Time to remission and relapse after the first hospital admission in severe bipolar disorder

A systematic review of interventions in the early course of bipolar disorder I or II: a report of the International Society for Bipolar Disorders Taskforce on early intervention

BACKGROUND

Given the likelihood of progressive illness in bipolar disorder (BD), it is important to understand the benefits and risks of interventions administered early in illness course. We conducted a systematic review of the effectiveness of interventions in the early course of BD I or II.

METHODS

We completed a systematic search on MEDLINE, PsycINFO, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL and Google Scholar from 1/1/1979 till 14/9/2022. We included controlled trials examining intervention effects on symptomatic, course, functional and tolerability outcomes of patients in the 'early course' of BD I or II. We classified patients to be in early course if they (a) were seeking help for the first time for a manic episode, (b) had a lifetime history of up to 3 manic episodes, or (c) had up to 6 lifetime mood episodes. Evidence quality was assessed using the GRADE approach.

RESULTS

From 4135 unique publications we included 25 reports representing 2212 participants in 16 randomized studies, and 17,714 participants from nine non-randomized studies. Available evidence suggested that in early illness course, lithium use was associated with lower recurrence risk compared with other mood stabilizers. Mood stabilizers were also associated with better global functioning, compared with the use of antipsychotics in the medium term. While summative findings regarding psychological therapies were limited by heterogeneity, family-focused and cognitive-behavioral interventions were associated with reduced recurrence risk or improved symptomatic outcomes. There was some evidence that the same pharmacological interventions were more efficacious in preventing recurrences when utilized in earlier rather than later illness course.

CONCLUSIONS AND RECOMMENDATIONS

While there are promising initial findings, there is a need for more adequately powered trials to examine the efficacy and tolerability of interventions in youth and adults in early illness course. Specifically, there is a compelling need to compare the relative benefits of lithium with other pharmacological agents in preventing recurrences. In addition to symptomatic outcomes, there should be a greater focus on functional impact and tolerability. Effective pharmacological and psychological interventions should be offered to those in early course of BD, balancing potential risks using shared decision-making approaches.

A Brief Psychoeducation Intervention to Prevent Rehospitalization in Severe Mental Disorder Inpatients

ABSTRACT

The efficacy of medium- to long-term psychoeducation in preventing relapse and hospitalization in people with severe mental disorders (SMDs) is robust. However, the evidence is inconclusive in brief interventions and individual modalities. The aim of this randomized clinical trial in SMD inpatients is to analyze the efficacy of a brief psychoeducation intervention added to treatment-as-usual, in improving the rehospitalization rate at 3 and 6 months after discharge. Fifty-one SMD inpatients were randomized to the intervention ( n = 24) or control group ( n = 27). Low insight and poor medication adherence were the most prevalent risk factors at admission. No significant differences were observed in the rehospitalization rate at 3 and 6 months after discharge. On the overall sample, the number of previous hospitalizations was a rehospitalization predictor at 3 (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.01-1.56; p = 0.04) and 6 months (OR, 1.85; 95% CI, 1.17-2.91; p = 0.009). SMD people require multimodal and persistent approaches focused on insight and medication adherence to prevent rehospitalizations.

A systematic review and meta-analysis of delayed help-seeking, delayed diagnosis and duration of untreated illness in bipolar disorders

OBJECTIVES

To examine the time delay between the age at onset of symptoms or episodes of bipolar disorders (BD) and the age at diagnosis of and/or receipt of clinical practice guideline recommended interventions for BD.

METHODS

Systematic search of five databases to identify publications from January 2000 to July 2022 that reported one or more of the following reliable and valid estimates of latency: delay in help seeking (DHS), delay in diagnosis (DD) and duration of untreated BD (DUB). Eligible studies were included in random effects meta-analyses and multivariate meta-regression was used to assess factors associated with each latency construct.

RESULTS

Screening of 1074 publications identified 59 eligible studies (reported in 66 publications) of >40,000 individuals that estimated DHS (8 studies), DD (20 studies) and/or DUB (45 studies). The median DHS, DD and DUB were 3.5 (IQR: 2.8, 8.48), 6.7 (IQR: 5.6, 8.9) and 5.9 years (IQR: 1.1, 8.2), respectively. Key factors associated with shorter DD included older age and residing outside North America; shorter DUB was associated with psychotic or manic onset and access to early intervention services.

CONCLUSIONS

Greater consensus on definitions of latency constructs and better-quality targeted research is required regarding DHS, DD and DUB. This review suggests that, while the peak age at onset of BD is 15-25, diagnosis and guideline recommended interventions (e.g., mood stabilizers) are likely to be delayed until age 25-35 years except for a minority of individuals with access to early intervention services.

Predictors of 1-year rehospitalization in inpatients with bipolar I disorder treated with atypical antipsychotics

Bipolar disorder (BPD) is debilitating disorder, and patients can experience multiple relapses and subsequent hospitalizations. Since pharmacotherapy is the mainstay of treatment for patients with BPD, investigations on the effects of atypical antipsychotics (AAP) on reducing rehospitalization risk are crucial. The objective of study is to explore predictors of 1-year rehospitalization in patients with bipolar I disorder treated with AAP. A retrospective chart review on inpatients with bipolar I disorder was conducted. All participants were followed up for 1 year, and they were subdivided into three AAP treatment groups (olanzapine, risperidone, and quetiapine group). Kaplan-Meier survival analysis was implemented to detect time to rehospitalization due to any mood episodes within 1 year after discharge. Cox proportional regression model was adopted to find predictors of 1-year hospitalization in patients who experienced rehospitalization. One hundred thirty-eight participants were included in the study, and a 1-year rehospitalization rate was 18.1%. Time to rehospitalization did not differ between three AAP treatment groups. Predictors of rehospitalization due to any episode within 1 year were family history of depression and number of previous admission. Our findings can be conducive to understanding prognosis, and predicting rehospitalization risk in patients with BPD on AAP.

