The prevalence and burden of bipolar disorder: findings from the Global Burden of Disease Study 2013

Sex-Specific Changes in Choroid Vasculature Among Patients with Schizophrenia and Bipolar Disorder

Purpose

While structural changes within the retina of psychosis patients have been established, no detailed studies of choroidal microvasculature in these patients have been performed. Given evidence of microvascular disruption in psychosis patients, this study sought to determine whether there exists evidence of microvascular disruption in the choroids in these patients.

Methods

Fifty-six subjects (20 controls and 36 psychosis patients) were recruited from April 2018 to February 2020. Five were excluded due to imaging artifact or missing demographic information. Swept-source optical coherence tomography angiography (SS-OCTA) images were obtained. Choroid vascular enface images (12 mm × 9mm) were exported every 2.6 μm from Bruch’s membrane to the choroid–scleral interface from Topcon to ImageJ. The images were binarized using Otsu’s method, signal from the optic disk and retinal vasculature was removed, and average choroid vascular density (CVD) was calculated as the average of percent area occupied by choroidal vasculature across images in the stack. Choroid vascular volume (CVV) was calculated as the CVD multiplied by maximum CT and image area. During image analysis, study staff were blinded to the phenotype of the study subjects.

Results

Compared with same-sex controls, male psychiatric patients had significantly lower CVD. Compared with same-sex controls, female psychiatric patients had significantly lower maximum CT with correspondingly decreased CVV, after adjusting for age. When all psychiatric patients were compared with all healthy controls, no significant differences in CT, CVD, or CVV were noted.

Conclusion

These results suggest that the pathogenesis of psychotic illness affects choroidal microvasculature in a sex-specific manner.

Neuropsychological aspects of bipolar disorder

Bipolar disorder (BD) is a chronic condition with serious consequences on the health and functionality of patients who suffer from it, with a high heritability and segregation, and aprevalence of between 1% and 2%. Neuropsychological deficits have been implicated as a very important issue related to BD prognosis, so a review was conducted of these deficits, the related factors and their functional consequences. It has been determined that the presence of neuropsychological deficits can vary in patients with BD according to their mood state, with a great influence of depressive symptoms on the cognitive variability of patients with respect to the general population and differences with respect to patients in the manic phase. In euthymic patients, the most affected cognitive domains are those of memory, attention, and executive function, associated with a more severe disease, sociodemographic vulnerability factors, and stable over time. A relationship has been found between poor cognitive performance, especially executive dysfunction, and objective functional deficit. Furthermore, cognitive differences have been outlined between BD and other serious mental illnesses that are described in this review.

Euthymic patients with predominantly manic polarity avoid happy faces in a dot probe task

BACKGROUND

Some studies suggest a mood-congruent attentional bias in bipolar patients. However, for euthymic patients, especially in dependence on the predominant polarity, there is little and inconsistent data. A clearer understanding of emotion-related attentional biases and their relationship to dysfunctional emotion regulation could help improving the diagnostics and treatment of bipolar disorder (BD). Twenty bipolar patients in a depressive state (BP-acute-D), 32 euthymic patients with manic (BP-euth-M) or depressive (BP-euth-D) predominant polarity, and 20 healthy control participants (HC) performed a dot-probe task (DPT) with happy and sad faces presented for 250 ms or 1250 ms in two different runs. Emotion regulation strategies were assessed with two questionnaires.

RESULTS

In the short presentation condition of the DPT, BP-euth-M showed less attention for happy faces than HC (p = .03, r = - 0.48). BP-acute-D scored lower in cognitive reappraisal and putting into perspective and higher in suppression, catastrophizing, and rumination than HC. BP-euth-M scored higher in rumination and BP-euth-D lower in putting into perspective and higher in catastrophizing than HC. In BP-euth-D and HC, bias scores for sad faces in the longer presentation condition and reappraisal scores correlated positively.

CONCLUSIONS

Results of the DPT suggest an avoidance of happy faces for BP-euth-M which we interpret as a protection mechanism for triggers of mania. That individuals who apply more reappraisal show more selective attention to sad faces could on the one hand reflect a mental effort in reevaluating the sad emotional input and on the other hand a greater tolerance for it.

Key findings on bipolar disorders from the longitudinal FondaMental Advanced Center of Expertise-Bipolar Disorder (FACE-BD) cohort

BACKGROUND

The FACE-BD cohort is an observational cohort of individuals with bipolar disorders (BD) who benefited from a systematic evaluation with evidence-based treatment recommendations and who were followed-up every year for 3 years in France. The objectives were to describe the lifetime course of BD, associated psychiatric and somatic comorbidities, and cognition profile. This cohort aims to identify clinical/biological signatures of outcomes, trajectories of functioning and transition between clinical stages. This article summarizes 10 years of findings of the FACE-BD cohort.

METHOD & RESULTS

We included 4422 individuals, all having a baseline assessment, among which 61.2% had at least one follow-up visit at either one, two or three years. A subsample of 1200 individuals had at least one biological sample (serum, plasma, DNA). Assessments include family history of psychiatric disorders, psychiatric diagnosis, current mood symptoms, functioning, hospitalizations, suicidal attempts, physical health, routine blood tests, treatment history, psychological dimensions, medico-economic data and a cognitive assessment. Studies from this cohort illustrate that individuals with BD display multiple coexistent psychiatric associated conditions including sleep disturbances, anxiety disorders, substance use disorders and suicide attempts as well as a high prevalence of metabolic syndrome. During follow-up, we observed a 55% reduction of the number of days of hospitalization and a significant improvement in functioning.

CONCLUSIONS

The FACE-BD cohort provides a strong research infrastructure for clinical research in BD and has a unique position among international cohorts because of its comprehensive clinical assessment and sustainable funding from the French Ministry of Health.

The pharmacotherapeutic management of comorbid bipolar disorder and alcohol use disorder

INTRODUCTION

Comorbidity of bipolar disorder (BD) and alcohol use disorder (AUD) is very frequent resulting in detrimental outcomes, including increased mortality. Diagnosis of AUD in BD and vice versa is often delayed as symptoms of one disorder mimic and obscure the other one. Evidence for pharmacotherapies for people with comorbid BD and AUD remains limited, and further proof-of-concept studies are urgently needed.

AREAS COVERED

This paper explores the currently available pharmacotherapies for AUD, BD and their usefulness for comorbid BD and AUD. It also covers to some degree the epidemiology, diagnosis, and potential common neurobiological traits of comorbid BD and AUD.

EXPERT OPINION

The authors conclude that more controlled studies are needed before evidence-based guidance can be drawn up for clinician's use. Since there are no relevant pharmacological interactions, approved medications for AUD can also be used safely in BD. For mood stabilization, lithium should be considered first in adherent persons with BD and comorbid AUD. Alternatives include valproate, lamotrigine, and some atypical antipsychotics, with partial D2/D3 receptor agonism possibly being beneficial in AUD, too.

Affective disorders: eliminate WArning signs and REstore functioning-AWARE-a randomised controlled multimodule intervention study, presentation of design and intervention

INTRODUCTION

Affective disorders are associated with impaired overall functioning and quality of life (QoL). Despite different medical and psychological treatment options, the prognosis remains largely unchanged. Consequently, the field needs new intervention strategies especially targeting patient groups with impaired functioning. This study aims to improve functioning and QoL in patients with affective disorders using a comprehensive 360° intervention.

METHODS AND ANALYSIS

Affective disorders: eliminate WArning signs And REstore (AWARE) functioning is a randomised, controlled, parallel-group design study. Participants will be 120 outpatients, men or women, aged 18-65 years, with a diagnosis of bipolar disorder or major depressive disorder. Inclusion requires an objectively rated impaired functioning defined as a score ≥11 according to the Functioning Assessment Short Test. Participants will be randomised to 6-month AWARE intervention or treatment as usual (TAU). The AWARE intervention is a 360° multimodal intervention based on the International Classification of Functioning Brief Core Set for bipolar and unipolar disorder targeting functioning.The primary outcome is improvement of observation-based activities of daily living (ADL) ability using Assessment of Motor and Process Skills. Secondary outcomes are changes from baseline to endpoint in functioning, QoL, stress, cognition and physical health.Our hypothesis is that the AWARE treatment in comparison with TAU will improve observed ability to perform ADL, patients self-perceived level of functioning and QoL.Status: currently recruiting patients.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from The Regional Ethics Committee in the Capital Region of Denmark. All patients will be provided oral and written information about the trial before informed consent is obtained. The study results will be disseminated by peer-review publications. If the present AWARE intervention shows beneficial effects, the goal is to use it as a template for future interventions addressing disability in patients with affective disorders as well as for patients within other diagnostic categories.

TRIAL REGISTRATION NUMBER

NCT04701827; Clinicaltrials.gov.

