Clinical features in co-occuring obsessive-compulsive disorder and bipolar disorder: A systematic review and meta-analysis

Obsessive-compulsive disorder (OCD) frequently co-occurs with various psychiatric conditions and may impact as many as one-fifth of individuals diagnosed with bipolar disorder (BD). Despite the expanding body of literature on the coexistence of OCD and BD, there is a notable lack of comprehensive data pertaining to the distinct features of obsessive-compulsive symptoms that define this comorbidity. To bridge this knowledge gap, we conducted a systematic search of PubMed/MEDLINE, Scopus, EMBASE, and PsycINFO until August 7th, 2023. We performed random-effects meta-analyses to compare individuals with both OCD and BD to those with OCD in terms of OCD symptomatology as well as the specific categories of obsessions and compulsions. Out of the 10,393 records initially screened, 17 studies were ultimately incorporated into the qualitative assessment, with 15 of them being included in the quantitative analysis. Individuals with OCD and BD experienced fewer lifetime contamination obsessions (OR=0.71; 95 %CI=0.53, 0.95; p = 0.021) and more sexual obsessions (OR=1.77; 95 %CI=1.03, 3.04; p = 0.04) compared to individuals with OCD without BD. No significant difference was observed for other types of obsessions or compulsions or for the severity of OCD symptoms, although BD type may play a role according to meta-regression analyses. The detection of the presence of sexual or contamination obsessions through a detailed interview may be the focus of clinical attention when assessing OCD in the context of comorbid BD. Sub-phenotyping complex clinical presentation of comorbid psychiatric disorders can aid in making more informed decisions when choosing an appropriate treatment approach.

Pharmacoepidemiology and Clinical Correlates of Lithium Treatment for Bipolar Disorder in Asia

BACKGROUND

As clinical practices with lithium salts for patients diagnosed with bipolar disorder (BD) are poorly documented in Asia, we studied the prevalence and clinical correlates of lithium use there to support international comparisons.

METHODS

We conducted a cross-sectional study of use and dosing of lithium salts for BD patients across 13 Asian sites and evaluated bivariate relationships of lithium treatment with clinical correlates followed by multivariate logistic regression modeling.

RESULTS

In a total of 2139 BD participants (52.3% women) of mean age 42.4 years, lithium salts were prescribed in 27.3% of cases overall, varying among regions from 3.20% to 59.5%. Associated with lithium treatment were male sex, presence of euthymia or mild depression, and a history of seasonal mood change. Other mood stabilizers usually were given with lithium, often at relatively high doses. Lithium use was associated with newly emerging and dose-dependent risk of tremors as well as risk of hypothyroidism. We found no significant differences in rates of clinical remission or of suicidal behavior if treatment included lithium or not.

CONCLUSIONS

Study findings clarify current prevalence, dosing, and clinical correlates of lithium treatment for BD in Asia. This information should support clinical decision-making regarding treatment of BD patients and international comparisons of therapeutic practices.

Evaluating the efficacy and safety of the currently available once-every-two months long-acting injectable formulations of aripiprazole for the treatment of schizophrenia or as a maintenance monotherapy for bipolar I disorder in adults

INTRODUCTION

An aripiprazole long-acting injectable (LAI) antipsychotic is now available for gluteal administration every 2 months via two different formulations: aripiprazole lauroxil (AL) and aripiprazole monohydrate (Ari 2MRTU). These longer dosing regimens of aripiprazole LAI offer new potential benefits for patients.

AREAS COVERED

The authors review the evidence supporting the efficacy and safety of aripiprazole LAIs given every 2 months for the treatment of schizophrenia or bipolar disorder (BD) in adults. The article culminates with the authors' expert perspectives on the subject.

EXPERT OPINION

AL 1064 mg every 2 months has established efficacy for the treatment of schizophrenia based on pharmacokinetic bridging studies and prospective data for treatment of an acute exacerbation of schizophrenia. In an open-label trial, Ari 2MRTU showed efficacy for the treatment of schizophrenia and BD type I based on pharmacokinetic parameters (comparable to aripiprazole once-monthly 400 mg); it also showed efficacy regarding the secondary endpoints. Multiple doses of AL 1064 mg or Ari 2MRTU 960 mg are generally well tolerated, in line with the safety profile of oral aripiprazole, with the exception of the injection-site reactions. While AL may require a 1-day initiation regimen, Ari 2MRTU 960 covers all the recommended doses of oral aripiprazole (10-20 mg).

Acute effects of military aircraft noise on sedative and analgesic drug administrations in psychiatric patients: A case-time series analysis

BACKGROUND

Existing evidence suggests that psychiatric patients are highly noise sensitive, and that noise exposure increases the risk for adverse mental health outcomes, such as psychiatric hospitalizations and even suicide. To investigate acute effects of noise in this vulnerable population, we assessed short-term associations between fighter jet noise and on-demand sedative and analgesic drug administrations in a psychiatric clinic located close to a military airfield in Switzerland.

METHODS

We applied a case time series analysis with an hourly time resolution using distributed-lag models. Analysis was adjusted for long-term and seasonal trends, day of week, time of day, time-varying weather conditions and the week of stay. Noise exposure (hourly A-weighted equivalent continuous sound pressure levels (LAeq)) was modelled using detailed flight plans and noise footprints for different fighter jet and route combinations. Outcome data were available from the clinic's records.

OUTCOMES

During the study period (06/2016-12/2021), 23,486 flights occurred. 5,968 clinical stays with a median length of 41 days (IQR: 28d, 50d) were recorded. The odds ratio (OR) for medication administration over the lag period of 3 hours after exposure was 1.016 (95 %CI: 1.006, 1.026) per 10 dB LAeq for sedatives and 1.032 (95 %CI: 1.016, 1.048) per 10 dB for analgesics. Effects were larger in multimorbid patients.

INTERPRETATION

Case time series analysis is a novel method to investigate transient associations in observational data while minimizing risk of bias. Using an objectively recorded outcome measure, our results demonstrate that psychiatric patients are a vulnerable population, in which noise exposure can lead to symptom exacerbations and adverse events.

Effects of Adjunctive Brexpiprazole on Individual Depressive Symptoms and Functioning in Patients With Major Depressive Disorder and Anxious Distress: Post Hoc Analysis of Three Placebo-Controlled Studies

PURPOSE/BACKGROUND

Anxiety symptoms in major depressive disorder (MDD) are frequent, and they decrease response to antidepressant treatment (ADT), and affect patient functioning. This post hoc analysis examined the efficacy of adjunctive brexpiprazole on individual depressive symptoms and functioning in patients with MDD with anxious distress.

METHODS/PROCEDURES

Data were included from three 6-week, randomized, double-blind, placebo-controlled studies of adjunctive brexpiprazole in patients with MDD and inadequate response to ADTs (ClinicalTrials.gov identifiers: NCT01360645, NCT01360632, NCT02196506). Patients were stratified using proxy criteria for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, anxious distress. Changes in Montgomery-Åsberg Depression Rating Scale item scores and Sheehan Disability Scale mean score from baseline to week 6 were determined for ADT + brexpiprazole (2 and 2-3 mg) versus ADT + placebo.

FINDINGS/RESULTS

At baseline, 450 of 746 patients (60.3%, 2 mg analysis) and 670 of 1162 patients (57.7%, 2-3 mg analysis) had anxious distress. In patients with anxious distress, ADT + brexpiprazole 2 mg or 2 to 3 mg showed greater improvements than ADT + placebo (P < 0.05) on the Montgomery-Åsberg Depression Rating Scale items of apparent sadness, reported sadness, inner tension, reduced sleep, reduced appetite, lassitude, inability to feel, and pessimistic thoughts (Cohen d effect sizes, 0.18-0.44), and on Sheehan Disability Scale mean score (effect sizes, 0.21-0.23).

IMPLICATIONS/CONCLUSIONS

Adjunctive brexpiprazole is efficacious in reducing core depressive symptoms, sleep, and appetite, as well as improving functioning, in patients with MDD and anxious distress who have inadequate response to ADTs.

Bipolarity in Older individuals Living without Drugs (BOLD): Protocol and preliminary findings

INTRODUCTION

Although clinical guidelines regard prophylactic medication as the cornerstone of treatment, it is estimated almost half of patients with bipolar disorder (BD) live without medication. This group is underrepresented in research but can provide indispensable knowledge on natural course, resilience and self-management strategies. We aim to describe the clinical phenotype of patients diagnosed with BD who have discontinued maintenance treatment.

METHODS

The mixed-methods BOLD study included 58 individuals aged 50 years and over with BD that did not use maintenance medication in the past 5 years. A preliminary, quantitative comparison of clinical characteristics between BOLD and our pre-existing cohort of >220 older BD outpatients with medication (Dutch Older Bipolars, DOBi) was performed.

RESULTS

BD-I, psychiatric comorbidities, number of mood episodes and lifetime psychotic features were more prevalent in BOLD compared to DOBi. BOLD participants had a younger age at onset and reported more childhood trauma. BOLD participants reported fewer current mood symptoms and higher cognitive, social, and global functioning.

