The association between diagnosis, treatment delay and outcome among patients with Bipolar disorders

Correlates of long duration of untreated illness (DUI) in patients with bipolar disorder: results of an observational study

BACKGROUND

Despite a high number of studies investigating the correlation between long Duration of Untreated Illness (DUI) and poor course of Bipolar Disorder (BD), the results concerning the impact of DUI on some specific factors, such as suicidality and medical comorbidities, are still inconsistent. This cross-sectional observational study aimed at analyzing potential socio-demographic and clinical correlates of long DUI in a large cohort of real-world, well-characterized BD patients.

METHODS

The socio-demographic and clinical characteristics of 897 patients with BD were collected. The sample was divided for analysis in two groups (short DUI vs long DUI) according to a DUI cutoff of 2 years. Comparisons were performed using χ2 tests for categorical variables and the Kruskal-Wallis test for continuous variables. Logistic regression (LogReg) was used to identify explanatory variables associated with DUI (dependent variable).

RESULTS

Six-hundred and sixty patients (75.5%) presented long DUI (> 2 years) and mean DUI was 15.7 years. The LogReg analysis confirmed the association of long DUI with bipolar II disorder (p: 0.016), lower age at onset (p < 0.001), depressive predominant polarity (p: 0.018), depressive polarity onset (p < 0.001), longer duration of illness (p < 0.001), lifetime suicide attempts (p: 0.045) and current medical comorbidities (p: 0.019).

CONCLUSIONS

The present study confirms the association between long DUI and higher risk of suicide attempts in patients with BD. Moreover, an association between long DUI and higher rates of medical conditions has been found.

Duration of untreated illness and bipolar disorder: time for a new definition? Results from a cross-sectional study

BACKGROUND

We primarily aimed to explore the associations between duration of untreated illness (DUI), treatment response, and functioning in a cohort of patients with bipolar disorder (BD).

METHODS

261 participants with BD were recruited. DUI was defined as months from the first affective episode to the start of a mood-stabilizer. The functioning assessment short test (FAST) scores and treatment response scores for lithium, valproate, or lamotrigine according to the Alda Scale Total Score (TS) were compared between patients with short (<24 months) or long DUI. Differences in FAST scores among good (GR; TS≥7), poor (PR; TS=2-6), or non-responders (NR; TS<2) to each mood-stabilizer were analyzed. Linear regression was computed using the FAST global score as the dependent variable.

RESULTS

DUI and FAST scores showed no statistically significant correlation. Patients with a longer DUI showed poorer response to lithium (Z=-3.196; p<0.001), but not to valproate or lamotrigine. Response to lithium (β=-1.814; p<0.001), number of hospitalizations (β=0.237; p<0.001), and illness duration (β=0.160; p=0.028) were associated with FAST total scores. GR to lithium was associated with better global functioning compared to PR or NR [H=27.631; p<0.001].

LIMITATIONS

The retrospective design could expose our data to a recall bias. Also, only few patients were on valproate or lamotrigine treatment.

CONCLUSIONS

Poor functioning in BD could be the result of multiple affective relapses, rather than a direct effect of DUI. A timely diagnosis with subsequent effective prophylactic treatment, such as lithium, may prevent poor functional outcomes in real-world patients with BD.

Duration of Untreated Psychosis in First-Episode Psychosis is not Associated With Common Genetic Variants for Major Psychiatric Conditions: Results From the Multi-Center EU-GEI Study

Duration of untreated psychosis (DUP) is associated with clinical outcomes in people with a diagnosis of first-episode psychosis (FEP), but factors associated with length of DUP are still poorly understood. Aiming to obtain insights into the possible biological impact on DUP, we report genetic analyses of a large multi-center phenotypically well-defined sample encompassing individuals with a diagnosis of FEP recruited from 6 countries spanning 17 research sites, as part of the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions (EU-GEI) study. Genetic propensity was measured using polygenic scores for schizophrenia (SZ-PGS), bipolar disorder (BD-PGS), major depressive disorder (MDD-PGS), and intelligence (IQ-PGS), which were calculated based on the results from the most recent genome-wide association meta-analyses. Following imputation for missing data and log transformation of DUP to handle skewedness, the association between DUP and polygenic scores (PGS), adjusting for important confounders, was investigated with multivariable linear regression models. The sample comprised 619 individuals with a diagnosis of FEP disorders with a median age at first contact of 29.0 years (interquartile range [IQR] = 22.0-38.0). The median length of DUP in the sample was 10.1 weeks (IQR = 3.8-30.8). One SD increases in SZ-PGS, BD-PGS, MDD-PGS or IQ-PGS were not significantly associated with the length of DUP. Our results suggest that genetic variation does not contribute to the DUP in patients with a diagnosis of FEP disorders.

Predictors of diagnostic delay: Assessment of psychiatric disorders in the clinic

BACKGROUND

Diagnostic delay contributes to morbidity in psychiatric disorders.