Systematic Review and Meta-Analysis on MS-Based Proteomics Applied to Human Peripheral Fluids to Assess Potential Biomarkers of Bipolar Disorder

Bipolar disorder (BD) is a clinically heterogeneous condition, presenting a complex underlying etiopathogenesis that is not sufficiently characterized. Without molecular biomarkers being used in the clinical environment, several large screen proteomics studies have been conducted to provide valuable molecular information. Mass spectrometry (MS)-based techniques can be a powerful tool for the identification of disease biomarkers, improving prediction and diagnosis ability. Here, we evaluate the efficacy of MS proteomics applied to human peripheral fluids to assess BD biomarkers and identify relevant networks of biological pathways. Following PRISMA guidelines, we searched for studies using MS proteomics to identify proteomic differences between BD patients and healthy controls (PROSPERO database: CRD42021264955). Fourteen articles fulfilled the inclusion criteria, allowing the identification of 266 differentially expressed proteins. Gene ontology analysis identified complement and coagulation cascades, lipid and cholesterol metabolism, and focal adhesion as the main enriched biological pathways. A meta-analysis was performed for apolipoproteins (A-I, C-III, and E); however, no significant differences were found. Although the proven ability of MS proteomics to characterize BD, there are several confounding factors contributing to the heterogeneity of the findings. In the future, we encourage the scientific community to use broader samples and validation cohorts, integrating omics with bioinformatics tools towards providing a comprehensive understanding of proteome alterations, seeking biomarkers of BD, and contributing to individualized prognosis and stratification strategies, besides aiding in the differential diagnosis.

Dosing of Mood Stabilizers for Bipolar Disorder Patients in the Research on Asian Psychotropic Prescription Patterns Consortium Study

BACKGROUND

Because use and dosing of mood stabilizers (MSs) to treat bipolar disorder (BD) patients in Asia are not well documented, we examined prevalence and clinical correlates of treatment of Asian BD patients with relatively high doses of MSs.

METHODS

We conducted a pharmacoepidemiological survey across 13 Asian countries and territory in the Research on Asian Psychotropic Prescription Patterns Consortium. Mood stabilizer doses were converted to lithium carbonate equivalents (Li-eq milligrams per day). We compared relatively high (>900 Li-eq mg/day) versus lower MS doses by bivariate comparisons, followed by multivariable linear regression to identify factors associated with higher MS doses.

RESULTS

Among 1647 participants, MS dose averaged 584 (confidence interval, 565-603 Li-eq mg/d). Preliminarily, the 13.1% of the subjects given greater than 900 mg/d versus those given lower doses were younger, male, currently hospitalized, not currently depressed, and reported lifetime suicidal ideation; they also received relatively high doses of antipsychotics, received electroconvulsive treatment within the previous 12 months, and had greater ratings of tremors and sedation. By linear regression modeling, the mean proportion given high doses of MS was associated significantly and independently with higher doses of antipsychotics, younger age, male sex, hospitalized, more years of illness, country, higher body mass index, recent electroconvulsive treatment, and being in illness remission.

CONCLUSIONS

Relatively high doses of MSs for BD are prevalent, but vary markedly among Asian countries, and are particularly likely among young males, ill for many years, and given high doses of antipsychotics or ECT. These characteristics allow better identification of patient profiles that can guide treatment of BD patients.

Efficacy and safety of scopolamine compared to placebo in individuals with bipolar disorder who are experiencing a depressive episode (SCOPE-BD): study protocol for a randomised double-blind placebo-controlled trial

Background

Current treatment options for the management of depressive episodes in bipolar disorder are often sub-optimal, with some treatments either noted to be only partially effective or to require long durations of treatment prior to a therapeutic response. Therefore, pharmaco-therapeutic options that reduce depressive symptoms in a more rapid manner might provide a viable therapeutic option for some people. Intravenous (IV) scopolamine, a pan muscarinic antagonist, has been demonstrated in a number of studies to confer a rapid antidepressant effect, albeit no study to date has exclusively evaluated its potential therapeutic effect in a cohort consisting solely of individuals with bipolar disorder.

Methods

Individuals with bipolar disorder who are currently experiencing a depressive episode of at least moderate severity will be included in this study. Eligible participants will undergo a screening and placebo-run in visit and will be randomised at visit 3 to the treatment or placebo group. Participants will receive the three blinded infusions over the course of 2 weeks, with two subsequent follow-up visits, 1 and 3 weeks after the last infusion visit. The total duration of the study will be approximately 6 weeks. Patients will continue their regular treatment regime in addition to study medication. Objective and subjective mood questionnaires, cognitive assessments and other psychometric instruments will be administered and recorded.

Discussion

To our knowledge, this is the first study to investigate the antidepressant effects of IV scopolamine in an exclusively bipolar disorder cohort. Trial findings will contribute to the evidence base regarding the cholinergic hypothesis of mood disorders and specifically might result in an additional safe therapeutic option for the management of depressive episodes in bipolar disorder.

Trial registration

ClinicalTrials.gov NCT04211961. December 26, 2019. EudraCT Number 2017-003112-39

The relationship between outpatient service use and emergency department visits among people treated for mental and substance use disorders: analysis of population-based administrative data in British Columbia, Canada

Background

Research findings on the association between outpatient service use and emergency department (ED) visits for mental and substance use disorders (MSUDs) are mixed and may differ by disorder type.

Methods

We used population-based linked administrative data in British Columbia, Canada to examine associations between outpatient primary care and psychiatry service use and ED visits among people ages 15 and older, comparing across people treated for three disorder categories: common mental disorders (MDs) (depressive, anxiety, and/or post-traumatic stress disorders), serious MDs (schizophrenia spectrum and/or bipolar disorders), and substance use disorders (SUDs) in 2016/7. We used hurdle models to examine the association between outpatient service use and odds of any ED visit for MSUDs as well count of ED visits for MSUDs, stratified by cohort in 2017/8.

Results

Having had one or more MSUD-related primary care visit was associated with lower odds of any ED visit among people treated for common MDs and SUDs but not people treated for serious MDs. Continuity of primary care was associated with slightly lower ED use in all cohorts. One or more outpatient psychiatrist visits was associated with lower odds of ED visits among people treated for serious MDs and SUDs, but not among people with common MDs.

Conclusion

Findings highlight the importance of expanded access to outpatient specialist mental health services, particularly for people with serious MDs and SUDs, and collaborative models that can support primary care providers treating people with MSUDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07759-z.

Evaluating the quality, safety, and functionality of commonly used smartphone apps for bipolar disorder mood and sleep self-management

Background

Individuals with bipolar disorder (BD) are increasingly turning to smartphone applications (apps) for health information and self-management support. While reviews have raised concerns regarding the effectiveness and safety of publicly available apps for BD, apps surveyed may not reflect what individuals with BD are using. The present study had two aims: first, to characterize the use of health apps to support mood and sleep amongst people with BD, and second, to evaluate the quality, safety and functionality of the most commonly used self-management apps.

Methods

A web-based survey was conducted to explore which apps people with BD reported using to support self-management of mood and sleep. The characteristics of the most commonly nominated apps were described using a standardized framework, including their privacy policy, clinical foundations, and functionality.

Results

Respondents (n = 919) were 77.9% female with a mean age of 36.9 years. 41.6% of participants (n = 382) reported using a self-management app to support mood or sleep. 110 unique apps were nominated in relation to mood, and 104 unique apps nominated in relation to sleep; however, most apps were only mentioned once. The nine most frequently nominated apps related to mood and sleep were subject to further evaluation. All reviewed apps offered a privacy policy, however user control over data was limited and the complexity of privacy policies was high. Only one app was developed for BD populations. Half of reviewed apps had published peer-reviewed evidence to support their claims of efficacy, but little research was specific to BD.

Conclusion

Findings illustrate the potential of smartphone apps to increase the reach of psychosocial interventions amongst people with BD. Apps were largely created by commercial developers and designed for the general population, highlighting a gap in the development and dissemination of evidence-informed apps for BD. There may be risks in using generic health apps for BD self-management; clinicians should enquire about patients’ app use to foster conversations about their particular benefits and limitations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00256-6.

Reliability and Validity of the Bipolar Prodrome Symptom Interview and Scale-Full Prospective in Its Turkish Translation

Editors' Note: The Editors would like to address issues related to the acceptance of this manuscript. The original manuscript referenced the study tool as the Bipolar Prodrome Symptom Interview Scale-Prospective (BPSS-P). After the manuscript's initial acceptance, the authors requested a revision of the tool name to Bipolar Prodrome Symptom Interview Scale-Full Perspective (BPSS-FP). When this request was made, the original acceptance was rescinded, and the authors were asked to formally revise and resubmit the manuscript with an explanation for the change. This revision and subsequent review led to the final acceptance of the manuscript. The authors have assured us that the tool used in the manuscript was the BPSS-FP (version 5) as opposed to abbreviated forms of this tool that are also used in research (e.g., Bipolar Prodrome Symptom Scale-Abbreviated Screen for Patients (BPSS-AS-P). Background: No scale exists to assess patients at-risk for bipolar disorder (BD) in Turkey. We aimed to assess the psychometric properties of the Turkish version of the Bipolar Prodrome Symptom Interview and Scale-Full Prospective (BPSS-FP). Method: Psychiatric service users aged 11-18 years old were interviewed using the BPSS-FP translated into Turkish and the Kiddie Schedule for Affective Disorders and Schizophrenia. Youth with major depressive disorder (MDD, n = 63), bipolar-spectrum disorder (n = 47), and healthy controls (n = 122) were included. Cronbach's alpha was calculated to assess internal consistency. The Young Mania Rating Scale (YMRS) and Children's Depression Rating Scale-Revised (CDRS-R) were administered to test convergent/discriminant validity. Discriminant validity was further tested using one-way ANOVA and "receiver operating characteristic" (ROC) curves. Inter-rater reliability was tested using correlation coefficients. Findings: Across 232 youth, Cronbach's alpha values were 0.932 for the BPSS-FP total score, 0.878 for the Mania Symptom Index, 0.887 for the Depression Symptom Index, and 0.797 for the General Symptom Index. Correlation coefficients for inter-rater reliability were high for the Mania Symptom Index (r = 0.989), Depression Symptom Index (r = 0.973), and General Symptom Index (r = 0.981). There were high correlations between the BPSS-FP Mania Symptom Index subscore and YMRS (r = 0.732), and the BPSS-FP Depression Symptom Index subscore and CDRS-R (r = 0.754), whereas cross-polarity correlations were non-significant. ROC analysis cut-off value was ≥21 for the BPSS-FP Mania Symptom Index between patients with BD and MDD (specificity = 85.7%, sensitivity = 78.7%). Conclusion: The Turkish version of the BPSS-FP has good psychometric properties and can be used in research. Longitudinal studies are needed to confirm the predictive value of the BPSS-FP.