LIMITATIONS

Our findings may not be generalizable to all individuals diagnosed with BD living without maintenance medication due to selection-bias.

CONCLUSION

A group of individuals exists that meets diagnostic criteria of BD and is living without maintenance medication. They appear to be relatively successful in terms of psychosocial functioning, although they do not have a milder clinical course than those on maintenance medication. The high prevalence of childhood trauma warrants further investigation. Future analyses will examine differences between BOLD and DOBi per domain (e.g. cognition, physical health, psychosocial functioning, coping).

Sex Differences Among Older Adults With Bipolar Disorder: Results From the Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) Project

OBJECTIVE

Sex-specific research in adult bipolar disorder (BD) is sparse and even more so among those with older age bipolar disorder (OABD). Knowledge about sex differences across the bipolar lifespan is urgently needed to target and improve treatment. To address this gap, the current study examined sex differences in the domains of clinical presentation, general functioning, and mood symptoms among individuals with OABD.

METHODS

This Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) study used data from 19 international studies including BD patients aged ≥50 years (N = 1,185: 645 women, 540 men).A comparison of mood symptoms between women and men was conducted initially using two-tailed t tests and then accounting for systematic differences between the contributing cohorts by performing generalized linear mixed models (GLMMs). Associations between sex and other clinical characteristics were examined using GLMM including: age, BD subtype, rapid cycling, psychiatric hospitalization, lifetime psychiatric comorbidity, and physical health comorbidity, with study cohort as a random intercept.

RESULTS

Regarding depressive mood symptoms, women had higher scores on anxiety and hypochondriasis items. Female sex was associated with more psychiatric hospitalizations and male sex with lifetime substance abuse disorders.

CONCLUSION

Our findings show important clinical sex differences and provide support that older age women experience a more severe course of BD, with higher rates of psychiatric hospitalization. The reasons for this may be biological, psychological, or social. These differences as well as underlying mechanisms should be a focus for healthcare professionals and need to be studied further.

Association between psychosis and substance use in Kenya. Findings from the NeuroGAP-Psychosis study

Background

Substance use is prevalent among people with mental health issues, and patients with psychosis are more likely to use and misuse substances than the general population. Despite extensive research on substance abuse among the general public in Kenya, there is a scarcity of data comparing substance use among people with and without psychosis. This study investigates the association between psychosis and various substances in Kenya.

Methods

This study utilized data from the Neuro-GAP Psychosis Case-Control Study between April 2018 and December 2022. The KEMRI-Wellcome Trust Research Programme recruited participants from various sites in Kenya, including Kilifi County, Malindi Sub-County, Port Reitz and Coast General Provincial Hospitals, and Moi Teaching and Referral Hospital, as well as affiliated sites in Webuye, Kapenguria, Kitale, Kapsabet, and Iten Kakamega. The collected data included sociodemographic information, substance use, and clinical diagnosis. We used the summary measures of frequency (percentages) and median (interquartile range) to describe the categorical and continuous data, respectively. We examined the association between categorical variables related to psychosis using the chi-square test. Logistic regression models were used to assess the factors associated with the odds of substance use, considering all relevant sociodemographic variables.

Results

We assessed a total of 4,415 cases and 3,940 controls. Except for alcohol consumption (p-value=0.41), all forms of substance use showed statistically significant differences between the case and control groups. Cases had 16% higher odds of using any substance than controls (aOR: 1.16, 95%CI: 1.05-1.28, p=0.005). Moreover, males were 3.95 times more likely to use any substance than females (aOR:3.95; 95%CI: 3.43-4.56). All the categories of living arrangements were protective against substance use.

Conclusion

The findings of this study suggest that psychotic illnesses are associated with an increased likelihood of using various substances. These findings are consistent with those of previous studies; however, it is crucial to investigate further the potential for reverse causality between psychosis and substance abuse using genetically informed methods.

French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN) guidelines for the management of patients with partially responsive depression and treatment-resistant depression: Update 2024

INTRODUCTION

The purpose of this update is to add newly approved nomenclatures and treatments as well as treatments yet to be approved in major depressive disorder, thus expanding the discussions on the integration of resistance factors into the clinical approach.

METHODS

Unlike the first consensus guidelines based on the RAND/UCLA Appropriateness Method, the French Association for Biological Psychiatry and Neuropsychopharmacology (AFPBN) developed an update of these guidelines for the management of partially responsive depression (PRD) and treatment-resistant depression (TRD). The expert guidelines combine scientific evidence and expert clinicians' opinions to produce recommendations for PRD and TRD.

RESULTS

The recommendations addressed three areas judged as essential for updating the previous 2019 AFPBN guidelines for the management of patients with TRD: (1) the identification of risk factors associated with TRD, (2) the therapeutic management of patients with PRD and TRD, and (3) the indications, the modalities of use and the monitoring of recent glutamate receptor modulating agents (esketamine and ketamine).

CONCLUSION

These consensus-based guidelines make it possible to build bridges between the available empirical literature and clinical practice, with a highlight on the 'real world' of the clinical practice, supported by a pragmatic approach centred on the experience of specialised prescribers in TRD.

Treatment-Resistant Depression in Older Adults

A 67-year-old woman with a history of obesity, chronic low back pain, and recurrent episodes of major depression presents with mild depressive symptoms of more than 2 years’ duration, with worsening symptoms over the past 4 months. She was receiving sertraline at a stable dose of 100 mg per day until 3 months ago, when she initially presented for her worsening depressive symptoms. At that time, sertraline was tapered off, and treatment with extra-long extended-release bupropion (bupropion XL) was started at a dose of 150 mg daily and was increased to 300 mg daily 3 weeks later. Despite having taken the higher dose of bupropion XL for more than 2 months, the patient continues to have low mood, loss of interest in usual pleasurable activities, trouble falling asleep, wakefulness several times during the night, diminished energy, poor appetite, difficulty concentrating, and intrusive thoughts of being “better off dead,” but she does not have active suicidal thinking. Her nine-question Patient Health Questionnaire (PHQ-9) score is 17 (on a scale of 0 to 27, with higher scores indicating greater severity of depressive symptoms). How would you evaluate and treat this patient?

Pharmacogenomic overlap between antidepressant treatment response in major depression & antidepressant associated treatment emergent mania in bipolar disorder

There is increasing interest in individualizing treatment selection for more than 25 regulatory approved treatments for major depressive disorder (MDD). Despite an inconclusive efficacy evidence base, antidepressants (ADs) are prescribed for the depressive phase of bipolar disorder (BD) with oftentimes, an inadequate treatment response and or clinical concern for mood destabilization. This study explored the relationship between antidepressant response in MDD and antidepressant-associated treatment emergent mania (TEM) in BD. We conducted a genome-wide association study (GWAS) and polygenic score analysis of TEM and tested its association in a subset of BD-type I patients treated with SSRIs or SNRIs. Our results did not identify any genome-wide significant variants although, we found that a higher polygenic score (PGS) for antidepressant response in MDD was associated with higher odds of TEM in BD. Future studies with larger transdiagnostic depressed cohorts treated with antidepressants are encouraged to identify a neurobiological mechanism associated with a spectrum of depression improvement from response to emergent mania.

Oxidation of DNA and RNA in young patients with newly diagnosed bipolar disorder and relatives

Excessive oxidative stress-generated nucleoside damage seems to play a key role in bipolar disorder (BD) and may present a trait phenomenon associated with familial risk and is one of the putative mechanisms explaining accelerated atherosclerosis and premature cardiovascular diseases (CVD) in younger patients with BD. However, oxidative stress-generated nucleoside damage has not been studied in young BD patients and their unaffected relatives (UR). Therefore, we compared oxidative stress-generated damage to DNA and RNA in young patients newly diagnosed with BD, UR, and healthy control individuals (HC). Systemic oxidative stress-generated DNA and RNA damage levels were compared by analyzing urinary levels of 8-oxo-7,8-dihydro-2'-deoxyguanosine and 8-oxo-7,8-dihydroguanosine in participants aged 15-25 years, including 133 patients newly diagnosed with BD, 57 UR, and 83 HC. Compared with HC, damage to DNA was 21.8% higher in BD patients (B = 1.218, 95% CI = 1.111-1.335, p = <0.001) and 22.5% higher in UR (B = 1.225, 95% CI = 1.090-1.377, p = <0.002), while damage to RNA was 14.8% higher in BD patients (B = 1.148, 95% CI = 1.082-1.219, p = <0.001) and 14.0% higher in UR (B = 1.140, 95% CI = 1.055-1.230, p = < 0.001) in models adjusted for sex and age after correction for multiple comparison. Levels did not differ between patients with BD and UR. Our findings support higher oxidative stress-generated nucleoside damage being a trait phenomenon in BD associated with familial risk and highlight the importance of early diagnosis and treatment to prevent illness progression and development of premature CVD.

