Bipolar disorder

Lithium effects on brain glutamatergic and GABAergic systems of healthy volunteers as measured by proton magnetic resonance spectroscopy

Lithium is a first-line medicinal treatment for acute bipolar disorder and is also used prophylactically in manic depressive illnesses; however, its mechanism of action is still largely unknown. Animal and human studies have suggested that lithium modulates glutamatergic and GABAergic neurotransmissions. The aim of this study is to investigate the effects of lithium on brain glutamate (Glu), glutamine (Gln), and gamma-aminobutyric acid (GABA) levels in healthy individuals using proton magnetic resonance spectroscopy (1H-MRS). In vivo 3 Tesla 1H-MRS was performed on the anterior cingulate cortex and bilateral basal ganglia initially and after two weeks of lithium administration on 8 healthy male subjects who had a mean age of 34.9 years. After two weeks of lithium administration, Gln significantly decreased in the left basal ganglia and showed a decreasing trend in the right basal ganglia. Additionally, Glu+Gln (Glx) significantly decreased in the right basal ganglia and showed a decreasing trend in the left basal ganglia. Glu did not significantly change in any of the three tested areas, and GABA exhibited no significant change after the lithium administration when measured in the anterior cingulate cortex and left basal ganglia. This study is the first to demonstrate that subchronic lithium treatment decreases Gln and Glx levels in the bilateral basal ganglia of healthy individuals. Our finding might suggest that the decrease of Glx levels is associated with the pharmacological actions of subchronic lithium treatment.

Cellular plasticity cascades in the pathophysiology and treatment of bipolar disorder

Bipolar disorder (BPD) is characterized by recurrent episodes of disturbed affect including mania and depression as well as changes in psychovegetative function, cognitive performance, and general health. A growing body of data suggests that BPD arises from abnormalities in synaptic and neuronal plasticity cascades, leading to aberrant information processing in critical synapses and circuits. Thus, these illnesses can best be conceptualized as genetically influenced disorders of synapses and circuits rather than simply as deficits or excesses in individual neurotransmitters. In addition, commonly used mood-stabilizing drugs that are effective in treating BPD have been shown to target intracellular signaling pathways that control synaptic plasticity and cellular resilience. In this article we draw on clinical, preclinical, neuroimaging, and post-mortem data to discuss the neurobiology of BPD within a conceptual framework while highlighting the role of neuroplasticity in the pathophysiology and treatment of this disorder.

Bipolar disorder and multiple sclerosis

Bipolar disorder may be overrepresented in multiple sclerosis (MS) patients. Although research in this area is limited, studies assessing the nature of this association have focused on genetic aspects, adverse reaction to drugs and brain demyelinating lesions. Herein we report three patients with MS that also presented bipolar disorder. The coexistence of neurological and psychiatric symptoms in most MS relapses highlights the relevance of biological factors in the emergence of mood disorders in these patients.

Antimanic therapies target brain arachidonic acid signaling: lessons learned about the regulation of brain fatty acid metabolism

Bipolar disorder is a major medical, social and economic burden worldwide. However, the biochemical basis of the disorder and the mechanisms of action of effective antibipolar disorder drugs remain elusive. In this paper, we review how combining a kinetic approach to studying the turnover of fatty acids within brain phospholipids of unanesthetized rats along with chronic administration of antimanic drugs (lithium, valproate and carbamazepine) at therapeutically relevant doses, shows that the brain arachidonic acid cascade is a common target of these drugs. The overlapping effects of the three drugs are decreased turnover of arachidonic acid but not of docosahexaenoic acid in rat brain phospholipids, and decreased brain cyclooxygenase-2 and prostaglandin E(2). Whereas lithium and carbamazepine target the transcription of the arachidonic acid-selective calcium-dependent cytosolic phospholipase A(2), valproate is a non-competitive inhibitor of an arachidonic acid-selective acyl-CoA synthetase. Two potential models of bipolar disorder, chronic N-methyl-d-aspartate and n-3 polyunsaturated fatty acid deprivation, opposite to the antimanic drugs, increase the turnover and markers of the arachidonic acid cascade in rat brain. These observations support the hypothesis proposed by Rapoport and colleagues that the arachidonic acid cascade is a common target of mood stabilizers and that by targeting substrate-specific enzymes the turnover of individual fatty acids can be regulated within the brain.

The role of hippocampus in the pathophysiology of bipolar disorder

Bipolar disorder (BD) is thought to be associated with abnormalities within discrete brain regions associated with emotional regulation, particularly in fronto-limbic-subcortical circuits. Several reviews have addressed the involvement of the prefrontal cortex in the pathophysiology of BD, whereas little attention has been given to the role of the hippocampus. This study critically reviews data from brain imaging, postmortem, neuropsychological, and preclinical studies, which suggested hippocampal abnormalities in BD. Most of the structural brain imaging studies did not find changes in hippocampal volume in BD, although a few studies suggested that anatomical changes might be restricted to the psychotic, pediatric, or unmedicated BD subgroups. Functional imaging studies showed abnormal brain activation in the hippocampus and its closely related regions during emotional, attentional, and memory tasks. This is consistent with neuropsychological findings that revealed a wide range of cognitive disturbances during acute mood episodes and a significant impairment in declarative memory during remission. Postmortem studies indicate abnormal glutamate and GABA transmission in the hippocampus of BD patients, whereas data from preclinical studies suggest that the regulation of hippocampal plasticity and survival might be associated with the therapeutic effects of mood stabilizers. In conclusion, the available evidence suggests that the hippocampus plays an important role in the pathophysiology of BD.

DNA damage in bipolar disorder

Bipolar disorder (BD) is a prevalent, chronic, severe, and highly disabling psychiatric disorder that is associated with increased morbidity and mortality due to general medical conditions. There is an emerging body of evidence correlating chronic medical conditions with DNA damage. The present study was designed to assess DNA damage in BD patients using the comet assay (CA). Thirty-two bipolar-I outpatients diagnosed using the Structured Clinical Interview for DSM-IV were matched with 32 healthy volunteers. Manic and depressive symptoms were assessed using the Young Mania Rating Scale and the Hamilton Depression Rating Scale, respectively. Peripheral blood samples were collected and a standard protocol for CA preparation and analysis was performed. The present study showed that BD outpatients present an increased frequency of DNA damage relative to controls. The frequency of DNA damage correlated with the severity of symptoms of depression and mania.

