Risk for Mood, Anxiety, and Psychotic Disorders in Individuals at High and Low Genetic Liability for Bipolar Disorder and Major Depression

Parental psychopathology and offspring anxiety disorders in childhood and adolescence: A Finnish nationwide register study

BACKGROUND

Research suggests an association between parental psychiatric disorders and offspring anxiety disorders, yet comprehensive studies are limited. This study aims to investigate the associations between various parental psychiatric disorders and anxiety disorders in their offspring.

METHOD

Using Finnish register data, this nested case-control study analyzed 867,175 singleton live births from 1992 to 2006, identifying 21,671 cases of anxiety disorders diagnosed between 1998 and 2016. Matched with four controls each (n = 72,414) based on age and biological sex, the study adjusted for demographic and prenatal factors using conditional logistic regression models to calculate odds ratios (aORs).

RESULTS

There was a significant association between parental psychiatric disorders and increased risk of anxiety disorders in offspring. The risk was notably higher when both parents had psychiatric disorders (aOR = 5.04; 95 % CI, 4.70-5.39; p < .001). Maternal psychiatric disorders were strongly associated with offspring anxiety than paternal disorders (aOR 1.52; 95 % CI 1.43-1.61; p < .001). This association was consistent regardless of timing of parental diagnosis. Significant associations were observed between any parental psychiatric disorder and increased risks in offspring for specific phobia, social phobia, generalized anxiety disorder, separation anxiety, and panic disorder. Maternal psychiatric disorders showed elevated risk for panic disorder and social phobia among girls and separation anxiety and generalized anxiety among boys.

CONCLUSION

The findings emphasize the significant impact of parental psychiatric health on offspring anxiety disorders, highlighting the influence of genetic and environmental factors. Addressing parental mental health is crucial in preventing childhood anxiety disorders.

Alcohol use disorder and risk of specific methods of suicide death in a national cohort

INTRODUCTION

Alcohol use disorder (AUD) is among the strongest correlates of suicide death, but it is unclear whether AUD status is differentially associated with risk of suicide by particular methods.

METHODS

The authors used competing risks models to evaluate the association between AUD status and risk of suicide by poisoning, suffocation, drowning, firearm, instruments, jumping, or other means in a large Swedish cohort born 1932-1995 (total N = 6,581,827; 48.8% female). Data were derived from Swedish national registers, including the Cause of Death Register and a range of medical registers.

RESULTS

After adjusting for sociodemographic factors and familial liability to suicidal behavior, AUD was positively associated with risk of suicide for each method evaluated (cumulative incidence differences: 0.006-1.040 for females, 0.046-0.680 for males), except the association with firearm suicide in females. AUD was most strongly associated with risk of suicide by poisoning. Sex differences in the effects of AUD and family liability were observed for some, but not all, methods. Furthermore, high familial liability for suicidal behavior exacerbated AUD's impact on risk for suicide by poisoning (both sexes) and suffocation and jumping (males only), while the inverse interaction was observed for firearm suicide (males only).

CONCLUSIONS

AUD increases risk of suicide by all methods examined and is particularly potent with respect to risk of suicide by poisoning. Differences in risk related to sex and familial liability to suicidal behavior underscore AUD's nuanced role in suicide risk. Future research should investigate targeted means restriction effectiveness among persons with AUD.

Risk of suicidal behavior as a function of alcohol use disorder typologies: A Swedish population-based study

BACKGROUND AND AIMS

Alcohol use disorder (AUD) is one of the strongest predictors of suicidal behavior. Here, we measured risk of suicide attempt and death as a function of AUD typologies.

DESIGN

We used AUD typologies from previous latent class analysis: (i) externalizing subtype (characterized by externalizing symptomatology and early age of onset; individuals in this group have lower education and higher familial/social difficulties); (ii) subtype described by minimal psychopathology; and (iii) internalizing subtype (characterized by internalizing symptomatology and later age of onset; individuals in this group have higher education). We used class membership to predict distal outcomes (attempt and death) and performed regressions to evaluate whether differences in suicidal behavior were explained by the group characteristics (sex, age of onset, number and type of AUD registrations, familial/genetic risk for AUD, externalizing and internalizing behaviors, socio-economic indicators, marital status and childhood family status). We also evaluated the effect of suicide attempt prior to AUD.