Cognitive Behavioral Therapy for Three Patients with Bipolar II Disorder during Depressive Episodes

Bipolar II disorder is a recurrent mental health disorder characterized by alternating hypomanic and depressive episodes. Providing cognitive behavioral therapy (CBT) as an adjuvant to pharmacotherapy can reduce the recurrence rate of bipolar disorder. It has not been examined whether CBT can be started during a depressive episode in patients with bipolar II disorder; however, the use of CBT during the remission period has been demonstrated to reduce recurrence. The current study is a case report involving three Japanese patients with bipolar II disorder, who started CBT during the depressive phase after a hypomanic episode was stabilized by pharmacotherapy. All patients experienced excessively positive thinking one week apart and were able to choose behaviors that would stabilize bipolar mood by observing its precursors. After intervention, patients' bipolar mood according to the Internal State Scale (ISS) and the Beck Depression Inventory-II (BDI-II) was improved. Our findings suggested that providing CBT to patients with bipolar II disorder during depressive episodes as an adjunct to pharmacotherapy is feasible.

Remission and recurrence in bipolar disorder: The data from health outcomes and patient evaluations in bipolar disorder (HOPE-BD) study

BACKGROUND

The HOPE-BD was a naturalistic study established to follow individuals in Canada seeking treatment for bipolar disorder (BD). The study aimed to examine the course of BD and describe how clinical and sociodemographic factors are associated with outcomes.

METHODS

Individuals with BD had their clinical data recorded at enrolment and were naturalistically treated. Participant were followed for up to four years, and visits occurred at least once every three months. We investigated the longitudinal outcomes with logistic, Cox, and quantile regressions.

RESULTS

Among the 354 participants, 57.3% had BD type I. Depression as first episode, younger ages at onset and older ages of the first professional help predicted longer delays in correct diagnosis. Among the symptomatic patients at baseline, the median time to remission was 10.9 months. Comorbid alcohol use disorder and the severity of baseline depressive symptoms predicted longer times to remission. Among the euthymic participants, the median time to recurrence was 14.5 months. History of anxiety disorder and younger ages at onset predicted shorter times to recurrence. Baseline depression scores predicted recurrence in euthymic patients.

LIMITATIONS

We did not investigate the predictors of each polarity. Our findings may not apply to individuals followed in non-specialised outpatient services.

CONCLUSION

Our study reinforces the necessity of early diagnosis and interventions, as well as the importance of treating depressive symptoms and comorbidities.

Predictors of 30-day rehospitalization in a sample of hospitalized patients with Bipolar I disorder

The transition from psychiatric hospitalization to home is marked by high clinical vulnerability, characterized by risk of symptom rebound, exposure to preexisting stressors, and challenges with outpatient treatment linkage. Rates of rehospitalization during this post-discharge period, particularly for those with bipolar disorder, are reported to be high. This study evaluated demographic and clinical predictors of early rehospitalization (within 30 days) in a sample of hospitalized adults with Bipolar I disorder (BD-I). A chart review was conducted for 215 patients with BD-I admitted to an academically-affiliated psychiatric hospital within one calendar year. A computer algorithm was used to extract relevant demographic, clinical, and treatment information. Univariate and multivariate logistic regression models were used to examine predictors of early rehospitalization. Overall, 12% of participants were readmitted within 30 days of discharge. Controlling for other clinical and demographic variables, patient functioning and pre-admission psychiatric polypharmacy, but not comorbid psychiatric diagnoses, predicted early readmission in patients with BD-I. Findings highlight the relative importance of considering low psychosocial functioning, and medication regimens containing multiple psychiatric medications, during hospitalizations. These features may indicate a subset of patients with BD-I who require more comprehensive discharge planning and support to transition to the community following a psychiatric hospitalization.

Childhood factors associated with increased risk for mood episode recurrences in bipolar disorder-A systematic review

BACKGROUND

Bipolar Disorder (BD) is a recurrent illness associated with high morbidity and mortality. The frequency of mood episode recurrence in BD is highly heterogeneous and significantly impacts the person's psychosocial functioning and well-being. Understanding the factors associated with mood recurrences could inform the prognosis and treatment. The objective of this review is to summarize the literature on factors, present during childhood, that influence recurrence.

METHODOLOGY

A systematic review of PubMed (1946-2017) and PsycINFO (1884-2017) databases was conducted to identify candidate studies. Search terms included bipolar disorder, episodes, predictors, recurrences, and course. Study characteristics, risk for bias, and factors associated with recurrence were coded by two raters according to predetermined criteria.

RESULTS

Twenty child studies and 28 adult studies that retrospectively evaluated childhood variables associated with mood recurrences were included. Early age of onset, low socioeconomic status, comorbid disorders, inter-episode subsyndromal mood symptoms, BD-I/II subtypes, presence of stressors, and family history of BD were associated with higher number of recurrences.

LIMITATIONS

Risk factors and mood recurrences were assessed and defined in different ways, limiting generalizability.

CONCLUSION

Multiple factors are associated with increased risk of mood episode recurrence in BD. Interventions targeting modifiable factors could reduce the impact of BD. For example, treatment of comorbid disorders and subsyndromal mood symptoms, coupled with appropriate cognitive behavioral and family-focused therapies could ameliorate risk related to many clinical factors. When coupled with social services to address environmental factors, the number of episodes could be reduced and the course of BD significantly improved.

Factors predicting re-hospitalization for inpatients with bipolar mania--A naturalistic cohort

Patients with bipolar mania often require re-hospitalization, which can be a social-economic burden. This study aimed to investigate the factors affecting time to re-hospitalization for inpatients with acute bipolar mania. In this 6-year naturalistic study we reviewed the charts of inpatients with acute bipolar mania. Potential dichotomous factors including sex, family history of affective disorder, suicide history, and discharge against medical advice, involuntary admission, psychotic features, substance use disorder, and remission at discharge were recorded. Continuous variables including age, age at onset of affective episodes, and number of previous hospitalizations were also recorded. We used survival analysis with a univariate Cox proportional hazard regression model, along with forward multivariate model, to identify the potential factors. Of the 165 patients, 23% achieved symptomatic remission at discharge. In the forward Cox model, psychotic features, discharge against medical advice and higher number of previous hospitalizations were significant risk factors for re-admission. Remission at discharge was significantly associated with preventing re-hospitalization. We identified several predictors for re-hospitalization among inpatients with bipolar mania. Further studies are needed in other real-world settings to validate our results.

