Staging in bipolar disorder: from theoretical framework to clinical utility

Clinical Staging for Personality Disorders in Older Adults

OBJECTIVE

This scientific research aimed to investigate the feasibility of implementing a clinical staging (CS) model for personality disorders (PDs) in older adults. The CS model could provide valuable insights into the life course of personality pathology, prognosis, and treatment decisions for PDs in older adults.

METHODS/DESIGN

The study employed an international Delphi methodology with three rounds and involved 21 experts.

RESULTS

Consensus was achieved on 12 out of 17 statements, confirming the viability of a CS model for PDs in older adults. The proposed model incorporates the Alternative Model for PDs, criterion A, and integrates life course information, distinguishing between chronic PD, re-emergent PD, late-onset PD, and past PD.

CONCLUSION

The findings suggest that international experts support the implementation of a CS model for PDs in older adults, considering both the severity of personality functioning and the retrospective life course of PD expression.

Prodromal symptoms of a first manic episode: a qualitative study to the perspectives of patients with bipolar disorder and their caregivers'

BACKGROUND

Diagnosing bipolar disorder (BD) is challenging, and adequate treatment is of major importance to minimalize the consequences of the illness. Early recognition is one way to address this. Although in clinical research the prodromal phase of BD is gaining interest, the perspective of patients with BD and their caregivers on prodromal symptoms is still lacking. The aim of this study is to gain insights in prodromal symptoms of patients with BD and their caregivers before the onset of a first manic episode.

METHODS

A qualitative research method was used to investigate prodromal symptoms one year prior to a first manic episode. In-depth interviews were conducted with patients with BD type I and their caregivers. Only patients with a first manic episode in the previous five years were included.

RESULTS

The prodromal symptoms from patients' and caregivers' perspectives could be clustered into seven themes, with underlying subthemes: behavior (increased activity, destructive behavior, disinhibited behavior, inadequate behavior, changes in appearance), physical changes (changes in sleep, physical signals, differences in facial expression), communication (reciprocity, process, changes in use of social media), thought (process and content), cognition (changes in attention and concentration, forgetfulness), emotions (positive emotions, more intense emotions, mood swings), and personality (more pronounced manifestation of existing personality traits).

CONCLUSION

Patients with bipolar I disorder and their caregivers described subsyndromal manic features one year prior to a first manic episode. In addition, they recognized mood lability, physical changes and more pronounced manifestation of existing personality traits. The results of this study confirm the presence of a prodromal phase. In clinical practice, monitoring of prodromal symptoms of BD can be useful in patients with depression, especially those with a familial risk of BD.

Who benefits from digital interventions for bipolar disorder? Stage of illness characteristics as predictors of changes in quality of life

OBJECTIVES

This study explored the potential role of stage-related variables in intervention outcomes in bipolar disorder (BD). Specifically, we aimed to identify which subgroups of individuals were most likely to experience improved quality of life following digitally delivered psychosocial interventions for BD.

METHODS

The study involved a secondary analysis of combined data from two randomised control trials (RCTs). Each trial assessed the effectiveness of digitally delivered interventions for improving quality of life, in late-stage (ORBIT RCT) or early-stage (BETTER RCT) BD. Three iterations of cluster analyses were performed, identifying subgroups of individuals based on (i) current phenomenology, (ii) course of illness and (iii) medication response. The resultant subgroups were compared with regard to changes in quality of life pre-post intervention, via repeated measures ANOVAs.

RESULTS

In each cluster analysis, two clusters were found. The current phenomenology clusters reflected two impairment levels, 'moderate impairment' and 'low impairment'. The course of illness clusters reflected 'more chronicity' and 'less chronicity' and the medication response clusters reflected 'good medication response' and 'poor medication response'. Differences in changes in quality of life over time were observed between the two current phenomenology clusters and between the medication response clusters, while the course of illness subgroups did not respond differently.

CONCLUSIONS

There are at least two distinct groups of treatment-seeking individuals with established BD, based on illness features with previously established links to different illness stages. Clusters within the current phenomenology and medication response domains demonstrated significantly different trajectories of QoL change over time in the context of our interventions, highlighting potential implications for treatment selection aligned with precision psychiatry.

Putative Risk Biomarkers of Bipolar Disorder in At-risk Youth

Bipolar disorder is a highly heritable and functionally impairing disease. The recognition and intervention of BD especially that characterized by early onset remains challenging. Risk biomarkers for predicting BD transition among at-risk youth may improve disease prognosis. We reviewed the more recent clinical studies to find possible pre-diagnostic biomarkers in youth at familial or (and) clinical risk of BD. Here we found that putative biomarkers for predicting conversion to BD include findings from multiple sample sources based on different hypotheses. Putative risk biomarkers shown by perspective studies are higher bipolar polygenetic risk scores, epigenetic alterations, elevated immune parameters, front-limbic system deficits, and brain circuit dysfunction associated with emotion and reward processing. Future studies need to enhance machine learning integration, make clinical detection methods more objective, and improve the quality of cohort studies.

Characterization and assessment of executive functions through a virtual cooking task in euthymic patients with bipolar disorder

Bipolar disorder (BD)1 implies impairments in executive functions during euthymia that interfere in psychosocial functioning. Virtual reality assessments may confer advantages respect to traditional assessments in terms of efficiency and ecological validity. The aim of this study was to validate a novel Virtual Cooking Task (VCT) for executive functions assessment in euthymic patients with BD. This is a cross-sectional study in which a group of BD patients (n = 42) and healthy controls (n = 42) were assessed with the VCT and a battery of computerized standard tasks (CST). Additionally, the influence on psychosocial functioning of both forms of assessment, measured with the FAST, was investigated to check ecological validity. In BD group significant impairments in interference, working memory and sustained attention were found in CST and VCT respect to controls. However, deficits in planning and problem-solving were also revealed with the VCT. With respect to psychosocial functioning, only VCT variables were able to predict FAST scores at the assessment time. The VCT showed a greater sensitivity than CST to assess executive functions and real-life functioning in BD. This provides evidence about the opportunity to design novel cognitive assessments for diagnostic and therapeutic purposes in BD.

Evaluation des Troubles Cognitifs Chez des Patients Tunisiens Atteints de Trouble Bipolaire en Rémission : Étude Cas-Témoins: Assessment of Cognitive Impairment in Tunisian Patients With Bipolar Disorder in Remission: A Case-Control Study

OBJECTIVES

Our aims were to assess cognitive impairment in bipolar patients in remission compared with healthy controls, and to study its connection to clinical and therapeutic factors.

METHODOLOGY

This was a case-control study of patients with bipolar disorder (BD) in remission and matched healthy controls. It was carried out at the Hédi Chaker University Hospital in Sfax, Tunisia. The Screen for Cognitive Impairment in Psychiatry (SCIP) scale was used to assess cognitive function in patients and controls. This scale comprises subtests for verbal learning with immediate (VLT-I) and delayed (VLT-D) recall, working memory (WMT), verbal fluency (VFT) and information processing speed (PST).

RESULTS

We recruited 61 patients and 40 controls. Compared with controls, patients had significantly lower scores on the overall SCIP scale and on all SCIP subtests (p < 0.001 throughout) with moderate to high effects. In multivariate analysis, the presence of psychotic characteristics correlated with lower scores on the overall SCIP (p = 0.001), VLT-I (p = 0.001) and VLT-D (p = 0.007), WMT (p = 0.002) and PST (p = 0.008). Bipolar II correlated with lower LTV-I scores (p = 0.023). Age of onset and duration of the disorder were negatively correlated with PST scores (p < 10-3 and p = 0.007, respectively). Predominantly manic polarity correlated with lower VFT scores (p = 0.007).

CONCLUSIONS

Our study showed that bipolar patients in remission presented significantly more marked cognitive impairments, affecting various cognitive domains, than the controls. These cognitive impairments appear to be linked to clinical and therapeutic factors that are themselves considered to be factors of poor prognosis in BD.