Off-label psychopharmacological interventions for autism spectrum disorders: strategic pathways for clinicians

The prevalence of autism spectrum disorder (ASD) continues to see a trend upward with a noticeable increase to 1 in 36 children less than 8 years of age in the recent MMWR. There are many factors linked to the substantially increased burden of seeking mental health services, and clinically these individuals are likely to present for impairments associated with co-occurring conditions. The advances in cutting-edge research and the understanding of co-occurring conditions in addition to psychosocial interventions have provided a window of opportunity for psychopharmacological interventions given the limited availability of therapeutics for core symptomatology. The off-label psychopharmacological treatments for these co-occurring conditions are central to clinical practice. However, the scattered evidence remains an impediment for practitioners to systematically utilize these options. The review collates the crucial scientific literature to provide stepwise treatment alternatives for individuals with ASD; with an aim to lead practitioners in making informed and shared decisions. There are many questions about the safety and tolerability of off-label medications; however, it is considered the best practice to utilize the available empirical data in providing psychoeducation for patients, families, and caregivers. The review also covers experimental medications and theoretical underpinnings to enhance further experimental studies. In summary, amidst the growing clinical needs for individuals with ASD and the lack of approved clinical treatments, the review addresses these gaps with a practical guide to appraise the risk and benefits of off-label medications.

A naturalistic effectiveness study of maintenance therapies for the bipolar disorders

BACKGROUND

Treatment decision-making for individuals with bipolar disorder can be difficult. Recommendations from clinical practice guidelines can be affected by multiple methodological limitations, while pharmaco-epidemiological data suggest great variety in prescription practices across regions. Given these inconsistencies, this study aimed to provide an alternative perspective on the effectiveness of common bipolar disorder maintenance treatments through considering naturalistic data.

METHODS

A total of 246 individuals with bipolar disorder (84 bipolar I [BP-I], 162 bipolar II [BP-II]) were recruited through clinics and/or websites. All were euthymic and had trialled at least one mood stabiliser. They completed an online survey containing questions on demographics, clinical variables, symptomatology, and the effectiveness/side effect profiles of any mood stabilisers (MSTs) or atypical antipsychotics (AAPs) that they have taken.

RESULTS

Lithium and lamotrigine were the most commonly prescribed MSTs and the most effective at mood stabilisation. Lithium and lamotrigine appeared marginally more effective for BP-I and BP-II respectively, however, only the latter difference was statistically significant. Furthermore, lamotrigine had the more favourable side effect profile. Amongst the AAPs, quetiapine and olanzapine were the most commonly prescribed, but they were negligibly superior to other AAPs.

CONCLUSION

This study clearly established a preference for lamotrigine in the maintenance treatment of BP-II. While the literature consistently emphasises the primacy of lithium in bipolar disorder treatment, its side effect profile as observed in this study remains a concern. Future research considering moderators of treatment response and concomitant medications could help to identify further nuances to consider for treatment decision-making.

Patterns of pharmacotherapy for bipolar disorder: A GBC survey

OBJECTIVES

To understand treatment practices for bipolar disorders (BD), this study leveraged the Global Bipolar Cohort collaborative network to investigate pharmacotherapeutic treatment patterns in multiple cohorts of well-characterized individuals with BD in North America, Europe, and Australia.

METHODS

Data on pharmacotherapy, demographics, diagnostic subtypes, and comorbidities were provided from each participating cohort. Individual site and regional pooled proportional meta-analyses with generalized linear mixed methods were conducted to identify prescription patterns.

RESULTS

This study included 10,351 individuals from North America (n = 3985), Europe (n = 3822), and Australia (n = 2544). Overall, participants were predominantly female (60%) with BD-I (60%; vs. BD-II = 33%). Cross-sectionally, mood-stabilizing anticonvulsants (44%), second-generation antipsychotics (42%), and antidepressants (38%) were the most prescribed medications. Lithium was prescribed in 29% of patients, primarily in the Australian (31%) and European (36%) cohorts. First-generation antipsychotics were prescribed in 24% of the European versus 1% in the North American cohort. Antidepressant prescription rates were higher in BD-II (47%) compared to BD-I (35%). Major limitations were significant differences among cohorts based on inclusion/exclusion criteria, data source, and time/year of enrollment into cohort.

CONCLUSIONS

Mood-stabilizing anticonvulsants, second-generation antipsychotics, and antidepressants were the most prescribed medications suggesting prescription patterns that are not necessarily guideline concordant. Significant differences exist in the prescription practices across different geographic regions, especially the underutilization of lithium in the North American cohorts and the higher utilization of first-generation antipsychotics in the European cohorts. There is a need to conduct future longitudinal studies to further explore these differences and their impact on outcomes, and to inform and implement evidence-based guidelines to help improve treatment practices in BD.

Treatment delays for mental disorders in Singapore: results from the Singapore Mental Health Study 2016

PURPOSE

Although the trajectory of mental disorders can be improved with timely treatment, many people defer treatment-seeking. This study aimed to examine the prevalence and correlates of treatment delays for mental disorders in Singapore, as well as perceived effectiveness of treatment received.

METHODS

A total of 6126 respondents, aged 18 and above, participated in the Singapore Mental Health Study 2016-a cross-sectional, nationwide study conducted in Singapore from 2016 to 2018. Lifetime treatment contact for mood, anxiety, and alcohol use disorders (AUD) was assessed using the World Mental Health-Composite International Diagnostic Interview (Version 3.0). Multivariable logistic regression was conducted to examine correlates of delayed treatment.

RESULTS

A total of 137 participants had made lifetime treatment contact for a mental disorder. The proportion of respondents who received delayed treatment (i.e., at least one year after onset of disorder) was 60.8% for any disorder, 59.5% for mood disorders, 56.3% for anxiety disorders, and 92.7% for AUD. The median delay was 5 years for mood disorders, one year for anxiety disorders, and 4 years for AUD. Treatment delay was significantly associated with older age, higher educational qualification, lifetime AUD, and earlier age of onset of disorder. 58.4% of respondents with lifetime treatment contact had received treatment that they considered effective.

CONCLUSION

The high prevalence and long durations of treatment delay underscore the need to encourage help-seeking for mental disorders, especially since treatment is generally perceived to be helpful. Our findings also highlight several population groups more susceptible to receiving delayed treatment.

Severe Sinus Dysfunction in the Context of Chronic Lithium Intoxication and Poorly Controlled Hypothyroidism

Cardiotoxicity associated with lithium is not a common event; however, it is potentially life-threatening, manifesting electrocardiographically with sinoatrial blocks, high-degree atrioventricular blocks, QT prolongation, and ventricular tachyarrhythmias. This case report presents a patient with severe sinus dysfunction in a clinically severe presentation secondary to cardiogenic shock. The patient sought medical attention for a one-week history of non-anginal chest pain, dizziness without syncope, generalized weakness, and somnolence progressing to bedridden status in the days preceding hospital admission. Laboratory findings revealed elevated blood levels of lithium and thyroid-stimulating hormone (TSH), along with concomitant Acute Kidney Injury Network (AKIN) II acute kidney injury. Subsequently, the patient was admitted to the intensive care unit, where persistent extreme sinus bradycardia of 30 bpm (beats per minute) with sinus pauses without ischemic changes was observed. The patient received supportive treatment, including renal replacement therapy, resulting in complete recovery of hemodynamic status without the need for long-term cardiac conduction devices.

Efficacy and effectiveness of antipsychotics in schizophrenia: network meta-analyses combining evidence from randomised controlled trials and real-world data

BACKGROUND

There is debate about the generalisability of results from randomised clinical trials (RCTs) to real-world settings. Studying outcomes of treatments for schizophrenia can shed light on this issue and inform treatment guidelines. We therefore compared the efficacy and effectiveness of antipsychotics for relapse prevention in schizophrenia and estimated overall treatment effects using all available RCT and real-world evidence.

METHODS

We conducted network meta-analyses using individual participant data from Swedish and Finnish national registries and aggregate data from RCTs. The target population was adults (age >18 and <65 years) with schizophrenia and schizoaffective disorder with stabilised symptoms. We analysed each registry separately to obtain hazard ratios (HRs) and 95% CIs for relapse within 6 months post-antipsychotic initiation as our main outcome. Interventions studied were antipsychotics, no antipsychotic use, and placebo. We compared HRs versus a reference drug (oral haloperidol) between registries, and between registry individuals who would be eligible and ineligible for RCTs, using the ratio of HRs. We synthesised evidence using network meta-analysis and compared results from our network meta-analysis of real-world data with our network meta-analysis of RCT data, including oral versus long-acting injectable (LAI) formulations. Finally, we conducted a joint real-world and RCT network meta-analysis.

