, and a probabilistic sensitivity analysis were performed to test the robustness of the model.

RESULTS

This pharmacoeconomic model showed that ASE resulted to be dominant over OLA; in fact, ASE was associated with lower direct costs (derived largely by the savings from hospitalizations avoided) and also generated a better quality of life. Results were robust to changes in key parameters; both scenario analyses and sensitivity analyses demonstrated model reliability.

CONCLUSIONS

Results from this study suggest that the management of bipolar I patients with mixed episodes using ASE as alternative to OLA can lead to cost saving for the Italian NHS and improve patients quality of life.

The emerging role of dopamine-glutamate interaction and of the postsynaptic density in bipolar disorder pathophysiology: Implications for treatment

Aberrant synaptic plasticity, originating from abnormalities in dopamine and/or glutamate transduction pathways, may contribute to the complex clinical manifestations of bipolar disorder (BD). Dopamine and glutamate systems cross-talk at multiple levels, such as at the postsynaptic density (PSD). The PSD is a structural and functional protein mesh implicated in dopamine and glutamate-mediated synaptic plasticity. Proteins at PSD have been demonstrated to be involved in mood disorders pathophysiology and to be modulated by antipsychotics and mood stabilizers. On the other side, post-receptor effectors such as protein kinase B (Akt), glycogen synthase kinase-3 (GSK-3) and the extracellular signal-regulated kinase (Erk), which are implicated in both molecular abnormalities and treatment of BD, may interact with PSD proteins, and participate in the interplay of the dopamine-glutamate signalling pathway. In this review, we describe emerging evidence on the molecular cross-talk between dopamine and glutamate signalling in BD pathophysiology and pharmacological treatment, mainly focusing on dysfunctions in PSD molecules. We also aim to discuss future therapeutic strategies that could selectively target the PSD-mediated signalling cascade at the crossroads of dopamine-glutamate neurotransmission.

Pharmacologic management of bipolar disorder in a Medicare Advantage population

OBJECTIVE

The purpose of this study was to examine patterns of pharmacotherapy for beneficiaries in a high-risk Medicare Advantage program who were diagnosed with bipolar disorder.

METHODS

This was a cross-sectional study of 2338 Medicare Advantage beneficiaries diagnosed with bipolar disorder. Pharmacotherapy treatment was assessed via receipt of (1) a mood stabilizer or antipsychotic or both (i.e., guideline concordant bipolar care) and (2) unopposed antidepressant (i.e., without prescription of a mood stabilizer or an antipsychotic). Logistic regression was used to examine correlates of bipolar disorder care.

RESULTS

Among those younger than 65 years of age (n = 1395), 54% received guideline concordant therapy and 29% received unopposed antidepressant therapy. Among those 65 years and older (n = 943), 40% received guideline concordant therapy and 33% received unopposed antidepressant therapy.

CONCLUSION

Overall, about half of beneficiaries in this Medicare Advantage plan received guideline concordant pharmacotherapy for bipolar disorder, while approximately one-third received an unopposed antidepressant prescription. Antipsychotic medications accounted for most of the monotherapy observed. This study identifies opportunities for further improvements in the pharmacotherapy of bipolar disorder in high-risk Medicare patients.

Identifying Potential Regions of Copy Number Variation for Bipolar Disorder

Bipolar disorder is a complex psychiatric disorder with high heritability, but its genetic determinants are still largely unknown. Copy number variation (CNV) is one of the sources to explain part of the heritability. However, it is a challenge to estimate discrete values of the copy numbers using continuous signals calling from a set of markers, and to simultaneously perform association testing between CNVs and phenotypic outcomes. The goal of the present study is to perform a series of data filtering and analysis procedures using a DNA pooling strategy to identify potential CNV regions that are related to bipolar disorder. A total of 200 normal controls and 200 clinically diagnosed bipolar patients were recruited in this study, and were randomly divided into eight control and eight case pools. Genome-wide genotyping was employed using Illumina Human Omni1-Quad array with approximately one million markers for CNV calling. We aimed at setting a series of criteria to filter out the signal noise of marker data and to reduce the chance of false-positive findings for CNV regions. We first defined CNV regions for each pool. Potential CNV regions were reported based on the different patterns of CNV status between cases and controls. Genes that were mapped into the potential CNV regions were examined with association testing, Gene Ontology enrichment analysis, and checked with existing literature for their associations with bipolar disorder. We reported several CNV regions that are related to bipolar disorder. Two CNV regions on chromosome 11 and 22 showed significant signal differences between cases and controls (p < 0.05). Another five CNV regions on chromosome 6, 9, and 19 were overlapped with results in previous CNV studies. Experimental validation of two CNV regions lent some support to our reported findings. Further experimental and replication studies could be designed for these selected regions.