Serum S100B and antioxidant enzymes in bipolar patients

Bipolar disorder (BD) is a chronic, severe, and highly disabling psychiatric disorder; peripheral markers have been used to assess biochemical alterations associated with BD and/or possibly involved in its pathophysiology. Beyond neuronal commitment, many groups have proposed the involvement of glial activity in psychiatric disorders. Other biochemical markers, particularly associated with oxidative stress, have been studied in BD. In the present study, we evaluated glial involvement and oxidative stress in patients with BD. Glial activity was assessed by measuring serum S100B content; oxidative stress was assessed using serum thiobarbituric acid reactive substances (TBARS) and activities of antioxidant enzymes in BD patients during different episodes of disease. We found a significant increment of serum S100B during episodes of mania and depression, but not in euthymic patients. Superoxide dismutase (SOD) activity, as well the SOD/glutathione peroxidase plus catalase ratio, was also increased in manic and depressed patients. On the other hand, TBARS levels were increased in BD patients regardless of the phase of the disorder. These findings suggest a potential oxidative damage in BD patients. This peripheral oxidative imbalance indicates that systemic changes are taking place during the active phases of the illness. Such changes appear to relate to astrocyte function, as indicated by serum S100B elevation.

A gastrin-releasing peptide receptor antagonist blocks D-amphetamine-induced hyperlocomotion and increases hippocampal NGF and BDNF levels in rats

The gastrin-releasing peptide receptor (GRPR) has emerged as a novel molecular target in neurological and psychiatric disorders, and previous animal studies suggest that GRPR antagonists might display cognitive-enhancing and antipsychotic properties. Hyperlocomotion produced by administration of D-amphetamine (D-AMPH) to rats has been put forward as a model of the manic phase of bipolar disorder (BD). In the present study, we examined the effects of a single systemic administration of the GRPR antagonist [D-Tpi(6), Leu(13) psi(CH(2)NH)-Leu(14)] bombesin (6-14) (RC-3095) on hyperlocomotion induced by a single systemic injection of D-AMPH in male rats. We also evaluated the levels of brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) in the hippocampus of rats treated with D-AMPH and RC-3095. Administration of RC-3095 at any of the doses used blocked D-AMPH-induced hyperlocomotion. Specific doses of RC-3095 increased the levels of NGF and BDNF in the dorsal hippocampus. Administration of D-AMPH did not affect NGF or BDNF levels by itself, but blocked the RC-3095 effects. The results suggest that GRPR antagonists might display anti-manic activity.

Lithium reduces tau phosphorylation but not A beta or working memory deficits in a transgenic model with both plaques and tangles

Glycogen synthase kinase 3 (GSK-3) is a major kinase implicated in the pathogenesis of Alzheimer's disease (AD), and reducing its activity may have therapeutic efficacy. Two variants exist, referred to as GSK-3 alpha and GSK-3beta. In addition to the latter's well-described role in the phosphorylation of tau, reports also suggest that GSK-3 alpha may regulate amyloid precursor protein processing and Abeta formation. The activities of both GSK-3 alpha and GSK-3beta are reduced by lithium, a well-tolerated drug used in humans to combat bipolar disorder. Here, we investigate the therapeutic efficacy of chronic lithium administration in aged 3xTg-AD mice that harbor both plaques and tangles. We found that lithium reduced tau phosphorylation but did not significantly alter the A beta load. Despite the reduction in phosphotau, lithium treatment did not improve deficits in working memory. Although other studies have investigated the effects of lithium on tau biochemistry, this study represents the first to address comprehensively its therapeutic potential on other critical aspects of AD including its effect on A beta and learning and memory. It remains to be determined from human clinical trials whether lithium treatment alone will improve the clinical outcome in AD patients. These results, however, suggest that the most efficacious treatment will be combining lithium with other anti-A beta interventions.

Effects of lithium and valproate on hippocampus citrate synthase activity in an animal model of mania

Some studies suggest that mitochondrial dysfunction may be related to the pathophysiology of bipolar disorder. In this work, we evaluated the activity of citrate synthase in rats, and the effects of the treatment with mood stabilizers (lithium and valproate) on the enzyme activity. In the first experiment (reversal treatment), amphetamine or saline were administered to rats for 14 days, and between day 8 and 14, rats were treated with either lithium, valproate or saline. In the second experiment (prevention treatment), rats were pretreated with lithium, valproate or saline, and between day 8 and 14, rats were administered amphetamine or saline. In reversal and prevention models, amphetamine administration significantly inhibited citrate synthase activity in rat hippocampus. In amphetamine-pretreated animals, valproate administration reversed citrate synthase activity inhibition induced by amphetamine. In the prevention model, pretreatment with lithium prevented amphetamine-induced citrate synthase inhibition. Our results showed that amphetamine inhibited citrate synthase activity and that valproate reversed and lithium prevented the enzyme inhibition.

Mood and anxiety disorders in chronic headache

Although most individuals with recurrent headache disorders in the general population do not experience severe psychopathology, population-based studies and clinical investigations find high rates of comorbidity between headache and mood and anxiety disorders. When present, psychiatric disorders may complicate headache treatment and portend a poorer treatment response. The negative prognosis associated with psychiatric comorbidity emphasizes the importance of the identification of psychopathology among those with headache beginning at an early age, and suggests that the treatment of psychiatric comorbidity is warranted to improve the outcome of headache management. In this article we describe the mood and anxiety disorders most commonly associated with migraine, tension-type headache, and chronic daily headache. We provide recommendations for the assessment of comorbid mood and anxiety disorders as well as a brief overview of treatment options. Last, we discuss the clinical implications of mood and anxiety disorders on the treatment and outcome of headache.