Aberrant brain network topology in youth with a familial risk for bipolar disorder: a task-based fMRI connectome study

BACKGROUND

Youth with a family history of bipolar disorder (BD) may be at increased risk for mood disorders and for developing side effects after antidepressant exposure. The neurobiological basis of these risks remains poorly understood. We aimed to identify biomarkers underlying risk by characterizing abnormalities in the brain connectome of symptomatic youth at familial risk for BD.

METHODS

Depressed and/or anxious youth (n = 119, age = 14.9 ± 1.6 years) with a family history of BD but no prior antidepressant exposure and typically developing controls (n = 57, age = 14.8 ± 1.7 years) received functional magnetic resonance imaging (fMRI) during an emotional continuous performance task. A generalized psychophysiological interaction (gPPI) analysis was performed to compare their brain connectome patterns, followed by machine learning of topological metrics.

RESULTS

High-risk youth showed weaker connectivity patterns that were mainly located in the default mode network (DMN) (network weight = 50.1%) relative to controls, and connectivity patterns derived from the visual network (VN) constituted the largest proportion of aberrant stronger pairs (network weight = 54.9%). Global local efficiency (Elocal, p = .022) and clustering coefficient (Cp, p = .029) and nodal metrics of the right superior frontal gyrus (SFG) (Elocal: p < .001; Cp: p = .001) in the high-risk group were significantly higher than those in healthy subjects, and similar patterns were also found in the left insula (degree: p = .004; betweenness: p = .005; age-by-group interaction, p = .038) and right hippocampus (degree: p = .003; betweenness: p = .003). The case-control classifier achieved a cross-validation accuracy of 78.4%.

CONCLUSIONS

Our findings of abnormal connectome organization in the DMN and VN may advance mechanistic understanding of risk for BD. Neuroimaging biomarkers of increased network segregation in the SFG and altered topological centrality in the insula and hippocampus in broader limbic systems may be used to target interventions tailored to mitigate the underlying risk of brain abnormalities in these at-risk youth.

Applying a clinical staging model in patients affected by schizophrenia spectrum disorder

Background

Clinical staging, already widespread in medicine, represents a new frontier in psychiatry. Our goal was to convert the existing theoretical staging model for schizophrenia into a feasible tool to have a timely assessment of patients' health status applicable in any psychiatric facility.

Methods

We assessed the empirical soundness of a staging model for schizophrenia spectrum disorders (SSDs), primarily centered on their current status. This model delineated six sequential stages (1, 2A, 2B, 3A, 3B, and 4) based on factors like symptom recurrence, persistence, and progression, including functional decline. Our analysis involved data from 137 individuals affected by SSDs. We examined 22 baseline variables, 23 construct-related variables, and 31 potentially modifiable clinical variables.

Results

The latter stages demonstrated significantly poorer outcomes compared to the early stages across various measures, indicating medium to large effect sizes and a dose-response pattern. This pattern confirmed the validity of the model. Notably, stages 2 and 3A exhibited pronounced differences in comparison to other stages, although variables from each validation category also distinguished between consecutive stages, particularly 3A and beyond.

Conclusion

Baseline predictors, such as familial predisposition to schizophrenia, neurodevelopmental impairment, childhood adversities, treatment delay, negative symptoms, neurological impairment, and inadequate early response to treatment, independently largely explained the staging variance. The clinical staging model, grounded in the extended course of psychosis, exhibited sound validity and feasibility, even without the use of biological or neuroimaging markers, which could greatly improve the sensitivity of the model. These findings provide insights into stage indicators and predictors of clinical stages from the onset of psychosis.

The key role of specific DSM-5 diagnostic criteria in the early development of alcohol use disorder: Findings from the RADAR prospective cohort study

BACKGROUND

Prevention and early intervention of alcohol use disorder (AUD) is a public health priority, yet there are gaps in our understanding of how AUD emerges, which symptoms of AUD come first, and whether there are modifiable risk factors that forecast the development of the disorder. This study investigated potential early-warning-sign symptoms for the development of AUD.

METHODS

Data were from the RADAR study, a prospective cohort study of contemporary emerging adults across Australia (n = 565, mean age = 18.9, range = 18-21 at baseline, 48% female). Participants were interviewed five times across a 2.5-year period. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) AUD criteria and diagnoses were assessed by clinical psychologists using the Structured Clinical Interview for DSM-IV (SCID-IV), modified to cover DSM-5 criteria. Hazard analyses modeled the time from first alcoholic drink to the emergence of any AUD criteria and determined which first-emergent AUD criteria were associated with a faster transition to disorder.

RESULTS

By the final time point, 54.8% of the sample had experienced at least one DSM-5 AUD criterion and 26.1% met criteria for DSM-5 AUD. The median time from first AUD criterion to a diagnosis of AUD was 4 years. Social problems from drinking (hazard ratio [HR] = 3.24, CI95 = 2.14, 4.92, p < 0.001), major role (HR = 2.53, CI95 = 1.58, 4.06, p < 0.001), and drinking larger amounts/for longer than intended (HR = 2.04, CI95 = 1.20, 3.46, p = 0.008) were first-onset criteria associated with a faster transition to AUD.

CONCLUSION

In the context of a prospective general population cohort study of the temporal development of AUD, alcohol-related social problems, major role problems, and using more or for longer than intended are key risk factors that may be targeted for early intervention.

Bipolar disorder staging and the impact it has on its management: an update

INTRODUCTION

The longitudinal course of bipolar disorder (BD) is associated with an active process of neuroprogression, characterized by structural brain alterations and progressive functional impairment. In the last decades, a growing need of a standardized staging model for BD arose, with the aim of a more appropriate definition of stage-specific clinical manifestations and the identification of more customized therapeutic tools.

AREAS COVERED

The authors review the literature on clinical aspects, neurobiological correlates and treatment issues related to BD progression. Thereafter, they address the definition, constructs, and evolution of the staging concept, focusing on the clinical applications of BD staging models available in literature.

EXPERT OPINION

Although several staging models for BD have been proposed to date, their application in clinical practice is still relatively scant. This may have a detrimental impact on the clinical and therapeutic management of BD, in terms of early and proper diagnosis as well as tailored treatment interventions according to the different stages of illness. Future research efforts should tend to the integration of recent insights on neuroimaging and epigenetic markers, toward a standardized and multidimensional staging model.

Staging 2.0: refining transdiagnostic clinical staging frameworks to enhance reliability and utility for youth mental health

Globally, 75% of depressive, bipolar, and psychotic disorders emerge by age 25 years. However, these disorders are often preceded by non-specific symptoms or attenuated clinical syndromes. Difficulties in determining optimal treatment interventions for these emerging mental disorders, and uncertainties about accounting for co-occurring psychopathology and illness trajectories, have led many youth mental health services to adopt transdiagnostic clinical staging frameworks. In this Health Policy paper, an international working group highlights ongoing challenges in applying transdiagnostic staging frameworks in clinical research and practice, and proposes refinements to the transdiagnostic model to enhance its reliability, consistent recording, and clinical utility. We introduce the concept of within-stage heterogeneity and describe the advantages of defining stage in terms of clinical psychopathology and stage modifiers. Using examples from medicine, we discuss the utility of categorising stage modifiers into factors associated with progression (ie, potential predictors of stage transition) and extension (ie, factors associated with the current presentation that add complexity to treatment selection). Lastly, we suggest how it is possible to revise the currently used transdiagnostic staging approach to incorporate these key concepts, and how the revised framework could be applied in clinical and research practice.

The Epidemiological, Clinical, and Therapeutic Profile of Bipolar Patients in Eastern Morocco

INTRODUCTION

 Bipolar disorder is a severe psychiatric disorder. The objective of our study is to describe the epidemiological, clinical, and therapeutic profile of patients followed for bipolar disorder in this hospital.

MATERIALS AND METHODS

This is a cross-sectional, descriptive study conducted over a period of two years within the mental health and psychiatric diseases department of the Mohammed VI University Hospital in Oujda, Morocco, including 206 patients followed for bipolar disorder on an outpatient basis or hospitalized in one of the departments of the hospital.