Gut Microbiota Research in Bipolar Disorder and Possible Implications for Precision Psychiatry: A Systematic Review

Bipolar disorder (BD) is a highly disabling condition with a chronic and relapsing nature. Despite the substantial socioeconomic burden associated with BD, there are still significant research gaps in risk stratification, diagnostic accuracy, and treatment selection, all key components of precision psychiatry. One possible strategy to increase the validity of precision psychiatry approaches in BD is to increase our knowledge of disorder-associated gut microbiota perturbations. To this end, we systematically reviewed the evidence on gut microbiota alterations in relation to precision psychiatry approaches on BD. We performed a systematic review on PubMed/MEDLINE and Web of Science to identify original articles investigating the possible clinical applications of microbiota analyses for pragmatic precision psychiatry in BD. A pearl growing strategy was employed to enlarge the scope of this review. The primary search strategy yielded one paper and an additional one was identified through reference tracking. The included studies were observational, with one study of good quality. The identified results justify the efforts devolved in this area of research and underscore the need to expand these investigations through additional larger and properly designed studies.

Neurophysiology in psychosis: The quest for disease biomarkers

Psychotic disorders affect 3% of the population at some stage in life, are a leading cause of disability, and impose a great economic burden on society. Major breakthroughs in the genetics of psychosis have not yet been matched by an understanding of its neurobiology. Biomarkers of perception and cognition obtained through non-invasive neurophysiological tools, especially EEG, offer a unique opportunity to gain mechanistic insights. Techniques for measuring neurophysiological markers are inexpensive and ubiquitous, thus having the potential as an accessible tool for patient stratification towards early treatments leading to better outcomes. In this paper, we review the literature on neurophysiological markers for psychosis and their relevant disease mechanisms, mainly covering event-related potentials including P50/N100 sensory gating, mismatch negativity, and the N100 and P300 waveforms. While several neurophysiological deficits are well established in patients with psychosis, more research is needed to study neurophysiological markers in their unaffected relatives and individuals at clinical high risk. We need to harness EEG to investigate markers of disease risk as key steps to elucidate the aetiology of psychosis and facilitate earlier detection and treatment.

Levetiracetam adjunct to quetiapine for the acute manic phase of bipolar disorder: a randomized, double-blind and placebo-controlled clinical trial of efficacy, safety and tolerability

Unsatisfactory responses to bipolar disorder treatments have necessitated novel therapeutic approaches. Evidence of levetiracetam's effectiveness in mania was reported in previous studies. This study evaluated its efficacy, safety and tolerability as an adjunct to quetiapine in mania. Forty-four patients with Young Mania Rating Scale (YMRS) score ≥20 entered and were randomized to receive levetiracetam plus quetiapine or placebo plus quetiapine for 6 weeks. Patients were assessed using the YMRS and Beck Scale for Suicidal Ideations (BSSI) at baseline and weeks 2, 4 and 6. Changes in the scores, remission rates and response to treatment were compared between the groups. Forty patients completed the trial. The general linear model (GLM) repeated measures demonstrated a significant effect for time × treatment interaction on the YMRS score during the trial (P = 0.04). A greater reduction in YMRS scores was seen in the levetiracetam group compared with the placebo group from baseline to week 4 (P = 0.045). Response to treatment was significantly better in the levetiracetam group (P = 0.046). No significant effect for time × treatment interaction on BSSI score was seen in GLM repeated measures. Finally, there was no significant difference in the frequency of adverse events. Adjunctive levetiracetam is effective, safe and well-tolerated in patients with mania. Further high-quality, large-scale trials are recommended.

Developing an International Standard Set of Patient-Reported Outcome Measures for Psychotic Disorders

OBJECTIVE

The objective of this project was to develop a set of patient-reported outcome measures for adolescents and adults who meet criteria for a psychotic disorder.

METHODS

A research team and an international consensus working group, including service users, clinicians, and researchers, worked together in an iterative process by using a modified Delphi consensus technique that included videoconferencing calls, online surveys, and focus groups. The research team conducted systematic literature searches to identify outcomes, outcome measures, and risk adjustment factors. After identifying outcomes important to service users, the consensus working group selected outcome measures, risk adjustment factors, and the final set of outcome measures. International stakeholder groups consisting of >100 professionals and service users reviewed and commented on the final set.

RESULTS

The consensus working group identified four outcome domains: symptoms, recovery, functioning, and treatment. The domains encompassed 14 outcomes of importance to service users. The research team identified 131 measures from the literature. The consensus working group selected nine measures in an outcome set that takes approximately 35 minutes to complete.

CONCLUSIONS

A set of patient-reported outcome measures for use in routine clinical practice was identified. The set is free to service users, is available in at least two languages, and reflects outcomes important to users. Clinicians can use the set to improve clinical decision making, and administrators and researchers can use it to learn from comparing program outcomes.

Diagnostic Trends and Prescription Patterns in Disruptive Mood Dysregulation Disorder and Bipolar Disorder

OBJECTIVE

Disruptive mood dysregulation disorder (DMDD) was introduced in DSM-5 to distinguish a subset of chronically irritable youth who may be incorrectly diagnosed and/or treated for pediatric bipolar disorder (BPD). This study characterized the rate of new treatment episodes and treated prevalence of BPD and DMDD from a longitudinal electronic health record database and examined the impact of DMDD on prescription trends.

METHOD

A retrospective cohort study using 2008-2018 Optum electronic health record data was conducted. Youth aged 10 to < 18 years with ≥ 183 days of database enrollment before the study cohort entry were included. Annual new treatment episode rates per 1,000 patient-years and treated prevalence (%) were estimated. Prescriptions for medications, concomitant diagnoses, and acute mental health service use for 2016-2018 were evaluated.

RESULTS

There were 7,677 youths with DMDD and 6,480 youths with BPD identified. Mean age (13-15 years) and ethnicity were similar for both groups. A rise in new treatment episode rates (0.87-1.75 per 1,000 patient-years, p < .0001) and treated prevalence (0.08%-0.35%, p < .0001) of DMDD diagnoses (2016-2018) following diagnosis inception was paralleled by decreasing new treatment episode rates (1.22-1.14 per 1,000 patient-years, p < .01) and treated prevalence (0.42%-0.36%, p < .0001) of BPD diagnoses (2015-2018). More youth in the DMDD group were prescribed medications compared with the BPD group (81.9% vs 69.4%), including antipsychotics (58.9% vs 51.0%). Higher proportions of youth with DMDD vs youth with BPD had disruptive behavior disorders (eg, 35.9% vs 20.5% had oppositional defiant disorder), and required inpatient hospitalization related to their mental health disorder (45.0% vs 33.0%).

CONCLUSION

Diagnosis of DMDD has had rapid uptake in clinical practice but is associated with increased antipsychotic and polypharmacy prescriptions and higher rates of comorbidity and inpatient hospitalization in youth with a DMDD diagnosis compared with a BPD diagnosis.

A Smartphone-Based Self-management Intervention for Individuals With Bipolar Disorder (LiveWell): Empirical and Theoretical Framework, Intervention Design, and Study Protocol for a Randomized Controlled Trial

Background

Bipolar disorder is a severe mental illness with high morbidity and mortality rates. Even with pharmacological treatment, frequent recurrence of episodes, long episode durations, and persistent interepisode symptoms are common and disruptive. Combining psychotherapy with pharmacotherapy improves outcomes; however, many individuals with bipolar disorder do not receive psychotherapy. Mental health technologies can increase access to self-management strategies derived from empirically supported bipolar disorder psychotherapies while also enhancing treatment by delivering real-time assessments, personalized feedback, and provider alerts. In addition, mental health technologies provide a platform for self-report, app use, and behavioral data collection to advance understanding of the longitudinal course of bipolar disorder, which can then be used to support ongoing improvement of treatment.

Objective

A description of the theoretical and empirically supported framework, design, and protocol for a randomized controlled trial (RCT) of LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder, is provided to facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar disorder. The goal of the trial is to determine the effectiveness of LiveWell for reducing relapse risk and symptom burden as well as improving quality of life (QOL) while simultaneously clarifying behavioral targets involved in staying well and better characterizing the course of bipolar disorder and treatment response.

Methods

The study is a single-blind RCT (n=205; 2:3 ratio of usual care vs usual care plus LiveWell). The primary outcome is the time to relapse. Secondary outcomes are percentage time symptomatic, symptom severity, and QOL. Longitudinal changes in target behaviors proposed to mediate the primary and secondary outcomes will also be determined, and their relationships with the outcomes will be assessed. A database of clinical status, symptom severity, real-time self-report, behavioral sensor, app use, and personalized content will be created to better predict treatment response and relapse risk.