Anticonvulsant efficacy of valproate-like carboxylic acids: a potential target for anti-bipolar therapy

BACKGROUND

Bipolar disorder (BPD) is a severe and chronic illness, with a lifetime prevalence of approximately 1.5%. Despite the availability of some mood stabilizing drugs including lithium, valproate (valproic acid), lamotrigine and carbamazepine, BPD is characterized by high rates of recurrence, as treatment with these and other drugs is ineffective for and not well-tolerated by a significant percentage of patients. Most drugs currently used for the maintenance treatment of BPD are anticonvulsants (e.g., valproate, carbamazepine and lamotrigine).

OBJECTIVES

The aim of this paper is to review the studies characterizing the anticonvulsant efficacy of valproate-like carboxylic acids and related compounds, some of which may have potential for the treatment of manic-depressive illness.

RESULTS

The data reviewed herein demonstrate clearly that some dietary fatty acids and other valproate-like carboxylic acids exhibit potent anticonvulsant activity, and may thus be candidates for mood stabilizing treatment options for BPD.

Serum levels of brain-derived neurotrophic factor in patients with schizophrenia and bipolar disorder

There is evidence that major psychiatric discords such as schizophrenia (SZ) and bipolar disorder (BD) are associated with dysregulation of synaptic plasticity with downstream alterations of neurotrophins. Brain-derived neurotrophic factor (BDNF) is the most widely distributed neurotrophin in the central nervous system (CNS), and performs many biological functions such as promoting the survival, differentiation, and plasticity of neurons. Variants in the BDNF gene increase the risk of SZ and bipolar disorder. Chronic administration of drugs used to treat SZ and BD, such as lithium, valproate, quetiapine, clozapine, and olanzapine, increases BDNF expression in rat brain. To examine serum BDNF, three groups of chronically medicated DSM-IV SZ patients, on treatment with clozapine (n=27), typical (n=14), and other atypical antipsychotics (n=19), 30 euthymic BD patients, and 26 healthy control had 5 ml blood samples collected by venipuncture. Serum BDNF levels were significantly higher in SZ patients (p<0.001) when compared to either controls or euthymic BD patients. Increased BDNF in SZ patients might be related to the course of illness or to treatment variables. Prospective studies are warranted.

Un syndrome de Brugada majoré par un traitement au lithium

INTRODUCTION

The Brugada syndrome is a rare genetic disease that can lead to death. Its diagnosis requires electrocardiography.

CASE

A 36-year-old man was admitted with syncope. Brugada syndrome was diagnosed by the typical ECG pattern. The interaction between lithium therapy and ECG was shown clearly by the alternating type 1 and type 3 Brugada ECG patterns, depending on lithium status.

DISCUSSION

The Brugada syndrome may be unmasked by lithium therapy, due to its properties as a Na+ channel blocker, even at low doses. This case also demonstrated the usefulness of ECG in detecting the Brugada syndrome before and during lithium prescription.

G protein-coupled receptors in major psychiatric disorders

Although the molecular mechanisms underlying psychiatric illnesses such as depression, bipolar disorder and schizophrenia remain incompletely understood, there is increasing clinical, pharmacologic, and genetic evidence that G protein-coupled receptors (GPCRs) play critical roles in these disorders and their treatments. This perspectives paper reviews and synthesizes the available data. Dysfunction of multiple neurotransmitter and neuropeptide GPCRs in frontal cortex and limbic-related regions, such as the hippocampus, hypothalamus and brainstem, likely underlies the complex clinical picture that includes cognitive, perceptual, affective and motoric symptoms. The future development of novel agents targeting GPCR signaling cascades remains an exciting prospect for patients refractory to existing therapeutics.

Anxiety comorbidity and quality of life in bipolar disorder patients

OBJECTIVE

To assess the impact of anxiety comorbidity on the quality of life of patients with bipolar disorder (BD).

METHODS

We undertook a cross-Sectional survey of 162 BD outpatients interviewed with the Structured Clinical Interview for DSM-IV. The primary outcome measure was quality of life, assessed with the 26-item WHO Quality of Life Instrument (WHOQOL-BREF).

RESULTS

Anxiety comorbidity in BD patients was associated with lower scores in all domains of quality of life. The impact of anxiety comorbidity on the psychological domain of the WHOQOL-BREF was kept, even when the current level of depression was added to the model as a confounding factor. Current anxiety comorbidity was also associated with lifetime alcohol abuse and dependence, rapid cycling, lifetime psychosis, number of suicide attempts, and a lower score in the Global Assessment of Functioning measure.

CONCLUSION

Our findings suggest that anxiety comorbidity in BD patients is related to lower quality of life, particularly on the psychological domain. BD-anxiety comorbidity may be associated with such markers of illness severity as number of suicide attempts, rapid cycling, lifetime alcohol abuse, and psychosis. The recognition and treatment of anxiety comorbidity may help patients with BD to relieve their psychological pain and improve their overall quality of life.

Serum neurotrophin-3 is increased during manic and depressive episodes in bipolar disorder

Accumulating evidence suggest that neural changes and cognitive impairment may accompany the course of bipolar disorder. Such detrimental effects of cumulative mood episodes may be related to changes in neurotrophins that take place during mood episodes but not during euthymic phases. The present study investigated serum neurotrophin-3 (NT-3) levels in patients with bipolar disorder during manic, depressed, and euthymic states, using an enzyme-linked immunosorbent assay (sandwich-ELISA). Serum NT-3 levels were increased in manic (p<0.001) and depressed (p<0.001) BD patients, as compared with euthymic patients and normal controls. These findings suggest that the NT-3 signaling system may play a role in the pathophysiology of BD.

Glycogen synthase kinase‐3 is required for optimalde novosynthesis of inositol

Studies have shown that the inositol biosynthetic pathway and the enzyme glycogen synthase kinase-3 (GSK-3) are targets of the mood-stabilizing drugs lithium and valproate. However, a relationship between these targets has not been previously described. We hypothesized that GSK-3 may play a role in inositol synthesis, and that loss of GSK-3 may lead to inositol depletion, thus providing a mechanistic link between the two drug targets. Utilizing a yeast Saccharomyces cerevisiae gsk-3Delta quadruple-null mutant, in which all four genes encoding homologues of mammalian GSK-3 are disrupted, we tested the hypothesis that GSK-3 is required for de novo inositol biosynthesis. The gsk-3Delta mutant exhibited multiple features of inositol depletion, including defective growth in inositol-lacking medium, decreased intracellular inositol, increased INO1 and ITR1 expression, and decreased levels of phosphatidylinositol. Treatment of wild-type cells with a highly specific GSK-3 inhibitor led to a significant increase in INO1 expression. Supplementation with inositol alleviated the temperature sensitivity of gsk-3Delta. Activity of myo-inositol-3 phosphate synthase, the rate-limiting enzyme in inositol de novo biosynthesis, was decreased in gsk-3Delta. These results demonstrate for the first time that GSK-3 is required for optimal myo-inositol-3 phosphate synthase activity and de novo inositol biosynthesis, and that loss of GSK-3 activity causes inositol depletion.