RESULTS

We included in our study 206 patients with an average age of 37.34+/-12.53 and a male predominance. About 17% of our patients reported a personal medical history and 18.4%, a personal surgical history. Regarding the family history, 40.3% have a medical and surgical history and 63.1%, a psychiatric family history. The consumption of psychoactive substances is present in 49.5% of our patients. About 26.7% reported psychological trauma during childhood. Our patients have reported a history of suicide attempts with a prevalence of 26.6% in several settings: depressive (15%), delusional (5.8%), hallucinatory (3.9%), and anxious (1.9%). Several means were used during these suicide attempts, in particular, defenestration (40%), drug ingestion (36.4%), caustic ingestion (16.4%), strangulation (16.4%), and hanging (10.9%).

CONCLUSION

 It is important to develop a personalized approach to the patient wherever possible and, if necessary, to involve other specialists in diagnosis and treatment.

The Association Between Mood Stabilizers, Sleep Quality, and Functioning in Patients With Remitted Bipolar Disorder

PURPOSE/BACKGROUND

The current study aimed to examine the differences in sleep quality, illness severity, and functioning in remitted bipolar disorder patients who are using mood stabilizers and antipsychotics either as monotherapy or as combination/additional therapy.

METHODS/PROCEDURES

A total of 113 remitted outpatients with Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) bipolar disorder were recruited. The patients were classified on the basis of their current treatment regimen: 44 patients were receiving a single mood stabilizer, 21 patients were receiving a single antipsychotic, and 48 patients were receiving a combination therapy of a single mood stabilizer and a single antipsychotic. The Pittsburgh Sleep Quality Index (PSQI), Global Assessment of Functioning (GAF), and Insomnia Severity Index (ISI) were applied.

FINDINGS/RESULTS

The GAF score was significantly lower in the combination group compared with the other 2 groups. Scores on the PSQI and ISI did not differ between the 3 groups. More than half (66.4%) of all patients had poor sleep quality. Total score on the PSQI was significantly correlated with age, body mass index, and GAF. Insomnia Severity Index was significantly correlated with the duration of illness, total number of episodes, and GAF. Multiple linear regression analysis indicated that GAF ( β = -0.114) and ISI ( β = 0.661) were significantly associated with the PSQI total score.

IMPLICATIONS/CONCLUSIONS

Our findings suggest that implementing interventions to enhance functioning is crucial for improving sleep quality in remitted bipolar patients.

Staging models in eating disorders: A systematic scoping review of the literature

Eating Disorders (ED) are characterized by low remission rates, treatment drop-out, and residual symptoms. To improve assessment and treatment of ED, the staging approach has been proposed. This systematic scoping review is aimed at mapping the existing staging models that explicitly propose stages of the progression of ED. A systematic search of PubMed, PsycINFO, Scopus was conducted with the terms staging, anorexia nervosa, bulimia nervosa, binge-eating disorders, eating disorders. Eleven studies met inclusion criteria presenting nine ED staging models, mostly for anorexia nervosa. Three were empirically tested, one of which was through an objective measure specifically developed to differentiate between stages. Most staging models featured early stages in which the exacerbation of EDs unfolds and acute phases are followed by chronic stages. Intermediate stages were not limited to acute stages, but also residual phases, remission, relapse, and recovery. The criteria for stage differentiation encompassed behavioral, psychological, cognitive, and physical features including body mass index and illness duration. One study recommended stage-oriented interventions. The current review underscores the need to empirically test the available staging models and to develop and test new proposals of staging models for other ED populations. The inclusion of criteria based on medical features and biomarkers is recommended. Staging models can potentially guide assessment and interventions in daily clinical settings.

Impulsivity and neural correlates of response inhibition in bipolar disorder and their unaffected relatives: A MEG study

BACKGROUND

Response inhibition is a core cognitive impairment in bipolar disorder (BD), leading to increased impulsivity in BD. However, the relationship between the neural mechanisms underlying impaired response inhibition and impulsivity in BD is not yet clear. Individuals who are genetically predisposed to BD give a way of identifying potential endophenotypes.

METHODS

A total of 97 participants, including 39 patients with BD, 22 unaffected relatives (UR) of patients with BD, and 36 healthy controls performed a Go/No-Go task during magnetoencephalography. We carried out time-frequency and connectivity analysis on MEG data.

RESULTS

Decreased beta power, prolonged latency and increased peak frequency in rIFG, decreased beta power in pre-SMA and reduced rIFG-to-pre-SMA connectivity were found in BD relative to healthy controls. In the UR group, we found a decrease in the beta power of pre-SMA and prolonged latency of rIFG. Furthermore, increased motor impulsiveness in BD was related to abnormal alterations in beta oscillatory activity of rIFG and functional connectivity between rIFG and pre-SMA.

CONCLUSIONS

Hypoactivity activity in rIFG and impaired dominant role of rIFG in the prefrontal control network may underlie the neuropathology of response inhibition dysfunction, resulting increased motor impulsivity in BD. Our findings point to measuring rIFG dysfunction as a potential means of identifying individuals at genetic high risk for transition to BD disease expression.

Increased metabolic variability in Korean patients with new onset bipolar disorder: a nationwide cohort study

Introduction

The aim of this study was to determine associations between changes of metabolic parameters and the development of BD using nationally representative data.

Methods

We used health examination data provided by the South Korean National Health Insurance System (NHIS) (n = 8,326,953). The variability of each metabolic parameter including weight circumference, blood pressure, fasting blood glucose, high-density lipoprotein cholesterol, and triglyceride levels was caculated using variability independent of mean (VIM) indices. The presence of metabolic syndrome was associated with new onset BD. Each metabolic parameter with high variability was associated with a higher risk of new onset BD compared to those with low variability after adjusting for age, sex, smoking, alcohol drinking, regular exercise, income status, baseline diabetes, hypertension, and dyslipidemia.

Results

As the number of highly variable metabolic parameters increased, the risk for new onset depression also increased even after covariates adjustment. The associations between new onset BD and metabolic variability were greater in populations with age > 50 years. In addition, these associations remained significant after adjusting for the presence of depression prior to diagnoses of BD.

Discussion

Our results suggest possibility of metabolic variability as an independent environmental risk factor for BD even after adjusting for the presence of metabolic syndrome.

Current practices of psychoeducation interventions with persons with bipolar disorders: a literature review

This review sought to summarize the literature on current practices and forms of psychoeducation in the management of patients with bipolar disorder (BD), including only randomized controlled trials to ensure the best level of evidence. An extensive review of the available literature was conducted using PubMed/MEDLINE, Embase, and PsychInfo databases from inception to April 28th, 2022. The search yielded 381 studies. Seventy articles were included after removing duplicates and applying the inclusion/exclusion criteria. A best-evidence synthesis was used to identify the key results of each study and summarize the outcomes. Eleven descriptive categories were made. They encompass different forms of psychoeducation compared or combined with other psychosocial interventions, varying in setting (individual or group), with or without family members, structured or unstructured, mediated or not by digital tools (smartphone, internet). Globally, these studies show that psychoeducation is important in the treatment of BD, as it leads to a decrease in relapses, mood episodes, hospitalizations, and improved functioning or quality of life. Some studies also showed the benefits of psychoeducation on the patient's level of knowledge of pharmacological treatment and the disorder or compliance with medication, as well as reduced self-stigma. The limitations of this review are linked to the selection of only RCTs and the reliance on their post-hoc analyses. This review confirms the benefit of psychoeducation and psychosocial interventions on the evolution of BD (in different outcomes, including quality of life, relapse, and rehospitalization rates, for example). More recent interventions, such as mindfulness or online psychoeducation, represent an interesting option but more evidence is needed.

Short-term ketamine use in bipolar depression: a review of the evidence for short-term treatment management

Bipolar depression constitutes a major problem in psychiatry. It correlates with high suicidality, treatment resistance, chronicity, and poor quality of life. Registered treatment for bipolar depression is limited and insufficient. There is an urgent need for implementing new therapeutic strategies. Intranasal ketamine's enantiomer-esketamine is a novel rapid-acting antidepressant with proven efficacy in treatment-resistant depression. Research on bipolar depression, although not as comprehensive, indicates that it may be a viable and safe substitute with minimal risk for mood polarity changes. Reports suggest that ketamine treatment in bipolar depression may reduce suicidal tendencies, decrease anhedonia, and alleviate anxiety. Ketamine's mood-stabilizing properties are also hypothesized. In this narrative review, we focus on ketamine use as an add-on to standard medication for the acute treatment of bipolar depression.