Course and naturalistic treatment seeking among persons with first episode mania in India: A retrospective chart review with up to five years follow-up

BACKGROUND

An understanding of the early course of Bipolar Disorder (BD) can contribute towards developing timely interventions. First episode mania (FEM) determines a diagnosis of bipolarity, and therefore, onset of BD-I. We investigated the course of BD-I over a five-year period after FEM by retrospective chart review.

METHODS

Charts of patients diagnosed with FEM in 2008 (n = 108) were reviewed. Data was extracted about FEM and subsequent course up to 5 years, for those who came for follow-up during this period. The factors influencing course were evaluated with statistical analyses including logistic regression and survival analysis.

RESULTS

The mean age at onset of BD was 26 ± 9.2 years and mean age at FEM was 27.1 ± 9 years. 41 (38%) patients had previous depression. Patients who returned for at least one follow-up were 60/108 (55.6%), with 54 (90%) of them experiencing another mood episode following FEM. Most recurrences occurred between 6 months to 1 year after FEM, with manic episodes occurring two-three times as frequently as depressive episodes. Good adherence to treatment was a predictor of fewer hospitalizations [B = -0.61; t = -3.1; p = 0.004].

LIMITATIONS

The study was limited by its retrospective design and high number of dropouts.

CONCLUSION

The five-year course after FEM showed twice the number of manic compared to depressive recurrences, irrespective of when the recurrence occurred. Consistent with earlier reports from India, BD-I appears to be mania-predominant, even early in the course. This has significant implications in planning maintenance treatments.

Lithium, valproate, and carbamazepine prescribing patterns for long-term treatment of bipolar I and II disorders: A prospective study

OBJECTIVE

This study aims to describe the prescription patterns of the mood stabilizers most commonly used for the treatment of bipolar I and II disorders (lithium, valproate, and carbamazepine) and to analyze the treatment outcomes.

METHODS

Two hundred and thirty-four outpatients with bipolar disorders receiving prophylactic treatment with lithium, valproate, carbamazepine, or their combination were followed up for at least 18 months in two Italian psychiatric centers specialized in mood disorders.

RESULTS

The combination of lithium and valproate or carbamazepine was the most common prophylactic treatment (54.3%), followed by valproate or carbamazepine (24%) and lithium monotherapy (22%). Polytherapy was prescribed mainly to patients with bipolar I disorder, a high number of previous episodes and lifetime psychotic symptoms, whereas valproate or carbamazepine monotherapy was prescribed to patients with anxiety comorbidity. The annual frequency of recurrences decreased significantly after entering the study in the overall sample, and the reduction was significantly higher in patients on lithium plus valproate or carbamazepine compared with the valproate or carbamazepine group, but not with the lithium monotherapy group. The number of mixed recurrences during the follow-up was significantly higher in patients on lithium plus valproate or carbamazepine.

CONCLUSIONS

Our findings may help clinicians to personalize long-term treatment to prevent relapses of bipolar disorder according to clinical presentation.

Factors affecting time to remission for inpatients with bipolar mania - A naturalistic Taiwanese study

BACKGROUND

Bipolar disorder is a complicated and chronic mental disorder. This study investigated factors affecting time to remission for inpatients with bipolar mania after 4 weeks of acute treatment.

METHODS

This naturalistic study recruited inpatients with bipolar mania for acute treatment. Symptom severity was assessed using the Young Mania Rating Scale (YMRS) at weeks 0, 1, 2, 3, and 4. Patients were included if they had had assessments at weeks 0 and 1 Remission was defined as an YMRS score ≤ 12. The Cox regression analysis was used to analyze factors associated with time to remission after 4 weeks of acute treatment.

RESULTS

Four hundred and forty-nine patients entered the analysis. Seventy-one of the 449 subjects (15.8%) reached symptomatic remission within 4 weeks of acute treatment. Using forward multivariate Cox regression analysis, comorbid substance use disorders, earlier age at onset, and greater manic symptom severity at baseline found to be statistically significant predictors of a longer time to reach remission after 4 weeks of treatment.

LIMITATIONS

As a retrospective chart review and naturalistic design, placebo effect and potentially confounding factors such as the possibility of missing records may have limited our results.

CONCLUSIONS

Early identification and intervention with integrated therapy is considered to shorten time to remission for patients at high risk of poor treatment outcome. More studies are needed in other real-world settings to generalize our results.

Risk of recurrence after a single manic or mixed episode - a systematic review and meta-analysis

OBJECTIVES

For the first time to estimate the risk of recurrence among patients with a single manic/mixed episode by systematically reviewing prior studies on cohorts of adults, and cohorts of children and adolescents, respectively.

METHODS

A systematic literature search up to August 2017 was carried out including studies in which < 25% of the participants were estimated to have had a mood episode that required pharmacological treatment prior to the index manic or mixed episode at inclusion.

RESULTS

Three studies including a total of 293 adult patients with a single manic or mixed episode and three studies of children and adolescents including 126 patients were identified. In the adult studies, 31%, 40% and 42% experienced recurrence after recovery within 1 year, 59% after 2 years, and 58% after 4 years, respectively. In the studies on children and adolescents, 40% and 52% experienced recurrence after recovery within 1 year, 30% and 60% after 2 years and 64% and 67% after 4 to 5 years, respectively. Results from meta-analyses showed a 1-year rate of recurrence of 35% (95% confidence interval [CI]: 30-41%) in adults, and in adolescents/children, a 1-year rate of recurrence of 48% (95% CI: 38-58%), a 2-year rate of 46% (95% CI: 33-60%) and a 4-5-year rate of recurrence of 65% (95% CI: 52-77%; as data from different studies were included at 1, 2 and 5 years, rates of recurrence did not increase steadily with time).