Results

Recruitment and screening began in March 2017 and ended in April 2019. Follow-up ended in April 2020. The results of this study are expected to be published in 2022.

Conclusions

This study will examine whether LiveWell reduces relapse risk and symptom burden and improves QOL for individuals with bipolar disorder by increasing access to empirically supported self-management strategies. The role of selected target behaviors (medication adherence, sleep duration, routine, and management of signs and symptoms) in these outcomes will also be examined. Simultaneously, a database will be created to initiate the development of algorithms to personalize and improve treatment for bipolar disorder. In addition, we hope that this description of the theoretical and empirically supported framework, intervention design, and study protocol for the RCT of LiveWell will facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar and other mental health disorders.

Trial Registration

ClinicalTrials.gov NCT03088462; https://www.clinicaltrials.gov/ct2/show/NCT03088462

International Registered Report Identifier (IRRID)

DERR1-10.2196/30710

Metabolic function in patients with bipolar depression receiving anti-inflammatory agents: Findings from the MINDCARE study, a multicentre, randomised controlled trial

BACKGROUND

Metabolic dysfunction is prevalent in bipolar disorder (BD) and associated with illness severity and treatment outcomes. There is little research exploring this relationship in low and middle-income countries (LMICs) and little is known about the moderating effect of metabolic health on treatment response to anti-inflammatory drugs in BD.

METHODS

MINDCARE, a randomized-controlled-trial conducted in Pakistan, investigated the efficacy of minocycline and celecoxib in 266 adults with bipolar depression. This secondary analysis evaluated the association between depression severity at baseline and treatment outcome with metabolic parameters including body mass index (BMI), waist circumference (WC), heart rate (HR), systolic blood pressure (s-BP), and diastolic blood pressure (d-BP). Depression severity was measured using the Hamilton Depression Rating Scale-17. The exploratory aim was to assess whether treatment impacted change in metabolic variables. Associations were evaluated using linear regression.

RESULTS

Higher BMI (B=-0.38, 95%CI: -0.55 to -0.21) and WC (B=-0.68, 95%CI: -0.97 to -0.39) were associated with lower baseline depression severity in both the unadjusted and the adjusted models. Baseline metabolic parameters were not associated with treatment response to minocycline or celecoxib nor did treatment significantly impact metabolic variables.

LIMITATIONS

Our sample represents patients in an RCT and may not be fully representative of the overall BD population in Pakistan.

CONCLUSIONS

Our findings indicate a potential association of poor metabolic health and lower severity of bipolar depression but not treatment outcomes. Future work should evaluate potential relationships of metabolic parameters and BD in diverse populations to increase the transferability of this line of work.

Randomised controlled trial of Interpersonal and Social Rhythm Therapy and group-based Cognitive Remediation versus Interpersonal and Social Rhythm Therapy alone for mood disorders: study protocol

BACKGROUND

Individuals with mood disorders frequently experience cognitive impairment, which impacts on the long-term trajectory of the disorders, including being associated with persisting difficulties in occupational and psychosocial functioning, residual mood symptoms, and relapse. Current first-line treatments for mood disorders do little to improve cognitive function. Targeting cognition in clinical research is thus considered a priority. This protocol outlines a prospectively-registered randomised controlled trial (RCT) which examines the impact of adding group-based Cognitive Remediation (CR) to Interpersonal and Social Rhythm Therapy (IPSRT-CR) for individuals with mood disorders.

METHODS

This is a pragmatic, two-arm, single-blinded RCT comparing IPSRT-CR with IPSRT alone for adults (n = 100) with mood disorders (Major Depressive Disorder or Bipolar Disorder) with subjective cognitive difficulties, on discharge from Specialist Mental Health Services in Christchurch, New Zealand. Both treatment arms will receive a 12-month course of individual IPSRT (full dose = 24 sessions). At 6 months, randomisation to receive, or not, an 8-week group-based CR programme (Action-based Cognitive Remediation - New Zealand) will occur. The primary outcome will be change in Global Cognition between 6 and 12 months (treatment-end) in IPSRT-CR versus IPSRT alone. Secondary outcomes will be change in cognitive, functional, and mood outcomes at 6, 12, 18, and 24 months from baseline and exploratory outcomes include change in quality of life, medication adherence, rumination, and inflammatory markers between treatment arms. Outcome analyses will use an intention-to-treat approach. Sub-group analyses will assess the impact of baseline features on CR treatment response. Participants' experiences of their mood disorder, including treatment, will be examined using qualitative analysis.

DISCUSSION

This will be the first RCT to combine group-based CR with an evidence-based psychotherapy for adults with mood disorders. The trial may provide valuable information regarding how we can help promote long-term recovery from mood disorders. Many issues have been considered in developing this protocol, including: recruitment of the spectrum of mood disorders, screening for cognitive impairment, dose and timing of the CR intervention, choice of comparator treatment, and choice of outcome measures.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, ACTRN12619001080112 . Registered on 6 August 2019.

Circulating hsa-let-7e-5p and hsa-miR-125a-5p as Possible Biomarkers in the Diagnosis of Major Depression and Bipolar Disorders

Background. Evidence shows that microRNAs (miRNAs) could play a key role in the homeostasis and development of major depressive disorder and bipolar disorder. The present study is aimed at investigating the changes in circulating miRNA expression profiles in a plasma of patients suffering from major depressive disorder (MDD) and bipolar disorder (BD) to distinguish and evaluate these molecules as biomarkers for mood disorders. Methods. A study enrolled a total of 184 subjects: 74 controls, 84 MDD patients, and 26 BD patients. Small RNA sequencing revealed 11 deregulated circulating miRNAs in MDD and BD plasma, of which expression of 5, hsa-miR-139-3p, miRNAs hsa-let-7e-5p, hsa-let-7f-5p, hsa-miR-125a-5p, and hsa-miR-483-5p, were further verified using qPCR. miRNA gene expression data was evaluated alongside the data from clinical assessment questionnaires. Results. hsa-let-7e-5p and hsa-miR-125a-5p were both confirmed upregulated: 0.75-fold and 0.25-fold, respectively, in the MDD group as well as 1.36-fold and 0.68-fold in the BD group. Receiver operating curve (ROC) analysis showed mediocre diagnostic sensitivity and specificity of both hsa-let-7e-5p and hsa-miR-125a-5p with approximate area under the curve (AOC) of 0.66. ROC analysis of combined miRNA and clinical assessment data showed that hsa-let-7e-5p and hsa-miR-125a-5p testing could improve MDD and BD diagnostic accuracy by approximately 10%. Conclusions. Circulating hsa-let-7e-5 and hsa-miR-125a-5p could serve as additional peripheral biomarkers for mood disorders; however, suicidal ideation remains the major diagnostic factor for MDD and BD.

Evaluating maintenance electroconvulsive therapy in Bipolar Disorders: 3-year mirror-image study

BACKGORUND

Maintenance electroconvulsive therapy (mECT) is underused in the treatment of bipolar disorder (BD). We aimed to study the real-life effectiveness of mECT in BD.

METHODS

Naturalistic 3-year mirror-image study in individuals diagnosed with BD who underwent mECT at a tertiary hospital. Intra-subject comparisons of psychiatric hospitalization were performed using McNemar test. Days and number of psychiatric hospitalizations before and during mECT were compared through wilcoxon signed-rank test. Mean annual days and mean annual number of psychiatric hospitalizations per patient were compared by means of the rate ratio (RR) estimation through a generalized estimating equation (GEE) model.

RESULTS

A total of 43 patients were included and 37 required psychiatric hospitalization during the study. The use of mECT showed an effectiveness of 62.2% for preventing psychiatric hospitalizations (p<0.01). We found significant reduction in days and number of psychiatric hospitalizations during mECT compared to before mECT (p<0.01). Comparison of the 3-year period before/during mECT showed a reduction in mean annual days (RR=0.14; 95%CI: 0.07-0.29) and mean annual number (RR=0.24; 95%CI: 0.13-0.43) of psychiatric hospitalizations, without substantial changes for adjusted models for gender and age of onset of the illness.

LIMITATIONS

The main limitations of this study consisted of the mirror-image retrospective naturalistic study design, the relatively small sample size, and possibly patient selection bias.

CONCLUSIONS

mECT reduced the number of psychiatric hospitalizations and hospitalization days in BD. The use of mECT outlines a mood stabilizing effect in BD. This naturalistic study supports the effectiveness of mECT in BD across several mood states.

A scoping review of near infrared spectroscopy studies employing a verbal fluency task in bipolar disorder

BACKGROUND

Deficits in cognitive functioning, including attention, memory, and executive functions, along with impairments in language production, are present in patients with bipolar disorder (BD) patients during mood phases, but also during euthymia.Verbal fluency tasks (VFTs), being able to evaluate integrity of a wide range of cognitive domains and represent, can be used to screen for these disturbances. Neuroimaging studies, including Near-InfraRed Spectroscopy (NIRS), have repeatedly showed widespread alterations in the prefrontal and temporal cortex during the performance of VFTs in BD patients. This review aims to summarize the results of NIRS studies that evaluated hemodynamic responses associated with the VFTs in prefrontal and temporal regions in BD patients.

METHODS

We performed a scoping review of studies evaluating VFT-induced activation in prefrontal and temporal regions in BD patients, and the relationship between NIRS data and various clinical variables.