A cross-sectional study of cognitive performance in bipolar disorder across the lifespan: the cog-BD project

BACKGROUND

Neuroprogressive models of the trajectory of cognitive dysfunction in patients with bipolar disorder (BD) have been proposed. However, few studies have explored the relationships among clinical characteristics of BD, cognitive dysfunction, and aging.

METHODS

We conducted a cross-sectional analysis in euthymic participants with the MATRICS Cognitive Consensus Battery, the Trail Making Test B, the Stroop Test, and the Wechsler Test of Adult Reading. Age- and gender-equated control participants without a mental disorder ['Healthy Controls' - HC)] were assessed similarly. We compared cognitive performance both globally and in seven domains in four groups: younger BD (age ⩽49 years; n = 70), older BD (age ⩾50 years; n = 48), younger HC (n = 153), and older HC (n = 44). We also compared the BD and HC groups using age as a continuous measure. We controlled for relevant covariates and applied a Bonferroni correction.

RESULTS

Our results support both an early impairment ('early hit') model and an accelerated aging model: impairment in attention/vigilance, processing speed, and executive function/working memory were congruent with the accelerated aging hypothesis whereas impairment in verbal memory was congruent with an early impairment model. BD and HC participants exhibited similar age-related decline in reasoning/problem solving and visuospatial memory. There were no age- or diagnosis-related differences in social cognition.

CONCLUSION

Our findings support that different cognitive domains are affected differently by BD and aging. Longitudinal studies are needed to explore trajectories of cognitive performance in BD across the lifespan.

Expression of ANK3 moderates the association between childhood trauma and affective traits in severe mental disorders

Exposure to early life trauma increases the risk of psychopathology later in life. Here we investigated if ANK3 mRNA levels influence the relationship between childhood trauma experiences and clinical characteristics in mental disorders. A sample of 174 patients with bipolar disorder and 291 patients with schizophrenia spectrum disorder were included. Patients were diagnosed using the Structured Clinical Interview for DSM-IV, and childhood trauma was assessed using the childhood trauma questionnaire. Age at illness onset and number of psychotic and affective episodes were assessed from interview and medical records. Current depressive symptoms were measured using the calgary depression scale for schizophrenia and the inventory for depressive symptomatology. ANK3 expression was analyzed in whole blood using the Illumina HumanHT-12 v4 Expression BeadChip. Analyses were carried out with the Process adjusted for confounders. Within the total sample, patients with both high ANK3 expression and with the most severe childhood sexual abuse had more manic/hypomanic episodes and an earlier age at onset of the first episode. ANK3 mRNA levels also moderated the relationship between emotional neglect and manic/hypomanic episodes. Our results suggest that ANK3 expression levels moderate the association between specific types of childhood trauma and affective traits in mental disorders.

The Role of Ketamine in the Treatment of Bipolar Depression: A Scoping Review

Bipolar depression remains a clinical challenge with a quarter of patients failing to respond to initial conventional treatments. Although ketamine has been extensively studied in unipolar depression, its role in bipolar disorder remains inconclusive. The aim of our scoping review was to comprehensively synthesize the current clinical literature around ketamine use in bipolar depression. A total of 10 clinical studies (5 randomized controlled trials and 5 open label studies) were selected. The preliminary evidence, albeit weak, suggests that ketamine is a promising treatment and calls for further interest from the research community. Overall, ketamine treatment appeared to be tolerable with minimal risk for manic/hypomanic switching and showed some effectiveness across parameters of depression and suicidality. Moreover, ketamine is a potential treatment agent in patients with treatment-resistant bipolar depression with promising data extracted from extant controlled trials and real-world effectiveness studies. Future studies are needed to identify ketamine's role in acute and maintenance treatment phases of bipolar depression. Moreover, future researchers should study the recurrence prevention and anti-suicidal effects of ketamine in the treatment of bipolar depression.

Mapping the ethical aspects in end-of-life care for persons with a severe and persistent mental illness: A scoping review of the literature

Persons with severe and persistent mental illness (SPMI) make up a vulnerable group within mental healthcare and society. Not only do they suffer from long-term, serious psychiatric disorders; they often also experience considerable problems in their psychosocial functioning. Research has disclosed that the care needs of this target group are complex, and that the life expectancy of these persons is significantly lower than in the general population. Given (1) the lower life expectancy of persons with SPMI, (2) the higher suicide risk related to mental disorders, and (3) the legalization and practice of medical assistance in dying in an increasing number of countries, it is of utmost importance to map the ethical aspects and challenges of end-of-life care needs in persons with SPMI. Therefore, we charted the way end-of-life care is provided for them by means of a scoping review of the scientific literature, with an emphasis on the ethical aspects surrounding it. We explore existing ethical dilemmas; the underlying ethical values, principles and attitudes; and the locus and stakeholders of ethical dialog regarding end-of-life care in persons with SPMI. The results indicate that the four guiding principles of biomedical ethics can well be identified in the literature, and are each addressed in their own specific way: Autonomy in relation to questions regarding the decision-making capacity of persons with SPMI; Justice in relation to access to quality care and the presence of stigma; and Non-maleficence and Beneficence in relation to the ongoing debate regarding the benefits and obstacles in applying palliative care approaches in the context of psychiatry, and the status of the futility-concept therein. Personal virtues and attitudes in care professionals, like compassion, non-abandonment and upholding dignity are key, as care professionals are the main advocates of persons with SPMI, which often lack an extensive social network. Further, we find that the ethical dialog is mainly focused on care professionals and relatives, rather than the persons with SPMI themselves. This is reflected in the existing research that often had the voices of the latter missing. Future research may benefit from the inclusion of persons with SMPI’s first-hand accounts. End-of-life care for persons with SPMI may benefit from identifying and integrating (locally developed) good practices like cross-sectoral education, specific care models, and ethics support.

Increased cortical surface area but not altered cortical thickness or gyrification in bipolar disorder following stabilisation from a first episode of mania

BACKGROUND

Despite reports of altered brain morphology in established bipolar disorder (BD), there is limited understanding of when these morphological abnormalities emerge. Assessment of patients during the early course of illness can help to address this gap, but few studies have examined surface-based brain morphology in patients at this illness stage.

METHODS

We completed a secondary analysis of baseline data from a randomised control trial of BD individuals stabilised after their first episode of mania (FEM). The magnetic resonance imaging scans of n = 35 FEM patients and n = 29 age-matched healthy controls were analysed. Group differences in cortical thickness, surface area and gyrification were assessed at each vertex of the cortical surface using general linear models. Significant results were identified at p < 0.05 using cluster-wise correction.

RESULTS

The FEM group did not differ from healthy controls with regards to cortical thickness or gyrification. However, there were two clusters of increased surface area in the left hemisphere of FEM patients, with peak coordinates falling within the lateral occipital cortex and pars triangularis.

CONCLUSIONS

Cortical thickness and gyrification appear to be intact in the aftermath of a first manic episode, whilst cortical surface area in the inferior/middle prefrontal and occipitoparietal cortex is increased compared to age-matched controls. It is possible that increased surface area in the FEM group is the outcome of abnormalities in a premorbidly occurring process. In contrast, the findings raise the hypothesis that cortical thickness reductions seen in past studies of individuals with more established BD may be more attributable to post-onset factors.