CONCLUSIONS

The rate of recurrence is high among adults as well as children and adolescents. It is important that clinicians and patients as well as relatives are well informed about these high risks when deciding to start maintenance treatment or not following onset of a single manic or mixed episode.

Predictors of recurrence during long-term treatment of bipolar I and II disorders. A 4 year prospective naturalistic study

BACKGROUND

Despite the large number of treatments available for bipolar disorder (BD), more than one half of patients have a recurrence within 2 years, and over 90% experience at least one additional affective episode during their lifetime.

METHODS

The aim of this study was to test the impact of a number of demographic and clinical features on the risk to recurrence in a real- word representative sample of 266 outpatients with BD-I or II treated in a naturalistic setting during a 4-years-follow-up period.

RESULTS

We found that the number of episodes per year after study entry, compared to the number of episodes per year before study entry,significantly decreased and that about one third of patients had no recurrences during the observation period. The length of follow-up and the number of previous episodes, mainly depressive, predicted the risk of recurrence, while female gender, higher age at intake, and a higher frequency of past mixed episodes predicted a higher frequency of recurrences.

LIMITATIONS

The study had some limitations to consider: i.e. the risk of poor reliability of information on the previous course of illness or the naturalistic treatment during the follow-up.

CONCLUSIONS

Our study suggests that (a) an evidence-based long-term treatment, with regular follow-up visits could improve the course of disease and prognosis; (b) clinicians should carefully consider the presence of a high number of mixed episodes, to provide more targeted treatment strategies; (c) an appropriate use of antidepressants in selected patients did not worsen the course of illness.

Remission and recovery from first-episode psychosis in adults: systematic review and meta-analysis of long-term outcome studies

BackgroundRemission and recovery rates for people with first-episode psychosis (FEP) remain uncertain.AimsTo assess pooled prevalence rates of remission and recovery in FEP and to investigate potential moderators.MethodWe conducted a systematic review and meta-analysis to assess pooled prevalence rates of remission and recovery in FEP in longitudinal studies with more than 1 year of follow-up data, and conducted meta-regression analyses to investigate potential moderators.ResultsSeventy-nine studies were included representing 19072 patients with FEP. The pooled rate of remission among 12301 individuals with FEP was 58% (60 studies, mean follow-up 5.5 years). Higher remission rates were moderated by studies from more recent years. The pooled prevalence of recovery among 9642 individuals with FEP was 38% (35 studies, mean follow-up 7.2 years). Recovery rates were higher in North America than in other regions.ConclusionsRemission and recovery rates in FEP may be more favourable than previously thought. We observed stability of recovery rates after the first 2 years, suggesting that a progressive deteriorating course of illness is not typical. Although remission rates have improved over time recovery rates have not, raising questions about the effectiveness of services in achieving improved recovery.

Predictors of a Shorter Time to Hospitalization in Patients with Bipolar Disorder: Medication during the Acute and Maintenance Phases and Other Clinical Factors

Objective

The present study was conducted to compare the effects of pharmacological treatments during the acute and maintenance phases of mood episodes, sociodemographic, and clinical characteristics between a shorter time to hospitalization group (<12 months) and a longer time to hospitalization group (≥12 months).

Methods

The discharge medication for the first hospitalization was considered the acute treatment and the medication used during the week prior to the second hospitalization at the outpatient clinic was considered the maintenance treatment. Additionally, the charts were reviewed to examine a variety of demographic and clinical characteristics.

Results

Patients in the shorter time to hospitalization group were more likely to be unmarried and/or unemployed, have had a previous hospital admission for a mood episode, and have used antidepressant during the acute phase than those in the longer time to hospitalization group. Patients in the shorter time to hospitalization group were also less likely to use olanzapine, serotonin-norepinephrine reuptake inhibitors, or mood stabilizer monotherapy as a maintenance treatment than were patients in the longer time to hospitalization group.

Conclusion

Predictors for shorter time to hospitalization were associated with number of previous hospital admissions for a mood episode, being unmarried and/or unemployed, and antidepressant use during the acute phase.

Modeling association between times to recurrence of the different polarities in bipolar disorder among service seekers in urban Nigeria: a survival analysis approach

INTRODUCTION

Bipolar disorder (BD) remains both a clinical and public health challenge worldwide, especially in developing countries such as Nigeria. Many studies have focused on prevalence and recurrences among BD service seekers but little has been documented on the nature, strength, direction, existence, and estimation of association between times to recurrence of the two possible polarities or mood episodes in BD. In this study, we explored the association between durations before recurrence of depression and manic episodes among people seeking treatment for BD.

METHODS

This analytical study used retrospective data of 467 persons who sought treatment for BD at the psychiatric clinic of University College Hospital, Ibadan, Nigeria between 2005 and 2014. Descriptive statistics were used to explore the data. We right-censored the data and obtained Kaplan-Meier estimates of the time to recurrence of the outcomes and transformed the estimates to standardized binormal data using quantile-quantile transformation. The likelihood was maximized to obtain the maximum likelihood estimate of the association parameter at 5% significance level.

RESULTS

The mean (± standard deviation) age of the respondents was 32.9±12.9 years, this was lower among service seekers who were initially diagnosed with mania than among those initially diagnosed with depression (31.3±11.6, 33.2±11.9, respectively). The median survival time to recurrence of mania and depression among the patients was 1,120 and 745 days, respectively, whereas association between times to recurrence of mania and depression was maximized at 0.67 (95% confidence interval: 0.62-0.71).

CONCLUSION

There exists a strong and positive association between times to recurrence of depression and mania in BD. The longer the time to recurrence of mania, the longer the time to recurrence of depression and vice versa.

A Descriptive Analysis of Factors Leading to a 1-Year Remission in Bipolar Disorder

BACKGROUND

Bipolar spectrum disorders are associated with symptomatic and functional disability in many patients. Other studies have examined predictors of outcome with variable results. The goal of this retrospective study was to identify medications associated with a minimum of 12 consecutive months of symptomatic, functional, and syndromal remission.