FINDINGS

We included 90 469 individuals from the Swedish and Finnish registries (mean age 45·9 [SD 14·6] years; 43 025 [47·5%] women and 47 467 [52·5%] men, ethnicity data unavailable) and 10 091 individuals from 30 RCTs (mean age 39·6 years [SD 11·7]; 3724 [36·9%] women and 6367 [63·1%] men, 6022 White [59·7%]). We found good agreement in effectiveness of antipsychotics between Swedish and Finnish registries (HR ratio 0·97, 95% CI 0·88-1·08). Drug effectiveness versus no antipsychotic was larger in RCT-eligible than RCT-ineligible individuals (HR ratio 1·40 [1·24-1·59]). Efficacy versus placebo in RCTs was larger than effectiveness versus no antipsychotic in real-world (HR ratio 2·58 [2·02-3·30]). We found no evidence of differences between effectiveness and efficacy for between-drug comparisons (HR ratio vs oral haloperidol 1·17 [0·83-1·65], where HR ratio >1 means superior effectiveness in real-world to RCTs), except for LAI versus oral comparisons (HR ratio 0·73 [0·53-0·99], indicating superior effectiveness in real-world data relative to RCTs). The real-world network meta-analysis showed clozapine was most effective, followed by olanzapine LAI. The RCT network meta-analysis exhibited heterogeneity and inconsistency. The joint real-world and RCT network meta-analysis identified olanzapine as the most efficacious antipsychotic amongst those present in both RCTs and the real world registries.

INTERPRETATION

LAI antipsychotics perform slightly better in the real world than according to RCTs. Otherwise, RCT evidence was in line with real-world evidence for most between-drug comparisons, but RCTs might overestimate effectiveness of antipsychotics observed in routine care settings. Our results further the understanding of the generalisability of RCT findings to clinical practice and can inform preferential prescribing guidelines.

FUNDING

None.

A prospective study of suicidal behavior in young patients of depressive episodes with hidden bipolarity exposed to selective serotonin reuptake inhibitor

Background

Treatment of depressive episodes in young patients is challenging owing to several reasons such as poor diagnostic stability and atypical presentation. Evidence regarding treating such patients with antidepressants such as selective serotonin reuptake inhibitor (SSRI) is not clear.

Methods

Fifty patients aged 10-24 years diagnosed with depressive episodes and drug-free for at least 3 months were rated on Beck's Depression Inventory (BDI), The Mood Disorder Questionnaire (MDQ), and Beck Scale for Suicidal Ideation (BSS). The scores of BSS and BDI were compared across four timeframes (weeks 0, 2, 4, and 6) for MDQ-positive and negative patients by using the generalized estimating equations model.

Results

Patients who were MDQ-positive (11 patients) tended to score higher on BDI (at weeks 2 and 4) and BSS (at weeks 2, 4, and 6) as compared to MDQ-negative patients (39 patients). After being started on SSRI, MDQ-positive patients showed a poorer response as compared to the other group. The small sample size and short follow-up duration were the major limitations.

Conclusions

Close clinical monitoring with regular follow-up during antidepressant initiation is recommended to reduce the risk of suicidality.

Bipolar Disorders in the Emergency Department

Affective disorders affect the way that people think and feel and are classified into unipolar disorders and bipolar disorders. Bipolar disorders represent a spectrum of these chronic mental health illnesses. Patients with bipolar disorder have high recurrence of acute symptoms, and on average spend 20% of their life in exacerbations characterized by mania, depression, or psychosis. Given the increased morbidity and mortality associated with bipolar disorders, it is imperative that the emergency physician remain vigilant when these patients seek emergency care.

Prescription patterns in unipolar depression: A nationwide Danish register-based study of 113,175 individuals followed for 10 years

BACKGROUND

Evidence-based use of antidepressant medications is of major clinical importance. We aimed to uncover precription patterns in a large cohort of patients with unipolar depression.

MATERIAL AND METHODS

Using Danish nationwide registers, we identified individuals with a first-time hospital diagnosis of unipolar depression between January 1st, 2001, and December 31st, 2016. Redemeed prescriptions of antidepressants from five years before to five years after diagnosis were retreived. Lithium and relevant antipsychotics were included. Data were analyzed with descriptive statistics including sunburst plots. Cox regressions were used to rank the risk of treatment failure according to antidepressant category and depression severity, as measured by hazard ratios of drug shift.

RESULTS

The full study population consisted of 113,175 individuals. Selective Serotonin Reuptake Inhibitors was the predominantly prescribed first-line group, both before (55.4%) and after (47.7%) diagnosis and across depression severities. Changes of treatment strategy were frequent; 60.8%, 33.7%, and 17.1% reached a second, third, and fourth treatment trial after the hospital diagnosis, respectively. More than half of patients continued their pre-diagnosis antidepressant after diagnosis. The risk of change of treatment strategy was generally lower in mild-moderate depression and higher in severe depression, with tricyclic antidepressants carrying the highest risk in the former and the lowest risks in the latter. Overall, prescribing were often not in accordance with guidelines.

CONCLUSION

These findings uncover a potential for improving the clinical care for patients with unipolar depression through optimization of the use of marketed antidepressants.

Long-acting second-generation injectable antipsychotics for the maintenance treatment of bipolar disorder: a narrative review

INTRODUCTION

Non-adherence to medication significantly affects bipolar disorder outcomes. Long-Acting Injectable antipsychotics show promise by ensuring adherence and averting relapses.

AREAS COVERED

This narrative review sought to evaluate the efficacy of second-generation injectable antipsychotics in bipolar disorder through searches in Embase, MEDLINE, and PsycInfo for randomized controlled trials and mirror-image studies.Risperidone and aripiprazole Long-Acting Injectables demonstrated effectiveness in preventing mood recurrences compared to placebos in adults with bipolar disorder. They showed superiority in preventing mania/hypomania relapses over placebos but did not appear to significantly outperform active oral controls. Notably, active controls seem to be more effective in preventing depression relapses than Long-Acting Injectables. Mirror-Image studies point toward the reduction of hospitalization rates following LAI initiation.

EXPERT OPINION

The available evidence points thus toward the efficacy of LAIs, especially in managing manic episodes and reducing hospitalizations, The current evidence does not however immediately support prioritizing LAIs over oral medications in bipolar disorder treatment. More high-quality studies, especially comparing LAIs directly with active controls, are crucial to gain a comprehensive understanding of their efficacy. These findings highlight the need for further research to guide clinicians in optimizing treatment strategies for bipolar disorder.

Challenges in defining treatment-resistant mania in adults: A systematic review

OBJECTIVES

To review the definitions of treatment-resistant mania (TRM) in the literature and propose criteria for an operationalized definition.

METHODS

A systematic search of five databases (MEDLINE, EMBASE, PsychInfo, Cochrane Central, and CINAHL) and data extraction of eligible articles.

RESULTS

In total, 47 articles addressing the concept of TRM were included, comprising 16 case reports, 11 case series, 3 randomized clinical trials, 8 open-label clinical trials, 1 experimental study, 7 narrative reviews, and 1 systematic review. While reviews discussed several challenges in defining TRM, definitions varied substantially based on different criteria for severity of mania, duration of mania, and use of specific therapeutic agents with minimal dosages and duration of treatment. Only a handful of the reviewed articles operationalized these criteria.

CONCLUSION

While the concept of TRM has been discussed in the literature for over three decades, we could not find an agreed-upon operationalized definition based on specific criteria. We propose and discuss a possible definition that could be used by clinicians to guide their practice and by researchers to assess the prevalence of TRM and develop and test interventions targeting TRM.

Differentiation between depression and bipolar disorder in child and adolescents by voice features

OBJECTIVE

Major depressive disorder (MDD) and bipolar disorder (BD) are serious chronic disabling mental and emotional disorders, with symptoms that often manifest atypically in children and adolescents, making diagnosis difficult without objective physiological indicators. Therefore, we aimed to objectively identify MDD and BD in children and adolescents by exploring their voiceprint features.

METHODS

This study included a total of 150 participants, with 50 MDD patients, 50 BD patients, and 50 healthy controls aged between 6 and 16 years. After collecting voiceprint data, chi-square test was used to screen and extract voiceprint features specific to emotional disorders in children and adolescents. Then, selected characteristic voiceprint features were used to establish training and testing datasets with the ratio of 7:3. The performances of various machine learning and deep learning algorithms were compared using the training dataset, and the optimal algorithm was selected to classify the testing dataset and calculate the sensitivity, specificity, accuracy, and ROC curve.

RESULTS

The three groups showed differences in clustering centers for various voice features such as root mean square energy, power spectral slope, low-frequency percentile energy level, high-frequency spectral slope, spectral harmonic gain, and audio signal energy level. The model of linear SVM showed the best performance in the training dataset, achieving a total accuracy of 95.6% in classifying the three groups in the testing dataset, with sensitivity of 93.3% for MDD, 100% for BD, specificity of 93.3%, AUC of 1 for BD, and AUC of 0.967 for MDD.

CONCLUSION

By exploring the characteristics of voice features in children and adolescents, machine learning can effectively differentiate between MDD and BD in a population, and voice features hold promise as an objective physiological indicator for the auxiliary diagnosis of mood disorder in clinical practice.