Sleep Disturbances in Generalized Anxiety Disorder: The Role of Calcium Homeostasis Imbalance

Patients with a generalized anxiety disorder (GAD) often report preeminent sleep disturbances. Recently, calcium homeostasis gained interest because of its role in the regulation of sleep-wake rhythms and anxiety symptoms. This cross-sectional study aimed at investigating the association between calcium homeostasis imbalance, anxiety, and quality of sleep in patients with GAD. A total of 211 patients were assessed using the Hamilton Rating Scale for Anxiety (HAM-A), Pittsburgh Sleep Quality Index questionnaire (PSQI) and Insomnia Severity Index (ISI) scales. Calcium, vitamin D, and parathyroid hormone (PTH) levels were evaluated in blood samples. A correlation and linear regression analysis were run to evaluate the association of HAM-A, PSQI, and ISI scores with peripheral markers of calcium homeostasis imbalance. Significant correlations emerged between HAM-A, PSQI, ISI, PTH, and vitamin D. The regression models showed that patients with GAD displaying low levels of vitamin D and higher levels of PTH exhibit a poor subjective quality of sleep and higher levels of anxiety, underpinning higher psychopathological burden. A strong relationship between peripheral biomarkers of calcium homeostasis imbalance, insomnia, poor sleep quality, and anxiety symptomatology was underlined. Future studies could shed light on the causal and temporal relationship between calcium metabolism imbalance, anxiety, and sleep.

Biomarkers of neuroprogression and late staging in bipolar disorder: A systematic review

BACKGROUND

Bipolar disorder may undertake a progressive course in a subset of patients, and research efforts have been made to understand the biological basis underlying this process. This systematic review examined the literature available on biological markers associated with illness progression in bipolar disorder.

METHODS

Peer-reviewed articles were assessed using Embase, PsycINFO and PubMed, as well as from external sources. After initial screening, a total of 871 citations from databases and other sources were identified. Participants with a diagnosis of bipolar disorder were included in our systematic review; however, studies with participants younger than 15 or older than 65 were excluded. All studies were assessed using the Newcastle-Ottawa Scale assessment tool, and data pertaining to the results were extracted into tabular form using Google Sheets and Google Documents. The systematic review was registered on PROSPERO international prospective register of systematic reviews (ID Number: CRD42020154305).

RESULTS

A total of 35 studies were included in the systematic review. Increased ventricular size and reduction of grey matter volume were the most common brain changes associated with illness progression in bipolar disorder. Among the several biomarkers evaluated in this systematic review, findings also indicate a role of peripheral inflammatory markers in this process.

DISCUSSION

The studies evaluating the biological basis of the illness progression in bipolar disorder are still scarce and heterogeneous. However, current evidence supports the notion of neuroprogression, the pathophysiological process related to progressive brain changes associated with clinical progression in patients with bipolar disorder. The increase in peripheral inflammatory biomarkers and the neuroanatomical changes in bipolar disorder suggest progressive systemic and structural brain alterations, respectively.

Expanding mental health services in low- and middle-income countries: A task-shifting framework for delivery of comprehensive, collaborative, and community-based care

This paper proposes a framework for comprehensive, collaborative, and community-based care (C4) for accessible mental health services in low-resource settings. Because mental health conditions have many causes, this framework includes social, public health, wellness and clinical services. It accommodates integration of stand-alone mental health programs with health and non-health community-based services. It addresses gaps in previous models including lack of community-based psychotherapeutic and social services, difficulty in addressing comorbidity of mental and physical conditions, and how workers interact with respect to referral and coordination of care. The framework is based on task-shifting of services to non-specialized workers. While the framework draws on the World Health Organization's Mental Health Gap Action Program and other global mental health models, there are important differences. The C4 Framework delineates types of workers based on their skills. Separate workers focus on: basic psychoeducation and information sharing; community-level, evidence-based psychotherapeutic counseling; and primary medical care and more advanced, specialized mental health services for more severe or complex cases. This paper is intended for individuals, organizations and governments interested in implementing mental health services. The primary aim is to provide a framework for the provision of widely accessible mental health care and services.

Staging the bipolar disorders: Are early stages at too early a stage for intervention?

OBJECTIVES

A number of staging models have been generated for the bipolar disorders, which include pre-onset as well as post-onset stages. Some models propose treatments for those at the pre-onset stage, a recommendation which is critiqued here.

METHODS

Several exemplar staging models are overviewed, and a critique is provided.

RESULTS

The critique argues against intervention at a pre-onset stage, in light of there being limited risk factors, unquantified sensitivity and specificity data for most putative onset illness risk factors, and thus there is the risk of overtreatment. Also, it is possible that many of the recommended interventions for those at risk of a bipolar disorder may have general non-specific benefits for those at risk.

CONCLUSIONS

While retaining a pre-onset phase in the staging model, it would appear wiser for it to not be populated with recommended interventions until they have a firmer empirical base.

Heterogeneous early illness courses of Korean patients with bipolar disorders: replication of the staging model

BACKGROUND

Clinical staging of bipolar disorder (BD) requires application of real-world data, as the next step in hypothesis. This study used the staging model to analyze the long-term course of BD in Korean patients based on clinical features and treatment responses to map the progression of bipolar illness from its early phase after the onset of illness.

METHODS

A total of 136 patients diagnosed with BD-I (n = 62) or BD-II (n = 74) were recruited. Their progressive stages were retrospectively evaluated. A multi-state model was used to calculate the probability of progression to each stage. Hazard ratios of covariates expected to influence different courses of BD were calculated. Using the Alda score, long-term responses to mood stabilizers depending on the current stage were compared.

RESULTS

Several sub-populations showed varied courses during the first five years after the onset of illness, with 41.5% remaining in stage 2 and 53% progressing to higher stages with shortened time for transition. Profiles of patients with BD-I and BD-II were different, suggesting biologically distinct groups. Comorbid psychiatric disorders, such as obsessive-compulsive disorder (OCD) and bulimia nervosa (BN) were associated with a recurrent course (stage 3a or 3b) or a malignant course (stage 3c or 4). Early age of onset, shorter duration of illness, older age at the start of medication, and poor response to lithium affected the illness progression.

CONCLUSION

We were able to apply the stage model based on episode recurrence patterns in early illness courses of Korean patients with BD. The stage progression pattern differed from the early phase in BD-I and BD-II patients. Psychotic comorbidity, age at onset, age at starting psychiatric treatment showed associations with the illness progression.

Cognitive impairment, childhood trauma, sedentary behaviour, and elevated C-reactive protein levels in major affective disorders

Elevated C-reactive protein (CRP) levels were associated with cognitive decline, sedentary behaviour, and childhood trauma in patients with major affective disorders. This study aims to examine the association of peripheral CRP levels, cognitive function, childhood trauma, sedentary behaviour, and quality of life in individuals with major affective disorders, including bipolar disorder (BD), major depressive disorder (MDD), and individuals without mood disorders (controls). We included outpatients with BD (n = 42), MDD (n = 27), and healthy controls (n = 40). All participants were assessed by a questionnaire, structured clinical interview, and the following scales: international physical activity questionnaire, childhood trauma questionnaire, 17-item Hamilton Depression Rating Scale (HDRS₁₇), and World Health Organization Quality of Life instrument, brief version (WHOQOL-BREF). Other measures were included: hs-CRP levels, anthropometric measures, and cognitive tests (Trail-making test part A and part B, Stroop test, phonemic verbal fluency test, and semantic verbal fluency test). Our results indicated that BD outpatients were less significantly physically active on leisure domain than controls. Levels of hs-CRP ≥ 5 mg/L were significantly linked with a history of childhood sexual abuse and childhood physical abuse, as well as worse neurocognitive performance in major depressive disorders, mainly in BD. There was a significant negative correlation between Trail-making part B score and WHOQOL-BREF total score. The findings support the hypothesis that levels of hs-CRP ≥ 5 mg/L may be a possible predictor of cognitive dysfunction, childhood sexual abuse and sedentary behaviour in major affective disorders.

Current Evidence and Theories in Understanding the Relationship between Cognition and Depression in Childhood and Adolescence: A Narrative Review

The present narrative review has covered the current evidence regarding the role of cognitive impairments during the early phase of major depressive disorder (MDD), attempting to describe the cognitive features in childhood, adolescence and in at-risk individuals. These issues were analyzed considering the trait, scar and state hypotheses of MDD by examining the cold and hot dimensions, the latter explained in relation to the current psychological theoretical models of MDD. This search was performed on several electronic databases up to August 2022. Although the present review is the first to have analyzed both cold and hot cognitive impairments considering the trait, scar and state hypotheses, we found that current evidence did not allow to exclusively confirm the validity of one specific hypothesis since several equivocal and discordant results have been proposed in childhood and adolescence samples. Further studies are needed to better characterize possible cognitive dysfunctions assessing more systematically the impairments of cold, hot and social cognition domains and their possible interaction in a developmental perspective. An increased knowledge on these topics will improve the definition of clinical endophenotypes of enhanced risk to progression to MDD and, to hypothesize preventive and therapeutic strategies to reduce negative influences on psychosocial functioning and well-being.