METHODS

Patients in an ambulatory psychiatry clinic were given patient-reported outcome measures at an initial visit, and a subset (N = 493) were given a structured interview (MINI International Neuropsychiatric Interview, MINI), in addition to the clinical encounter (CLIN). Diagnostic agreement between MINI and CLIN was assessed at an initial and follow-up visit. Diagnostic delay was identified if diagnostic disagreement between MINI and CLIN occurred at the initial visit and changed to an agreement at a follow-up visit. Registry data was compiled by an honest broker.

RESULTS

Significant agreement occurred between MINI and CLIN diagnoses for major depressive disorder (MDD), bipolar disorder (BD), generalized anxiety disorder, and panic disorder. Diagnostic agreement for MDD occurred at initial visit for 63% of patients, and at follow-up for 87% of those with initial diagnostic disagreement; for BD, 75% at initial visit and 28% at follow-up. No demographic, socioeconomic, symptom severity or functioning measures predicted diagnostic agreement for the MDD group at the first visit, however initial psychopathological symptom complexity predicted diagnostic agreement in the diagnostic delay group. Initial diagnostic agreement for BD was predicted by lower symptom burden and better social, physical, and occupational functioning. No factors predicted additional diagnostic agreement at the second visit in the diagnostic delay group.

CONCLUSION

Initial assessment by a structured interview aided physicians in identifying MDD by the second visit in patients with complex psychopathology. Patients with high complexity/severity of symptoms and more difficulty with functioning were less commonly identified with BD even with the assistance of a structured interview. Use of structured assessment tools may improve the detection of psychiatric illness by clinicians at the first visit.

Could "triple-therapy" considered as a novel-optimal treatment model for acute bipolar depression? A prospective real-world research in China

BACKGROUND

Results of researches of bipolar depression treatment are inconsistent and to our knowledge, no study has previously revealed an optimal treatment model for bipolar depression in the real-world through a prospective way.

OBJECTIVE

To find out an optimal treatment model for bipolar depression in the real-world by evaluating the effect of different treatment models: monotherapy, double-therapy and triple-therapy.

DESIGN

and Intervention: This 12 or 16-week, multi-center, real-world clinical study was conducted at 15 study sites (inpatient or outpatient department) in West China and a total of 573 patients completed the follow-up. During the study weeks, all researchers could choose a most proper treatment model freely basing on the evaluation of patient's symptoms and complete the follow-up according to the procedure.

MAIN OUTCOMES AND MEASURES

The primary outcomes were baseline-to-endpoint change in Montgomery-Asberg Depression Rating Scale (MADRS) total score and the constituent ratio of effects. Total score change in Young Mania Rating Scale (YMRS) and Clinical Global Impression (CGI) from baseline to endpoint, treatment-emergent mania rate and severe adverse events rate were used as secondary outcomes.

RESULTS

During all study weeks, all the 3 groups showed a statistically significant improvement in MARDS, YMRS and CGI (P＜0.001), but the triple-therapy group showed much more effective in significant response and response rates at endpoint than double-therapy group and monotherapy group (P＜0.001) with lower treatment-emergent mania rates (P = 0.001). At week 4, mean scores of MARDS in triple-therapy group are statistically significant lower than monotherapy group (P = 0.013) and at the endpoint, mean scores of MARDS in triple-therapy group are statistically significant lower than both double-therapy and monotherapy groups (P = 0.011). The severe adverse events rates are rare in all the 3 groups at week 4 and endpoint, and the rate of dry mouth in triple-therapy group at week 4 is statistically significant lower than the other 2 groups (P = 0.002).

CONCLUSIONS

Triple-therapy is more effective in treating bipolar depression than double-therapy and monotherapy model with a lower risk of developing manic symptoms.

TRIAL REGISTRATION

Chinese Clinical Trial Registry. Identifier: ChiCTR1800019064.

Short versions of the 32-item Hypomania Checklist: A systematic review

PURPOSE

Bipolar disorder (BD) is frequently misdiagnosed, which can lead to negative outcomes. The 32-item Hypomania Checklist (HCL-32) is one of the most widely used self-reported screening instruments for hypomanic symptoms, which has several short versions. This systematic review examined the psychometric properties of HCL-32 short versions.

DESIGN AND METHODS

Five international databases were systematically and independently searched by two researchers for studies that developed the HCL short versions. Basic demographic and clinical characteristics and the psychometric properties of the HCL short versions were recorded.

FINDINGS

Eighteen studies were identified. The majority of the HCL short versions showed satisfactory to good psychometric properties.

PRACTICE IMPLICATIONS

Validated HCL short versions with satisfactory psychometric properties may be helpful in screening for BD.