International Trends in Lithium Use for Pharmacotherapy and Clinical Correlates in Bipolar Disorder: A Scoping Review

Lithium remains an effective option in the treatment of bipolar disorder (BD). Thus, we aim to characterize the pharmaco-epidemiological patterns of lithium use internationally over time and elucidate clinical correlates associated with BD using a scoping review, which was conducted using the methodological framework by Arksey and O'Malley (2005). We searched several databases for studies that examined the prescriptions for lithium and clinical associations in BD from inception until December 2023. This review included 55 articles from 1967 to 2023, which collected data from North America (n = 24, 43.6%), Europe (n = 20, 36.4%), and Asia (n = 11, 20.0%). The overall prescription rates ranged from 3.3% to 84% (33.4% before and 30.6% after the median year cutoffs). Over time, there was a decline in lithium use in North America (27.7% before 2010 to 17.1% after 2010) and Europe (36.7% before 2003 to 35.7% after 2003), and a mild increase in Asia (25.0% before 2003 to 26.2% after 2003). Lithium use was associated with specific demographic (e.g., age, male gender) and clinical factors (e.g., lower suicide risk). Overall, we found a trend of declining lithium use internationally, particularly in the West. Specific clinical correlates can support clinical decision-making for continued lithium use.

The causal relationship of female infertility and psychiatric disorders in the European population: a bidirectional two-sample Mendelian randomization study

BACKGROUND

Infertility affects many couples globally, causing physical, emotional, and financial burdens. While observational studies suggest a link between psychiatric disorders and female infertility, causal relationships remain uncertain. Mendelian randomization analysis, using genome-wide association studies data, minimizes confounding factors and reverse causation, providing valuable insights into causal associations.

METHODS

We conducted Mendelian randomization analysis to explore the potential causal relationship between female infertility and psychiatric disorders. Genome-wide association studies summary data for female infertility (112,105 individuals of European ancestry, comprising 11,442 cases and 100,663 controls), depression (807,553 individuals of European ancestry, comprising 246,363 cases and 561,190 controls), anxiety (21,763 individuals of European ancestry, comprising 7,016 cases and 14,745 controls), bipolar disorder (51,710 individuals of European ancestry, comprising 20,352 cases and 31,358 controls), and eating disorders (72,517 individuals of European ancestry, comprising 16,992 cases and 55,525 controls) were utilized. Instrumental variables were selected based on significant single nucleotide polymorphisms associated with each phenotype. We assessed instrumental variable strength, examined confounding factors, and employed inverse variance weighting, weighted median, and MR-Egger approaches for analysis.

RESULTS

Our analysis included 85 single nucleotide polymorphisms for female infertility and 62 single nucleotide polymorphisms for psychiatric disorders. Results suggest a potential causal relationship between depression and female infertility, with both inverse variance weighting and weighted median methods showing increased infertility risk in depressed patients. Evidence is weak regarding bipolar disorder not increasing female infertility risk. We found no evidence supporting causal links between anxiety, eating disorders, and female infertility. Similarly, no causal relationship was found between female infertility and psychiatric disorders in the opposite direction. Sensitivity analyses and tests for heterogeneity and polymorphism supported result robustness.

CONCLUSIONS

This analysis provides evidence for a potential causal relationship between depression and female infertility. Addressing depression in infertile women may improve fertility outcomes. Further research is needed to explore underlying mechanisms and potential interventions for improving fertility outcomes in women with psychiatric disorders.

Why is lithium [not] the drug of choice for bipolar disorder? a controversy between science and clinical practice

BACKGROUND

During over half a century, science has shown that lithium is the most efficacious treatment for bipolar disorder but despite this, its prescription has consistently declined internationally during recent decades to approximately 35% ever use or less of patients with bipolar disorder.

CONTENT

This narrative review provides an overview of the decreasing use of lithium in bipolar disorder internationally, shortly summarises the evidence for lithium's acute and prophylactic effects in bipolar disorder, discuss the challenges in relation to lithium including side effects, long-term risks and myths around lithium and provides two detailed examples on how specialised care models may result in successful increase of the use of lithium to 70% of patients with bipolar disorder largescale and improve care regionally and nationally.

CONCLUSIONS

Decades of scientific investigations and education and teaching of clinicians and the public has not increased the use of lithium on a population-based large scale. It is argued that lithium should be the drug of choice for maintenance therapy as the single first-line treatment and that organizational changes are needed with specialised care for bipolar disorder to systematically and long-term change the use of lithium on a large-scale population-level.

Co-occurrence of bipolar disorder and personality disorders in the United States: Prevalence, suicidality, and the impact of substance abuse

BACKGROUND

This study investigates prevalence rates of specific personality disorders (PDs) in individuals with bipolar disorder (BD) and their impact on substance abuse and suicidality, addressing existing gaps in the literature.

METHODS

Using Nationwide Inpatient Sample data (2016-2020), adult hospitalizations for BD with coexisting PDs were analyzed. Study variables were defined using ICD-10-CM codes. Prevalence of PD were reported as cases per 100,000 BD admissions. Regression models assessed the association between substance abuse and suicidality.

RESULTS

About 993,000 admissions for BD were analyzed. The cohort was predominantly Caucasian (70.5 %) with higher female representation (54.5 %). The mean age was 41 years. 89.4 % of individuals had a Charlson Comorbidity Index score ≤ 1. The most common diagnostic subtype was manic episode of BD with or without psychotic features (32.3 %). Coexisting PDs were observed in 12.2 % of the population, with borderline PD (8.2 %) and antisocial PD (2.6 %) being most prevalent. Substance abuse was common (44.8 %), with cannabis (23.8 %), alcohol (19.4 %), cocaine (10.5 %), and opioids (9.6 %) being most reported. Substance abuse was higher in individuals with BD and PD (50 %) compared to BD alone (44.1 %). 596 suicide attempts were recorded (60 per 100,000 BD admissions). Substance abuse and coexisting PD in bipolar individuals elevated the likelihood of attempts (P < 0.001).

LIMITATIONS

Use of administrative data (retrospective, inpatient); treatment not studied.

CONCLUSION

The study reveals a notable prevalence of PDs in individuals with BD, with increased likelihood of substance abuse and suicide attempts in those with coexisting BD and PD compared to BD alone.

Electrodermal activity in bipolar disorder: Differences between mood episodes and clinical remission using a wearable device in a real-world clinical setting

BACKGROUND

Bipolar disorder (BD) lacks objective measures for illness activity and treatment response. Electrodermal activity (EDA) is a quantitative measure of autonomic function, which is altered in manic and depressive episodes. We aimed to explore differences in EDA (1) inter-individually: between patients with BD on acute mood episodes, euthymic states and healthy controls (HC), and (2) intra-individually: longitudinally within patients during acute mood episodes of BD and after clinical remission.

METHODS

A longitudinal observational study. EDA was recorded using a research-grade wearable in patients with BD during acute manic and depressive episodes and at clinical remission. Euthymic BD patients and HC were recorded during a single session. We compared EDA parameters derived from the tonic (mean EDA, mEDA) and phasic components (EDA peaks per minute, pmEDA, and EDA peaks mean amplitude, pmaEDA). Inter- and intra-individual comparisons were computed respectively with ANOVA and paired t-tests.

RESULTS

49 patients with BD (15 manic, 9 depressed, and 25 euthymic), and 19 HC were included. Patients with bipolar depression showed significantly reduced mEDA (p = 0.003) and pmEDA (p = 0.001), which increased to levels similar to euthymia or HC after clinical remission (mEDA, p = 0.011; pmEDA, p < 0.001; pmaEDA, p < 0.001). Manic patients showed no differences compared to euthymic patients and HCs, but a significant reduction of tonic and phasic EDA parameters after clinical remission (mEDA, p = 0.035; pmEDA, p = 0.004).

LIMITATIONS

Limited sample size, high inter-individual variability of EDA parameters, limited comparability to previous studies and non-adjustment for medication.

CONCLUSION

EDA ecological monitoring might provide several opportunities for early detection of depressive symptoms, and might aid at assessing early response to treatments in mania and bipolar depression.

Identification of Predictors of Mood Disorder Misdiagnosis and Subsequent Help-Seeking Behavior in Individuals With Depressive Symptoms: Gradient-Boosted Tree Machine Learning Approach

BACKGROUND

Misdiagnosis and delayed help-seeking cause significant burden for individuals with mood disorders such as major depressive disorder and bipolar disorder. Misdiagnosis can lead to inappropriate treatment, while delayed help-seeking can result in more severe symptoms, functional impairment, and poor treatment response. Such challenges are common in individuals with major depressive disorder and bipolar disorder due to the overlap of symptoms with other mental and physical health conditions, as well as, stigma and insufficient understanding of these disorders.

OBJECTIVE

In this study, we aimed to identify factors that may contribute to mood disorder misdiagnosis and delayed help-seeking.

METHODS

Participants with current depressive symptoms were recruited online and data were collected using an extensive digital mental health questionnaire, with the World Health Organization World Mental Health Composite International Diagnostic Interview delivered via telephone. A series of predictive gradient-boosted tree algorithms were trained and validated to identify the most important predictors of misdiagnosis and subsequent help-seeking in misdiagnosed individuals.