Machine learning algorithms revealed distorted retinal vascular branching in individuals with bipolar disorder

BACKGROUND

Converging evidence designate vascular vulnerability in bipolar disorder. The predisposition progresses into distortion in time, thus detection of the vascular susceptibility may help reducing morbidity and mortality. It was aimed to assess retinal fundus vasculature in cardiovascular risk-free patients with bipolar disorder.

METHODS

Total of 68 individuals (38 patients with bipolar disorder, 30 healthy controls) were enrolled. In order to avoid from degenerative processes, participants were between 18 and 45 years of age, vascular risk factors were eliminated. Microscopic retinal fundus images were processed with machine learning algorithms (multilayer perceptron and support vector machine) and artificial neural network approaches.

RESULTS

In comparison to the healthy control group, the bipolar disorder group had lower number of breaking points (P < 0.001), lower number of curved vessel segments (P < 0.001). Total length of smooth vessels was longer (P = 0.040), and total length of curved vessel segments was significantly shorter (P < 0.001) than the control group. Vascular endothelial growth factor levels and gender were the confounders. There were significant correlations between vascular measures and serum lipid levels.

LIMITATIONS

Sample size was small and patients were on various medications.

CONCLUSIONS

These results indicate distortion in retinal vascular branching in bipolar disorder. Disrupted branching may reflect disturbed prosperity of retinal vascular plexus in patients with bipolar disorder. Alterations in the retinal vessels might be indicators of disruption in cerebral vascular system efficiency and thus neurovascular unit dysfunction in bipolar disorder.

The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management

Bipolar disorder is heterogeneous in phenomenology, illness trajectory, and response to treatment. Despite evidence for the efficacy of multimodal-ity interventions, the majority of persons affected by this disorder do not achieve and sustain full syndromal recovery. It is eagerly anticipated that combining datasets across various information sources (e.g., hierarchical "multi-omic" measures, electronic health records), analyzed using advanced computational methods (e.g., machine learning), will inform future diagnosis and treatment selection. In the interim, identifying clinically meaningful subgroups of persons with the disorder having differential response to specific treatments at point-of-care is an empirical priority. This paper endeavours to synthesize salient domains in the clinical characterization of the adult patient with bipolar disorder, with the overarching aim to improve health outcomes by informing patient management and treatment considerations. Extant data indicate that characterizing select domains in bipolar disorder provides actionable information and guides shared decision making. For example, it is robustly established that the presence of mixed features - especially during depressive episodes - and of physical and psychiatric comorbidities informs illness trajectory, response to treatment, and suicide risk. In addition, early environmental exposures (e.g., sexual and physical abuse, emotional neglect) are highly associated with more complicated illness presentations, inviting the need for developmentally-oriented and integrated treatment approaches. There have been significant advances in validating subtypes of bipolar disorder (e.g., bipolar I vs. II disorder), particularly in regard to pharmacological interventions. As with other severe mental disorders, social functioning, interpersonal/family relationships and internalized stigma are domains highly relevant to relapse risk, health outcomes, and quality of life. The elevated standardized mortality ratio for completed suicide and suicidal behaviour in bipolar disorder invites the need for characterization of this domain in all patients. The framework of this paper is to describe all the above salient domains, providing a synthesis of extant literature and recommendations for decision support tools and clinical metrics that can be implemented at point-of-care.

Understanding the development of bipolar disorder and borderline personality disorder in young people: a meta-review of systematic reviews

BACKGROUND

There is ongoing debate on the nosological position of bipolar disorder (BD) and borderline personality disorder (BPD). Identifying the unique and shared risks, developmental pathways, and symptoms in emerging BD and BPD could help the field refine aetiological hypotheses and improve the prediction of the onset of these disorders. This study aimed to: (a) systematically synthesise the available evidence from systematic reviews (SRs) and meta-analyses (MAs) concerning environmental, psychosocial, biological, and clinical factors leading to the emergence of BD and BPD; (b) identify the main differences and common features between the two disorders to characterise their complex interplay and, (c) highlight remaining evidence gaps.

METHODS

Data sources were; PubMed, PsychINFO, Embase, Cochrane, CINAHL, Medline, ISI Web of Science. Overlap of included SRs/MAs was assessed using the corrected covered area process. The methodological quality of each included SR and MA was assessed using the AMSTAR.

RESULTS

22 SRs and MAs involving 249 prospective studies met eligibility criteria. Results demonstrated that family history of psychopathology, affective instability, attention deficit hyperactivity disorder, anxiety disorders, depression, sleep disturbances, substance abuse, psychotic symptoms, suicidality, childhood adversity and temperament were common predisposing factors across both disorders. There are also distinct factors specific to emerging BD or BPD.

CONCLUSIONS

Prospective studies are required to increase our understanding of the development of BD and BPD onset and their complex interplay by concurrently examining multiple measures in BD and BPD at-risk populations.

Pharmacological Potential of the Standardized Methanolic Extract of Prunus armeniaca L. in the Haloperidol-Induced Parkinsonism Rat Model

Parkinson's disease (PD) is a complex, age-related neurodegenerative disease that causes neuronal loss and dysfunction over time. An imbalance of redox potential of oxidative stress in the cell causes neurodegenerative diseases and dysfunction of neurons. Plants are a rich source of bioactive substances that attenuate oxidative stress in a variety of neurological disorders. The aim of the present study was to evaluate the Prunus armeniaca L. methanolic extract (PAME) for anti-Parkinson activity in rats. PD was induced with haloperidol (1 mg/kg, IP). The PAME was administered orally at 100, 300, and 800 mg/kg dose levels for 21 days. Behavioral studies (catalepsy test, hang test, open-field test, narrow beam walk, and hole-board test), oxidative stress biomarkers (SOD, CAT, GSH, and MDA) levels, neurotransmitters (dopamine, serotonin, and noradrenaline) levels, and acetylcholinesterase activity were quantified in the brain homogenate. Liver function tests (LFTs), renal function tests (RFTs), complete blood count (CBC), and lipid profiles were measured in the blood/serum samples to note the side effects of PAME at the selected doses. Histopathological analysis was performed on the brain (anti-PD study), liver, heart, and kidney (to check the toxicity of PAME on these vital organs). Motor functions were improved in the behavioral studies. Dopamine, serotonin, and noradrenaline levels were significantly increased (P < 0.001), whereas the level of acetylcholinesterase was decreased significantly (P < 0.001). The levels of superoxide dismutase (SOD), catalase (CAT), and reduced glutathione (GSH) were increased, while malondialdehyde (MDA) and nitrite levels were decreased in the PAME-treated groups significantly compared with the disease control group, hence reducing oxidative stress. The incidence of toxicity was determined by biochemical analysis of LFT and RFT biomarkers testing. The histopathological analysis indicated that neurofibrillary tangles and plaques decreased in a dose-dependent manner in the PAME-treated groups. Based on the data, it is concluded that PAME possessed good anti-Parkinson activity, rationalizing the plant's traditional use as a neuroprotective agent.