RESULTS

15 studies met the inclusion criteria. In BD patients, compared to healthy controls, NIRS studies showed hypoactivation of the dorsolateral prefrontal cortex, ventrolateral prefrontal cortex and anterior temporal regions. Moreover, clinical variables, such as depressive and social adaptation scores, were negatively correlated with hemodynamic responses in prefrontal and temporal regions, while a positive correlation were reported for measures of manic symptoms and impulsivity.

LIMITATIONS

The heterogeneity of the studies in terms of methodology, study design and clinical characteristics of the samples limited the comparability of the findings.

CONCLUSIONS

Given its non-invasiveness, good time-resolution and no need of posturalconstraint, NIRS technique could represent a useful tool for the evaluation of prefrontal and temporal haemodynamic correlates of cognitive performances in BD patients.

Repetitive transcranial magnetic stimulation (rTMS) in bipolar disorder: A systematic review

OBJECTIVES

Repetitive transcranial magnetic stimulation (rTMS) is commonly used in unipolar depression; yet, its evidence in bipolar disorder (BD) is limited. We sought to review the evidence on the use of rTMS across the different stages of BD.

METHODS

MEDLINE database was systematically searched using the PubMed interface following the PRISMA guidelines. Inclusion criteria were as follows: (i) randomized clinical trials (RCTs), open-label studies, and case series; (ii) specific evaluation of the treatment outcomes using psychometric scales; (iii) clinical studies in adults; and (iv) articles in the English language. The systematic review has been registered on PROSPERO (CRD42020192788).

RESULTS

Thirty-one papers were included in the review. Most studies included participants diagnosed with a bipolar depressive episode (N = 24), have yielded mixed findings, and have yet to reach a consensus on the most effective rTMS protocol. Few studies examined the effect of rTMS during manic (N = 5) or mixed episode (N = 1), or as maintenance treatment (N = 1). The limited data thus far suggest rTMS to be relatively safe and well tolerated. Small sample sizes, heterogeneity among study designs, patients and control groups recruited, rTMS parameters, and outcome measures are among the most significant limitations to these studies.

CONCLUSION

The current data regarding the application of rTMS in BD patients remain limited. More adequately powered sham-controlled studies are required to verify its efficacy. Large-scale clinical trials are needed to also determine whether its effects extend to manic and mixed episodes, as well as its role in mood stabilization and amelioration of suicidal behavior.

Bipolar Disorder in pediatric patients: A nationwide retrospective study from 2000 to 2015

BACKGROUND

Pediatric Bipolar Disorder (BD) has been the focus of increased attention. To date, in Portugal, there is no evidence available for pediatricBD-related hospitalization rates. This study aimed to describe and characterize all pediatric hospitalizations with a primary diagnosis of BD registered in Portugal from 2000 to 2015.

METHODS

A retrospective observational study was conducted. Pediatric (< 18 years) inpatient episodes with a primary diagnosis of BD were selected from a national administrative database. The ICD-9-CM codes 296.x (excluding 296.2x, 296.3x and 296.9x) identified the diagnosis of interest. Additionally, age at discharge, sex, psychiatric comorbidities, length of stay (LoS), admission type and date, in-hospital mortality and hospital charges were analyzed.

RESULTS

A total of 348 hospitalizations, representing 258 patients, were identified. The overall population-based rate of hospitalizations was 1.18/100 000 youths. A non-linear increase throughout the study period was found. Patients were mostly female (60.6%), with a median age of 16 years (Q1-Q3:14-17). Admissions were mostly emergent (81%), and the median LoS was 14 days (Q1-Q3:7-24). Moreover, about 26% of all episodes were readmissions. Mean estimated charges per episode were 3503.10€, totalizing 1.20M€.

LIMITATIONS

Limitations include the use of secondary data and the retrospective nature of the study.

CONCLUSIONS

Annual rates of pediatric BD hospitalizations showed a non-linear increase. These findings may contribute to better understand the pediatric BD burden. Nevertheless, more research is warranted, to better characterize sociodemographic and clinical trends in pediatric BD to prevent the high number of acute hospitalizations and readmissions of these patients.

Schema Therapy for Patients with Bipolar Disorder: Theoretical Framework and Application

Bipolar disorder (BD) is a severe mood disorder characterized by episodes of depression and hypomania or mania. Despite its primarily biological roots, the onset and course of the disorder have also been related to psychosocial factors such as early adverse experiences and related maladaptive schemas. Several researchers proposed a schema therapeutic model to treat patients with BD. In this paper, we further develop the theoretical model and elaborate on seven elements that were found effective in the psychosocial interventions with individuals with BD: monitoring mood and early symptoms of relapse, recognizing and management of stressful situations and interpersonal conflicts, creating a relapse prevention plan, stabilizing the sleep/wake cycle and daily routine, encouraging the use of medication, and reducing self-stigma and substance use. Apart from that, we describe the elements of the schema work with patients who suffer from BD. Illustrative clinical cases accompany the theoretical framework. The research of the schema therapy with patients with severe mental illnesses has only recently started developing. The presented paper also aims to encourage further research in this area and highlight potentially beneficial research goals.

Designing and testing of a health-economic Markov model to assess the cost-effectiveness of treatments for Bipolar disorder: TiBipoMod

BACKGROUND

Bipolar disorder is an often recurrent mood disorder that is associated with a significant economic and health-related burden. Increasing the availability of health-economic evidence may aid in reducing this burden. The aim of this study is to describe the design of an open-source health-economic Markov model for assessing the cost-effectiveness of interventions in the treatment of Bipolar Disorders type I and II, TiBipoMod.

METHODS

TiBipoMod is a decision-analytic Markov model that allows for user-defined incorporation of both pharmacological and non-pharmacological interventions for the treatment of BD. TiBipoMod includes the health states remission, depression, (hypo)mania and death. Costs and effects are modeled over a lifetime horizon from a societal and healthcare perspective, and results are presented as the total costs, Quality-Adjusted Life Years (QALY), Life Years (LY), and incremental costs per QALYs and LYs gained.

RESULTS

Functionalities of TiBipoMod are demonstrated by performing a cost-utility analysis of mindfulness-based cognitive therapy (MBCT) compared to the standard of care. Treatment with MBCT resulted in an increase of 0.18 QALYs per patient, and a dominant incremental cost-effectiveness ratio per QALY gained for MBCT at a probability of being cost-effective of 71% when assuming a €50,000 willingness-to-pay threshold.

CONCLUSION

TiBipoMod can easily be adapted and used to determine the cost-effectiveness of interventions in the treatment in Bipolar Disorder type I and II, and is freely available for academic purposes upon request at the authors.

Alterations of Plasma Lipids in Adult Women With Major Depressive Disorder and Bipolar Depression

Lipidomics has been established as a potential tool for the investigation of mental diseases. However, the composition analysis and the comparison of the peripheral lipids regarding adult women with major depressive depression (MDD) or bipolar depression (BPD) has been poorly addressed. In the present study, age-matched female individuals with MDD (n = 28), BPD (n = 22) and healthy controls (HC, n = 25) were enrolled. Clinical symptoms were assessed and the plasma samples were analyzed by comprehensive lipid profiling based on liquid chromatography-mass spectrometry (LC/MS). We found that the composition of lipids was remarkably changed in the patients with MDD and BPD when compared to HC or compared to each other. Moreover, we identified diagnostic potential biomarkers comprising 20 lipids that can distinguish MDD from HC (area under the curve, AUC = 0.897) and 8 lipids that can distinguish BPD from HC (AUC = 0.784), as well as 13 lipids were identified to distinguish MDD from BPD with moderate reliability (AUC = 0.860). This study provides further understanding of abnormal lipid metabolism in adult women with MDD and BPD and may develop lipid classifiers able to effectively discriminate MDD from BPD and HC.

Alterations in the Plasma Lipidome of Adult Women With Bipolar Disorder: A Mass Spectrometry-Based Lipidomics Research

Lipidomics has become a pivotal tool in biomarker discovery for the diagnosis of psychiatric illnesses. However, the composition and quantitative analysis of peripheral lipids in female patients with bipolar disorder (BD) have been poorly addressed. In this study, plasma samples from 24 female patients with BD and 30 healthy controls (HCs) were analyzed by comprehensive lipid profiling and quantitative validation based on liquid chromatography-mass spectrometry. Clinical characteristics and a correlation between the level of lipid molecules and clinical symptoms were also observed. We found that the quantitative alterations in several lipid classes, including acylcarnitine, lysophosphatidylethanolamine, GM2, sphingomyelin, GD2, triglyceride, monogalactosyldiacylglycerol, phosphatidylinositol phosphate, phosphatidylinositol 4,5-bisphosphate, phosphatidylethanolamine, phosphatidylserine, and lysophosphatidylinositol, were remarkably upregulated or downregulated in patients with BD and were positively or negatively correlated with the severity of psychotic, affective, or mania symptoms. Meanwhile, the composition of different carbon chain lengths and degrees of fatty acid saturation for these lipid classes in BD were also different from those of HCs. Moreover, 55 lipid molecules with significant differences and correlations with the clinical parameters were observed. Finally, a plasma biomarker set comprising nine lipids was identified, and an area under the curve of 0.994 was obtained between patients with BD and the HCs. In conclusion, this study provides a further understanding of abnormal lipid metabolism in the plasma and suggests that specific lipid species can be used as complementary biomarkers for the diagnosis of BD in women.