Hypomania spectrum disorder in adolescence: a 15-year follow-up of non-mood morbidity in adulthood

BACKGROUND

We investigated whether adolescents with hypomania spectrum episodes have an excess risk of mental and physical morbidity in adulthood, as compared with adolescents exclusively reporting major depressive disorder (MDD) and controls without a history of adolescent mood disorders.

METHODS

A community sample of adolescents (N = 2 300) in the town of Uppsala, Sweden, was screened for depressive symptoms. Both participants with positive screening and matched controls (in total 631) were diagnostically interviewed. Ninety participants reported hypomania spectrum episodes (40 full-syndromal, 18 with brief episode, and 32 subsyndromal), while another 197 fulfilled the criteria for MDD without a history of a hypomania spectrum episode. A follow up after 15 years included a blinded diagnostic interview, a self-assessment of personality disorders, and national register data on prescription drugs and health services use. The participation rate at the follow-up interview was 71% (64/90) for the hypomania spectrum group, and 65.9% (130/197) for the MDD group. Multiple imputation was used to handle missing data.

RESULTS

The outcomes of the hypomania spectrum group and the MDD group were similar regarding subsequent non-mood Axis I disorders in adulthood (present in 53 vs. 57%). A personality disorder was reported by 29% of the hypomania spectrum group and by 20% of the MDD group, but a statistically significant difference was reached only for obsessive-compulsive personality disorder (24 vs. 14%). In both groups, the risk of Axis I disorders and personality disorders in adulthood correlated with continuation of mood disorder. Prescription drugs and health service use in adulthood was similar in the two groups. Compared with adolescents without mood disorders, both groups had a higher subsequent risk of psychiatric morbidity, used more mental health care, and received more psychotropic drugs.

CONCLUSIONS

Although adolescents with hypomania spectrum episodes and adolescents with MDD do not differ substantially in health outcomes, both groups are at increased risk for subsequent mental health problems. Thus, it is important to identify and treat children and adolescents with mood disorders, and carefully follow the continuing course.

Allostasis as a conceptual framework linking bipolar disorder and addiction

Bipolar disorders (BDs) and addictions constitute reciprocal risk factors and are best considered under a unitary perspective. The concepts of allostasis and allostatic load (AL) may contribute to the understanding of the complex relationships between BD and addictive behaviors. Allostasis entails the safeguarding of reward function stability by recruitment of changes in the reward and stress system neurocircuitry and it may help to elucidate neurobiological underpinnings of vulnerability to addiction in BD patients. Conceptualizing BD as an illness involving the cumulative build-up of allostatic states, we hypothesize a progressive dysregulation of reward circuits clinically expressed as negative affective states (i.e., anhedonia). Such negative affective states may render BD patients more vulnerable to drug addiction, fostering a very rapid transition from occasional drug use to addiction, through mechanisms of negative reinforcement. The resulting addictive behavior-related ALs, in turn, may contribute to illness progression. This framework could have a heuristic value to enhance research on pathophysiology and treatment of BD and addiction comorbidity.

Risk factors for an anxiety disorder comorbidity among Thai patients with bipolar disorder: results from the Thai Bipolar Disorder Registry

BACKGROUND

The aim of the study was to determine in a clinical setting the risk factors for current anxiety disorder (AD) comorbidity among Thai patients with bipolar disorder (BD), being treated under the Thai Bipolar Disorder Registry Project (TBDR).

METHODS

The TBDR was a multisite naturalistic study conducted at 24 psychiatric units (ie, at university, provincial mental, and government general hospitals) between February 2009 and January 2011. Participants were in- or out-patients over 18 years of age who were diagnosed with BD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Instruments used in this study included the Thai Mini International Neuropsychiatric Interview version 5; Thai Montgomery-Åsberg Depression Rating Scale (MADRS); Thai Young Mania Rating Scale; Clinical Global Impression of Bipolar Disorder-Severity (CGI-BP-S), CGI-BP-S-mania, CGI-BPS-depression, and CGI-BP-S-overall BP illness; and the Thai SF-36 quality of life questionnaire.