The Mediation Effect of Peripheral Biomarkers of Calcium Metabolism and Chronotypes in Bipolar Disorder Psychopathology

Calcium (Ca++) metabolism may be impaired in several psychiatric diseases. We hypothesize that calcium imbalance might also correlate with a specific chronotype and could be recognized as a marker of illness severity in bipolar disorder (BD). We aimed to (1) identify the association between calcium imbalance and a specific chronotype in a cohort of BD patients, and (2) test the mediation role of high parathyroid hormone (PTH) levels towards a specific chronotype and illness severity in BD patients. Patients’ socio-demographic and clinical characteristics were collected with an ad-hoc schedule. We administered the Hamilton Depression Rating Scale (HAM-D), the Hamilton Rating Scale for Anxiety (HAM-A), the Young Mania Rating Scale (YMRS), and the Morningness Eveningness Questionnaire (MEQ). 100 patients affected by BD were recruited. The Kruskal-Wallis test showed a significant difference between the three MEQ groups in PTH levels (p < 0.001) and vitamin D levels (p = 0.048) but not in Ca++ levels (p = 0.426). Dwass-Steel-Critchlow-Fligner Pairwise analyses performed concerning three MEQ groups revealed significantly higher scores on PTH levels in MEQ-E subjects compared to MEQ-M and MEQ-I (in both cases, p < 0.001). No differences emerged between calcium levels among the three chronotypes. The mediation analysis has shown that elevated PTH levels are directly influenced by more severe HAM-A, HAM-D, and YMRS scores. MEQ-E could be a marker related to BD and predispose to various factors influencing mood symptoms. The combination of vitamin D therapy in MEQ-E may help to improve prognosis in this subtype of patients affected by BD.

Prevalence and 5-year trend of incidence for medical illnesses after the diagnosis of bipolar disorder: A nationwide cohort study

OBJECTIVE

Medical comorbidities are prevalent in patients with bipolar disorder. Evaluating longitudinal trends of the incidence of medical illnesses enables implementation of early prevention strategies to reduce the high mortality rate in this at-risk population. However, the incidence risks of medical illnesses in the early stages of bipolar disorder remain unclear. This study investigated the incidence and 5-year trend of medical illnesses following bipolar disorder diagnosis.

METHODS

We identified 11,884 patients aged 13-40 years who were newly diagnosed as having bipolar disorder during 1996-2012 and 47,536 age- and sex-matched controls (1:4 ratio) who represented the general population from Taiwan's National Health Insurance Research Database. We estimated the prevalence and incidence of individual medical illnesses yearly across the first 5 years after the index date. The adjusted incidence rate ratio was calculated to compare the occurrence of specific medical illnesses each year between the bipolar disorder group and control group using the Poisson regression model.

RESULTS

Apart from the prevalence, the adjusted incidence rate ratios of most medical illnesses were >1.00 across the first 5-year period after bipolar disorder diagnosis. Cerebrovascular diseases, ischaemic heart disease, congestive heart failure, other forms of heart disease, renal disease and human immunodeficiency virus infection exhibited the highest adjusted incidence rate ratios during the first year. Except for that of renal disease, the 5-year trends of the adjusted incidence rate ratios decreased for cerebrovascular diseases, cardiovascular diseases (e.g. ischaemic heart disease, other forms of heart disease, and vein and lymphatic disease), gastrointestinal diseases (e.g. chronic hepatic disease and ulcer disease) and communicable diseases (e.g. human immunodeficiency virus infection, upper respiratory tract infection and pneumonia).

CONCLUSION

Incidence risks of medical illnesses are increased in the first year after bipolar disorder diagnosis. Clinicians must carefully evaluate medical illnesses during this period because the mortality rates from medical illnesses are particularly high in people with bipolar disorder.

Novel splice‑site variants c.393G>A, c.278_2A>G in exon 2 and Q705K variant in exon 3 of NLRP3 gene are associated with bipolar I disorder

NOD‑like receptor pyrin domain‑containing 3 (NLRP3) has been considered to play a crucial role in triggering the host's immune and inflammatory responses. Genetic variants are critical determinants of interindividual variances in inflammatory responses and clinical outcomes. The role of NLRP3 gene variations in bipolar I (BPI) disorder, which is known to include genetic factors in its aetiology, has not been previously reported, at least to the best of our knowledge. The present study aimed to determine the role and frequency ofta exon 2 and exon 3 variants of NLRP3 in BPI disorder and to evaluate the association between different phenotypic traits. A case‑control study with 123 patients and 107 healthy controls was conducted to investigate the association of variants identified in the exon 2 and exon 3 regions of NLRP3, with the risk of BPI. Regions of interest were sequenced using a PCR‑based Sanger sequencing method. Three BPI‑related variants were identified. The genotype Q705K CA was detected more frequently in BPI patients, as compared to the control group [P<0.001; odds ratio (OR), 0.202; 95% confidence interval (CI), 0.080‑0.508]. In addition, two novel splice‑site variants (c.393G>A and c.278_2A>G) that, to the best of our knowledge, have not been previously reported in any database, were detected only in the BPI patient group [P<0.001; OR, 0.846; 95% CI, 0.784‑0.912; P<0.001; OR, 0.886; 95% CI, 0.832‑0.944, respectively]. There was no significant association between the Q795K variant and phenotypic traits (P>0.05). However, there was a significant association between those carrying the heterozygous c.393G>A variant and a positive family history (P=0.043). It was also observed that those with the heterozygous c.278‑2A>G variant presented with a significantly early‑onset (P=0.003). On the whole, the data of the present study suggested that NLRP3 plays a crucial role in the pathogenesis of BPI and may be a potential risk factor. However, further functional studies and repeated studies in other populations are required to properly comprehend the roles of the NLRP3 variants in the risk of developing BPI.

Psychosocial markers of age at onset in bipolar disorder: a machine learning approach

BACKGROUND

Bipolar disorder is a chronic and severe mental health disorder. Early stratification of individuals into subgroups based on age at onset (AAO) has the potential to inform diagnosis and early intervention. Yet, the psychosocial predictors associated with AAO are unknown.

AIMS

We aim to identify psychosocial factors associated with bipolar disorder AAO.

METHOD

Using data from the Bipolar Disorder Research Network UK, we employed least absolute shrinkage and selection operator regression to identify psychosocial factors associated with bipolar disorder AAO. Twenty-eight factors were entered into our model, with AAO as our outcome measure.

RESULTS

We included 1022 participants with bipolar disorder (μ = 23.0, s.d. ± 9.86) in our model. Six variables predicted an earlier AAO: childhood abuse (β = -0.2855), regular cannabis use in the year before onset (β = -0.2765), death of a close family friend or relative in the 6 months before onset (β = -0.2435), family history of suicide (β = -0.1385), schizotypal personality traits (β = -0.1055) and irritable temperament (β = -0.0685). Five predicted a later AAO: the average number of alcohol units consumed per week in the year before onset (β = 0.1385); birth of a child in the 6 months before onset (β = 0.2755); death of parent, partner, child or sibling in the 6 months before onset (β = 0.3125); seeking work without success for 1 month or more in the 6 months before onset (β = 0.3505) and a major financial crisis in the 6 months before onset (β = 0.4575).

CONCLUSIONS

The identified predictor variables have the potential to help stratify high-risk individuals into likely AAO groups, to inform treatment provision and early intervention.

Employing biochemical biomarkers for building decision tree models to predict bipolar disorder from major depressive disorder

BACKGROUND

Conventional biochemical parameters may have predictive values for use in clinical identification between bipolar disorder (BD) and major depressive disorder (MDD).

METHODS

This study enrolled 2470 hospitalized patients with BD (n = 1333) or MDD (n = 1137) at reproductive age from 2009 to 2018 in China. We extracted 8 parameters, uric acid (UA), direct bilirubin (DBIL), indirect bilirubin (IDBIL), lactic dehydrogenase (LDH), free triiodothyronine (FT3), thyroid-stimulating hormone (TSH), high-density lipoprotein (HDL) and prealbumin of male, patients and 12 parameters, UA, DBIL, IBIL, LDH, FT3, TSH, glutamic-pyruvic transaminase (GPT), white blood cell (WBC), alkaline phosphatase (ALP), fasting blood glucose (FBG), triglyceride and low-density lipoprotein (LDL) of female patients. Backward stepwise multivariate regression analysis and the Chi-Square Automatic Interaction Detection (CHAID) segmentation analysis via SPSS Decision Tree were implemented to define the discrimination of BD and MDD.

RESULTS

DBIL was extracted as the first splitting variable, with LDH and IBIL as the second, TSH and prealbumin as the third in the model of male patients (p-value < .05). For the model of female patients, DBIL was also extracted as the first splitting variable, with UA, LDH, and IBIL as the second, triglyceride and FT3 as the third (p-value < .05). The predictive accuracies of the Decision Tree and multiple logistic regression models were similar (74.9% vs 76.9% in males; 74.4% vs 79.5% in females).