Transtornos mentais auto-referidos em estudantes universitários

OBJETIVOS: Verificar a prevalência de transtornos mentais auto-referidos entre estudantes de graduação, identificando os fatores demográficos e psicossociais associados. MÉTODOS: Foi realizado um estudo de corte transversal entre 2005 e 2006, com aplicação de um questionário anônimo e de autopreenchimento dentro de sala de aula, utilizando-se um tipo de amostra proporcional por áreas dos cursos. Foi analisado um total de 1.290 estudantes, de ambos os sexos, regularmente matriculados (períodos diurno e noturno) nos cursos das áreas de humanas, artes, profissões da saúde, ciências básicas, exatas e tecnológicas, nos campi de Campinas/SP e de Limeira/SP da Universidade Estadual de Campinas (Unicamp). O questionário utilizado abordou questões sobre o perfil sociodemográfico e saúde mental (por meio do instrumento padronizado M.I.N.I. - Mini International Neuropsychiatric Interview). Os dados foram submetidos à análise estatística e o nível de significância adotado foi de 5%. RESULTADOS: A prevalência de pelo menos um tipo de transtorno mental foi de 58%, sendo 69% em mulheres e 45% em homens. CONCLUSÕES: Este estudo revelou que estudantes do gênero feminino apresentam mais queixas de sofrimento mental e maiores dificuldades psicossociais.

Bipolar disorder: etiology, diagnosis, and management

PURPOSE

To review the epidemiology and disease characteristics of the bipolar disorder (BD) spectrum, render an accurate and timely diagnosis, and review treatment options through provider and patient collaboration.

DATA SOURCES

Comprehensive review of current scientific literature derived from electronic databases and professional medical references.

CONCLUSIONS

BD is a multifactorial disease that can interfere with cognition and behavior, causing a severe impact on patients and families. The variable course and often delayed diagnosis of this disorder can cause frustration for the patient and the healthcare provider. Because most undiagnosed patients with BD seek treatment within the primary care setting, it is imperative that clinicians become expert in the recognition of and intervention for this condition.

IMPLICATIONS FOR PRACTICE

The primary care provider is in a key position to render early diagnosis and treatment of BD. This disease should always be considered as part of the differential diagnosis for depression or anxiety. Nurse practitioners can be effective providers by using good nursing practices of communication, education, and advocacy for the patient and family. Knowledge of current diagnostic criteria and management is imperative for successful treatment of patients with BD.

Establishing a standardized therapeutic testing protocol for spinal muscular atrophy

Several mice models have been created for spinal muscular atrophy (SMA); however, there is still no standard preclinical testing system for the disease. We previously generated type III-specific SMA model mice, which might be suitable for use as a preclinical therapeutic testing system for SMA. To establish such a system and test its applicability, we first created a testing protocol and then applied it as a means to investigate the use of valproic acid (VPA) as a possible treatment for SMA. These SMA mice revealed tail/ear/foot deformity, muscle atrophy, poorer motor performances, smaller compound muscle action potential and lower spinal motoneuron density at the age of 9 to 12 months in comparison with age-matched wild-type littermate mice. In addition, VPA attenuates motoneuron death, increases spinal SMN protein level and partially normalizes motor function in SMA mice. These results suggest that the testing protocol developed here is well suited for use as a standardized preclinical therapeutic testing system for SMA.

[Lithium: 55 years of history in the therapy of bipolar affective disorder]

The clinical history of lithium began in mid-19th century when it was used to treat gout. It was subsequently administered as a substitute for sodium chloride and towards the end of 1940 its effects for the control of mania were discovered. At present it is used effectively for treatment of mania and for the prophylaxis of bipolar disorder. Though its effect on affective illnesses is evident, the same cannot be said of its mechanism of action, since in spite of the numerous studies performed to date it is still not known exactly how this ion acts. Many theories have been proposed, the most important of which are: normalisation of possible ionic alterations; interactions with the adenylyl cyclase cAMP system; effects on the phosphatidylinositol cycle; stabilisation of the levels of neuroprotective proteins; normalisation of the values of some cytosolic endopeptidases; etc. In any case, it has yet to be determined which of these is the principal factor responsible for lithium's therapeutic action, while at the same time the possibility cannot be totally ruled out that its precise mechanism of action is still to be discovered.

Do benzodiazepines extend the duration of follow-up treatment in patients with bipolar disorder?

INTRODUCTION

In patients with bipolar disorder, relapse and recurrence from the premature discontinuation of pharmacotherapy are serious clinical problems. Thus, clinicians must make every effort to ensure the sufficient duration of continual treatment even after the remission of acute episodes. Here, we examine whether there is any association between benzodiazepine (BZD) use and the duration of follow-up treatment in patients with bipolar disorder.

METHODS

The medical records of 70 bipolar patients hospitalized in a university hospital psychiatry ward were reviewed. Selected demographic and clinical variables, such as extent of BZD use and the total duration of outpatient follow-up treatment, were compared.

RESULTS

The duration of maintenance treatment at the outpatient department differed significantly between patients who were or were not given BZDs during admission (571 vs. 179 days) and after discharge (836 vs. 154 days). The variables that differed significantly between patients who received follow-up treatment for 6 or more months and those who did not was the number of days of BZD administration during admission (11 vs. 5 days) and after discharge (280 vs. 7 days), and years of education (11 vs. 13 years).

CONCLUSION

In the present study, BZDs are suggested as a possible adjunctive therapy for extending follow-up and thus preventing recurrence in patients with bipolar disorder.