RESULTS

Among the 424 BD patients, 404 (95.3%) had BD type I. The respective mean ± standard deviation of age of onset of mood disturbance, first diagnosis of BD, and first treatment of BD was 32.0±11.9, 36.1±12.2, and 36.2±12.2 years. The duration of illness was 10.7±9.0 years. Fifty-three (12.5%) of the 424 participants had a current AD while 38 (9%) had a substance use disorder (SUD). The univariate analysis revealed 13 significant risks for current AD comorbidity, which the multivariate analysis narrowed to age at first diagnosis of BD (odds ratio =0.95, P<0.01), family history of SUD (odds ratio =2.18, P=0.02), and having a higher current MADRS score (odds ratio =1.11, P<0.01).

CONCLUSION

A diagnosis of AD comorbid with BD is suggested by early-age onset of BD together with a higher MADRS score and a family history of SUD. The likelihood of AD comorbidity decreases by 5% with each passing year; early-age onset of BD is a risk while later age onset is protective. Our results underscore how SUD within the family significantly contributes to the risk of an AD comorbidity.

Evaluating depressive symptoms in hypomanic and manic episodes using a structured diagnostic tool: validation of a new Mini International Neuropsychiatric Interview (M.I.N.I.) module for the DSM-5 'With Mixed Features' specifier

Background

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), includes a new 'With Mixed Features’ specifier for mood episodes. In (hypo-)manic episodes, the specifier is given if three or more depressive symptoms are present nearly every day during the episode. A new module of the Mini International Neuropsychiatric Interview (M.I.N.I.) has been developed as a patient-completed questionnaire to evaluate the DSM-5 specifier for (hypo-)manic episodes. The objective of this study was to validate this new module.

Methods

In Phase I, patients with a manic episode in the past 6 months completed the module and were asked whether the wording was clear, understandable, relevant and specific. Based on their feedback, the module was refined and finalised. In Phase II, psychiatrists each invited five patients to complete the module. The psychiatrists completed record forms for these five patients, which included their diagnoses, made according to DSM-5 criteria during clinical interviewing. The module was validated by comparing depressive symptoms reported by the patients themselves using the M.I.N.I. module with those evaluated by their psychiatrist using DSM-5 criteria during clinical interviewing.

Results and discussion

In Phase I, a few changes were made to the M.I.N.I. module based on feedback from 20 patients (60% of whom had mixed features). In Phase II, 23 psychiatrists completed record forms for 115 patients, 99 (86.1%) of whom completed the M.I.N.I. module. Agreement between psychiatrists' DSM-5 diagnoses and patients' M.I.N.I. responses was substantial (Cohen's kappa coefficient, 0.60). The overall sensitivity of the M.I.N.I. was 0.91 and its specificity was 0.70. Sensitivity ranged from 0.63 for psychomotor retardation to 0.90 for suicidal thoughts. Specificity ranged from 0.63 for diminished interest/pleasure to 0.90 for suicidal thoughts. The module's positive and negative predictive values were 0.72 and 0.90, respectively. In summary, the M.I.N.I. module demonstrated good concurrent validity with psychiatrists' evaluation of DSM-5 mixed features in manic patients, accurately detecting mixed features with limited risk of over-diagnosis. Due to its simplicity, the M.I.N.I. module could be incorporated into routine psychiatric evaluation of patients with manic episodes. It could also provide a valuable standardised tool for clinical and epidemiological research.

Electronic supplementary material

The online version of this article (doi:10.1186/2194-7511-1-21) contains supplementary material, which is available to authorized users.

Molecular hydrogen: an overview of its neurobiological effects and therapeutic potential for bipolar disorder and schizophrenia

Hydrogen gas is a bioactive molecule that has a diversity of effects, including anti-apoptotic, anti-inflammatory and anti-oxidative properties; these overlap with the process of neuroprogression in major psychiatric disorders. Specifically, both bipolar disorder and schizophrenia are associated with increased oxidative and inflammatory stress. Moreover, lithium which is commonly administered for treating bipolar disorder has effects on oxidative stress and apoptotic pathways, as do valproate and some atypical antipsychotics for treating schizophrenia. Molecular hydrogen has been studied pre-clinically in animal models for the treatment of some medical conditions including hypoxia and neurodegenerative disorders, and there are intriguing clinical findings in neurological disorders including Parkinson’s disease. Therefore, it is hypothesized that administration of hydrogen molecule may have potential as a novel therapy for bipolar disorder, schizophrenia, and other concurrent disorders characterized by oxidative, inflammatory and apoptotic dysregulation.