SETTING AND PARTICIPANTS

Based on longitudinal Swedish registry data, we included 217 074 individuals with AUD born 1950-80.

MEASUREMENTS

Suicide attempts were identified using medical registers and deaths using the mortality register.

FINDINGS

Individuals with the externalizing subtype had higher risks of suicidal behavior than other groups [attempt: externalizing versus minimal psychopathology: odds ratio (OR) = 1.35, 95% confidence interval (CI) = 1.35, 1.35; externalizing versus internalizing: OR = 1.47, 95% CI = 1.46, 1.48; death: externalizing versus minimal psychopathology: OR = 1.57, 95% CI = 1.57, 1.58; externalizing versus internalizing: OR = 1.99, 95% CI = 1.93, 2.06]. Individuals with minimal psychopathology had higher risks than those with internalizing symptomatology (attempt: OR = 1.09, 95% CI = 1.08, 1.10, death: OR = 1.26, 95% CI = 1.23, 1.30). These differences were explained by age at registration and were related to the number of registrations, sex, education, family disruption and suicide attempt prior to AUD.

CONCLUSIONS

Among people in Sweden, considering alcohol use disorder (AUD) heterogeneity appears to be a meaningful way to evaluate suicide risk. The highest risk of suicide attempt and death occurs in the externalizing subtype of AUD, followed by the minimal psychopathology subtype, and then the internalizing subtype.

The Nature of the Familial Risk for Psychosis in Bipolar Disorder

BACKGROUND AND HYPOTHESIS

To clarify whether the familial liability to psychosis associated with bipolar disorder (BD) is nonspecific or has a greater effect on risk for psychosis in cases with prominent mood symptoms and/or a remitting course.

STUDY DESIGN

We examined, in 984 809 offspring raised in intact families in Sweden, born 1980-1996 and followed-up through 2018, by multivariable Cox proportional hazards regression, risk in offspring of parents with BD for 7 psychotic disorders: Psychotic MD (PMD), psychotic BD (PBD), schizoaffective disorder (SAD), acute psychoses, psychosis NOS, delusional disorder (DD) and schizophrenia (SZ). Diagnoses were obtained from national registers.

STUDY RESULTS

In the offspring of BD parents, the hazard ratios (HR) for these 7 disorders formed an inverted U-shaped curve, rising from 2.98 for PMD, to peak at 4.49 for PBD and 5.25 for SAD, and then declining to a HR of 3.48 for acute psychoses and 3.22 for psychosis NOS, to a low of 2.19 for DD and 2.33 for SZ. A similar pattern of risks was seen in offspring of mothers and fathers affected with BD and in offspring predicted from age at onset in their BD parent.

CONCLUSIONS

The BD-associated risk for psychosis impacts most strongly on mood disorders, moderately on episodic psychotic syndromes, and least on chronic psychotic disorders. These results support prior clinical studies suggesting a qualitative difference in the familial substrate for psychosis occurring in BD and SZ.

Predictors of diagnostic conversion from major depression to bipolar disorder: a Swedish national longitudinal study

BACKGROUND

It is clinically important to predict the conversion of major depression (MD) to bipolar disorder (BD). Therefore, we sought to identify related conversion rates and risk factors.

METHODS

This cohort study included the Swedish population born from 1941 onward. Data were collected from Swedish population-based registers. Potential risk factors, including family genetic risk scores (FGRS), which were calculated based on the phenotypes of relatives in the extended family and not molecular data, and demographic/clinical characteristics from these registers were retrieved. Those with first MD registrations from 2006 were followed up until 2018. The conversion rate to BD and related risk factors were analyzed using Cox proportional hazards models. Additional analyses were performed for late converters and with stratification by sex.