Lipid connection to bipolar disorder

Bipolar disorder is a severe and chronic illness affecting approximately 1.5% of the American population. Despite the availability of mood bipolarstabilizers such as lithium, valproate, carbamazepine and lamotrigine, bipolar disorder is characterized by high rates of recurrence, as treatment with these and other drugs is ineffective for and not tolerated by a significant percentage of patients. Several hypotheses have been postulated to explain the mechanism(s) of action of mood stabilizers. However, the biological and molecular bases of the disease are not fully understood, hampering the development of more effective and safer drugs. A large body of evidence associates lipids (cholesterol, phospholipids and fatty acids) with the mechanism and pathology of bipolar disorder. The purpose of this paper is to review the lipid connection to bipolar disorder.

Lithium increases nerve growth factor levels in the rat hippocampus in an animal model of mania

Pharmacological studies suggest that neurotrophins may play a role in the effects of lithium and valproate on mood regulation. In this study, we tested the hypotheses that lithium and valproate would reverse and prevent the behavioral and biochemical effects of amphetamine, using a rat model of mania. In the reversal treatment, male Wistar rats were first administered D-amphetamine or saline for 14 days, and then, between days 8-14, rats were treated with lithium, valproate or saline. In the prevention treatment, rats were pretreated with lithium, valproate or saline, and then, between days 8-14, rats were administered D-amphetamine or saline. Locomotor behavior was assessed using the open-field task and hippocampal nerve growth factor levels were determined by enzyme-linked immunosorbent assay. Both lithium and valproate reversed and prevented D-amphetamine-induced hyperactivity. Lithium increased nerve growth factor content in rat hippocampus in both experiments, but this effect was blocked with the co-administration of D-amphetamine. No significant effects on nerve growth factor levels were observed with valproate or D-amphetamine alone. These findings suggest that nerve growth factor may play a role in the neurotrophic effects of lithium but do not support the hypotheses that the nerve growth factor/TrkA pathway is involved in the pathophysiology of bipolar disorder.

Bipolar depression: the importance of being on remission

OBJECTIVE: The aim of the present study is to compare quality of life among currently depressed, subsyndromal and remitted patients with bipolar disorder (BD) and to assess whether the level of depression correlates with the scores of quality of life in BD patients. METHOD: Sixty bipolar outpatients diagnosed using the Structured Clinical Interview for DSM-IV who met criteria for diagnosis of BD type I, II or not otherwise specified (BD-NOS), and who were not currently on a manic or mixed episode were included. The main variables of interest were quality of life (QOL) assessed using the 26-item World Health Organization QOL instrument (WHOQOL-BREF) and depression assessed using the 17-item Hamilton Depression Rating Scale (HDRS). RESULTS: A linear trend test showed a dose response association between patients' current mood state and all domains of quality of life. Higher quality of life scores were found among remitted patients, followed by subsyndromal patients; depressed patients presented lower scores of quality of life, except for the social domain. The four domains of the WHOQOL scale correlated negatively with the HDRS. CONCLUSIONS: Our findings suggest that bipolar depression and residual symptoms of depression are negatively correlated with QOL in BD patients.

Increased oxidative stress after repeated amphetamine exposure: possible relevance as a model of mania

BACKGROUND

Acute mania can be modeled in animals using D-amphetamine (AMPH). Acute AMPH injections are associated with monoamine depletion, loss of neurofilaments and neurite degeneration. However, the precise mechanisms underlying AMPH-induced neurotoxicity are still unclear. Several studies have demonstrated that oxidative stress may play a role in the behavioral and neurochemical changes observed after AMPH administration.

METHODS

The effects of a single and repeated injections (seven daily injections) of AMPH administered intraperitonially on locomotion and the production of lipid and protein oxidative markers in rat cortex, striatum and hippocampus were assessed. Locomotion was assessed in an open-field task and markers of oxidative stress were assessed in brain tissue.

RESULTS

Both single and repeated injections of AMPH increased protein carbonyl formation in rat brain. Repeated exposure to AMPH induced an additional increase in thiobarbituric acid reactive species in brain tissue.

CONCLUSIONS

Longer periods of exposure to AMPH were associated with increased oxidative stress in rat brain. This adds to the notion that repeated manic episodes may be associated with greater brain damage and, therefore, poorer outcomes.

Cytoprotection by lithium and valproate varies between cell types and cellular stresses

Despite much evidence that lithium and valproate, two commonly used mood stabilizers, exhibit neuroprotective properties against an array of insults, the pharmacological relevance of such effects is not clear because most of these studies examined the acute effect of these drugs in supratherapeutic doses against insults which were of limited disease relevance to bipolar disorder. In the present study, we investigated whether lithium and valproate, at clinically relevant doses, protects human neuroblastoma (SH-SY5Y) and glioma (SVG and U87) cells against oxidative stress and endoplasmic reticulum stress in a time-dependent manner. Pretreatment of SH-SY5Y cells for 7 days, but not 1 day, with 1 mM of lithium or 0.6 mM of valproate significantly reduced rotenone and H2O2-induced cytotoxicity, cytochrome c release and caspase-3 activation, and increased Bcl-2 levels. Conversely, neither acute nor chronic treatment of SH-SY5Y cells with lithium or valproate elicited cytoprotective responses against thapsigargin-evoked cell death and caspase-3 activation. Moreover, inhibitors of glycogen synthase kinase-3 (GSK-3), kenpaullone and SB216763, abrogated rotenone-induced, but not H2O2-induced, cytotoxicity. Thus the cytoprotective effects of lithium and valproate against H2O2-induced cell death is likely independent of GSK-3 inhibition. On the other hand, chronic lithium or valproate treatment did not ameliorate cytotoxicity induced by rotenone, H2O2, and thapsigargin in SVG astroglial and U87 MG glioma cell lines. Our results suggest that lithium and valproate may decrease vulnerability of human neural, but not glial, cells to cellular injury evoked by oxidative stress possibly arising from putative mitochondrial disturbances implicated in bipolar disorder.