Sex is a defining feature of neuroimaging phenotypes in major brain disorders

Sex is a biological variable that contributes to individual variability in brain structure and behavior. Neuroimaging studies of population-based samples have identified normative differences in brain structure between males and females, many of which are exacerbated in psychiatric and neurological conditions. Still, sex differences in MRI outcomes are understudied, particularly in clinical samples with known sex differences in disease risk, prevalence, and expression of clinical symptoms. Here we review the existing literature on sex differences in adult brain structure in normative samples and in 14 distinct psychiatric and neurological disorders. We discuss commonalities and sources of variance in study designs, analysis procedures, disease subtype effects, and the impact of these factors on MRI interpretation. Lastly, we identify key problems in the neuroimaging literature on sex differences and offer potential recommendations to address current barriers and optimize rigor and reproducibility. In particular, we emphasize the importance of large-scale neuroimaging initiatives such as the Enhancing NeuroImaging Genetics through Meta-Analyses consortium, the UK Biobank, Human Connectome Project, and others to provide unprecedented power to evaluate sex-specific phenotypes in major brain diseases.

Is aripiprazole similar to quetiapine for treatment of bipolar depression? Results from meta-analysis of Chinese data

OBJECTIVE

To study the similarities and differences in the clinical efficacy of aripiprazole and quetiapine in Chinese patients with bipolar depression through meta-analysis. Additionally, to provide evidence of aripiprazole in treatment for bipolar depression.

METHODS

We searched Chinese literature related to the study of aripiprazole and quetiapine in treatment for bipolar depression, among which results such as comments, letters, reviews, and case reports were excluded. The clinical efficacy between aripiprazole and quetiapine was synthesized and discussed.

RESULT

A total of 1,546 subjects were included in 17 studies. The random effect model was used to review the data by RevMan 5.2. The results showed that there was no significant difference in the remission rate between patients treated with aripiprazole and quetiapine evidenced by the scale used to evaluate the patients being treated for bipolar depression (221/501 vs. 193/501, Z = 1.12, P = 0.26). But the results also showed that the remission rate of aripiprazole with lithium carbonate was significantly higher than quetiapine with lithium carbonate in the treatment of bipolar depression (111/232 vs. 69/232, Z = 3.92, P < 0.0001). The results showed that the effective rate of aripiprazole was similar to quetiapine (426/572 vs. 386/572, Z = 2.70, P = 0.007). Overall, there was no difference in the Hamilton Rating Scale for Depression (HAMD) score between patients treated with aripiprazole and quetiapine (Z = 1.68, P = 0.09). The results also show that the drop-out rate of aripiprazole was similar to quetiapine in the treatment of patients with bipolar depression (Z = 1.80, P = 0.07).

CONCLUSION

As an atypical antipsychotic, aripiprazole may be similar to quetiapine for treating bipolar depression with similar drop-out and higher remission rates when combined with lithium carbonate. However, the results of this study need to be read with caution given the poor quality of collected/analyzed literature.

Comparative efficacy of mitochondrial agents for bipolar disorder during depressive episodes: a network meta-analysis using frequentist and Bayesian approaches

RATIONALE

Mitochondrial dysfunctions have emerged as new biological hypothesis and therapeutic target for bipolar disorder. This network meta-analysis has been done to evaluate the comparative efficacy of mitochondrial agents in bipolar depression.

METHODS

After a comprehensive literature search on PubMed/MEDLINE, Cochrane databases, and International Trials Registry Platform, efficacy data were extracted from 15 randomized controlled trials. Random-effects meta-analysis was done following both frequentist and Bayesian approaches to pool the effects across the interventions. A network graph was built, relative effects of interventions in respect to one another and placebo were calculated, and treatments were ranked as per P- and SUCRA scores. Change in depression rating score was the primary outcome. Data was entered in contrast level and arm level for frequentist and Bayesian approaches, respectively.

RESULTS

Amongst mitochondrial agents, N-acetylcysteine (NAC) was shown to have the highest probability of being the best treatment, followed by coenzyme Q10 and combination therapy of alpha-lipoic acid (ALA) and acetyl-L-carnitine (ALCAR) as depicted by P- and SUCRA scores. In the Bayesian approach, none of the treatments had better efficacy than placebo, but in the frequentist approach, NAC (effect estimate: - 1.18 (95% CI: - 2.05; - 0.31)) was significantly better than placebo.

CONCLUSION

Methodically, there may be a difference of magnitude in frequentist and Bayesian approaches, but the direction of effect and ranking probabilities do not differ. We conclude that none of the existing mitochondrial agents showed better efficacy than placebo in bipolar depression regarding depression rating scores.

Exploring machine learning to predict depressive relapses of bipolar disorder patients

BACKGROUND

Bipolar disorder (BD) is a chronic mood disorder characterized by recurrent episodes of mania or hypomania and depression, expressed by changes in energy levels and behavior. However, most of relapse studies use evidence-based approaches with statistical methods. With the advance of the precision medicine this study aims to use machine learning (ML) approaches as a possible predictor in depressive relapses in BD.

METHOD

Four accepted and well used ML algorithms (Support Vector Machines, Random Forests, Naïve Bayes, and Multilayer Perceptron) were applied to the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) dataset in a cohort of 800 patients (507 patients presented depressive relapse and 293 did not), who became euthymic during the study and were followed for one year.

RESULTS

The ML algorithms presented reasonable performance in the prediction task, ranging from 61 to 80% in the F-measure. The Random Forest algorithm obtained a higher average of performance (Relapse Group 68%; No Relapse Group 74%). The three most important mood symptoms observed in the relapse visit (Random Forest) were: interest; depression mood and energy.

LIMITATIONS

Social and psychological parameters such as marital status, social support system, personality traits, might be an important predictor in depressive relapses, although we did not compute this data in our study.

CONCLUSIONS

Our findings indicate that applying precision medicine models by means of machine learning in BD studies could be feasible as a sensible approach to better support medical decision-making in the BD treatment and prevention of future relapses.

Age moderates the relationship between affective response inhibition and bipolar disorder in adults

BACKGROUND

Patients with bipolar disorder (BD) often have impairments in neurocognition, including affective processing and affective response inhibition. While studies suggest that cognitive control in general may decline with age in BD, less is known about age-related changes in response inhibition to emotionally salient information.

METHODS

258 participants with BD and 54 healthy controls, ages 18-70, completed the Cambridge Neuropsychological Test Automated Battery (CANTAB) Affective Go/No-Go task to assess affective response inhibition to positive and negative valenced stimuli. We examined the relationship between BD and affective response inhibition (number of commission and omission errors and reaction time), as well as a potential moderating effect of age, using mixed effects linear regression models.

RESULTS

The BD group made more omission and commission errors overall than the control group (p < 0.018). We observed a significant 3-way group-by-age-by-valence interaction for reaction time (p = 0.006). Within BD, a slower reaction time to negative than positive stimuli was found in middle and older age groups (p < 0.012), but not in the younger age group. No significant moderating effect of age was observed within the control group.

CONCLUSIONS

These cross-sectional findings indicate that compared with healthy controls, individuals with BD display differential and age-related effects in inhibition to emotionally salient information that is valence-dependent. The observed pattern of a switch in bias from negative to positive stimuli with age in BD may aid in our understanding of the progression of neurocognitive changes with aging in BD, as well as inform targeted treatments for cognitive symptoms.

Treatment of mixed depression with theta-burst stimulation (TBS): results from a double-blind, randomized, sham-controlled clinical trial

Mixed depression is probably different in terms of clinical course and response to treatment. Repetitive transcranial magnetic stimulation (rTMS) is well established in non-mixed depression, and theta-burst stimulation (TBS) protocol is replacing conventional protocols because of noninferiority and reduced delivery time. However, TBS has not been adequately studied in mixed states. This study was a double-blind, six-week, sham-controlled, and randomized clinical trial of bilateral TBS targeting the right and left dorsolateral prefrontal cortex, respectively. Adults with bipolar and major depressive disorder experiencing an acute mixed depression were eligible if they had not benefited from a first- or second-line treatment for acute unipolar or bipolar depression recommended by the Canadian Network for Mood and Anxiety Treatments. Out of 100 patients included, 90 composed modified intention-to-treat sample, which was patients that completed at least one week of the intervention. There were no significant differences in Montgomery-Asberg depression rating scale score changes (least squares mean difference between groups at week 3, -0.06 [95% CI, - 3.39 to 3.51; P = 0.97] in favor of sham TBS). Response and remission rates per MADRS were also not statistically different among active and sham groups (35.7% vs. 43.7%, and 28.5% vs. 37.5% respectively at week 6, ps > 0.51). No other analyses from baseline to weeks 3 or 6 revealed significant time x group interaction or mean differences among groups in the mITT sample. Bilateral TBS targeting the DLPFC is not efficacious as an add-on treatment of acute bipolar and unipolar mixed depression. ClinicalTrials.govIdentifier: NCT04123301.