RESULTS

The analysis included data from 924 symptomatic individuals for predicting misdiagnosis and from a subset of 379 misdiagnosed participants who provided follow-up information when predicting help-seeking. Models achieved good predictive power, with area under the receiver operating characteristic curve of 0.75 and 0.71 for misdiagnosis and help-seeking, respectively. The most predictive features with respect to misdiagnosis were high severity of depressed mood, instability of self-image, the involvement of a psychiatrist in diagnosing depression, higher age at depression diagnosis, and reckless spending. Regarding help-seeking behavior, the strongest predictors included shorter time elapsed since last speaking to a general practitioner about mental health, sleep problems disrupting daily tasks, taking antidepressant medication, and being diagnosed with depression at younger ages.

CONCLUSIONS

This study provides a novel, machine learning-based approach to understand the interplay of factors that may contribute to the misdiagnosis and subsequent help-seeking in patients experiencing low mood. The present findings can inform the development of targeted interventions to improve early detection and appropriate treatment of individuals with mood disorders.

Comparing the metabolic pathways of different clinical phases of bipolar disorder through metabolomics studies

This study identified the metabolic biomarkers for different clinical phases of bipolar disorder (BD) through metabolomics. BD patients were divided into three groups: patients with BD and depressive episodes (BE, n = 59), patients with BD and mania/hypomania episodes (BH, n = 16), patients with BD and mixed episodes (BM, n = 10), and healthy controls (HC, n = 10). Serum from participants was collected for metabolomic sequencing, biomarkers from each group were screened separately by partial least squares analysis, and metabolic pathways connected to the biomarkers were identified. Compared with the controls, 3-D-hydroxyacetic acid and N-acetyl-glycoprotein showed significant differences in the BE, BH, and BM groups. This study suggests that different clinical types of BD share the same metabolic pathways, such as pyruvate, glycolysis/gluconeogenesis, and ketone body metabolisms. In particular, abnormal glycine, serine, and threonine metabolism was specific to BM; β-glucose, glycerol, lipids, lactate, and acetoacetate metabolites were specific to depressive episodes; the guanidine acetic acid metabolites specific to BH; and the acetic and ascorbic acids were metabolites specific to manic and BM. We screened potential biomarkers for different clinical phases of BD, which aids in BD typing and provides a theoretical basis for exploring the molecular mechanisms of BD.

Factors associated with self-perceived treatment-resistance in bipolar disorder

Patients with bipolar disorder often report self-perceived treatment resistance. However, it is not known to what extent it is due to actual treatment resistance. The Juntendo University provides "Bipolar Disorder Treatment Rebuilding Program," in which patients with self-reported treatment resistant bipolar disorder are hospitalized for 2 weeks and undergo detailed examinations. In this study, we report our experience with the initial 43 patients hospitalized during the one and half years after the launch of the program. Among the patients who underwent full assessment, only one was regarded as having genuine treatment-resistant bipolar disorder without comorbidity. In other cases, ten were not diagnosed with bipolar disorder, 3 had organic brain diseases, 12 had comorbid mental disorders and its symptoms were regarded as treatment-resistant bipolar symptoms by the patients, and 18 did not receive adequate treatment because attendant physicians did not adhere to the treatment guidelines or patients did not adhere to the treatment because of lack of insight. The number of participants was not large, and selection bias hampered the generalization of the findings. Insight and adherence were assessed without the use of validated tools. We could not verify recovery after adequate treatment because of the limited hospitalization period. The findings suggest that most patients with self-perceived treatment-resistant bipolar disorder may not have genuine treatment-resistant bipolar disorder. These results shed light on the difficulties of public education of bipolar disorder and importance of providing appropriate services for diagnosis and treatment of bipolar disorder in the community.

Conceptual foundations of acetylcarnitine supplementation in neuropsychiatric long COVID syndrome: a narrative review

Post-acute sequelae of COVID-19 can present as multi-organ pathology, with neuropsychiatric symptoms being the most common symptom complex, characterizing long COVID as a syndrome with a significant disease burden for affected individuals. Several typical symptoms of long COVID, such as fatigue, depressive symptoms and cognitive impairment, are also key features of other psychiatric disorders such as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and major depressive disorder (MDD). However, clinically successful treatment strategies are still lacking and are often inspired by treatment options for diseases with similar clinical presentations, such as ME/CFS. Acetylcarnitine, the shortest metabolite of a class of fatty acid metabolites called acylcarnitines and one of the most abundant blood metabolites in humans can be used as a dietary/nutritional supplement with proven clinical efficacy in the treatment of MDD, ME/CFS and other neuropsychiatric disorders. Basic research in recent decades has established acylcarnitines in general, and acetylcarnitine in particular, as important regulators and indicators of mitochondrial function and other physiological processes such as neuroinflammation and energy production pathways. In this review, we will compare the clinical basis of neuropsychiatric long COVID with other fatigue-associated diseases. We will also review common molecular disease mechanisms associated with altered acetylcarnitine metabolism and the potential of acetylcarnitine to interfere with these as a therapeutic agent. Finally, we will review the current evidence for acetylcarnitine as a supplement in the treatment of fatigue-associated diseases and propose future research strategies to investigate the potential of acetylcarnitine as a treatment option for long COVID.

Dental and medical management of the patient with bipolar disorder

OBJECTIVE

The objective of this literature review is to understand the appropriate medical management of patients with bipolar disorder (BD) which subsequently can translate into the effective dental management of patients suffering with this illness METHODS: This study was completed using three databases which included PubMed, Google Scholar and Cochrane library. Additionally, relevant dental and medical textbooks were also used to summarize more complex topics regarding BD. Descriptors used to find relevant articles included "Bipolar Disorder", "Adverse drug effects of bipolar medications", and "Orofacial findings with patients with bipolar disorder". A total of 49 relevant articles and textbooks were found which were included in this literature review.

RESULTS

BD is a mental illness which affects millions worldwide. It is characterized by alternating episodes of mania and depression. During the manic phase there is an abnormal elevation in mood whereas the depressive episodes consist of the opposite. The medical management of BD involves pharmacotherapy and psychotherapy. Common dental findings in patients with BD include caries, periodontal disease, xerostomia and adverse oral effects from the medications used to manage this illness.

CONCLUSION

BD has a significant burden on society and to effectively manage their medical and dental needs, the clinician must be well versed in their illness.

Postpartum Psychosis: A Proposed Treatment Algorithm

Background

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

Methods

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

Objective

To provide a treatment algorithm for the management of PPP based on available evidence.

Results

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

Conclusion

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.Reprinted from J Psychopharmacol 2023; 37:960-970, with permission from Sage Journals. Copyright © 2023.

Lamotrigine efficacy, safety, and tolerability for women of childbearing age with bipolar I disorder: Meta-analysis from four randomized, placebo-controlled maintenance studies

This meta-analysis investigated the efficacy, safety, and tolerability of lamotrigine versus placebo in preventing relapse and recurrence of mood episodes in women of childbearing age with bipolar I disorder. Following up to 16 weeks' open-label lamotrigine treatment, responders were randomized to double-blind treatment, including lamotrigine 100-400 mg/day or placebo, in four trials of up to 76 weeks. Women aged 18-45 years who received ≥ 1 dose of study treatment and had ≥ 1 efficacy assessment in the double-blind phase were pooled for efficacy analysis. The primary outcome was median time to intervention for any mood episode (TIME). Of 717 eligible women in the open-label phase, 287 responded and were randomized to lamotrigine (n = 153) or placebo (n = 134). The randomized group had a mean (SD) of 2.0(2.02) manic and 2.5(2.02) depressive episodes in the 3 years before screening. Median TIME was 323 days with lamotrigine and 127 days with placebo (HR 0.69; 95% CI 0.49, 0.96; p = 0.030). Lamotrigine delayed time to intervention for any depressive episode (HR 0.59; 95% CI 0.39, 0.90; p = 0.014) with no treatment difference for manic episodes (HR 0.91; 95% CI 0.52, 1.58; p = 0.732). 2/717 (< 1%) participants experienced serious rash-related adverse events (AEs) during the open-label phase, and 52/717 (7%) had non-serious rash-related events leading to study withdrawal. Incidence of AEs and AEs leading to withdrawal were similar between lamotrigine and placebo groups. Lamotrigine delayed relapse and recurrence of mood episodes, largely by preventing depressive episodes, and was well tolerated in women of childbearing age.

Preparations of Students for Enrollment in Medical Schools

Improving medical education is an important process that changes from time to time based on the development of medical science and practice, society's need for a certain number of quality doctors, better preparations, and better selection of candidates for admission into medical schools. In most European countries, partial preparation of students for admission is done in secondary schools, and additional preparation is achieved in the first year of medical school. Such preparations enabled more than 60% of students to complete their studies, before the German Federal Ministry of Science and Education implemented the Masterplan Medizinstudium 2020. However, after a 4-year university preparation in the United States, close to 95% of students finish their medical studies on time. We proposed a 2-year university preparation for each student before his enrollment into the medical school because this strengthens his medical study, and later on, he becomes a better doctor. Thus, the number of graduated students may increase, medical studies could be shortened to 1 year, and candidates who do not enroll in medical school may continue their previous studies.