RESULTS

The cumulative incidence of conversion was 5.84% [95% confidence interval (95% CI) 5.72-5.96] for 13 years. In the multivariable analysis, the strongest risk factors for conversion were high FGRS of BD [hazard ratio (HR) = 2.73, 95% CI 2.43-3.08], inpatient treatment settings (HR = 2.64, 95% CI 2.44-2.84), and psychotic depression (HR = 2.58, 95% CI 2.14-3.11). For late converters, the first registration of MD during the teenage years was a stronger risk factor when compared with the baseline model. When the interactions between risk factors and sex were significant, stratification by sex revealed that they were more predictive in females.

CONCLUSIONS

Family history of BD, inpatient treatment, and psychotic symptoms were the strongest predictors of conversion from MD to BD.

The Interrelationship of the Genetic Risks for Different Forms of Substance Use Disorder in a Swedish National Sample: A Top-Down Genetic Analysis

OBJECTIVE

The purpose of this study was to determine, using a top-down genetic analysis, the degree of specificity of the genetic risk factors for individual forms of substance use disorders (SUD).

METHOD

We examined and followed to December 31, 2018, all individuals born in Sweden between 1960 and 1990 (N = 2,772,752) diagnosed with any of the following six SUDs: alcohol use disorder (AUD), drug use disorder (DUD), or one of four specific forms of DUD involving cannabis (CUD), cocaine and other stimulants (CSUD), opioids (OUD), or sedatives (SeUD). We examined population subsamples at high versus median genetic liability to each of these SUDs. In those samples, we then examined the prevalence of our SUDs in the high versus median liability groups, expressed as a tetrachoric correlation. Genetic liability was assessed by a family genetic risk score.

RESULTS

All SUDs were concentrated in those at high versus median risk for all six groups. DUD, CUD, and CSUD showed modest genetic specificity in that they were more concentrated in samples with high genetic liability to each of them than were other SUDs. The differences, however, were modest. No evidence for genetic specificity was seen for AUD, OUD, and SeUD, as other disorders were equally or more concentrated in those at high versus median genetic risk for that form of SUD.

CONCLUSIONS

Individuals at high genetic risk for particular forms of SUD typically had elevated rates for all forms of SUDs, consistent with the nonspecificity of much of SUD genetic liability. Evidence of specificity of genetic risk for particular forms of SUD was noted but was quantitatively modest.

Burning down the house: reinventing drug discovery in psychiatry for the development of targeted therapies

Despite advances in neuroscience, limited progress has been made in developing new and better medications for psychiatric disorders. Available treatments in psychiatry rely on a few classes of drugs that have a broad spectrum of activity across disorders with limited understanding of mechanism of action. While the added value of more targeted therapies is apparent, a dearth of pathophysiologic mechanisms exists to support targeted treatments, and where mechanisms have been identified and drugs developed, results have been disappointing. Based on serendipity and early successes that led to the current drug armamentarium, a haunting legacy endures that new drugs should align with outdated and overinclusive diagnostic categories, consistent with the idea that "one size fits all". This legacy has fostered clinical trial designs focused on heterogenous populations of patients with a single diagnosis and non-specific outcome variables. Disturbingly, this approach likely contributed to missed opportunities for drugs targeting the hypothalamic-pituitary-adrenal axis and now inflammation. Indeed, cause-and-effect data support the role of inflammatory processes in neurotransmitter alterations that disrupt specific neurocircuits and related behaviors. This pathway to pathology occurs across disorders and warrants clinical trial designs that enrich for patients with increased inflammation and use primary outcome variables associated with specific effects of inflammation on brain and behavior. Nevertheless, such trial designs have not been routinely employed, and results of anti-inflammatory treatments have been underwhelming. Thus, to accelerate development of targeted therapeutics including in the area of inflammation, regulatory agencies and the pharmaceutical industry must embrace treatments and trials focused on pathophysiologic pathways that impact specific symptom domains in subsets of patients, agnostic to diagnosis. Moreover, closer collaboration among basic and clinical investigators is needed to apply neuroscience knowledge to reveal disease mechanisms that drive psychiatric symptoms. Together, these efforts will support targeted treatments, ultimately leading to new and better therapeutics in psychiatry.