METHODS

The charts of 121 patients with confirmed bipolar disorder were reviewed. Data on medical regimen and demographic and adherence factors were gathered using standardized data collection sheets approved by the University of Toledo Institutional Review Board. The criterion for improvement was set at 12 consecutive months of Clinical Global Impressions Improvement ratings of ≤2, which is a far higher standard of syndromal and functional remissions than the usual 8 consecutive weeks used by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision.

RESULTS

In this sample of 121 patients, 43.8% achieved a minimum of 12 consecutive months of remission, whereas 56.2% did not. When bipolar disorder was divided into its subtypes, 45.5% of our cohort were diagnosed with bipolar I disorder, 27.3% were diagnosed with bipolar II disorder, and 27.3% were diagnosed with bipolar disorder, not otherwise specified. Of the 55 patients with bipolar I disorder, 27 remitted and 28 did not. Of the 33 patients with bipolar II disorder, 12 remitted and 21 did not. Of the 33 patients with bipolar disorder, not otherwise specified, 14 remitted and 19 did not. The treatment regimen that was most closely associated with remission was a combination of atypical antipsychotics (primarily aripiprazole), mood stabilizers (primarily lamotrigine), and an antidepressant. In addition, the patients who achieved remission were more likely to be adherent to medication and with appointments.

CONCLUSIONS

The chart review showed that 12 consecutive months of symptomatic remission was achieved in our clinic in 43.8% of patients with bipolar disorder when they were treated with tailored medication regimens. The remainder (56.2%) failed to achieve 12 consecutive months of remission based on real-time Clinical Global Impressions Improvement ratings. The combination of an atypical antipsychotic, a mood stabilizer, and an antidepressant was highly correlated with 1-year remission.

Course and outcome following a first episode of mania: four-year prospective data from the Systematic Treatment Optimization Program (STOP-EM)

BACKGROUND

First episode mania (FEM) cohorts provide an opportunity to identify windows for intervention to potentially alter the course of bipolar disorder (BD). Despite several efforts to prospectively characterize first episode patients, follow-up of such cohorts has seldom exceeded 1 year. We present 4-year outcomes from the STOP-EM FEM cohort.

METHOD

Of 101 identified FEM patients, 81 had longitudinal follow-up. Clinical evaluations including substance misuse, sociodemographics and family history were characterized using semi-structured instruments. Clinical reassessments occurred every 6 months.

RESULTS

Within one year, all patients had remitted and 95% recovered. Recurrence following remission occurred in 58% of patients by 1 year and 74% by 4 years (60% depressive, 28% manic and 12% hypomanic). Recurrence within one year was associated with a higher rate of recurrence thereafter. Older age was associated with a shorter time to remission. Substance misuse was associated with delayed recovery and earlier recurrence.

LIMITATIONS

This prospective multiwave longitudinal design employed may be limited by the assessment schedule and associated recall bias. The influences of attrition of this sample should be considered when attempting to generalize our findings.

CONCLUSIONS

Best practices in FEM result in remission and recovery. While recurrence is common, minimizing recurrence within the first year through risk factor modification may alter the course of the BD.

The influence of life events on first and recurrent admissions in bipolar disorder

Background

Life events play an important role in the onset and course of bipolar disorder. We will test the influence of life events on first and recurrent admissions in bipolar disorder and their interaction to test the kindling hypothesis.

Methods

We collected information about life events and admissions across the life span in 51 bipolar patients. We constructed four models to explore the decay of life event effects on admissions. To test their interaction, we used the Andersen-Gill model.

Results

The relationship between life events and admissions was best described with a model in which the effects of life events gradually decayed by 25% per year. Both life event load and recurrent admissions significantly increased the risk of both first and subsequent admissions. No significant interaction between life event load and number of admissions was found.

Conclusions

Life events increase the risk of both first and recurrent admissions in bipolar disorder. We found no significant interaction between life events and admissions, but the effect of life events on admissions decreases after the first admission which is in line with the kindling hypothesis.

Association between toll-like receptor 2 gene diversity and early-onset bipolar disorder

BACKGROUND

Toll-like receptor 2 (TLR2) molecules play a pivotal role in innate immune responses by their ability to recognize and sense a wide repertoire of infectious and endogenous cellular structural elements. Here we evaluated whether genetic variants in TLR2 influence the age of the disease onset in bipolar disorder (BD).

METHODS

DNAs from 571 BD patients 229 early-onset (EO-BD) and 342 late-onset (LO-BD) and 199 healthy controls (HC) were analyzed for the following TLR2 polymorphisms: the 5'-UTR -196 to -174 insertion/deletion (ins/del), the intron 1 rs4696480 A/T, and the exon 3 rs3804099 C/T and rs3804100 C/T. PHASE software was used for haplotype reconstruction. Genetic associations were examined using a chi-square test.

RESULTS

We found that the TLR2 rs3804099 TT was significantly more prevalent in EO-BD than in LO-BD patients (corrected p (pc)=0.024). After excluding family history of psychiatric disorders, we also found that the TLR2 rs4696480 TT genotype was significantly more prevalent in EO-BD as compared to LO-BD and controls (pc=0.002 and 0.002). Homozygous state for the insTTT haplotype, carrying the above mentioned risk genotypes, was significantly more frequent in EO-BD than in LO-BD patients (pc=0.007) and in EO-BD without family history of psychiatric disorders as compared to (i) those with positive history (pc=0.03), (ii) with LO-BD without family history (pc=0.001) and (iii) with HC (pc=0.009).

LIMITATIONS

Confirmation by replication in independent BD cohorts is warranted.

CONCLUSIONS

Our data suggest the potential role of TLR2 genetic variants in the pathogen-mediated susceptibility to BD.