Cerebrospinal fluid proteomics targeted for central nervous system processes in bipolar disorder

The etiopathology of bipolar disorder is largely unknown. We collected cerebrospinal fluid (CSF) samples from two independent case-control cohorts (total n = 351) to identify proteins associated with bipolar disorder. A panel of 92 proteins targeted towards central nervous system processes identified two proteins that replicated across the cohorts: the CSF concentrations of testican-1 were lower, and the CSF concentrations of C-type lectin domain family 1 member B (CLEC1B) were higher, in cases than controls. In a restricted subgroup analysis, we compared only bipolar type 1 with controls and identified two additional proteins that replicated in both cohorts: draxin and tumor necrosis factor receptor superfamily member 21 (TNFRSF21), both lower in cases than controls. This analysis additionally revealed several proteins significantly associated with bipolar type 1 in one cohort, falling just short of replicated statistical significance in the other (tenascin-R, disintegrin and metalloproteinase domain-containing protein 23, cell adhesion molecule 3, RGM domain family member B, plexin-B1, and brorin). Next, we conducted genome-wide association analyses of the case-control-associated proteins. In these analyses, we found associations with the voltage-gated calcium channel subunit CACNG4, and the lipid-droplet-associated gene PLIN5 with CSF concentrations of TNFRSF21 and CLEC1B, respectively. The reported proteins are involved in neuronal cell-cell and cell-matrix interactions, particularly in the developing brain, and in pathways of importance for lithium's mechanism of action. In summary, we report four novel CSF protein associations with bipolar disorder that replicated in two independent case-control cohorts, shedding new light on the central nervous system processes implicated in bipolar disorder.

A randomized pilot study of Rhythms And You (RAY): An internet-based program for bipolar disorder administered with and without clinical helper support in primary care

BACKGROUND

Rhythms And You (RAY) is an online intervention for bipolar disorders (BD) based on Interpersonal and Social Rhythm Therapy. We examined RAY's feasibility and acceptability for individuals with BD recruited from primary care. Because online interventions may be more effective when paired with human support, we evaluated RAY with and without weekly brief (∼5 min) calls from clinical helpers (CH).

METHODS

Participants (n = 47) meeting criteria for BD I, II or other specified BD, presenting for primary care, were randomly assigned to RAY, RAY-CH, or Adjunctive Reading Material (ARM) control. RAY consisted of 12 weekly online modules. ARM consisted of 12 weekly emails. Participants were assessed at baseline, 4, 8, and 12 weeks.

RESULTS

RAY showed high completion rates and Client Satisfaction Questionnaire scores (36/47, 77% and 25.1 ± 5.5, respectively; no group differences). Effect sizes for RAY- CH ranged from small [Internal State Scale-Activation Subscale (ISS-ACT); d = 0.3] to large [SF-12 Mental Health Composite Score (SF-12 MHC); d = 1.3]. ARM also showed moderate effects (ISS-ACT d = 0.7; Quick Inventory of Depressive Symptoms, d = 0.8). SF-12 MHC scores showed a time*group interaction (F = 2.38, df = 6,32, p = 0.05) favoring RAY-CH. Number of logins trended toward significant association with improved social rhythm regularity (F = 4.09, df = 1, 17, p = 0.06).

LIMITATIONS

Sample size is small, limiting conclusions that can be drawn.

CONCLUSIONS

Remote delivery of RAY for individuals with BD is feasible and acceptable. More time spent engaged in RAY was associated with greater improvement in social rhythm regularity. Preliminary evidence suggests adding brief human support to RAY may yield better outcomes.

Understanding the Barriers and Facilitators to Employment for People with Bipolar Disorder

People with Bipolar Disorder (BD) consistently report a desire for employment; however, this is not reflected in employment figures. Individuals' perceptions of barriers to employment, along with endorsement of facilitators to employment remain under-investigated. We aimed to address this limitation by: (i) first examining differences in employed versus unemployed individuals (demographic, clinical, functioning); then (ii) identifying barriers and/or facilitators to employment, perception of same, and subsequent impact on employment. We assessed demographics, functioning, and illness-related characteristics in 35 participants with BD (19 employed, 16 unemployed). Participants were asked to indicate perception of common barriers and facilitators to employment. Groups did not differ regarding demographic or clinical variables. High levels of absenteeism, termination of last role and commonly perceived barriers were attributed to mental ill-health. 93.3% of unemployed participants reportedly desired employment, and more perceived barriers were observed in the unemployed group. Identified facilitators included increased support and flexible work strategies. A comprehensive understanding of perceptions of limiting and helpful factors related to employment for people with BD was obtained. These findings have implications for service provision, encouraging targeted discussion, and tailored treatment approaches to individual's unique perceptions of factors related to employment.

Combining schizophrenia and depression polygenic risk scores improves the genetic prediction of lithium response in bipolar disorder patients

Lithium is the gold standard therapy for Bipolar Disorder (BD) but its effectiveness differs widely between individuals. The molecular mechanisms underlying treatment response heterogeneity are not well understood, and personalized treatment in BD remains elusive. Genetic analyses of the lithium treatment response phenotype may generate novel molecular insights into lithium's therapeutic mechanisms and lead to testable hypotheses to improve BD management and outcomes. We used fixed effect meta-analysis techniques to develop meta-analytic polygenic risk scores (MET-PRS) from combinations of highly correlated psychiatric traits, namely schizophrenia (SCZ), major depression (MD) and bipolar disorder (BD). We compared the effects of cross-disorder MET-PRS and single genetic trait PRS on lithium response. For the PRS analyses, we included clinical data on lithium treatment response and genetic information for n = 2283 BD cases from the International Consortium on Lithium Genetics (ConLi⁺Gen; www.ConLiGen.org ). Higher SCZ and MD PRSs were associated with poorer lithium treatment response whereas BD-PRS had no association with treatment outcome. The combined MET2-PRS comprising of SCZ and MD variants (MET2-PRS) and a model using SCZ and MD-PRS sequentially improved response prediction, compared to single-disorder PRS or to a combined score using all three traits (MET3-PRS). Patients in the highest decile for MET2-PRS loading had 2.5 times higher odds of being classified as poor responders than patients with the lowest decile MET2-PRS scores. An exploratory functional pathway analysis of top MET2-PRS variants was conducted. Findings may inform the development of future testing strategies for personalized lithium prescribing in BD.

Stress predicts depression symptoms for women living with bipolar disorder during the menopause transition

OBJECTIVE

Although sleep disturbance is an important feature in bipolar disorder, the relationship between mood symptoms, sleep disturbances, and hot flash symptom severity during menopause for women with bipolar disorder is largely unknown.

METHODS

Women with bipolar disorder (n = 100) who were categorized as perimenopausal using the STRAW and Monash criteria took part in an international online survey. The survey contained questions on history of reproductive health; the clinical course of bipolar disorder; menopausal symptoms (Menopause Rating Scale [MRS]); depression, anxiety, and stress (Depression Anxiety and Stress Scale-21) and the Altman Mania Rating Scale.

RESULTS

MRS sleep problems and hot flash severity were positively correlated with each other and with depression, anxiety, and stress symptoms. Mania scores were not significantly correlated with sleep or hot flash severity scores. A stepwise regression analysis on depression symptoms, using MRS sleep disturbance and MRS hot flash severity scores as predictors with anxiety and stress symptoms in the model, found that stress alone predicted 40% of the variance in total depression scores.

CONCLUSION

Stress plays an important role in the experience of depression for women living with bipolar disorder during the perimenopausal phase. More research is needed to determine if stress management programs may be helpful for women living with bipolar disorder during this time of life and if these in turn, may improve depressive symptoms.

The course of bipolar disorder in pregnant versus non-pregnant women

Background and rationale

Although it has been suggested that pregnancy may influence the course of bipolar disorder (BD), studies show contradictory results. Until now, no studies included a finegrained validated method to report mood symptoms on a daily basis, such as the lifechart method (LCM). The aim of the present study is to investigate the course of BD during pregnancy by comparing LCM scores of pregnant and non-pregnant women.

Methods

Study design: Comparison of LCM scores of two prospective observational BD cohort studies, a cohort of pregnant women (n = 34) and a cohort of non-pregnant women of childbearing age (n = 52). Main study parameters are: (1) proportions of symptomatic and non-symptomatic days; (2) symptom severity, frequency, and duration of episodes; (3) state sequences, longitudinal variation of symptom severity scores.

Results

No differences in clinical course variables (symptomatic days, average severity scores, frequency, and duration of episodes in BD were found between pregnant and non-pregnant women. With a combination of State Sequence Analysis (SSA) and cluster analysis on the sequences of daily mood scores three comparable clusters were found in both samples: euthymic, moderately ill and severely ill. The distribution differences between pregnant and non-pregnant women were significant, with a majority of the pregnant women (68%) belonging to the moderately ill cluster and a majority of the non-pregnant women (46%) to the euthymic cluster. In pregnant women the average daily variation in mood symptoms as assessed with Shannon’s entropy was less than in non-pregnant women (respectively 0.43 versus 0.56).

Conclusions

Although the use of daily mood scores revealed no difference in overall course of BD in pregnant versus non-pregnant women, more pregnant than non-pregnant women belonged to the moderately ill cluster, and during pregnancy the variation in mood state was less than in non-pregnant women. Further research is necessary to clarify these findings.