Health morbidities associated with the dispensing of lithium to males and females: Cross-sectional analysis of the 10 % Pharmaceutical Benefits Scheme sample for 2022

OBJECTIVES

This study examined the association of gender on the physical morbidity of individuals likely living with bipolar disorder (BD) using a comprehensive health-related database. It investigated the association between lithium dispensing (a surrogate marker for BD) and other health morbidities, considering age and sex.

METHODS

The cross-sectional study design used the 10 % Schedule of Pharmaceutical Benefits Scheme (PBS) database in Australia for 2022. Medication dispensing, age, and sex were available. A validated algorithm inferred 45 health morbidities from dispensed medicines. Statistical analyses, including logistic regression, assessed the relationship between lithium dispensing, sex, and age with inferred health morbidities.

RESULTS

The sample consisted of 1,594,112 individuals aged 10 to over 95 years. A higher proportion of women than men were dispensed lithium (0.33 % vs 0.30 %). Lithium dispensing and age were associated with higher prevalence of inferred morbidities. Women dispensed lithium had a greater physical health burden compared to men, with higher odds of chronic airways diseases, diabetes, ischaemic heart disease/hypertension, inflammation, pain, psychosis, and steroid-responsive diseases. Conversely, women dispensed lithium had lower odds of cardiac arrhythmias and hypothyroidism compared to men.

CONCLUSIONS

This study provides evidence that individuals with BD, indicated by the dispensing of lithium, experience a relatively higher frequency of physical health morbidities, with women being disproportionally affected compared to men. The findings highlight the need for comprehensive care for people living with BD, particularly women.

Management of Lithium Dosing Around Delivery: An Observational Study

Objectives

Recommendations on lithium dosing around delivery vary, with several guidelines suggesting that lithium should be discontinued prior to delivery. We aimed to evaluate the validity of these recommendations by investigating 1) maternal lithium blood level changes following delivery, and 2) the association between neonatal lithium blood levels at delivery and neonatal outcomes.

Methods

In this retrospective observational cohort study, we included women with at least one lithium blood level measurement during the final week of pregnancy and the first postpartum week. For aim 2, we included a subcohort of women with neonates for whom neonatal lithium blood levels (obtained from the umbilical cord or a neonatal vein puncture within 24 hours of delivery) were available.

Results

There were a total of 233 maternal lithium blood level measurements; 55 (23.6%) in the week before delivery and 178 (76.4%) in the week after. There was no association between time and lithium blood level/dose ratio (Pearson correlation coefficient -0.03, P = .63). Additionally, we included a total of 29 neonates for whom a lithium measurement was performed within 24 hours postpartum. Maternal and neonatal lithium blood levels were strongly correlated. We observed no associations between neonatal lithium blood levels at delivery and neonatal outcomes.

Conclusion

Based on our findings, we do not recommend lowering the dosage or discontinuation of lithium prior to delivery. Stable dosing can prevent subtherapeutic lithium serum levels, which is especially important in the postpartum period when relapse risks are highest.Appeared originally in Bipolar Disord 2021; 23:49-54.

Characterization of Psychiatric Inpatients: The Role of Gender Differences in Clinical and Pharmacological Patterns

BACKGROUND

Severe mental disorders that require hospitalization are disabling conditions that contribute to the burden of mental diseases. They pose increased clinical challenges and highlight the need to thoroughly explore variables emerging from daily clinical practice. In this study, we assessed to what extent gender differences may characterize a large population of psychiatric inpatients.

METHODS

We conducted a cross-sectional study in 2 Italian teaching medical centers, which included 2358 patients who were consecutively admitted to the psychiatric emergency units. We explored and characterized gender differences for variables such as prevalence of psychiatric diagnosis, presence of suicidal ideation, suicide attempts, age at onset of psychiatric illness, presence of substance or alcohol abuse, length of stay, number of hospitalizations, presence of involuntary admission, type of discharge from the hospital, and pharmacological treatment at discharge.

RESULTS

Female patients were primarily diagnosed with bipolar disorder or personality disorders. Female patients had a significantly higher prevalence of lifetime suicide attempts (23.1% vs. 16.5%, P<0.001) and a longer length of hospitalization (11.43±10.73 d vs. 10.52±10.37 d, t=-2.099, gl=2356, P=0.036) compared with male patients. Male patients had more involuntary admissions (25.1% vs. 19.7%, χ2=9.616, gl=1, P=0.002), more use of illicit substances (34.1% vs. 20.9%, χ2=51.084, gl=1, P<0.001), and higher rates of alcohol abuse (21.3% vs. 14.7%, χ2=17.182, gl=1, P<0.001) compared with female patients. Finally, antidepressants and lithium were prescribed more frequently to the female patients, whereas other mood stabilizers were more often prescribed to the male patients.

CONCLUSIONS

Our real-world results highlighted gender differences among patients with severe mental disorders admitted to psychiatric units, and suggest further investigations that may help in understanding trajectories accompanying disabling clinical conditions.

Structural brain plasticity and inflammation are independently related to changes in depressive symptoms six months after an index ECT course

BACKGROUND

Electroconvulsive therapy (ECT) is effective for treatment-resistant depression and leads to short-term structural brain changes and decreases in the inflammatory response. However, little is known about how brain structure and inflammation relate to the heterogeneity of treatment response in the months following an index ECT course.

METHODS

A naturalistic six-month study following an index ECT course included 20 subjects with treatment-resistant depression. Upon conclusion of the index ECT course and again after six months, structural magnetic resonance imaging scans and peripheral inflammation measures [interleukin-6 (IL-6), IL-8, tumor necrosis factor (TNF-α), and C-reactive protein] were obtained. Voxel-based morphometry processed with the CAT-12 Toolbox was used to estimate changes in gray matter volume.

RESULTS

Between the end of the index ECT course and the end of follow-up, we found four clusters of significant decreases in gray matter volume (p < 0.01, FWE) and no regions of increased volume. Decreased HAM-D scores were significantly related only to reduced IL-8 level. Decreased volume in one cluster, which included the right insula and Brodmann's Area 22, was related to increased HAM-D scores over six months. IL-8 levels did not mediate or moderate the relationship between volumetric change and depression.

CONCLUSIONS

Six months after an index ECT course, multiple regions of decreased gray matter volume were observed in a naturalistic setting. The independent relations between brain volume and inflammation to depressive symptoms suggest novel explanations of the heterogeneity of longer-term ECT treatment response.

Phencyclidine Disrupts Neural Coordination and Cognitive Control by Dysregulating Translation

Background

Phencyclidine (PCP) causes psychosis, is abused with increasing frequency, and was extensively used in antipsychotic drug discovery. PCP discoordinates hippocampal ensemble action potential discharge and impairs cognitive control in rats, but how this uncompetitive NMDA receptor (NMDAR) antagonist impairs cognition remains unknown.

Methods

The effects of PCP were investigated on hippocampal CA1 ensemble action potential discharge in vivo in urethane-anesthetized rats and during awake behavior in mice, on synaptic responses in ex vivo mouse hippocampus slices, in mice on a hippocampus-dependent active place avoidance task that requires cognitive control, and on activating the molecular machinery of translation in acute hippocampus slices. Mechanistic causality was assessed by comparing the PCP effects with the effects of inhibitors of protein synthesis, group I metabotropic glutamate receptors (mGluR1/5), and subunit-selective NMDARs.

Results

Consistent with ionotropic actions, PCP discoordinated CA1 ensemble action potential discharge. PCP caused hyperactivity and impaired active place avoidance, despite the rodents having learned the task before PCP administration. Consistent with metabotropic actions, PCP exaggerated protein synthesis-dependent DHPG-induced mGluR1/5-stimulated long-term synaptic depression. Pretreatment with anisomycin or the mGluR1/5 antagonist MPEP, both of which repress translation, prevented PCP-induced discoordination and the cognitive and sensorimotor impairments. PCP as well as the NR2A-containing NMDAR antagonist NVP-AAM077 unbalanced translation that engages the Akt, mTOR (mechanistic target of rapamycin), and 4EBP1 translation machinery and increased protein synthesis, whereas the NR2B-containing antagonist Ro25-6981 did not.

Conclusions

PCP dysregulates translation, acting through NR2A-containing NMDAR subtypes, recruiting mGluR1/5 signaling pathways, and leading to neural discoordination that is central to the cognitive and sensorimotor impairments.

Neuroprotective Properties of Antiepileptics: What are the Implications for Psychiatric Disorders?