How to Understand Divergent Views on Bipolar Disorder in Youth

There are two divergent viewpoints on the phenomenology and outcome of bipolar I (BP I) disorder in youth. Disparities evolved as unintended consequences from investigators' inconsistencies both in translating the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, DSM-III-R, and DSM-IV criteria and in operationalizing them differently in their standardized assessments. Rates of conservatively diagnosed BP I are lower both in community studies of youths than in adults and from liberally defined BP I in youths. Rates of co-occurring attention-deficit hyperactivity disorder (ADHD) are lower in conservatively than liberally defined children and adolescents with BP I. Rates of both BP I and of ADHD are lower in offspring of BP I probands, and outcome more closely approximates that of adults with BP I in conservatively versus liberally defined children and teens with BP I. Both perspectives can claim evidence for reliability and validity that support their positions. However, the samples are so different that it is difficult to compare studies conducted from these different perspectives.

Time to relapse and remission of bipolar disorder: findings from a 1-year prospective study in Thailand

BACKGROUND AND METHODS

This study aimed to determine time to relapse and remission of mood episodes in Thai patients with bipolar disorder (BD). The Thai Bipolar Disorder Registry was a multicenter, prospective, naturalistic, observational study conducted in Thailand. Participants were adult inpatients or outpatients with Diagnostic and Statistical Manual of Mental Disorders bipolar disorder. The diagnosis of bipolar disorder, current psychiatric comorbidity, mood relapse, and mood remission were determined by using the Mini International Neuropsychiatric Interview. Relapse and remission were assessed every 2 months.

RESULTS

Of 424 BD participants, 404 (95.3%) were BD I, and 258 (60.8%) were female. At entry, 260 (61.3%) had recovered, and 49 (11.6%) were recovering. During 1-year follow-up (381.7 person-years), 92 participants (21.7%) had 119 relapses or 0.31 (95% confidence interval 0.25-0.35) episodes per person-year. Among 119 relapses, 58 (48.7%), 39 (32.7%), and 21 (17.6%) of them were depressive, hypomanic, and manic episodes, respectively. Using the Kaplan-Meier method, we found that 25% of the participants relapsed in 361 days. Of the 400 participants who reached remission, 113 (28.2%) had mood relapses. Of 173 mood events accountable for remission analysis, the median time to remission was 67.5 days (72.5 days for depressive episodes versus 58.0 days for manic episodes, log rank P = 0.014).

CONCLUSIONS

The 1-year relapse rate in Thai patients with BD was 21.7% or 0.31 episodes per person-year. About one-fifth of recovered patients had mood relapses within 371 days. On average, a mood episode would remit in 67.5 days.

Course, outcomes, and psychosocial interventions for first-episode mania

OBJECTIVES

The course of bipolar disorder tends to worsen over time, highlighting the importance of early intervention. Despite the recognized need for adjunctive psychosocial treatments in first-episode mania, very few studies have evaluated psychological interventions for this period of significant risk. In this empirical review, we evaluate existing research on first-episode bipolar disorder, compare this body of research to parallel studies of first-episode schizophrenia, and identify strategies for future research.

METHODS

A comprehensive literature search of the MEDLINE and PsychINFO databases was conducted to identify studies of first-episode mania, as well as first-episode schizophrenia. Recovery and relapse rates were compared across studies.

RESULTS

In contrast to a number of studies of first-episode schizophrenia, the authors identified only seven independent programs assessing first-episode mania. Findings from these studies suggest that, while pharmacological treatment helps patients achieve recovery from acute episodes, it fails to bring patients to sustained remission. Early psychosocial intervention may be imperative in reducing residual symptoms, preventing recurrence of mood episodes, and improving psychosocial functioning. However, very few studies of psychosocial interventions for first-episode mania have been systematically studied.

CONCLUSIONS

Studies of first-episode mania indicate a gap between syndromal/symptomatic and functional recovery. Novel psychosocial interventions for first-episode mania may help bridge this gap, but require controlled study.

Predictive factors for time to remission and recurrence in patients treated for acute mania: health outcomes of manic episodes (HOME) study

OBJECTIVE

To determine the time to remission and recurrence in patients treated for acute mania and the predictive factors associated with these outcomes.

METHOD

This observational study, conducted in Turkey from April 2003 to January 2005, included patients with a DSM-IV diagnosis of bipolar I disorder, acute manic or mixed episode who were eligible to have an oral medication initiated or changed for the treatment of the episode. The patients were followed-up for 12 months.

RESULTS

A total of 584 patients (mean ± SD age = 33.9 ± 11.2, 55.2% outpatients) were enrolled in 53 centers. Eighty-five percent of patients had a manic episode at baseline, with a mean ± SD duration of 21.6 ± 24.4 days. The baseline mean ± SD Clinical Global Impressions scale for use in bipolar disorder and Young Mania Rating Scale (YMRS) scores were 4.9 ± 0.9 (median = 5.0) and 33.2 ± 9.3 (median = 33), respectively. 539 patients achieved remission and, of those, 141 patients had recurrence. One-year remission and recurrence rates were 99.0% and 35.7%, respectively. Mean ± SD times to remission and recurrence in descriptive statistics were 80.9 ± 73.8 (median = 50) and 159.0 ± 95.5 (median = 156) days, respectively. In Cox regression analysis, psychiatric comorbidities (p = .048), a higher YMRS score (p < .001), and a higher number of previous depressive episodes (p = .009) were statistically significant predictors of a longer time to reach remission. Index episodes of longer duration (p = .033) and mixed type (p = 0.49) were significant predictors of a shorter time to recurrence. Confounding factors like concomitant treatment, comorbidities, and lack of blinding and randomization were other limitations.

CONCLUSION

Predictors for a longer time to remission were psychiatric comorbidities, a higher YMRS score, and a higher number of previous depressive episodes. Predictors for a shorter time to recurrence were episodes of longer duration and mixed type.