Effects of mood stabilizers on hippocampus BDNF levels in an animal model of mania

There is an emerging body of data suggesting that mood disorders are associated with decreased brain-derived neurotrophic factor (BDNF). The present study aims to investigate the effects of the mood stabilizers lithium (Li) and valproate (VPT) in an animal model of bipolar disorder. In the first experiment (acute treatment), rats were administered D-amphetamine (AMPH) or saline for 14 days, and then between day 8 and 14, rats were treated with either Li, VPT or saline. In the second experiment (maintenance treatment), rats were pretreated with Li, VPT or saline, and then between day 8 and 14, rats were administered AMPH or saline. In both experiments, locomotor activity was measured using the open-field test and BDNF levels were measured in rat hippocampus by sandwich-ELISA. Li and VPT reversed AMPH-induced behavioral effects in the open-field test in both experiments. In the first experiment, Li increased BDNF levels in rat hippocampus. In the second experiment, AMPH decreased BDNF levels and Li and VPT increased BDNF levels in rat hippocampus. Our results suggest that the present model fulfills adequate face, construct and predictive validity as an animal model of mania.

Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder

BACKGROUND

Preliminary evidence suggests that valproate is associated with isolated features of polycystic ovarian syndrome (PCOS), while contradictory data support an association between epilepsy and PCOS. The development of PCOS features after initiation of valproate was therefore examined in women with bipolar disorder using a standardized definition of PCOS.

METHODS

Three hundred women 18 to 45 years old with bipolar disorder were evaluated for PCOS at 16 Systematic Treatment Enhancement for Bipolar Disorder sites. A comparison was made between the incidence of hyperandrogenism (hirsutism, acne, male-pattern alopecia, elevated androgens) with oligoamenorrhea that developed while taking valproate versus other anticonvulsants (lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine) and lithium. Medication and menstrual cycle histories were obtained, and hyperandrogenism was assessed.

RESULTS

Among 230 women who could be evaluated, oligoamenorrhea with hyperandrogenism developed in 9 (10.5%) of 86 women on valproate and in 2 (1.4%) of 144 women on a nonvalproate anticonvulsant or lithium (relative risk 7.5, 95% confidence interval [CI] 1.7-34.1, p = .002). Oligoamenorrhea always began within 12 months of valproate use.

CONCLUSIONS

Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism. Monitoring for reproductive-endocrine abnormalities is important when starting and using valproate in reproductive-aged women. Prospective studies are needed to elucidate risk factors for development of PCOS on valproate.

The extracellular signal-regulated kinase pathway: an emerging promising target for mood stabilizers

PURPOSE OF REVIEW

There exists a growing appreciation that, though not classical neurodegenerative disorders, severe mood disorders are associated with regional impairments of structural plasticity and cellular resilience. Exciting recent data suggest that synaptic plasticity probably is involved in mechanisms of actions of mood stabilizers and antidepressants. Notably, the extracellular signal-regulated kinase pathway is a critical 'plasticity pathway' in the brain. The present review summarizes neurobiological, pharmacological, and behavioral data on the role of the extracellular signal-regulated kinase pathway in regulating some of the symptoms of bipolar disorder and as a therapeutically relevant target for mood stabilizers.

RECENT FINDINGS

The extracellular signal-regulated kinase pathway is known to mediate neurotrophic actions and synaptic plasticity. Treatment with lithium and valproate activates the extracellular signal-regulated kinase pathway in cultured cells and in prefrontal cortex and hippocampus. In addition, lithium or valproate treatment promotes neurogenesis, neurite growth, and cell survival. The extracellular signal-regulated kinase pathway is also targeted by antipsychotics. Modulation of the central nervous system extracellular signal-regulated kinase pathway induces animal behavioral alterations reminiscent of manic symptoms; these complex behaviors probably depend on the effects of extracellular signal-regulated kinase on discrete brain regions and the presence of other interacting molecules.

SUMMARY

The extracellular signal-regulated kinase pathway may represent a novel target for the development of improved therapeutics for bipolar disorder.

Serum brain-derived neurotrophic factor is decreased in bipolar disorder during depressive and manic episodes

Genetic and pharmacological studies have suggested that brain-derived neurotrophic factor (BDNF) may be associated with the pathophysiology of bipolar disorder (BD). The present study investigated serum BDNF levels in manic, depressed, euthymic BD patients and in matched healthy controls, using an enzyme-linked immunosorbent assay (sandwich-ELISA). Serum BDNF levels were decreased in manic (p=0.019) and depressed (p=0.027) BD patients, as compared with euthymic patients and controls. Serum BDNF levels were negatively correlated with the severity of manic (r=-0.37, p=0.005) and depressive (r=-0.30, p=0.033) symptoms. These findings further support the hypothesis that the BDNF signaling system may play a role in the pathophysiology of BD.

Inositol phosphates and phosphoinositides in health and disease

In the past two decades, considerable progress has been made toward understanding inositol phosphates and PI metabolism. However, there is still much to learn. The present challenge is to understand how inositol phosphates and PIs are compartmentalized, identify new targets of inositol phosphates and PIs, and elucidate the mechanisms underlying spatial and temporal regulation of the enzymes that metabolize inositol phosphates and PIs. Answers to these questions will help clarify the mechanisms of the diseases associated with these molecules and identify new possibilities for drug design.

Incurring greater health care costs: risk stratification of employees with bipolar disorder

PURPOSE

To compare the costs of employees with bipolar disorder with other employee cohorts and to assess cost differences among employees with bipolar disorder of varying severity.

METHODS

Retrospective data analysis comparing employees with bipolar disorder (cohort 1) with employees without bipolar disorder (cohort 2), employees with other mental disorders (cohort 3), and employees with no mental disorders (cohort 4). Sick leave, short-term disability, long-term disability, and workers' compensation data were used to compare annual lost time and work-absence costs from January 1, 2001, through December 31, 2002. For bipolar disorder severity and risk stratification, quintiles were identified based on total medical and prescription drug costs and analyzed for many health benefits cost categories.

RESULTS

Cohort 1 was the most costly in nearly every health benefits cost category. All comparisons between cohort 1 and cohorts 2, 3, and 4 yielded significant (p ≤ .05) differences except for sick leave costs in cohorts 1 and 3. The aggregate health benefits costs for the highest-cost cohort 1 quintile were $70,616, or 21 times greater than the health benefits costs for the lowest-cost quintile ($3385). Medical comorbidity costs accounted for most of this difference ($51,495; p ≤ .05).