Identifying the Complexity of Diagnosing Bipolar Disorder: A Focused Ethnography

Purpose: To identify and describe the complexity of diagnosing bipolar disorder, including the diagnostic process and patient experiences of being newly diagnosed with bipolar disorder. Design: A mixed-methods focused ethnography was conducted, grounded in a post-positivist foundation. Methods: Medical records (n = 100) of patients whose diagnosis had been switched to bipolar disorder were examined. Six weeks post-hospitalization, ten outpatients with the diagnosis of bipolar disorder underwent an in-depth interview. Findings: Four diagnostic processes were identified during the retrospective record review. Two patterns and five themes were identified from the interviews. The first pattern, living with undiagnosed bipolar disorder, demonstrated common experiences of distinguishing impulsive moods and behavior, suffering life challenges, and seeking relief. The second pattern, acclimating to a new diagnosis of bipolar disorder, demonstrated participants' ways of understanding the diagnosis and reconciling the diagnosis. Patterns in the interviews corroborated data from the record review. Conclusions: The rendering of an appropriate diagnosis is key. Many participants' lives were significantly improved when diagnosis was made, and treatment recommendations for bipolar disorder (BPD) were initiated. These findings offer clinicians and researchers new ways to think about the complexity of the diagnosis of BPD including contrasting decision-making outcomes along a screening, diagnosis, and treatment continuum, as well as using the diagnostic event to instigate meaningful life change in the patient.

Duration of untreated bipolar disorder: a multicenter study

Little is known about the demographic and clinical differences between short and long duration of untreated bipolar disorder (DUB) in Chinese patients. This study examined the demographic and clinical features of short (≤2 years) and long DUB (>2 years) in China. A consecutively recruited sample of 555 patients with bipolar disorder (BD) was examined in 7 psychiatric hospitals and general hospital psychiatric units across China. Patients' demographic and clinical characteristics were collected using a standardized protocol and data collection procedure. The mean DUB was 3.2 ± 6.0 years; long DUB accounted for 31.0% of the sample. Multivariate analyses revealed that longer duration of illness, diagnosis of BD type II, and earlier misdiagnosis of BD for major depressive disorder or schizophrenia were independently associated with long DUB. The mean DUB in Chinese BD patients was shorter than the reported figures from Western countries. The long-term impact of DUB on the outcome of BD is warranted.

Risk of psychiatric disorders following pelvic inflammatory disease: a nationwide population-based retrospective cohort study

Pelvic inflammatory disease (PID) a common infection in women that is associated with significant morbidity and is a major cause of infertility. A clear temporal causal relationship between PID and psychiatric disorders has not been well established. We used a nationwide population-based retrospective cohort study to explore the relationship between PID and the subsequent development of psychiatric disorders. We identified subjects who were newly diagnosed with PID between 1 January 2000 and 31 December 2002 in the Taiwan National Health Insurance Research Database. A comparison cohort was constructed for patients without PID. A total of 21 930 PID and 21 930 matched control patients were observed until diagnosed with psychiatric disorders, or until death, withdrawal from the NHI system, or until 31 December 2009. Adjusted hazard ratio (HR) of bipolar disorder, depressive disorder, anxiety disorder and sleep disorder in subjects with PID were significantly higher (HR: 2.671, 2.173, 2.006 and 2.251, respectively) than that of the controls during the follow-up. PID may increase the risk of subsequent newly diagnosed bipolar disorder, depressive disorder, anxiety disorder and sleep disorder, which will impair life quality. Our findings highlight that clinicians should pay particular attention to psychiatric comorbidities in PID patients.

Risk of Psychiatric Disorders Following Symptomatic Menopausal Transition: A Nationwide Population-Based Retrospective Cohort Study

Menopausal transition is highly symptomatic in at least 20% of women. A higher prevalence of psychiatric symptoms, including depression, anxiety, and sleep disturbance, has been shown in women with symptomatic menopausal transition. However, a clear correlation between symptomatic menopausal transition and psychiatric disorders has not been established.We explored the association between symptomatic menopausal transition and subsequent newly diagnosed psychiatric disorders, including schizophrenia as well as bipolar, depressive, anxiety, and sleep disorders.We investigated women who were diagnosed with symptomatic menopausal transition by an obstetrician-gynecologist according to the data in the Taiwan National Health Insurance Research Database. A comparison cohort comprised age-matched women without symptomatic menopausal transition. The incidence rate and the hazard ratios of subsequent newly diagnosed psychiatric disorders were evaluated in both cohorts, based on the diagnoses of psychiatrists.The symptomatic menopausal transition and control cohorts each consisted of 19,028 women. The incidences of bipolar disorders (hazard ratio [HR] = 1.69, 95% confidence interval [CI] = 1.01-2.80), depressive disorders (HR = 2.17, 95% CI = 1.93-2.45), anxiety disorders (HR = 2.11, 95% CI = 1.84-2.41), and sleep disorders (HR = 2.01, 95% CI = 1.73-2.34) were higher among the symptomatic menopausal transition women than in the comparison cohort. After stratifying for follow-up duration, the incidence of newly diagnosed bipolar disorders, depressive disorders, anxiety disorders, and sleep disorders following a diagnosis of symptomatic menopausal transition remained significantly increased in the longer follow-up groups (1-5 and ≥ 5 years).Symptomatic menopausal transition might increase the risk of subsequent newly onset bipolar disorders, depressive disorders, anxiety disorders, and sleep disorders. A prospective study is necessary to confirm these findings.