Early determinants of four-year clinical outcomes in bipolar disorder with psychosis

OBJECTIVE

Bipolar disorder with psychosis is common in inpatient settings and is associated with diverse outcomes after hospital discharge, which can range from a return to premorbid functioning with no recurrence, to a chronic or recurring illness. Less is known, however, about factors that can predict a better or worse clinical outcome. The present study sought to assess four-year clinical outcomes and their predictors in patients hospitalized for bipolar I disorder with psychosis.

METHODS

Participants from the Suffolk County Mental Health Project (SCMHP) with a baseline diagnosis of bipolar I disorder with psychotic features (N=126) were reassessed using face-to-face interviews at six months, two years, and four years following their first hospitalization. At each time point, clinical status, role functioning, and treatment were assessed by highly trained interviewers using standardized instruments.

RESULTS

The majority of participants (73.2%) returned to their premorbid level of role functioning by the four-year follow-up and the median percentage of time ill during the interval was less than 20%. Nevertheless, almost half of the sample (46.9%) was rehospitalized at least once. Psychotic symptoms at baseline (particularly Schneiderian symptoms), depressive phenomenology, childhood psychopathology, and younger age at first hospitalization predicted worse outcome, whereas mood-incongruent psychotic features and age of mood disorder onset did not.

CONCLUSIONS

The four-year outcomes of a first-admission cohort with bipolar I disorder with psychosis were generally favorable. Poorer premorbid functioning, Schneiderian delusions, greater depressive symptoms, and a younger age of first hospitalization portend a worse course.

Bipolar disorder and polymorphisms of glutathione S-transferases M1 (GSTM1) and T1 (GSTT1)

Glutathione S-transferases are ubiquitous multifunctional enzymes, which play a key role in cellular detoxification. The present case-control study was performed in Shiraz, Iran to investigate the association between polymorphisms of glutathione S-transferases M1 (GSTM1) and T1 (GSTT1) and susceptibility to bipolar disorder (BPD). A total of 228 BPD patients participated in the study. In addition, 236 healthy blood donors, who frequency matched with the patients according to age and gender, were also studied as a control group. Statistical analysis revealed that polymorphisms of neither GSTM1 (OR=0.73, 95% CI: 0.50-1.05) nor GSTT1 (OR=0.98, 95% CI: 0.65-1.47) were associated with risk of BPD. Patients were stratified according to their age of onset into early onset (below 19 years old) and late onset (more than 19 years old) groups. Among the early onset group, the GSTM1 null genotype decreases the risk of BPD (OR=0.43, 95% CI: 0.24-0.79). Further analysis showed that a combination of "GSTM1 positive genotype and GSTT1 null genotype" versus "positive genotypes of GSTM1 and GSTT1" increased the risk of BPD (OR=2.28, 95% CI: 1.07-4.85). However, there was no significant association between the study polymorphisms and risk of BPD among the late onset group. The present finding indicated that GSTM1 and GSTT1 are candidate polymorphisms for susceptibility to BDP among adolescents.

Poor adherence to treatment associated with a high recurrence in a bipolar disorder outpatient sample

BACKGROUND

We analyzed the association of previous course-of-illness and other variables of clinical interest with a high frequency of both depressive or (hypo)manic episodes controlling for the effect of socio-demographic characteristics.

METHODS

A total of 108 outpatients with a DSM-IV diagnosis of bipolar disorder (BD) were recruited. A retrospective and naturalistic study was conducted to examine the number of affective episodes and their relationship with socio-demographic, clinical and course-of-illness variables, including adherence to medication, type of medication used and the use of addictive substances. The episode frequency was estimated as the number of "major instances" of depression, hypomania and mania during the illness. To classify the patients into two groups (higher and lower-episode frequency), we used the statistical criterion of median split. Results were analyzed with logistic regression models to control for the effects of potential confounders.

RESULTS

A high episode frequency (nine or more episodes) was associated with age (36-55years), delay in diagnosis, poor adherence to medication and current use of antipsychotic medication. In addition, a high frequency of manic episodes (four or more) was associated with female sex, age (>36years) and a manic onset of the illness, whereas a high frequency of depressive episodes (five or more) was associated with delay in diagnosis and poor adherence to medication.

LIMITATIONS

Cross-sectional study design.

CONCLUSIONS

Avoiding delay in diagnosis and enhancing treatment adherence might be important targets for reducing recurrences in BD.

Frequency of and rationales for the combined use of electroconvulsive therapy and antiepileptic drugs in Austria and the literature

Our aim was to observe the frequency of combination therapy using antiepileptic drugs (AEDs) and electroconvulsive therapy (ECT) in Austria and the literature, and to provide rationales and recommendations based on clinical and molecular properties. The responsible ECT leaders of eight Austrian departments were contacted for information about combination therapy. A computerized PubMed database search was performed and supplemented by cross-referencing from papers, review articles and psychiatric manuals. The frequency of combination therapy in Austrian departments ranges between 0 and 85.7%. In 17 studies enrolling a total of 189 patients, 87 (46.0%) patients received combination therapy. Of these 87 patients, nine (10.3%) reported adverse effects. ECT and AEDs show overlapping clinical and molecular properties. Combination therapy is an observed reality and, according to the currently available literature, feasible. A comparison of clinical and molecular properties indicates possible augmentative effects, making combination therapy a promising alternative in treatment-resistant cases. But there is still a clear need for prospective case controlled data concerning side effects, safety profiles and effectiveness until it can be recommended.

Unmet need for mental health care in schizophrenia: an overview of literature and new data from a first-admission study

We present an overview of the literature on the patterns of mental health service use and the unmet need for care in individuals with schizophrenia with a focus on studies in the United States. We also present new data on the longitudinal course of treatments from a study of first-admission patients with schizophrenia. In epidemiological surveys, approximately 40% of the respondents with schizophrenia report that they have not received any mental health treatments in the preceding 6-12 months. Clinical epidemiological studies also find that many patients virtually drop out of treatment after their index contact with services and receive little mental health care in subsequent years. Clinical studies of patients in routine treatment settings indicate that the treatment patterns of these patients often fall short of the benchmarks set by evidence-based practice guidelines, while at least half of these patients continue to experience significant symptoms. The divergence from the guidelines is more pronounced with regard to psychosocial than medication treatments and in outpatient than in inpatient settings. The expansion of managed care has led to further reduction in the use of psychosocial treatments and, in some settings, continuity of care. In conclusion, we found a substantial level of unmet need for care among individuals with schizophrenia both at community level and in treatment settings. More than half of the individuals with this often chronic and disabling condition receive either no treatment or suboptimal treatment. Recovery in this patient population cannot be fully achieved without enhancing access to services and improving the quality of available services. The recent expansion of managed care has made this goal more difficult to achieve.