CONCLUSION

Employees with bipolar disorder are the most costly in nearly every health benefits category, with a small minority (2.4%) accounting for 20% of the costs. Employers need to identify and target high-risk ("high cost") employees with bipolar disorder and coexisting conditions that use resources more frequently for appropriate interventions that may include early screening and diagnosis, appropriate treatment, and/or behavioral strategies for improved adherence. These strategies have the potential to improve quality of patient care and reduce costs.

Chronic lithium treatment decreases tau lesions by promoting ubiquitination in a mouse model of tauopathies

Lithium, a widely used drug for treating affective disorders, is known to inhibit glycogen synthase kinase-3 (GSK-3), which is one of the major tau kinases. Thus, lithium could have therapeutic benefit in neurodegenerative tauopathies by reducing tau hyperphosphorylation. We tested this hypothesis and showed that long-term administration of lithium at relatively low therapeutic concentrations to transgenic mice that recapitulate Alzheimer's disease (AD)-like tau pathologies reduces tau lesions, primarily by promoting their ubiquitination rather than by inhibiting tau phosphorylation. These findings suggest novel mechanisms whereby lithium treatment could ameliorate tauopathies including AD. Because lithium also has been shown to reduce the burden of amyloid-beta pathologies, it is plausible that lithium could reduce the formation of both amyloid plaques and tau tangles, the two pathological hallmarks of AD, and thereby ameliorate the behavioral deficits in AD.

Review and meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents

OBJECTIVE

Using predetermined criteria for study quality and methods, a literature review and meta-analysis of seven reports about pediatric bipolar disorder (BPD) was conducted to determine if there is a consistent picture of the phenomenology and clinical characteristics of BPD in children and adolescents.

METHODS

Searches were conducted in MedLine and PsycINFO using the terms mania, BPD, children and adolescents, and was limited to published articles in peer-reviewed journals. Seven reports were selected that met the following criteria: a systematic method for the elicitation and reporting of symptoms and clinical characteristics of subjects; subjects were interviewed by a trained researcher or clinician; ages 5-18 years; use of a diagnostic system, either DSM or RDC for categorization; a consensus method for the establishment of the diagnosis of BPD.

RESULTS

Most DSM-IV symptoms of mania were common in the children and adolescents with BPD with the most common symptoms being increased energy, distractibility, and pressured speech. On average, four of five bipolar cases also showed threshold levels of irritable mood and grandiosity, and more than 70% of all cases showed elated/euphoric mood, decreased need for sleep, or racing thoughts. Roughly 69% of cases also showed poor judgment, whereas only half of bipolar cases demonstrated flight of ideas, and slightly more than one-third showed hypersexuality or psychotic features.

CONCLUSIONS

The clinical picture that emerges is that of children or adolescents with periods of increased energy (mania or hypomania), accompanied by distractibility, pressured speech, irritability, grandiosity, racing thoughts, decreased need for sleep and euphoria/elation.

Lost Time, Absence Costs, and Reduced Productivity Output for Employees With Bipolar Disorder

OBJECTIVE

We sought to evaluate the incremental health-related lost work time and at-work productivity loss for employees with bipolar disorder (BPD).

METHODS

Health-related absence and real productivity output of employees with BPD were compared with that of non-BPD and other employee cohorts from a large employer database using multivariate regression to control for cohort differences.

RESULTS

After adjusting for confounding factors, employees with BPD had significantly higher absence costs (1,219 dollars) and 11.5 additional lost days (P<0.05) per year than those without BPD. Adjusted annual productivity output was 20% lower for the BPD group (P<0.05).

CONCLUSIONS

Employees with BPD are less likely to be present for work. When present, their productivity level is similar to that of other employees, but over the course of a year, their absence rates result in significant productivity losses.

Pain complaints in adolescent patients with affective disorders versus adolescent psychiatric controls

OBJECTIVE

To ascertain the frequencies of 4 prospectively determined pain complaints among adolescents meeting the criteria for major depressive episode (MDE) relative to non-affectively ill controls.

METHOD

In a community mental health clinic for the indigent situated on the border of the United States and Mexico (Rio Grande City, Tex.), adolescents (age range, 12-17 years) who consecutively presented to the clinic from August 2001 to November 2003 received structured psychiatric diagnostic screens for depression and mania using the modules from the DSM-IV. Subsequently, all subjects were asked whether they had had significant (distressing or bothersome) backache, abdominal pain, headaches, or myalgia in the last 7 days. We compared patients meeting the criteria for MDE with individuals without affective symptomatology. Significance of the differences between groups was assessed using the Fisher exact test and multivariate logistic regression analysis. The odds ratios were adjusted for age and sex.

RESULTS

One hundred thirty-two subjects met the criteria for MDE. Forty-eight had non-affective disorders. Seventy-six percent of the subjects meeting the criteria for MDE had at least 1 pain complaint compared to 33% of the control subjects (p < .0001). Fifty percent of the subjects in the midst of a MDE had at least 2 pain complaints compared to 6% of the control subjects (p < .0001). Twenty-nine percent of the subjects in the midst of a MDE had at least 3 pain complaints compared to 2% of the control subjects (p < .0001). Fourteen percent of the subjects in the midst of a MDE had all 4 pain complaints compared to none of the control subjects (p = .002). The odds ratio of subjects with a MDE having a pain complaint relative to control subjects was 5.8 (p < .0001).

CONCLUSION

That in excess of three fourths of clinically depressed adolescents had 1 or more pain complaints has important implications for adolescent psychiatry and primary care, as well as somatic medicine.