Since the discovery of the first antiepileptic compound, increasing attention has been paid to antiepileptic drugs (AEDs), and recently, with the understanding of the molecular mechanism underlying cells death, a new interest has revolved around a potential neuroprotective effect of AEDs. While many neurobiological studies in this field have focused on the protection of neurons, growing data are reporting how exposure to AEDs can also affect glial cells and the plastic response underlying recovery; however, demonstrating the neuroprotective abilities of AEDs remains a changeling task. The present work aims to summarize and review the literature available on the neuroprotective properties of the most commonly used AEDs. Results highlighted how further studies should investigate the link between AEDs and neuroprotective properties; while many studies are available on valproate, results for other AEDs are very limited and the majority of the research has been carried out on animal models. Moreover, a better understanding of the biological basis underlying neuro-regenerative defects may pave the way for the investigation of further therapeutic targets and eventually lead to an improvement in the actual treatment strategies.

Young people at risk for developing bipolar disorder: Two-year findings from the multicenter prospective, naturalistic Early-BipoLife study

Early identification and intervention of individuals with an increased risk for bipolar disorder (BD) may improve the course of illness and prevent long‑term consequences. Early-BipoLife, a multicenter, prospective, naturalistic study, examined risk factors of BD beyond family history in participants aged 15-35 years. At baseline, positively screened help-seeking participants (screenBD at-risk) were recruited at Early Detection Centers and in- and outpatient depression and attention-deficit/hyperactivity disorder (ADHD) settings, references (Ref) drawn from a representative cohort. Participants reported sociodemographics and medical history and were repeatedly examined regarding psychopathology and the course of risk factors. N = 1,083 screenBD at-risk and n = 172 Ref were eligible for baseline assessment. Within the first two years, n = 31 screenBD at-risk (2.9 %) and none of Ref developed a manifest BD. The cumulative transition risk was 0.0028 at the end of multistep assessment, 0.0169 at 12 and 0.0317 at 24 months (p = 0.021). The transition rate with a BD family history was 6.0 %, 4.7 % in the Early Phase Inventory for bipolar disorders (EPIbipolar), 6.6 % in the Bipolar Prodrome Interview and Symptom Scale-Prospective (BPSS-FP) and 3.2 % with extended Bipolar At-Risk - BARS criteria). In comparison to help-seeking young patients from psychosis detection services, transition rates in screenBD at-risk participants were lower. The findings of Early-BipoLife underscore the importance of considering risk factors beyond family history in order to improved early detection and interventions to prevent/ameliorate related impairment in the course of BD. Large long-term cohort studies are crucial to understand the developmental pathways and long-term course of BD, especially in people at- risk.

Omega-3 polyunsaturated fatty acids in the prevention of relapse in patients with stable bipolar disorder: A 6-month pilot randomized controlled trial

This study investigated the efficacy and safety of omega-3 polyunsaturated fatty acids (n-3 PUFAs) in relapse prevention of bipolar disorder (BD), addressing the shortcomings of current medications. Thirty-one stable BD patients were randomized to receive n-3 PUFAs or placebo for 6 months and intergroup differences in the incidence of the recurrence of bipolar depression were assessed. Differences in depression severity, manic symptoms, and routine biochemical parameters were also assessed. Interestingly, n-3 PUFAs demonstrated a favorable preventive effect on bipolar depression recurrence (p=0.005; Log-Rank) and reduced depression severity compared to placebo, and were well-tolerated, suggesting their potential as a safe prophylactic therapy for BD.

Antidepressant Use and Risk of Manic Episodes in Children and Adolescents With Unipolar Depression

Importance

Antidepressants are increasingly prescribed to pediatric patients with unipolar depression, but little is known about the risk of treatment-emergent mania. Previous research suggests pediatric patients may be particularly vulnerable to this adverse outcome.

Objective

To estimate whether pediatric patients treated with antidepressants have an increased incidence of mania/hypomania compared with patients not treated with antidepressants and to identify patient characteristics associated with the risk of mania/hypomania.

Design, Setting, and Participants

In a cohort study applying the target trial emulation framework, nationwide inpatient and outpatient care in Sweden from July 1, 2006, to December 31, 2019, was evaluated. Follow-up was conducted for 12 and 52 weeks after treatment initiation, with administrative follow-up ending December 31, 2020. Data were analyzed between May 1, 2022, and June 28, 2023. Individuals aged 4 to 17 years with a diagnosis of depression, but without a prior diagnosis of mania/hypomania, bipolar disorder, or psychosis or treatment with mood stabilizer (lithium, valproate, or carbamazepine), prescriptions were included.

Exposures

The treatment group included patients who initiated any antidepressant medication within 90 days of diagnosis. The control group included patients who did not initiate antidepressants within 90 days.

Main Outcomes and Measures

Diagnosis of mania/hypomania or initiation of mood stabilizer therapy. Incidences were estimated with Kaplan-Meier estimator, and inverse probability of treatment weighting was used to adjust for group differences at baseline.

Results

The cohort included 43 677 patients (28 885 [66%] girls); 24 573 in the treatment group and 19 104 in the control group. The median age was 15 (IQR, 14-16) years. The outcome occurred in 96 individuals by 12 weeks and in 291 by 52 weeks. The cumulative incidence of mania was 0.26% (95% CI, 0.19%-0.33%) in the treatment group and 0.20% (95% CI, 0.13%-0.27%) in the control group at 12 weeks, with a risk difference of 0.06% (95% CI, -0.04% to 0.16%). At 52 weeks, the cumulative incidence was 0.79% (95% CI, 0.68%-0.91%) in the treatment group and 0.52% (95% CI, 0.40%-0.63%) in the control group (risk difference, 0.28%; 95% CI, 0.12%-0.44%). Hospitalizations, parental bipolar disorder, and use of antipsychotics and antiepileptics were the most important predictors of mania/hypomania by 12 weeks.

Conclusion

This cohort study found no evidence of treatment-emergent mania/hypomania by 12 weeks in children and adolescents. This corresponds to the time frame for antidepressants to exert their psychotropic effect. A small risk difference was found only with longer follow-up. Certain patient characteristics were associated with mania/hypomania, which warrants clinical attention.

Prediction of estimated risk for bipolar disorder using machine learning and structural MRI features

BACKGROUND

Individuals with bipolar disorder are commonly correctly diagnosed a decade after symptom onset. Machine learning techniques may aid in early recognition and reduce the disease burden. As both individuals at risk and those with a manifest disease display structural brain markers, structural magnetic resonance imaging may provide relevant classification features.

METHODS

Following a pre-registered protocol, we trained linear support vector machine (SVM) to classify individuals according to their estimated risk for bipolar disorder using regional cortical thickness of help-seeking individuals from seven study sites (N = 276). We estimated the risk using three state-of-the-art assessment instruments (BPSS-P, BARS, EPIbipolar).

RESULTS

For BPSS-P, SVM achieved a fair performance of Cohen's κ of 0.235 (95% CI 0.11-0.361) and a balanced accuracy of 63.1% (95% CI 55.9-70.3) in the 10-fold cross-validation. In the leave-one-site-out cross-validation, the model performed with a Cohen's κ of 0.128 (95% CI -0.069 to 0.325) and a balanced accuracy of 56.2% (95% CI 44.6-67.8). BARS and EPIbipolar could not be predicted. In post hoc analyses, regional surface area, subcortical volumes as well as hyperparameter optimization did not improve the performance.

CONCLUSIONS

Individuals at risk for bipolar disorder, as assessed by BPSS-P, display brain structural alterations that can be detected using machine learning. The achieved performance is comparable to previous studies which attempted to classify patients with manifest disease and healthy controls. Unlike previous studies of bipolar risk, our multicenter design permitted a leave-one-site-out cross-validation. Whole-brain cortical thickness seems to be superior to other structural brain features.

Characterizing the longitudinal course of symptoms and functioning in bipolar disorder

BACKGROUND

The course of Bipolar Disorder (BD) is highly variable, with marked inter and intra-individual differences in symptoms and functioning. In this study, we identified illness trajectories across major clinical domains that could have etiological, prognostic, and therapeutic relevance.

METHODS

Using the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study, we performed univariate and multivariate trajectory modeling of depressive symptoms, manic symptoms, and psychosocial functioning. Multinomial regression was performed to identify baseline variables associated with poor outcome trajectories.

RESULTS

Depressive symptoms predominated, with most subjects being found in trajectories characterized by various degrees of depressive symptoms and 13% of subjects being classified in a poor outcome 'persistently depressed' trajectory. Most subjects experienced few manic symptoms, although approximately 10% of subjects followed a trajectory of persistently manic symptoms. Trajectory analysis of psychosocial functioning showed impairment in most of the sample, with little improvement during follow up. Multi-trajectory analyses highlighted significant impairment in subjects with persistently mixed and persistently depressed trajectories of illness. In general, poor outcome trajectories were marked by lower educational attainment, higher unemployment and disability, and a greater likelihood of adverse clinical features (rapid cycling and suicide attempts) and comorbid diagnoses (anxiety disorders, PTSD, and substance abuse/dependence disorders).

CONCLUSIONS

Subjects with BD can be classified into several trajectories of clinically relevant domains that are prognostically relevant and show differing degrees of associations with a broad range of negative clinical risk factors. The highest level of psychosocial disability was found in subjects with chronic mixed and depressive symptoms, who show limited improvement despite guideline-based treatment.