Antidepressant-associated switches from depression to mania in severe bipolar disorder

OBJECTIVES

To determine whether switching from depression to mania is part of the natural history of bipolar illness or results from antidepressant (AD) treatment by examining bipolar patients with psychosis early in their illness course.

METHODS

A multi-facility cohort of 123 first-admission inpatients, aged 15-60 years, with DSM-IV bipolar disorder (BD) with psychotic features, was followed for four years, and 76 individuals experienced at least one episode of depression. Frequency of and risk factors for switches from depression to mania, time to switch, and duration of the subsequent manic episode were examined in relation to AD use (with anti-manic and/or antipsychotic medications).

RESULTS

The 76 respondents experienced 113 depressive episodes. Those prescribed ADs had more depressive episodes and spent more time depressed than non-users. A total of 23 depressive episodes in 17 respondents ended in a manic/hypomanic/mixed episode (20%). The time to switch and duration of the subsequent manic episode were not significantly different for the seven respondents and nine episodes involving AD treatment versus the 10 respondents and 14 episodes without ADs. None of the risk factors (age of onset <or=18 years, childhood psychopathology, depressive first episode, substance abuse at index admission, bipolar family history, type of AD used) was associated with switching.

CONCLUSIONS

In this sample with severe BD, switching from depression to mania was not associated with AD treatment. Respondents who experienced switching appeared to have a more relentless form of BD. In only a few did ADs appear to be responsible for the switch.

Remission and relapse after the first hospital admission in psychotic depression: a 4-year naturalistic follow-up

BACKGROUND

Few studies have examined the course of illness among severely depressed patients ascertained at first hospitalization. Using data from the Suffolk County Mental Health Project (SCMHP), we investigated the times to and predictors of the first full remission and the first relapse during a 4-year period in a first-admission cohort with major depressive disorder (MDD) with psychotic features.

METHOD

The cohort included 87 county-wide, first-admission patients with a longitudinal consensus diagnosis of MDD with psychotic features who were systematically followed over a 4-year period. We examined the associations of background, clinical and treatment factors, and time-varying indices of antidepressant (AD) and antipsychotic (AP) medication use to time to remission and relapse using Cox regression.

RESULTS

By the 4-year follow-up, 60 respondents (69.0%) had achieved a period of full remission (median time of 22 weeks among remitters and 54 weeks in the full sample). In the multivariable analysis, longer time to remission was associated with longer latency between initial episode and hospitalization, lower pre-hospital Global Assessment of Functioning (GAF) score, and lack of insurance, but not use of medication. Twenty-six remitters (43.3%) relapsed (median time of 50 weeks among those who relapsed and 192 weeks among all remitters). None of the risk factors or time-varying medication variables was significantly associated with time to relapse.

CONCLUSION

Only two-thirds of the sample had at least one full remission by 4 years, and almost half of them subsequently relapsed. Poorer pre-hospital resources predicted remission but not relapse. Medication use over the follow-up was not associated with remission or relapse.

Childhood-onset bipolar disorder: Evidence for increased familial loading of psychiatric illness

OBJECTIVE

To determine whether childhood-onset bipolar disorder (BP) is associated with an increased psychiatric family history compared with adolescent-onset BP.

METHOD

Semistructured psychiatric interviews were conducted for 438 youth with BP spectrum disorders. To evaluate the effects of age at onset and psychiatric family history, the sample was divided into childhood-onset BP (age and BP onset <12 years; n = 192), adolescents with early-onset BP (age > or =12 years and BP onset <12 years; n = 136), and adolescents with late-onset BP (age and BP onset > or =12 years; n = 110). Lifetime family history of psychiatric illness was ascertained for first- and second-degree relatives through both direct interview of caretakers and the Family History Screen.

RESULTS

After significant demographic and clinical factors were controlled for, children and adolescents with childhood-onset BP showed higher percentages of positive first-degree family history for depression, anxiety, attention-deficit/hyperactivity, conduct, and substance dependence disorders and suicidal behaviors compared with adolescents with late onset. Subjects with childhood-onset BP also showed elevated familial loading for depression and attention-deficit/hyperactive disorder in second-degree relatives.

CONCLUSIONS

These data support a model that postulates a higher density of familial risk for a broad range of psychopathology in childhood-onset BP.

Predictors of relapse in bipolar disorder: A review

INTRODUCTION

Bipolar disorder is the sixth leading cause of disability in the United States. Moreover, repeated episodes and non-responsiveness to treatment continue to present a significant problem, and little is known about the factors that may precipitate relapse. This article reviews the available literature on predictors of bipolar relapse.

METHODS

We conducted a literature search on Medline from 1996 to March 2006, using the keywords "relapse," "recurrence," "compliance," "adherence," "life events," "kindling," and "predictors" combined with the term "bipolar disorder(s)." References from the resulting articles also supplemented the initial search. Thirty-eight articles were included in the analysis.

RESULTS

Predictors of episodes include stressful life events, increased number of previous episodes, decreased interval between episodes, and persistence of affective symptoms and episodes. Factors associated with longer survival times include psychotherapy, social support, and medication adherence.

CONCLUSIONS

Our review suggests several reliable predictors of bipolar episodes. Knowledge of these factors has significant clinical implications and could aid in treatment and prevention strategies. However, further research is clearly needed to address the limitations of the existing research and to increase our understanding of predictors of relapse, with the intent of improving quality of life and preventing episodes in patients with bipolar disorder.