Mitochondrial dysfunction in bipolar disorder: evidence from magnetic resonance spectroscopy research

Magnetic resonance spectroscopy (MRS) affords a noninvasive window on in vivo brain chemistry and, as such, provides a unique opportunity to gain insight into the biochemical pathology of bipolar disorder. Studies utilizing proton ((1)H) MRS have identified changes in cerebral concentrations of N-acetyl aspartate, glutamate/glutamine, choline-containing compounds, myo-inositol, and lactate in bipolar subjects compared to normal controls, while studies using phosphorus ((31)P) MRS have examined additional alterations in levels of phosphocreatine, phosphomonoesters, and intracellular pH. We hypothesize that the majority of MRS findings in bipolar subjects can be fit into a more cohesive bioenergetic and neurochemical model of bipolar illness that is both novel and yet in concordance with findings from complementary methodological approaches. In this review, we propose a hypothesis of mitochondrial dysfunction in bipolar disorder that involves impaired oxidative phosphorylation, a resultant shift toward glycolytic energy production, a decrease in total energy production and/or substrate availability, and altered phospholipid metabolism.

Valproic acid induces extracellular signal-regulated kinase 1/2 activation and inhibits apoptosis in endothelial cells

The histone deacetylase (HDAC) inhibitor valproic acid (VPA) was recently shown to inhibit angiogenesis, but displays no toxicity in endothelial cells. Here, we demonstrate that VPA increases extracellular signal-regulated kinase 1/2 (ERK 1/2) phosphorylation in human umbilical vein endothelial cells (HUVEC). The investigation of structurally modified VPA derivatives revealed that the induction of ERK 1/2 phosphorylation is not correlated to HDAC inhibition. PD98059, a pharmacological inhibitor of the mitogen-activated protein kinase kinase 1/2, prevented the VPA-induced ERK 1/2 phosphorylation. In endothelial cells, ERK 1/2 phosphorylation is known to promote cell survival and angiogenesis. Our results showed that VPA-induced ERK 1/2 phosphorylation in turn causes phosphorylation of the antiapoptotic protein Bcl-2 and inhibits serum starvation-induced HUVEC apoptosis and cytochrome c release from the mitochondria. Moreover, the combination of VPA with PD98059 synergistically inhibited angiogenesis in vitro and in vivo.

Extended-release carbamazepine capsules : in bipolar I disorder

An extended-release capsule formulation of carbamazepine is approved for use in adult patients experiencing an acute manic or mixed episode associated with bipolar I disorder. A capsule of extended-release carbamazepine contains three types of bead: immediate release, extended release and enteric release, constituting 25%, 40% and 35% of the dose, respectively.black triangle Extended-release carbamazepine capsules 200--1600 mg/day demonstrated superior antimanic efficacy to placebo in two 3-week, well designed trials in adult patients with bipolar I disorder and acute manic or mixed episodes. At study end, reductions from baseline in Young Mania Rating Scale scores were significantly greater with carbamazepine than with placebo (primary endpoint). The active treatment was effective from the end of the first week of treatment (post hoc analysis).black triangle In the 3-week trials and a 6-month extension study, most treatment-emergent adverse events observed with extended-release carbamazepine were of mild or moderate severity. In the 3-week trials, although significantly greater reductions in white blood cell count occurred with extended-release carbamazepine than with placebo, only one case of leukopenia was deemed serious. There were no reports of agranulocytosis or aplastic anaemia with up to 6 months' treatment.

Unmasking of brugada syndrome by lithium

BACKGROUND

The characteristic ECG pattern of ST-segment elevation in V1 and V2 in the Brugada syndrome is dynamic; it is often intermittently present in affected individuals and can be unmasked by sodium channel blockers, including antiarrhythmic drugs and tricyclic antidepressants. We report here 2 patients who developed the Brugada ECG pattern after administration of lithium, a commonly used drug not previously reported to block cardiac sodium channels.

METHODS AND RESULTS

Lithium induced transient ST-segment elevation (type 1 Brugada pattern) in right precordial leads at therapeutic concentrations in 2 patients with bipolar disorder. Lithium withdrawal in the patients resulted in reversion to type 2 or 3 Brugada patterns or resolution of ST-T abnormalities. In Chinese hamster ovary cells transfected with SCN5A, which encodes the cardiac sodium channel, lithium chloride caused concentration-dependent block of peak INa at levels well below the therapeutic range (IC50 of 6.8+/-0.4 micromol/L).

CONCLUSIONS

The widely used drug lithium is a potent blocker of cardiac sodium channels and may unmask patients with the Brugada syndrome.

Calbindin D28k targets myo-inositol monophosphatase in spines and dendrites of cerebellar Purkinje neurons

The Ca(2+)-binding protein calbindin D28k (CB) is vital for the normal function of the central nervous system but its specific functional role is largely unclear. CB is typically described as a mobile Ca(2+)buffer that shapes the spatiotemporal extent of cellular Ca(2+)signals. Recent biochemical data, however, indicate that CB also has characteristics of a Ca(2+) sensor and activates myo-inositol monophosphatase (IMPase), a key enzyme of the inositol-1,4,5-trisphosphate signaling cascade and an assumed target of mood-stabilizing drugs in the treatment of bipolar disorder. Here, we show that CB interacts with IMPase in cerebellar Purkinje neurons, a cell type well known to rely on inositol-1,4,5-trisphosphate-dependent synaptic integration. Quantification of the mobility of dye-labeled CB with two-photon fluorescence recovery after photobleaching revealed that a substantial fraction of CB is immobilized in spines and dendrites, but not in axons. Immobilization occurs over several seconds, is increased by suprathreshold synaptic activity, and can be relieved by a synthetic peptide that resembles the putative CB-binding site of IMPase, indicating that CB binds to immobilized IMPase. Measurements of the apparent diffusion coefficients of CB imply that CB does not interact with cytosolic IMPase or that the latter is present only in minute amounts in the spiny dendrites of Purkinje neurons. Our results suggest that CB acts as an activity-dependent sensor that targets membrane/cytoskeleton-bound IMPase in central neurons.

Oral lichenoid drug reaction by lithium in a patient with bipolar disorder

Bipolar disorder (BD) is a psychiatric disease characterized by recurrent and alternated episodes of depression and mania. For the treatment of BD, anticonvulsants drugs as lithium, carbamazepine and oxcarbazepine can be used. These drugs can be associated with potential adverse effects: weight gain, tremors, thyroid abnormalities, and cognitive, gastrointestinal, cardiac or dermatological problems. We describe a case of BD with oral lichenoid drug reaction probably because of the mood stabilizers.