CONCLUSIONS

This study suggests the value of the Decision Tree models, which employ biochemical parameters as diagnostic predictors for BD and MDD. The CHAID Decision Tree identified that patients with concomitantly increased LDH, IBIL, and decreased DBIL could be in the group that showed the highest risk of being diagnosed as BD.

Gut Microbial Dysbiosis and Cognitive Impairment in Bipolar Disorder: Current Evidence

Recent studies have reported that the gut microbiota influences mood and cognitive function through the gut-brain axis, which is involved in the pathophysiology of neurocognitive and mental disorders, including Parkinson’s disease, Alzheimer’s disease, and schizophrenia. These disorders have similar pathophysiology to that of cognitive dysfunction in bipolar disorder (BD), including neuroinflammation and dysregulation of various neurotransmitters (i.e., serotonin and dopamine). There is also emerging evidence of alterations in the gut microbial composition of patients with BD, suggesting that gut microbial dysbiosis contributes to disease progression and cognitive impairment in BD. Therefore, microbiota-centered treatment might be an effective adjuvant therapy for BD-related cognitive impairment. Given that studies focusing on connections between the gut microbiota and BD-related cognitive impairment are lagging behind those on other neurocognitive disorders, this review sought to explore the potential mechanisms of how gut microbial dysbiosis affects cognitive function in BD and identify potential microbiota-centered treatment.

The Role of Kynurenines in Cognitive Dysfunction in Bipolar Disorder

INTRODUCTION

Chronic low-grade inflammation is suggested to play a pathophysiological role in bipolar disorder (BD) and its related cognitive dysfunctions. Although kynurenine (KYN) pathway metabolites are key inflammatory mediators, studies investigating the association between KYN metabolism and cognition in BD are scarce. We aimed to explore the relationship between KYN metabolism and cognitive functioning across different mood states in BD.

METHODS

Sixty-seven patients with BD (35 depressed and 32 [hypo] manic) and 29 healthy controls were included. Cognitive functioning was assessed at 3 time intervals (baseline, 4, and 8 months) assessing processing speed, sustained attention, verbal memory, working memory, and response inhibition. Plasma samples for quantification of 3-hydroxykynurenine, quinolinic acid, and kynurenic acid (KYNA) were concurrently provided. Linear mixed models were used for statistical analysis.

RESULTS

The manic group showed deficits in all assessed cognitive domains with the exception of verbal memory at all test moments. The bipolar depression group showed deficits in the processing speed at all test moments. Throughout the whole follow-up period, KYNA was significantly lower in both patient groups than in controls. Only in the bipolar depression group, low KYNA was associated with worse global cognitive functioning (B = 0.114, p = 0.02) and slower processing speed in particular (B = 0.139, p = 0.03).

CONCLUSION

Only in the bipolar depression group, lower KYNA was associated with worse cognitive functioning. Future large-scale longitudinal studies are warranted to confirm the role of KYN metabolites in cognitive impairment in patients with BD and the possible therapeutic implications of this relationship.

Clinical profiles of subsequent stages in bipolar disorder: Results from the Dutch Bipolar Cohort

INTRODUCTION

The manifestation of bipolar disorder (BD) is hypothesized to be determined by clinical characteristics such as familial loading, childhood abuse, age at onset, illness duration, comorbid psychiatric disorders, addiction, treatment resistance, and premorbid cognitive functioning. Which of these are associated with a more severe course and worse outcome is currently unknown. Our objective is to find a combination of clinical characteristics associated with advancement to subsequent stages in two clinical staging models for BD.

METHODS

Using cross-sectional data from the Dutch Bipolar Cohort, staging was applied to determine the progression of bipolar-I-disorder (BD-I; N = 1396). Model A is primarily defined by recurrence of mood episodes, ranging from prodromal to chronicity. Model B is defined by level of inter-episodic functioning, ranging from prodromal to inability to function autonomously. For both models, ordinal logistic regression was conducted to test which clinical characteristics are associated with subsequent stages.

RESULTS

For model A, familial loading, childhood abuse, earlier onset, longer illness duration, psychiatric comorbidity, and treatment resistance were all predictors for a higher stage in contrast to addiction and cognitive functioning. For model B, childhood abuse, psychiatric comorbidity, cognitive functioning, and treatment resistance were predictors for a more severe stage, whereas age at onset, illness duration, and addiction were not.

DISCUSSION/CONCLUSIONS

Differences in clinical characteristics across stages support the construct validity of both staging models. Characteristics associated with a higher stage largely overlapped across both models. This study is a first step toward determining different clinical profiles, with a corresponding course and outcome.

Bipolar disorder treatment according to illness trajectory: a systematic review of clinical trials

The current bipolar disorder treatment guidelines focus mainly on the prevention of recurrence and stabilization of acute mood episodes while neglecting outcomes related to the longitudinal course of illness. We systematically reviewed studies that assess the impact of disease progression in the treatment of patients with bipolar disorder. We searched PubMed, Embase, and Web of Science for clinical trials that moderated treatment effects by number of previous episodes, disease length, or a clinical staging model. We retrieved 6,156 potential abstracts. After deduplication, 5,376 were screened and eight studies met inclusion criteria. Seven trials moderated results by number of prior episodes, and one of those also used a measure of disease length. One trial used a clinical staging model and yielded informing results. Only three studies evaluated pharmacological interventions, the other five assessing psychotherapeutic modalities. Most of the studies were post-hoc analysis of clinical trials not primarily aimed at studying variables associated with illness trajectory. Overall, a loss of efficacy was found according to clinical progression, which supports early intervention. Tailored recommendations according to disease stages cannot be made. Furthermore, we identified methodological weaknesses and strengths in this subfield of research, suggesting the use of clinical staging models for future studies.

A network analysis of rest-activity rhythms in young people with emerging bipolar disorders

AIMS

Actigraphy studies of individuals with bipolar disorders (BD) suggest that illness progression may be associated with a range of progressive disruptions in 24-hour rest-activity rhythms (RAR). However, those longitudinal studies were undertaken in older adults with extended histories or illness and treatment rather than young people with emerging BD. To our knowledge, this is the first study to use network modelling to examine the statistical associations between clinical phenotypes of BD and different subsets of RAR markers.

METHODS

This study of adolescents and young adults (mean age 22 years; 69% female) uses network modelling to examine which self-rated or actigraphic markers of RAR are more strongly associated with full threshold BD (referred to as Stage 2; N = 15) compared with BD-at risk syndromes (subthreshold presentations referred to as Stage 1; N = 25).

RESULTS

Network analysis demonstrated that some RAR are associated with both stage of BD and a family history of BD (such as longer sleep duration and higher levels of daytime impairment). Markers of circadian rhythmicity indicated that regulation of this system is weaker in Stage 2 compared with Stage 1 of BD.

LIMITATIONS

The small subgroup samples may have undermined the ability to detect some associations between phenotypes and RAR.

CONCLUSIONS

Network modelling may offer a useful strategy for visualizing and analysing patterns of association between RAR and clinical phenotypes defined by stage of illness, familial loading or symptom profile. This could prove useful in understanding the underlying pathophysiology of sleep-wake cycle and circadian rhythm disturbances in BD.

Magnetic Resonance Spectroscopy and Bipolar Disorder: How Feasible Is This Pairing?

Bipolar disorder is a psychiatric disorder that affects a significant part of the world's population; however, its diagnosis is difficult, mainly because of the lack of biomarkers and objective tests that aid the clinical evaluation. Proton magnetic resonance spectroscopy (MRS) is a tool that is relatively unused in the medical field. Its application arises from conventional magnetic resonance, and allows non-invasive, in vivo, the study of various metabolites and compounds in the human brain. This method may allow the assessment of neurobiochemical alterations in bipolar patients. One of the main advantages of this study type is the simplicity in its use since it only needs a standard magnetic resonator. All these characteristics make it an attractive diagnostic tool that can be used anywhere, including in low-middle-income countries. In conclusion, MRS has potential as a diagnostic tool for bipolar disorder; nevertheless, using it for this purpose still requires additional steps.