Safety and Efficacy of Combined Low-Dose Lithium and Low-Dose Aspirin: A Pharmacological and Behavioral Proof-of-Concept Study in Rats

Despite established efficacy in bipolar disorder patients, lithium (Li) therapy has serious side effects, particularly chronic kidney disease. We examined the safety and behavioral effects of combined chronic low-dose aspirin plus low-dose Li in rats to explore the toxicity and therapeutic potential of this treatment. Rats were fed regular or Li-containing food (0.1% [low-dose, LLD-Li] or 0.2% [standard-dose, STD-Li]) for six weeks. Low-dose aspirin (1 mg/kg) was administered alone or together with Li. Renal function and gastric mucosal integrity were assessed. The effects of the combination treatment were evaluated in depression-like and anxiety-like behavioral models. Co-treatment with aspirin did not alter plasma Li levels. Chronic STD-Li treatment resulted in significant polyuria and polydipsia, elevated blood levels of creatinine and cystatin C, and increased levels of kidney nephrin and podocin—all suggestive of impaired renal function. Aspirin co-treatment significantly damped STD-Li-induced impairments in kidney parameters. There were no gastric ulcers or blood loss in any treatment group. Combined aspirin and LLD-Li resulted in a significant increase in sucrose consumption, and in the time spent in the open arms of an elevated plus-maze compared with the LLD-Li only group, suggestive of antidepressant-like and anxiolytic-like effects, respectively. Thus, we demonstrate that low-dose aspirin mitigated the typical renal side effects of STD-Li dose and enhanced the beneficial behavioral effects of LLD-Li therapy without aggravating its toxicity.

Repurposed drugs as adjunctive treatments for mania and bipolar depression: A meta-review and critical appraisal of meta-analyses of randomized placebo-controlled trials

Several drugs previously tested in clinical trials and approved for different indications have been repurposed for bipolar disorder. We carried out a systematic meta-review of meta-analyses of randomized placebo-controlled trials investigating repurposed drugs as adjunctive treatments for mania and bipolar depression. We performed a critical appraisal using 'A MeaSurement Tool to Assess systematic Reviews' Version 2 (AMSTAR 2). We synthesized results on efficacy, tolerability, and safety, assessing evidence quality according to the 'Grading of Recommendations, Assessment, Development and Evaluations' (GRADE) approach. Our systematic search identified nine eligible studies investigating 12 drugs, four for mania and eight for bipolar depression. The quality of reporting was heterogeneous according to AMSTAR 2. In mania, allopurinol (for symptoms reduction and remission at 4-8 weeks) and tamoxifen (for response and symptoms reduction at 4-6 weeks) showed higher efficacy than placebo, with low and very low quality of evidence, respectively. Concerning bipolar depression, modafinil/armodafinil (for response, remission, and symptoms reduction at 6-8 weeks) and pramipexole (for response and symptoms reduction at 6 weeks) were superior to placebo, despite the low quality of evidence. Results on the efficacy of celecoxib and N-acetylcysteine were of low quality and limited to certain outcomes. Overall, the lack of evidence of high and moderate quality does not allow us to draw firm conclusions on the clinical utility of repurposed drugs as adjunctive treatments for mania and bipolar depression, highlighting the need for additional research.

The efficacy of vitamin B6 as an adjunctive therapy to lithium in improving the symptoms of acute mania in patients with bipolar disorder, type 1; a double-blind, randomized, placebo-controlled, clinical trial

OBJECTIVE

Vitamin B6 has been linked to a variety of probable roles, including anti-inflammatory, homocysteine-lowering, serotonin-regulating, and dopamine-lowering. In this study, we investigated the possible effect of vitamin B6 on bipolar disorder in manic episode with psychotic feature in a placebo-controlled double-blind clinical trial in a psychiatric hospital.

METHODS

This study was performed on 50 patients who were equally divided into two groups (each group included 25 patients) using 80 mg of vitamin B6 daily or placebo. At the beginning and end of the study, they were evaluated for lab tests, inflammatory biomarkers and level of blood homocysteine. Also, at the baseline and in weeks 2, 4, and 8, they were evaluated based on the anthropometric measurements, score obtained from the Young Mania Questionnaire, Mini-Mental State Examination (MMSE), and the Pittsburgh Sleep Questionnaire.

RESULTS

Accordingly, based on Yang Mania scoring scale, no significant difference was observed between the two groups receiving vitamin B6 and placebo (22.68 ± 5.39 vs. 21.80 ± 5.39 [p-value = .51]). Based on MMSE, significant improvement in cognitive status was obtained in group placebo compared to vitamin B6 group (25.24 ± 1.96 vs. 24.40 ± 3.25, respectively [p-value = .01]). At the Pittsburg scale (total, there was no statistically significant difference between the two groups receiving vitamin B6 and placebo (1.04 ± 0.20 vs. 0.48 ± 0.50 [p-value = .23]). Additionally, no significant difference was observed between the two groups regarding the anthropometric status.

CONCLUSIONS

According to this study, the daily dose of 80 mg of vitamin B6 for 8 weeks in patients with bipolar disorder in the manic episode with psychotic feature treated daily with lithium, was not associated with a significant improvement in mood status compared to the control-placebo group. It is recommended to perform similar studies in a multi-center manner with a larger sample size and longer duration.

An epidemiological study of externally determined and self-identified mental and physical disability across the spectrum of bipolar disorders

BACKGROUND

Studies exploring disability in bipolar disorder (BD) have primarily assessed clinical samples of full-threshold BD-I and BD-II alongside so-called objective criteria such as unemployment or receipt of government disability payments. This study extends research on disability by examining externally determined and self-identified disability in a community sample and by including subthreshold BD (BDS).

METHODS

Data were extracted from the USA Collaborative Psychiatric Epidemiology Surveys about individuals who met recognized criteria for BD-I, BD-II and BDS who had completed self-ratings of physical and mental disability, comorbidities, and health risk factors (e.g., obesity). Rates of disability were estimated, and logistic regression analyses were used to determine demographic and clinical variables associated with externally determined and self-identified of disability.

RESULTS

Of 408 individuals who met eligibility criteria (BD-I = 100; BD-II=104; BDS=204), 35% met criteria for externally determined disability, about 40% self-reported mental disability and about 23% self-reported physical disability. The odds were three-fold (Odds Ratio (OR): 3.05; 95% Confidence Intervals (CI): 1.69, 5.53) that someone with self-identified physical disability would meet criteria for externally determined disability, but associations with mental disability were non-significant (OR: 1.06; 95% CI: 0.63, 1.80). Regression analyses demonstrated that mental disability was associated with being a current or past smoker and physical disability was associated with BD-I.

LIMITATIONS

the adequacy of the assessments of disability and definition of BDS can be questioned.

CONCLUSIONS

Future clinical and community studies need to consider both externally determined and self-identified disability across the entire Bd spectrum.

Effect of Pharmacological and Neurostimulation Interventions for Cognitive Domains in Patients with Bipolar Disorder: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

The priority of interventions to alleviate cognitive deficits in patients with bipolar disorder (BD) is inconclusive. We systematically evaluate the efficacy of pharmacological or neurostimulation interventions for cognitive function in BD through a network meta-analysis.

METHODS

The PubMed, PsycINFO, Embase, and Cochrane Library databases were searched from database inception to September 30, 2021. Following PRISMA guidelines, all eligible studies were randomized controlled trials of adult bipolar patients that provided detailed cognitive outcomes. Studies were excluded if participants limited to comorbid substance use disorder or the intervention was a psychotherapy. Network meta-analysis comparing different interventions was conducted for 8 cognitive domains. Partially ordered set with Hasse diagram was used to resolve conflicting rankings between outcomes. The study was preregistered on PROSPERO database (CRD42020152044).

RESULTS

Total 21 RCTs including 42 tests for assessing intervention effects on cognition were retrieved. Adjunctive erythropoietin (SMD = 0.61, 95% CI = 0.00-1.23), Withania somnifera (SMD = 0.58, 95% CI = 0.03-1.13), and galantamine (SMD = 1.22, 95% CI = 0.10-2.35) was more beneficial for attention, working memory, and verbal learning in euthymic BD patients than treatment as usual, respectively. Hasse diagram suggested ranking of choice when multiple domains were combined.

CONCLUSION

Considerable variability in measurements of cognitive domains in BD was observed, and no intervention resulted in superior benefits across all domains. We suggested interventions priority can be tailored according to individual patients' cognitive deficits. As current findings from relatively small and heterogeneous dataset, future trials with consensus should be applied for building further evidence.

The costs of bipolar disorder in the United Kingdom

OBJECTIVES

To estimate the individual cost and population-level economic burden of Bipolar Disorder (BD), and explore the impact of clinical and sociodemographic factors on costs in the United Kingdom.

METHODS

Annual UK health care, social care and societal cost data were collected from a prospective cohort of 91 BD patients using digital monitoring of symptoms. Costs (in £) were calculated for the year of resource use collection (2010-2011) and main results inflated to year 2018-2019. A Generalized Estimating Equation framework was used to investigate individual factors influencing costs. An economic burden estimate was derived by multiplying the mean annual cost per patient with literature-based population prevalence.

RESULTS

The average annual cost of BD per patient was £12,617 (SE = ±£1085) or £14,938 (SE = ±£1281) at 2018-2019 prices with 68% of the total costs attributed to lost productivity and informal care, 31% to health care costs, 1% to private out-of-pocket expenses, and 0.5% to social care costs. A unit increase in average levels of depressive or manic symptoms were associated with 7% and 11% higher societal costs, respectively. The estimated annual prevalence of BD in the United Kingdom was 0.8% resulting in a population-level economic burden estimate of £5.1 billion for 2010-2011 or £6.43 billion for 2018-2019.

CONCLUSIONS

BD is a disease of substantial costs in the United Kingdom with the majority of the economic burden falling outside the health care system in the form of productivity losses and informal care. These costs highly correlate with patient outcomes highlighting further needs for improved treatment efforts into functionality.